1
|
Granström AL, Irvine W, Hoel AT, Tabbers M, Kyrklund K, Leon FF, Fusaro F, Thapar N, Dariel A, Sloots CEJ, Miserez M, Lemli A, Alexander S, Lambe C, Crétolle C, Qvist N, Schukfeh N, Lacher M, Cavalieri D, van Heurn E, Sfeir R, Pakarinen MP, Bjørnland K, Wester T. Ernica Clinical Consensus Statements on Total Colonic and Intestinal Aganglionosis. J Pediatr Surg 2024:S0022-3468(24)00295-1. [PMID: 38763854 DOI: 10.1016/j.jpedsurg.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Hirschsprung disease is a congenital intestinal motility disorder characterized by an absence of enteric ganglion cells. Total colonic aganglionosis and near total or total intestinal aganglionosis, defined as absence of ganglion cells in the entire colon and with variable length of small bowel involved, are life-threatening conditions which affect less than 10 % of all patients with Hirschsprung disease. The aim of this project was to develop clinical consensus statements within ERNICA, the European Reference Network for rare congenital digestive diseases, on four major topics: Surgical treatment of total colonic aganglionosis, surgical treatment of total intestinal aganglionosis, management of poor bowel function in total colonic and/or intestinal aganglionosis and long-term management in total colonic and or intestinal aganglionosis. METHODS A multidisciplinary panel of representatives from ERNICA centers was invited to participate. Literature was searched, using specified search terms, in Medline (ALL), Embase and Google Scholar. Abstracts were screened and full text publications were selected. The panel was divided in four groups that extracted data from the full text publications and suggested draft statements for each of the major topics. A modified Delphi process was used to refine and agree on the statements. RESULTS The consensus statement was conducted by a multidisciplinary panel of 24 participants from 10 European countries, 45 statements reached consensus after 3 Delphi-rounds. The availability of high-quality clinical evidence was limited, and most statements were based on expert opinion. Another 25 statements did not reach consensus. CONCLUSIONS Total colonic and total intestinal aganglionosis are rare variants of Hirschsprung disease, with very limited availability of high-quality clinical evidence. This consensus statement provides statements on the surgical treatment, management of poor bowel function and long-term management for these rare patients. The expert panel agreed that patients benefit from multidisciplinary and personalized care, preferably in an expert center. TYPE OF STUDY Clinical consensus statement. LEVEL OF EVIDENCE 3a.
Collapse
Affiliation(s)
- Anna Löf Granström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Willemijn Irvine
- Department of Evidence Based Medicine and Methodology, Qualicura Healthcare Support Agency, Breda, the Netherlands
| | - Anders Telle Hoel
- Department of Pediatric Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Merit Tabbers
- Emma Children's Hospital - Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Kristiina Kyrklund
- Section of Pediatric Surgery, New Children's Hospital, University of Helsinki, Finland
| | - Francesco Fascetti Leon
- University of Padua, Department of Women's and Children's Health, Padua, Italy; University Hospital, Unit of Pediatric Surgery, Division of Women's and Children's Health, Padua, Italy
| | - Fabio Fusaro
- Neonatal Surgery Unit, Bambino Gesù Children's Research Hospital, Rome, Italy
| | - Nikhil Thapar
- Stem Cell and Regenerative Medicine, Gos Institute of Child Health, University College London, London, UK; Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia; Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
| | - Anne Dariel
- Department of Pediatric Surgery, Assistance Publique Des Hôpitaux De Marseille, Hôpital Timone Enfants, Marseille, France
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus Mc - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marc Miserez
- Department of Abdominal Surgery, University Hospital Gasthuisberg, Ku Leuven, Belgium
| | - Annette Lemli
- Soma, The German Patient Support Organization for Anorectal Malformations and Hirschsprung Disease, Munich, Germany
| | - Sabine Alexander
- Soma, The German Patient Support Organization for Anorectal Malformations and Hirschsprung Disease, Munich, Germany
| | - Cecile Lambe
- Service De Gastro-Entérologie Et Nutrition Pédiatrique, Hôpital Necker-Enfants Malades, Université Paris Cité, Paris, France
| | - Célia Crétolle
- Pediatric Surgery Department, National Reference Center for Ano Rectal Malformations and Rare Pelvic Anomalies Marep, Assistance Publique-Hôpitaux De Paris, Université Paris Cité, Paris, France
| | - Niels Qvist
- Research Unit for Surgery, And Centre of Excellence in Gastrointestinal Diseases and Malformations in Infancy and Childhood (Gain), Odense University Hospital, Odense Denmark, University of Southern Denmark, Odense, Denmark
| | - Nagoud Schukfeh
- Hannover Medical School, Department of Pediatric Surgery, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Germany
| | - Duccio Cavalieri
- Department of Biology, University of Florence and Associazione Famiglie Pazienti Morbo Di Hirschprung (Amorhi), Italy
| | - Ernst van Heurn
- Department of Paediatric Surgery, Amsterdam University Medical Centres, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Rony Sfeir
- Department of Pediatric Surgery, Jeanne De Flandre Hospital, Lille, France
| | - Mikko P Pakarinen
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Section of Pediatric Surgery, New Children's Hospital, University of Helsinki, Finland
| | - Kristin Bjørnland
- Department of Pediatric Surgery, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tomas Wester
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
2
|
Alhellani H, Mottadelli G, Erculiani M, Casaccia G, Caraccia M, Grandi A, Felici E, Pini Prato A. Skipped Aganglionic Lengthening Transposition (SALT) is highly effective to achieve enteral autonomy in selected patients with intestinal failure secondary to total intestinal aganglionosis. Pediatr Surg Int 2024; 40:79. [PMID: 38492075 DOI: 10.1007/s00383-024-05661-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Intestinal Failure, parenteral nutrition (PN) dependence, and subsequent liver disease are the most challenging and life-threatening complications of short bowel syndrome experienced by patients with total intestinal aganglionosis. Skipped Aganglionic Lengthening Transposition (SALT) showed to be a promising procedure to overcome such problems. We herein report the results of two patients who underwent SALT at the Umberto Bosio Center for Digestive Diseases. PATIENTS AND METHODS Between November 2019 and July 2022, 2 patients with total intestinal aganglionosis underwent SALT as autologous intestinal lengthening procedure. Perioperative data and long-term outcomes are reported. Patient #1-A 18 month-old male (PN dependant) with 30 cm of ganglionated bowel at birth experienced a 35% increase of intestinal length after SALT (from 43 to 58 cm) thanks to three 5 cm interposed aganglionic loops. Postoperative course was uneventful and he was totally weaned by PN after 28 months postoperatively. He is without PN only receiving enteric feeding 53 months after the procedure. Patient #2-A 11 year-old female (PN dependant) with 100 cm of ganglionated jejunum underwent SALT at 11 years and experienced a 19% increase of bowel length thanks to four 5 to 7 cm interposed aganglionic loops. Postoperatively she required excision of two out of the four loops due to severe strictures and inadequate perfusion with a subsequent overall 10% increase of length after SALT. Of note, she improved significantly with a progressive reduction of PN that has been stopped after 18 months. CONCLUSION Skipped aganglionic lengthening transposition (SALT) seems to be very effective in improving nutrients absorption in patients with total intestinal aganglionosis by increasing absorptive bowel surface and decelerating intestinal flow for a longer and more effective contact of enteric material with ileal mucosa. Provided these impressive results are confirmed in the very long-term, SALT could become a valid alternative for the treatment of patients with total intestinal aganglionosis carrying at birth at least 20 to 30 cm of ganglionated jejunum.
Collapse
Affiliation(s)
- H Alhellani
- Umberto Bosio Center for Digestive Diseases, The Children Hospital, AOU SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - G Mottadelli
- Umberto Bosio Center for Digestive Diseases, The Children Hospital, AOU SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - M Erculiani
- Umberto Bosio Center for Digestive Diseases, The Children Hospital, AOU SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - G Casaccia
- Umberto Bosio Center for Digestive Diseases, The Children Hospital, AOU SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - M Caraccia
- Umberto Bosio Center for Digestive Diseases, The Children Hospital, AOU SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - A Grandi
- Umberto Bosio Center for Digestive Diseases, The Children Hospital, AOU SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - E Felici
- Umberto Bosio Center for Digestive Diseases, The Children Hospital, AOU SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - A Pini Prato
- Umberto Bosio Center for Digestive Diseases, The Children Hospital, AOU SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.
| |
Collapse
|
3
|
Pan W, Goldstein AM, Hotta R. Opportunities for novel diagnostic and cell-based therapies for Hirschsprung disease. J Pediatr Surg 2022; 57:61-68. [PMID: 34852916 PMCID: PMC9068833 DOI: 10.1016/j.jpedsurg.2021.10.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/17/2021] [Accepted: 10/28/2021] [Indexed: 12/26/2022]
Abstract
Despite significant progress in our understanding of the etiology and pathophysiology of Hirschsprung disease (HSCR), early and accurate diagnosis and operative management can be challenging. Moreover, long-term morbidity following surgery, including fecal incontinence, constipation, and Hirschsprung-associated enterocolitis (HAEC), remains problematic. Recent advances applying state-of-the art imaging for visualization of the enteric nervous system and utilizing neuronal stem cells to replace the missing enteric neurons and glial cells offer the possibility of a promising new future for patients with HSCR. In this review, we summarize recent research advances that may one day offer novel approaches for the diagnosis and management of this disease.
Collapse
Affiliation(s)
- Weikang Pan
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, 185 Cambridge St, CPZN 6-215, Boston, MA 02114, USA; Department of Pediatric Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Allan M Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, 185 Cambridge St, CPZN 6-215, Boston, MA 02114, USA
| | - Ryo Hotta
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, 185 Cambridge St, CPZN 6-215, Boston, MA 02114, USA.
| |
Collapse
|
4
|
Outcome of Total Colonic Aganglionosis Involving the Small Bowel Depends on Bowel Length, Liver Disease, and Enterocolitis. J Pediatr Gastroenterol Nutr 2022; 74:582-587. [PMID: 35175997 DOI: 10.1097/mpg.0000000000003415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Total colonic aganglionosis involving the small bowel is a rare form of Hirschsprung disease. We aim to analyse the long-term outcomes, digestive autonomy, and complications, to suggest recommendations for prevention and treatment. METHODS All patients born between 2000 and 2015 followed in our centre were retrospectively included. We analysed the length of aganglionosis, surgical procedures, growth, duration of parenteral nutrition (PN), enterocolitis, liver disease, intestinal transplantation. RESULTS Twenty-five patients were followed for a median of 10.9 years. Fifteen patients had less than 80 cm of ganglionic small bowel (SB) with a median of 20 cm. Ten patients had more than 80 cm of ganglionic sB with a median of 115 cm. The median PN duration was significantly shorter for patients with more than 80 cm: 0.9 versus 7.5 years in those with less than 80 cm (P < 0.001). No patient with less than 80 cm was weaned off PN, except 1 who underwent intestinal transplantation. Ten patients with less than 80 cm develop enterocolitis on the excluded segment, leading to emergency entero-colectomy in 5. Liver disease was more frequent in patients with less than 80 cm (11 vs 0). Three patients required combined liver-intestine transplantation; 2 underwent an isolated intestinal transplantation. CONCLUSIONS Digestive autonomy was possible in most patients with more than 80 cm of ganglionic SB. The more severe complication was enterocolitis. Liver disease compromised long-term survival without transplantation. Both complications should be prevented by early diversion and enterectomy of the whole aganglionic segment. Follow-up in or together with a multidisciplinary intestinal rehabilitation centre is suggested.
Collapse
|
5
|
Coletta R, Zulli A, O’Shea K, Mussi E, Bianchi A, Morabito A. Minimizing Enterostomy Complication in Neonates, Lessons Learnt from Three European Tertiary Centres. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9020162. [PMID: 35204883 PMCID: PMC8870697 DOI: 10.3390/children9020162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Stoma formation in neonates is often a life-saving procedure across a variety of conditions but is still associated with significant morbidity. Tube stoma technique was originally described for short bowel patients, but in selected cases of neonates this approach could prevent the incidence of stoma-related complications. The aim of the study was to evaluate the safety and utility of tube stomas as an alternative to conventional enterostomy in the neonatal population. MATERIAL AND METHODS A retrospective multicentre analysis of neonates undergoing emergency laparotomy and tube stoma formation between 2005 and 2017 was performed. Tube stoma complications were analysed. The investigation focused on stricture, skin lesion, enteric fistula and prolapse. RESULTS Thirty-seven neonates underwent tube stoma fashioning during the study period. Tube-stoma complications were limited to three patients (8.1%), with two children (5.4%) requiring additional stoma surgery during the first 30 days because of an enterocutaneous fistula, and one child (2.7%) for bowel stenosis. CONCLUSIONS In select neonates, such as those with proximal enteric stomas, the tube stoma avoids some of the commonly encountered complications (prolapse, skin excoriation). Further prospective studies are needed to validate these findings in order for us to recommend this technique as superior.
Collapse
Affiliation(s)
- Riccardo Coletta
- Department of Paediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (A.Z.); (A.M.)
- School of Environment and Life Science, University of Salford, Salford M5 4NT, UK
- Correspondence:
| | - Andrea Zulli
- Department of Paediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (A.Z.); (A.M.)
- Department of Neurofarba, University of Florence, Viale Pieraccini 6, 50121 Florence, Italy
| | - Kathryn O’Shea
- Department of Paediatric Surgery, Royal Manchester Children’s Hospital, Manchester M13 9WL, UK;
| | - Elisa Mussi
- Department of Industrial Engineering, University of Florence, 50139 Florence, Italy;
| | - Adrian Bianchi
- Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK;
| | - Antonino Morabito
- Department of Paediatric Surgery, Meyer Children’s Hospital, 50139 Florence, Italy; (A.Z.); (A.M.)
- Department of Neurofarba, University of Florence, Viale Pieraccini 6, 50121 Florence, Italy
| |
Collapse
|
6
|
Youn JK, Yang HB, Ko D, Park KW, Jung SE, Kim HY. Comparison of long-term outcome according to involved aganglionic segments of total colonic aganglionosis. Medicine (Baltimore) 2021; 100:e27432. [PMID: 34622856 PMCID: PMC8500650 DOI: 10.1097/md.0000000000027432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 09/15/2021] [Indexed: 01/05/2023] Open
Abstract
Total colonic aganglionosis (TCA) is a rare form of Hirschsprung disease, with more severe symptoms than rectosigmoid Hirschsprung disease. We aimed to evaluate the surgical outcomes according to the involved segments of TCA.Patients with aganglionosis extending from the anus to at least the ileocecal valve were included. The medical records of 33 TCA patients from 1981 to 2014 were reviewed. Three groups were analyzed based on the involved segment (jejunum, jejunoileal junction, and distal ileum).The median age at the pull-through operation was 6.2 (3.3-114) months. The median follow-up duration was 216 (21-411) months. Transition zone in the jejunum, jejunoileal junction, and distal ileum was identified in 3, 5, and 25 patients, respectively. The most common method of operation was Duhamel pull-through. Perianal excoriation and enterocolitis were the most common postoperative complications. The complication rates were 45% to 51% and not different among the groups. The defecation frequency normalized 3 years postoperatively, and body weight started to recover after 2 years irrespective of the involved segment.Therefore, close monitoring with proper management of defecation and body weight for at least 2 to 3 years postoperatively is required.
Collapse
Affiliation(s)
- Joong Kee Youn
- Department of Pediatric Surgery, Seoul National University Hospital, Seoul, Korea
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hee-Beom Yang
- Department of Surgery, Seoul National University Bundang Hospital, Gyeonggi, Korea
| | - Dayoung Ko
- Department of Pediatric Surgery, Seoul National University Hospital, Seoul, Korea
| | - Kwi-Won Park
- Department of Surgery, Chung-Ang University Hospital, Seoul, Korea
| | - Sung-Eun Jung
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, Seoul National University Hospital, Seoul, Korea
- Department of Pediatric Surgery, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
7
|
Yan JY, Peng CH, Pang WB, Chen YW, Ding CL, Chen YJ. Redo pull-through in total colonic aganglionosis due to residual aganglionosis: a single center's experience. Gastroenterol Rep (Oxf) 2021; 9:363-369. [PMID: 34567569 PMCID: PMC8460105 DOI: 10.1093/gastro/goaa064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/23/2020] [Accepted: 03/24/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Reoperation for total colonic aganglionosis (TCA) may be required for residual aganglionosis after an initial radical operation. We aimed to investigate the symptoms, management, and outcomes of patients who required a redo pull-through (Redo PT). METHODS Nine TCA patients underwent Redo PT at our center between 2007 and 2017. Their medical records were reviewed. Parental telephone interviews that included disease-specific clinical outcomes were conducted, and post-operative complications and long-term outcomes (including height-for-age/weight-for-age and bowel-function score) were compared to those of single-pull-through (Single PT) patients (n = 21). RESULTS All the nine Redo PT patients suffered obstruction within 1 month after the initial operation that could not be alleviated by conservative treatment. All abdominal X-ray/contrast barium enemas showed proximal bowel dilatation, indicating residual aganglionosis. The median ages at the initial operation and Redo PT were 200 and 509 days, respectively. Reoperation consisted of an intraoperative frozen biopsy and a modified laparotomic Soave procedure in all patients. Post-operative complications included perianal excoriation (n = 3), intestinal obstruction (n = 2), enterocolitis (n = 2), and rectovestibular fistula (n = 1). Seven Redo PT patients were followed up for a mean time of 7.1 ± 2.3 years; six (85.7%) had good growth and four (57.1%) had good bowel-function recovery. Post-operative complications and long-term outcomes were almost equal between the Redo PT and Single PT groups (all P > 0.05). CONCLUSION TCA patients with recurrent obstructive symptoms and dilated proximal bowel may have residual aganglionosis after an initial operation. Redo PT is effective and provides good long-term outcomes comparable to those of patients who benefited from Single PT.
Collapse
Affiliation(s)
- Jia-Yu Yan
- Department of General Surgery, Beijing Children's Hospital, National Center of Children's Health, Capital Medical University, Beijing, P. R. China
| | - Chun-Hui Peng
- Department of General Surgery, Beijing Children's Hospital, National Center of Children's Health, Capital Medical University, Beijing, P. R. China
| | - Wen-Bo Pang
- Department of General Surgery, Beijing Children's Hospital, National Center of Children's Health, Capital Medical University, Beijing, P. R. China
| | - Yong-Wei Chen
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center of Children's Health, Capital Medical University, Beijing, P. R. China
| | - Cai-Ling Ding
- Department of General Surgery, Beijing Children's Hospital, National Center of Children's Health, Capital Medical University, Beijing, P. R. China
| | - Ya-Jun Chen
- Department of General Surgery, Beijing Children's Hospital, National Center of Children's Health, Capital Medical University, Beijing, P. R. China
| |
Collapse
|
8
|
Lamoshi A, Ham PB, Chen Z, Wilding G, Vali K. Timing of the definitive procedure and ileostomy closure for total colonic aganglionosis HD: Systematic review. J Pediatr Surg 2020; 55:2366-2370. [PMID: 32106964 DOI: 10.1016/j.jpedsurg.2020.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/02/2020] [Accepted: 02/03/2020] [Indexed: 01/10/2023]
Abstract
AIM To establish the cogency of recommendations for the appropriate age for pull-through and ileostomy closure in Total Colonic Aganglionosis-Hirschsprung Disease's (TCA-HD). METHOD Medline, PubMed, Cochrane, and the ClinicalKey databases were searched without date restriction. The studies that reported TCA-HD cases were evaluated for the number of cases, age at the definitive procedure, age at the ileostomy closure, reported complications, and the type of procedure. Perianal excoriation and diaper rash rates were analyzed using SPSS software, with p < 0.05 considered significant. RESULTS Twenty-five studies mentioned TCA-HD findings between 1968 and 2019. The total number of patients who had definitive surgery was 218. Analysis showed no correlation between development of diaper rash and the age of the patient at the time of the definitive surgery or ileostomy closure. Studies scored between six and nine of nine possible stars on the NOS scoring system. CONCLUSION There is no correlation between age of surgery and postoperative diaper rash. Delaying the definitive procedure or ileostomy closure for TCA-HD has limited support on a review of current studies. The perianal excoriation/diaper rash is not reported in the literature at a high enough frequency to warrant keeping a diverting ileostomy until toilet trained of urine. TYPE OF STUDY Systematic review and meta-analysis. Levels of evidence IV.
Collapse
Affiliation(s)
- Abdulraouf Lamoshi
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY.
| | - P Benson Ham
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY
| | - Z Chen
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - G Wilding
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - Kaveh Vali
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY
| |
Collapse
|
9
|
New Insights Into the Indications for Intestinal Transplantation: Consensus in the Year 2019. Transplantation 2020; 104:937-946. [PMID: 31815899 DOI: 10.1097/tp.0000000000003065] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In 2001, a Statement was published that described indications for intestinal transplantation in patients with intestinal failure expected to require parenteral nutrition indefinitely. Since 2001, advances in the management of intestinal failure including transplantation and patient survival, both on extended parenteral nutrition and after transplantation, have improved, leading to a reduction in the number of intestinal transplants worldwide from a peak of 270 per year in 2008 to 149 per year in 2017. These changes suggest that the original 2001 Statement requires reassessment. All patients with permanent intestinal failure should be managed by dedicated multidisciplinary intestinal rehabilitation teams. Under care of these teams, patients should be considered for intestinal transplantation in the event of progressive intestinal failure-associated liver disease, progressive loss of central vein access, and repeated life-threatening central venous catheter-associated infections requiring critical care. Additional indications for transplantation include large desmoid tumors and other intra-abdominal tumors with reasonable expectation of posttransplant cure, extensive mesenteric vein thrombosis and intestinal infarction, total intestinal aganglionosis, and nonrecoverable congenital secretory diarrhea. Quality of life typically improves after successful intestinal transplantation and may support the decision to proceed with transplantation when other indications are present. However, the requirement for life-long immunosuppression and its associated side effects preclude intestinal transplantation if motivated only by an expectation of improved quality of life. Increasing experience with intestinal transplantation and critical appraisal of transplant outcomes including graft survival and patient quality of life together with potential advances in immunosuppression can be expected to influence transplant practices in the future.
Collapse
|
10
|
Stenström P, Kyrklund K, Bräutigam M, Engstrand Lilja H, Juul Stensrud K, Löf Granström A, Qvist N, Söndergaard Johansson L, Arnbjörnsson E, Borg H, Wester T, Björnland K, Pakarinen MP. Total colonic aganglionosis: multicentre study of surgical treatment and patient-reported outcomes up to adulthood. BJS Open 2020; 4:943-953. [PMID: 32658386 PMCID: PMC7528515 DOI: 10.1002/bjs5.50317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/26/2020] [Indexed: 12/29/2022] Open
Abstract
Background Surgery for total colonic aganglionosis (TCA) is designed to preserve continence and achieve satisfactory quality of life. This study evaluated a comprehensive group of clinical and social outcomes. Methods An international multicentre study from eight Nordic hospitals involving examination of case records and a patient‐reported questionnaire survey of all patients born with TCA between 1987 and 2006 was undertaken. Results Of a total of 116 patients, five (4·3 per cent) had died and 102 were traced. Over a median follow‐up of 12 (range 0·3–33) years, bowel continuity was established in 75 (73·5 per cent) at a median age of 11 (0·5–156) months. Mucosectomy with a short muscular cuff and straight ileoanal anastomosis (SIAA) (29 patients) or with a J pouch (JIAA) (26) were the most common reconstructions (55 of 72, 76 per cent). Major early postoperative complications requiring surgical intervention were observed in four (6 per cent) of the 72 patients. In 57 children aged over 4 years, long‐term functional bowel symptoms after reconstruction included difficulties in holding back defaecation in 22 (39 per cent), more than one faecal accident per week in nine (16 per cent), increased frequency of defaecation in 51 (89 per cent), and social restrictions due to bowel symptoms in 35 (61 per cent). Enterocolitis occurred in 35 (47 per cent) of 72 patients. Supplementary enteral and/or parenteral nutrition was required by 51 (55 per cent) of 93 patients at any time during follow‐up. Of 56 responders aged 2–20 years, true low BMI for age was found in 20 (36 per cent) and 13 (23 per cent) were short for age. Conclusion Reconstruction for TCA was associated with persistent bowel symptoms, and enterocolitis remained common. Multidisciplinary follow‐up, including continuity of care in adulthood, might improve care standards in patients with TCA.
Collapse
Affiliation(s)
- P Stenström
- Department of Paediatric Surgery, Children's Hospital in Lund, Skane University Hospital Lund, Lund, Sweden
| | - K Kyrklund
- Department of Paediatric Surgery, Paediatric Research Centre, Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - M Bräutigam
- Department of Paediatric Surgery, Queen Silvia's Children's Hospital, Sahlgrenska University Hospital Gothenburg, Gothenburg, Sweden
| | - H Engstrand Lilja
- Department of Paediatric Surgery, Uppsala University Children's Hospital, Uppsala, Sweden
| | - K Juul Stensrud
- Department of Paediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - A Löf Granström
- Division of Paediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Qvist
- Department of Paediatric Surgery, Odense University Hospital, Research Unit Surgery, University of Southern Denmark, Odense
| | | | - E Arnbjörnsson
- Department of Paediatric Surgery, Children's Hospital in Lund, Skane University Hospital Lund, Lund, Sweden
| | - H Borg
- Department of Paediatric Surgery, Queen Silvia's Children's Hospital, Sahlgrenska University Hospital Gothenburg, Gothenburg, Sweden
| | - T Wester
- Division of Paediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - K Björnland
- Department of Paediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - M P Pakarinen
- Department of Paediatric Surgery, Paediatric Research Centre, Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
11
|
Clinical Outcomes After Staged and Primary Laparotomy Soave Procedure for Total Colonic Aganglionosis: a Single-Center Experience from 2007 to 2017. J Gastrointest Surg 2020; 24:1673-1681. [PMID: 31325138 DOI: 10.1007/s11605-019-04319-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 07/01/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE To compare the clinical outcomes of the staged laparotomy Soave procedure (SLSP) and primary laparotomy Soave procedure (PLSP) for patients with total colonic aganglionosis (TCA), including some patients who underwent surgical treatment after the age of 1 year. METHODS A retrospective, comparative study of TCA patients who underwent SLSP or PLSP at Beijing Children Hospital from 2007 to 2017 was conducted. The primary outcomes were height-for-age (HFA), weight-for-age (WFA), and bowel function score (BFS); the major types of postoperative complications were also analyzed. RESULTS Thirty-five patients (SLSP = 14, PLSP = 21) were included. The patients in the SLSP group underwent an enterostomy at a median age of 47 (14, 104) days. The median age at the time of the Soave procedure showed no significant difference between the two groups ([181 (131,346) vs 55 (29, 343)] days, p = 0.072). No significant differences between groups were noted in terms of presenting symptoms, perioperative results, and postoperative outcomes. Twenty-three patients (SLSP = 8, PLSP = 15) were followed for more than 1 year. Both the SLSP and PLSP groups showed similar operative mortality ([1/14, 7.1%] vs [3/21, 14.3%], p = 0.635) and complication rates ([postoperative enterocolitis, (5/8, 62.5%) vs (5/15, 33.3%), p = 0.221] [perianal excoriation, (7/8, 87.5%) vs (10/15, 66.6%), p = 0.369]). Nineteen patients (19/23, 82.6%) had normal growth according to the median percentage of HFA or WFA. Mean BFS was 15.9 ± 3.3 in the 15 patients aged older than 4 years who were followed up. Six patients (SLSP = 1, PLSP = 5) who underwent surgical treatment aged older than 1 year were all alive with good outcomes. CONCLUSION PLSP and SLSP had equivalent clinical outcomes, but enterocolitis and perianal excoriation after the Soave procedure need to be managed carefully. PLSP is a feasible option for older TCA patients after conservative treatment.
Collapse
|
12
|
Sekioka A, Fukumoto K, Miyake H, Nakaya K, Nomura A, Yamada Y, Yamada S, Urushihara N. Unexpected gap between intraoperative caliber change of the intestine and normoganglia in patients with intestinal aganglionosis. Pediatr Surg Int 2019; 35:1115-1121. [PMID: 31392504 DOI: 10.1007/s00383-019-04534-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Intestinal aganglionosis (IA) is so rare that the entity remains unclear. The aim of the present study was to compare the outcomes of patients with IA and those with total colonic aganglionosis (TCA). METHODS The hospital records were retrospectively reviewed from 1977 to 2018. Outcomes were analyzed for the IA group and the TCA group, including clinical presentation, initial management, and operative details. RESULTS There were six patients were managed in IA (all male) and seven patients in TCA (4 male). The median age at the first operation was significantly younger in IA than TCA (2 days vs 24 days, p = 0.01). The gap between the intraoperative caliber change (CC) of the intestine and the initial stoma location was not significantly different (7.5 cm vs 12 cm, p = 0.61), but the rate of stoma dysfunction was significantly higher in IA (83% vs 0%, p = 0.005). The gap between the CC and the ganglionated bowel was significantly longer in IA (85 cm vs 10 cm, p = 0.003). CONCLUSION Patients with IA appear to have a high risk for stoma dysfunction after the first operation because of the unexpected gap between the CC and normoganglia. The initial location of the stoma requires careful consideration.
Collapse
Affiliation(s)
- Akinori Sekioka
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, Shizuoka, 420-8660, Japan.
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, Shizuoka, 420-8660, Japan
| | - Hiromu Miyake
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, Shizuoka, 420-8660, Japan
| | - Kengo Nakaya
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, Shizuoka, 420-8660, Japan
| | - Akiyoshi Nomura
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, Shizuoka, 420-8660, Japan
| | - Yutaka Yamada
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, Shizuoka, 420-8660, Japan
| | - Susumu Yamada
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, Shizuoka, 420-8660, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, Shizuoka, 420-8660, Japan
| |
Collapse
|
13
|
Autologous Intestinal Reconstructive Surgery in the Management of Total Intestinal Aganglionosis. J Pediatr Gastroenterol Nutr 2019; 68:635-641. [PMID: 30614951 DOI: 10.1097/mpg.0000000000002260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Total/near total intestinal aganglionosis (TIA/NTIA) is the most uncommon and life-threatening form of Hirschsprung disease (HD). The management of TIA/NTIA is challenging and the role of autologous intestinal reconstructive (AIR) surgery is controversial. The objective is to evaluate the effectiveness of AIR in patients with TIA/NTIA. METHODS Records from children affected by TIA and enrolled in the multicenter international Pediatric Intestinal Rehabilitation and Transplantation Registry were retrospectively reviewed. RESULTS Fourteen patients with TIA were identified. TIA diagnosis was confirmed histologically at the median age of 14 days of life. All received a proximal decompressive jejunostomy. Two patients died, 4 patients had satisfactory stoma output with enteral tolerance without additional procedures, 8 underwent 10 AIR procedures (4 Ziegler myotomy-myectomy, 3 transposition of aganglionic ileum with or without myotomy, 2 simple tapering, 1 longitudinal lengthening and tailoring procedure with associated myotomy). AIR significantly reduced median stoma output, from 197 to 31 mL · kg · day (P = 0.0001). The reduction was seen in all patients. In addition, AIR improved enteral tolerance in the long term in 5 of 8 patients (63%), and temporarily in 1, leading to a reduction of parenteral nutrition requirement from 100% to 70% (P = 0.0231). CONCLUSIONS AIR surgery in carefully selected patients may be useful and effective way to enhance residual bowel absorptive function and to reduce parenteral nutrition requirements. AIR and intestinal transplantation are complementary surgical tools in the complex treatment algorithm of TIA/NTIA.
Collapse
|
14
|
Abstract
PURPOSE Hirschsprung's disease-related short bowel syndrome (HDSBS) is characterized by aganglionosis that extends orally to 75 cm from Treitz's band. The condition is reported be associated with a high mortality rate of 50-80%. This retrospective study aimed to survey the current trends in HDSBS treatment in Japan. METHODS Patient data were extracted from the results of a nationwide survey we conducted, resulting in the retrospective collection of the data of 1087 HD patients from 2008 to 2012 in Japan. RESULTS A total of 11 (0.9%) cases of HDSBS were noted. All patients underwent jejunostomy as neonates. Radical procedures performed in five patients (A-colon patch method in four, Duhamel's procedure in one). Ziegler's myotomy-myectomy and serial transverse enteroplasty (STEP) were performed in each patient as palliative procedures. No radical operations were performed in 4 of the 11 cases. The mortality rate was 36.4%. Four patients died, 1 patient who underwent STEP and 3 patients who received no radical procedures. The causes of death were sepsis due to enterocolitis or central intravenous catheter infection, and hepatic failure. All patients who underwent radical procedures survived and showed satisfactory outcomes. CONCLUSION HDSBS still showed a high mortality rate, although surgical approaches such as the A-colon patch method resulted in satisfactory outcomes.
Collapse
|
15
|
Salimi Jazi F, Chandler JM, Thorson CM, Sinclair TJ, Hazard FK, Kerner JA, Dutta S, Dunn JCY, Chao SD. Delayed appearance of mature ganglia in an infant with an atypical presentation of total colonic and small bowel aganglionosis: a case report. BMC Pediatr 2019; 19:93. [PMID: 30953480 PMCID: PMC6449943 DOI: 10.1186/s12887-019-1456-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 03/13/2019] [Indexed: 12/14/2022] Open
Abstract
Background Total colonic and small bowel aganglionosis (TCSA) occurs in less than 1% of all Hirschsprung’s disease patients. Currently, the mainstay of treatment is surgery. However, in patients with TCSA, functional outcomes are often poor. A characteristic transition zone in TCSA can be difficult to identify which may complicate surgery and may often require multiple operations. Case presentation We present the case of a male infant who was diagnosed with biopsy-proven total colonic aganglionosis with extensive small bowel involvement as a neonate. The patient was diverted at one month of age based on leveling biopsies at 10 cm from the Ligament of Treitz. At 7 months of age, during stoma revision for a prolapsed stoma, intra-operative peristalsis was observed in nearly the entire length of the previously aganglionic bowel, and subsequent biopsies demonstrated the appearance of mature ganglion cells in a previously aganglionic segment. Conclusions TCSA remains a major challenge for pediatric surgeons. Our case introduces new controversy to our understanding of aganglionosis. Our observations warrant further research into the possibility of post-natal ganglion maturation and encourage surgeons to consider a more conservative surgical approach.
Collapse
Affiliation(s)
- Fereshteh Salimi Jazi
- Department of Surgery, University of Texas at Galveston, 301 University Blvd, Galveston, TX, 77555, USA
| | - Julia M Chandler
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building M116, MC: 5733, Stanford, CA, 94305, USA
| | - Chad M Thorson
- Division of Pediatric Surgery, Department of Surgery, University of Miami Health System, 1120 NW 14th Street, Suite 450, Miami, FL, 33136, USA
| | - Tiffany J Sinclair
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building M116, MC: 5733, Stanford, CA, 94305, USA
| | - Florette K Hazard
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive Rm H2110, Stanford, CA, 94305, USA
| | - John A Kerner
- Department of Pediatrics - Gastroenterology, Stanford University School of Medicine, 730 Welch Rd 2nd Fl, Palo Alto, CA, 94304, USA
| | | | - James C Y Dunn
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building M116, MC: 5733, Stanford, CA, 94305, USA
| | - Stephanie D Chao
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building M116, MC: 5733, Stanford, CA, 94305, USA.
| |
Collapse
|
16
|
The challenges of closing an ileostomy in patients with total intestinal aganglionosis after small bowel transplant. Pediatr Surg Int 2018; 34:113-116. [PMID: 29170900 DOI: 10.1007/s00383-017-4216-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2017] [Indexed: 10/18/2022]
Abstract
We present the case of a 14-year-old male with a history of small bowel transplantation for long segment Hirschsprung's disease who underwent Duhamel ileorectal pull-through procedure. In post-transplant, the patient had no restrictions and was not TPN-dependent. To improve his quality of life, he and his family were interested in closing the ileostomy and undergoing pull-through surgery. The complexity of the case includes the presence of an aganglionic rectal segment-a short root of the mesentery due to the small bowel transplant-and significant immunosuppression. At the moment, he is continent, doing well, and has not had any remarkable complications.
Collapse
|
17
|
Stenström P, Brautigam M, Borg H, Graneli C, Lilja HE, Wester T. Patient-reported Swedish nationwide outcomes of children and adolescents with total colonic aganglionosis. J Pediatr Surg 2017; 52:1302-1307. [PMID: 27912975 DOI: 10.1016/j.jpedsurg.2016.11.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/10/2016] [Accepted: 11/10/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the nationwide outcome of children with total colonic aganglionosis (TCA) during the last 20years. METHODS This was an observational, cross-sectional study where all patients with TCA, including aganglionosis of 0-50cm of ileum, born in Sweden 1995-2014 were included. Data were collected from the medical records. Patients >4years old without stoma answered a questionnaire regarding bowel function (bowel function score, BFS, score 1-20), medical treatment and nutrition. RESULTS Twenty-seven children were included. Twenty-five children were reconstructed at median age of 56 (4-236) weeks. Reconstruction procedures included Swenson (6), Soave (5), mucosectomy with short muscular cuff with or without J-pouch (9), Duhamel (3) and Rehbein (2). There was no mortality. The median follow-up time was 9.5years (8months-20years). At follow-up 7 (26%) patients had an ileostomy, 4 with a syndrome. Eight patients required parenteral support, until a median age of 11 (2-24) months. Oral energy support was used by 5/27 (15%), still 5/22 (23%) were underweighted. Obstructive symptoms were reported by 7/20 (31%). All 17 patients >4years old completed the BFS questionnaire at median age of 10 (4-20) years. Median stool frequency/24h was 5 (1-30). Fecal accidents at least once per week was reported by 4 (24%), and social problems by 8 (47%). The median BFS was 15 (11-19) without any gender differences. CONCLUSION One-third of patients with TCA report obstructive symptoms, one-third need additional nutrition and one-fifth require a permanent stoma. TCA have a negative impact on social life. Subsequently, children with TCA need a careful lifelong follow-up of specialized teams.
Collapse
Affiliation(s)
- Pernilla Stenström
- Lund University, Department of Pediatric Surgery, Skane University Hospital Lund, 22185 Lund, Sweden.
| | - Matilda Brautigam
- The Queen Silvia Children's Hospital, The Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
| | - Helena Borg
- The Queen Silvia Children's Hospital, The Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
| | - Christina Graneli
- Lund University, Department of Pediatric Surgery, Skane University Hospital Lund, 22185 Lund, Sweden
| | - Helene Engstrand Lilja
- Unit of Pediatric Surgery, Department of Women's and Children's Health, University Children's Hospital, Uppsala, Sweden
| | - Tomas Wester
- Unit of Pediatric Surgery, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
18
|
Nakamura H, Henderson D, Puri P. A meta-analysis of clinical outcome of intestinal transplantation in patients with total intestinal aganglionosis. Pediatr Surg Int 2017; 33:837-841. [PMID: 28600659 DOI: 10.1007/s00383-017-4107-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 12/26/2022]
Abstract
AIM OF THE STUDY Total intestinal aganglionosis (TIA) occurs in less than 1% of patients with Hirschsprung disease (HD), and TIA is the most severe form of HD. Survival has improved with the advent of parenteral nutrition and intestinal transplantation (ITx). The field of ITx has rapidly progressed in the last two decades and has now become an established treatment for patients with intestinal failure. The purpose of this meta-analysis was to determine the clinical outcome of ITx in patients with TIA. METHODS A systematic literature search for relevant articles was performed in four databases using the combinations of the following terms: "total intestinal aganglionosis", "intestinal transplantation", and "Hirschsprung disease/Hirschsprung's disease" for studies published between 2003 and 2016. The relevant cohorts of ITx in patients with TIA were systematically searched for clinical outcomes. MAIN RESULTS Thirteen studies met defined inclusion criteria, reporting a total of 63 patients who underwent ITx for TIA. Majority of patients were males (71.0%), and median age of ITx was 4.3 (range 0.25-17.6) years. Isolated ITx was performed in 37% patients and multivisceral ITx in 63%. Mean follow-up period was 40 months (range 1-154). Overall survival rate was 66%; the longest survivor was 12.8-year-old after ITx. CONCLUSION ITx appears promising in the management of TIA. ITx can be considered a feasible treatment option for patients with TIA who suffer from life-threatening complications of intestinal failure.
Collapse
Affiliation(s)
- Hiroki Nakamura
- National Children's Research Centre, Our Lady's Children's Hospital, Dublin, Ireland.
| | - Davina Henderson
- Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Ireland
| | - Prem Puri
- National Children's Research Centre, Our Lady's Children's Hospital, Dublin, Ireland
- School of Medicine and Medical Science, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
| |
Collapse
|
19
|
Taguchi T, Obata S, Ieiri S. Current status of Hirschsprung's disease: based on a nationwide survey of Japan. Pediatr Surg Int 2017; 33:497-504. [PMID: 28058486 DOI: 10.1007/s00383-016-4054-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2016] [Indexed: 01/07/2023]
Abstract
PURPOSE The diagnosis and surgical treatments of Hirschsprung's disease (HD) have undergone various changes in the last few decades because of establishment of laparoscopic procedures. A retrospective nationwide survey for 4 decades was performed to study the changing profile of HD in Japan. METHODS The patient data were collected in 4 phases: Group 1, between 1978 and 1982; Group 2, between 1988 and 1992; Group 3, between 1998 and 2002; and Group 4, between 2008 and 2012. RESULTS The incidence and the male/female ratio remained almost the same over time (1/4, 895 in newborns and 2.9:1 in Group 4). The patients with a family history increased to 7.1% in Group 4, in comparison to 2.8-6.0% in other groups. Regarding the extent of aganglionosis, sigmoid colon increased to 63.1% in Group 4, compared to 51.9% in Group 3. Manometry was performed less frequently in Group 4 (45.8%) than in Group 3 (66.1%). Transanal endorectal pull-through (TAEPT) was the most popular operation in Group 4 (49.6%). In addition, laparoscopy-assisted operations increased to 46.9% in Group 4, in comparison to 29.7% in Group 3. The incidence of preoperative enterocolitis and the mortality rate in Group 4 were 17.2% and 2.4%, respectively, and were markedly decreased in comparison to Group 1 (29.2% and 6.5%, respectively). The mortality rate decreased over time to 2.4% in Group 4. Over the last decade, there has been remarkable improvement in the mortality rate associated with the small intestine (aganglionosis extending orally to more than 30 cm of the terminal ileum). The rates were 25.5% in Group 4, 53.6% in Group 1, 33.3% in Group 2, and 35.5% in Group 3. In addition, the mortality rates of the remaining aganglionosis subgroups also improved. CONCLUSION Primary operations without laparotomy, including TAEPT and laparoscopy-assisted operations, have become the first choice for the definitive surgical treatment of HD in Japan. The mortality rate has decreased over time. However, the mortality rate of small intestinal aganglionosis is still relatively high. The development of new treatment strategy for small intestinal aganglionosis is called for.
Collapse
Affiliation(s)
- Tomoaki Taguchi
- The Japanese Study Group for Hirschsprung's Disease, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Fukuoka, 812-8582, Japan.
| | - Satoshi Obata
- The Japanese Study Group for Hirschsprung's Disease, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Satoshi Ieiri
- The Japanese Study Group for Hirschsprung's Disease, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Department of Pediatric Surgery, Field of Developmental Medicine, Kagoshima University, Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| |
Collapse
|
20
|
Li Q, Li L, Jiang Q, Zhang Z, Xiao P. The mid-term outcomes of TRM-PIAS, proctocolectomy and ileoanal anastomosis for total colonic aganglionosis. Pediatr Surg Int 2016; 32:477-82. [PMID: 26833313 DOI: 10.1007/s00383-016-3870-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 11/29/2022]
Abstract
AIMS The present study aimed to evaluate the mid-term outcomes of total colonic aganglionosis (TCA) after transanal rectal mucosectomy and partial internal anal sphincterectomy (TRM-PIAS), proctocolectomy and ileoanal anastomosis. PATIENTS AND METHODS From 2012 to 2014, 12 patients (7 boys; 58.3 %) diagnosed with TCA and treated with the TRM-PIAS, proctocolectomy and ileoanal anastomosis. Seven TCA patients who underwent laparotomy-assisted endorectal pull-through (LEPT) between 2010 and 2012 were used as control group. Demographic features and complication of the two groups were evaluated. The functional outcomes were assessed by using a score system. RESULTS The procedure was successfully performed in all patients. The incidence of postoperative HAEC in the TRM-PIAS group was significantly lower (25.0 vs 85.7 %; p < 0.05) than control group within the second postoperative year. The number of bowel movement after 3, 12 and 24 months postoperatively, was 8.5 ± 3.5, 5.3 ± 2.9 and 3.1 ± 1.4 (p < 0.05) per day, respectively, in the TRM-PIAS group. The soiling was noted in 50.0 % (n = 6) of the patients in the 6th postoperative month, and 25.0 % (n = 3) in the 24th postoperative month in the TRM-PIAS group. There was no significant difference in overall functional outcome between two groups, but the TRM-PIAS group was better in terms of bowel movement and soiling. CONCLUSION TRM-PIAS, proctocolectomy and ileoanal anastomosis might be an effective treatment for TCA. More prospective studies evaluating the TRM-PIAS technique over longer period and with greater sample size are needed to confirm the findings in this study.
Collapse
Affiliation(s)
- Qi Li
- Department of General Surgery, Capital Institute of Pediatrics, No. 2 Yabao Rd, 100020, Beijing, China.
| | - Long Li
- Department of General Surgery, Capital Institute of Pediatrics, No. 2 Yabao Rd, 100020, Beijing, China
| | - Qian Jiang
- Department of Medical Genetics, Capital Institute of Pediatrics, No. 2 Yabao Rd, 100020, Beijing, China
| | - Zhen Zhang
- Department of General Surgery, Capital Institute of Pediatrics, No. 2 Yabao Rd, 100020, Beijing, China
| | - Ping Xiao
- Department of Pathology, Capital Institute of Pediatrics, No. 2 Yabao Rd, 100020, Beijing, China
| |
Collapse
|