Transanal endorectal pull-through for Hirschsprung's disease: experience with 68 patients

Minimally invasive surgery in older children with Hirschsprung's disease in a North African Country

Introduction

Hirschsprung's disease (HSD) is a bowel congenital anomaly affecting mainly the enteric nervous system of the rectosigmoid region. Surgical resection of the aganglionic segment and restoration of bowel continuity via coloanal anastomosis is the main stay of treatment. In 1999, Georgeson et al. introduced a new minimally invasive approach as a standard for the pull-through mechanism. This study aims to evaluate the safety and possibility of the use of a laparoscope in older children with HSD with various techniques for HSD surgery.

Methods

This study was performed based on 20 patients diagnosed with HSD. The patients are older children, whose mean age is 3 years. The cases showing enterocolitis or obstruction were excluded from the study. We divided these cases into two groups: Group A, consisting of 10 cases where laparoscopic-aided transanal pull-through was done, and group B, in which the laparoscopic Duhamel procedure was done.

Results

We compared between two groups for the first year follow-up period. In Group A, there were two cases of stenosis that respond to regular dilation: one case of enterocolitis and one case of fecal incontinence. In Group B, we had two cases of constipation and three cases of enterocolitis. There was no anastomotic leak in both groups.

Conclusion

Minimally invasive surgery is safe in management of HSD in older children in one stage, either by using the Duhamel or transanal Swenson procedure.

Laparoscopic-assisted duhamel for hirschsprung's children older than 3 years

CONTEXT

Hirschsprung's disease (HD) is a congenital anomaly affecting the enteric nervous system commonly the rectosigmoid region. Treatment is surgical where the aganglionic segment is resected, and bowel continuity is achieved by a colo-anal anastomosis. In 1999, Georgeson et al. proposed a new technique of primary laparoscopic-assisted pull through for HD as a new gold standard.

AIM OF THE STUDY

To evaluate the outcome of the laparoscopic Duhamel procedure for the management of HD in children older than 3 years.

METHODS

This study was performed on 8 patients who were more than 3-year-old, with confirmed diagnoses of HD. Patients who initially presented with enterocolitis or obstruction were excluded from this study. In all cases, laparoscopic-assisted Duhamel was done.

RESULTS

We reported our results for the 1^st year follow-up period and divided our results into early outcome for the first 3 months postoperative during which we had 2 cases complaining of enterocolitis that responded to conservative treatment, we observed 2 cases of perianal excoriation that responded to medical treatment while the late outcome was reported after 3 months postoperative: We had two cases with attacks of enterocolitis at 6 months and 9 months postoperatively that needed conservative treatment in the hospital in the form of parenteral antibiotics, rectal irrigation, intravenous fluids and NP0. There was neither anastomotic leak nor stenosis.

CONCLUSION

Laparoscopic Duhamel for the management of HD in children older than 3 years is safe and useful procedure.

Robotic Soave pull-through procedure for Hirschsprung's disease in children under 12-months: long-term outcomes

PURPOSE

To describe the long-term outcomes of the robotic Soave pull-through (RSPT) procedure for Hirschsprung's disease (HSCR) in children younger than 12 months.

METHODS

A prospective observational study was conducted on HSCR patients under 12 months of age who underwent RSPT at our institution between 2011 and 2020. Data regarding demographics, clinical features, technical details, operative time, hospital stay, postoperative complications, and long-term outcomes were prospectively collected.

RESULTS

A total of 15 patients (9 male; 6 female) were included, with a median age at surgery of 4 months (interquartile range 3-6), and a mean weight of 6.8 ± 1.3 kg. Twelve patients suffered from rectosigmoid aganglionosis and three from long HSCR (extending up to the hepatic flexure). The mean total operative time was 240 ± 72 min. The median hospital stay was 3 days (interquartile range 3-4). Partial anastomosis dehiscence was observed in one patient, requiring reoperation on the 4th postoperative day. With a median follow-up of 79 months (interquartile range 45-115), no fecal incontinence or mild soiling were observed. Constipation occurred in two patients and mild enterocolitis in one case.

CONCLUSION

RSPT procedure for Hirschsprung's disease in children younger than 12 months is a safe and effective procedure, with few complications and satisfactory long-term continence outcomes.

The follow-up of the robotic-assisted Soave procedure for Hirschsprung's disease in children

Robotic surgery offers three-dimensional visualization and precision of movement that could be of great value to gastrointestinal surgeons. There were many previous reports on robotic technology in performing Soave colonic resection and pull-through for Hirschsprung’s disease in children. This study described the follow-up of the Robotic-assisted Soave procedure for Hirschsprung’s disease in children. Robotic-assisted endorectal pull-through was performed using three robotic arms and an additional 5-mm trocar. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies. The rest of the procedure was carried out according to the Soave procedure. We left a short rectal seromuscular sleeve of 1.5–2 cm above the dentate line. From December 2014 to December 2017, 55 pediatric patients were operated on. Age ranged from 6 months to 10 years old (median = 24.5 months). The aganglionic segment was located in the rectum (n = 38), the sigmoid colon (n = 13), and the left colon (n = 4). The mean total operative time was 93.2 ± 35 min (ranging from 80 to 180 min). Minimal blood was lost during the surgery. During the follow-up period, 41 patients (74.6%) had 1–2 defecations per day, 12 patients (21.8%) had 3–4 defecations per day, and 2 patients (3.6%) had more than 4 defecations per day. Fecal incontinence, enterocolitis, and mild soiling occurred in three (5.4%), four (7.3%), and two pediatric patients, respectively. Robotic-assisted Soave procedure for Hirschsprung’s disease in children is a safe and effective technique. However, a skilled robotic surgical team and procedural modifications are needed.

Evaluation of Bowel Function, Urinary Tract Function, and Quality of Life after Transanal Endorectal Pull-Through Surgery for Hirschsprung's Disease

INTRODUCTION

 The objective of this study is to determine short-term complications and evaluate long-term bowel function, lower urinary tract symptoms, and quality of life (QoL) in patients treated for Hirschsprung's disease (HSCR) with transanal endorectal pull-though (TERPT) compared with healthy controls.

MATERIALS AND METHODS

 This cross-sectional case-control study included 30 HSCR patients treated with TERPT in 2006 to 2014 at Karolinska University Hospital, and 30 healthy controls matched for age and gender. Data on short-term complications were compiled from medical records and classified according to Clavien-Dindo. Bowel function and QoL were evaluated with the validated questionnaires bowel function score and KIDSCREEN-52. Lower urinary tract symptoms were evaluated through an 8-item lower urinary tract symptoms (LUTS) questionnaire.

RESULTS

 Six (20%) patients had a short-term postoperative complication according to Clavien-Dindo, with insufficient pain management being the most common complication. The median age at follow-up was 7 years (range = 4-11). Median bowel function score was significantly lower in HSCR patients than in controls, 14 versus 19 (p < 0.001). Twenty-one of the HSCR patients reported impaired bowel function compared with two of the controls (p < 0.001). The overall prevalence of LUTS was 11 (38%) in the HSCR patients compared with seven (23%) in the controls (p = 0.751). HSCR patients reported a slightly lower QoL in the KIDSCREEN domain "financial resources" compared with controls (p = 0.008).

CONCLUSION

 According to Clavien-Dindo, short-term postoperative complications occurred in 20% of the patients. Impaired bowel function persists throughout childhood for most HSCR patients. The prevalence of LUTS and QoL is not affected in HSCR patients compared with controls.

Transumbilical enterostomy for Hirschsprung's disease with a two-stage laparoscopy-assisted pull-through procedure

BACKGROUND

A one-stage laparoscopic operation has recently been considered a favorable option for the management of patients with Hirschsprung's disease (HD) due to its superior cosmetic results. One-stage transanal endorectal pull-through for the treatment of rectosigmoid HD has been widely used in newborns without complications. However, enterostomy is required in some HD cases for enterocolitis and dilated colon. Our transumbilical enterostomy (TUE) and two-stage laparoscopy-assisted anorectoplasty were effective and achieved a similar cosmetic effect to one-stage laparoscopy on the abdominal wall in patients with anorectal malformation, but the effect in patients with HD is unclear.

AIM

To evaluate the safety, efficacy and cosmetic results of TUE in two-stage laparoscopy-assisted pull-through for HD.

METHODS

From June 2013 to June 2018, 53 patients (40 boys, 13 girls; mean age at enterostomy: 5.5 ± 2.2 mo) who underwent enterostomy and two-stage laparoscopy-assisted pull-through for HD with stoma closure were reviewed at our institution. Two enterostomy approaches were used: TUE in 24 patients, and conventional abdominal enterostomy (CAE) in 29 patients. Eleven patients with rectosigmoid HD had severe preoperative enterocolitis or a dilated colon. 26 patients had long-segment HD, and 16 patients had total colonic aganglionosis (TCA). The patients with left-sided HD underwent the two-stage laparoscopic Soave procedure, and the patients with right-sided HD and TCA underwent the laparoscopic Duhamel procedure. Demographics, enterostomy operative time, complications and cosmetic results were respectively evaluated.

RESULTS

There were no differences between the groups with respect to gender, age at enterostomy, weight and clinical type (P > 0.05). No conversion to open technique was required. Two patients experienced episodes of stomal mucosal prolapse in the TUE group and 1 patient in the CAE group (8.33% vs 3.45%, P > 0.05). No parastomal hernia was observed in either of the two groups. Wound infection at the stoma was seen in 1 case in the TUE group, and 2 cases in the CAE group (4.17% vs 6.90%, P > 0.05). No obstruction was noted in any of the patients in the TUE group, whereas obstruction was found in 1 patient in the CAE group. Enterocolitis was observed in 3 and 5 patients in the TUE and CAE group, respectively (12.50% vs 17.24%, P > 0.05). There was no significant difference between the TUE group and CAE group in terms of the incidence of soiling and constipation (P > 0.05). The cosmetic result using the scar score in the TUE group was better than that in the CAE group (6.83 ± 0.96 vs 13.32 ± 1.57, P < 0.05).

CONCLUSION

TUE is a safe and feasible method for the treatment of HD, and the staged enterostomy and two-stage laparoscopy-assisted pull-through achieved a similar cosmetic effect to the one-stage laparoscopic procedure.

Hirschsprung's disease in the laparoscopic transanal pull-through era: implications of age at surgery and technical aspects

AIM

Detailed implications of age at laparoscopic transanal pull-through (LTAPT) on postoperative bowel function (POBF) in Hirschsprung's disease (HD) are somewhat obscure because of a spectrum of factors.

METHODS

Age at surgery was used to categorize 106 consecutive postoperative HD cases treated by our modified LTAPT (JLTPAT) between 1997 and 2015; group A: < 3 months old (n = 31); group B: 3-11 months old (n = 44); group C: 1-3 years old (n = 19); and group D: ≥ 4 years old (n = 12). POBF was assessed by reviewing outpatient records 1, 3, 5, 7, and 10 years after JLTAPT prospectively and scoring each of 5 criteria on a scale of 0-2; best score = 10.

RESULTS

Only operative time was statistically longer in group D versus groups A, B, and C. Differences in gender ratios, blood loss, duration of follow-up, and POBF scores were not statistically significant. Mean POBF scores over time were: group A: 6.8, 7.6, 8.4, 8.6, and 8.4; group B: 7.1, 7.8, 8.3, 8.5, and 9.0; group C: 6.9, 7.9, 8.1, 8.3, and 8.6; group D: 7.0, 7.4, 8.2, 8.1, and 8.5, respectively.

CONCLUSION

Age at JLTAPT was not correlated with POBF in HD.

Redo pull-through surgery in Hirschsprung disease: Short-term clinical outcome

INTRODUCTION

Although surgery is effective in most patients with Hirschsprung disease (HD), some have persistent obstructive symptoms. Additional medical treatment is generally sufficient, but a small fraction of these patients needs secondary surgery. Series on redo surgery are scarce. Aim of this study is to evaluate complications and clinical outcome of patients in need of redo surgery for HD.

MATERIALS AND METHODS

Sixteen patients underwent redo endorectal pull-through surgery in our center between 2007 and 2015. Medical records were reviewed and demographics, indication for redo surgery, surgical procedures, complications, and clinical outcome were scored.

RESULTS

The median age at the time of redo was 4.6years (range: 2months-21years). Median follow-up after redo was 3years (range: 9months-7years). Before redo surgery, all patients (100%) had obstructive symptoms, one patient had recurrent enterocolitis, and four patients were fecally incontinent despite adequate attempts of bowel management. Surgical procedure consisted of a transanal endorectal pull-through (TERPT) in all patients, with additional laparotomy in 7 (44%) and protective stoma in 8 patients (50%). Complications within 30days after redo surgery were anastomotic dehiscence (3; 19%), wound abscess (2; 13%), rectovaginal fistula (1; 7%) or enterocutaneous fistula (1; 7%). During follow-up, nine patients needed additional surgery, mainly to close the stoma. At final follow-up there were no patients with stenosis, obstructive symptoms, remaining rectovaginal fistula, or small bowel obstruction. Only one patient experienced enterocolitis. Six patients (43%) reported soiling or fecal incontinence.

CONCLUSION

TERPT for redo surgery for HD is effective in resolving sustained severe obstructive symptoms after primary surgery, but the outcome is complicated by a relatively high rate of soiling and fecal incontinence.

Laparoscopic-assisted transanal pull-through (LATP) versus complete transanal pull-through (CTP) in the surgical management of Hirschsprung's disease

BACKGROUND

It is unclear whether laparoscopic-assisted transanal pull-through (LATP) or complete transanal pull-through (CTP) is superior for the surgical management of Hirschsprung's disease. We compared outcomes between approaches.

METHODS

We retrospectively reviewed patients with Hirschsprung's disease who underwent LATP or CTP at our centre between 1995 and 2014. Patients were matched based on age, birth weight, and level of aganglionosis. A systematic literature review and meta-analysis were also performed.

RESULTS

From our data, LATP (n=24) took significantly longer than CTP (n=12; 3.9±1.1 vs. 2.6±0.6h, p=0.001). There was no difference in length of stay or incidence of postoperative complications. A literature search identified 17 published studies, of which 2 were comparative. Our pooled analysis of comparative studies including our results showed that operative time was significantly longer for the LATP group (OR 1.59, 95% CI 1.21-1.96, p<0.001). There was no significant difference in major complications (OR 1.75, 95% CI 0.76-4.04, p=0.19) or length of stay (OR 0.33, 95% CI -0.41 to 1.08, p=0.38).

CONCLUSION

Clinical outcomes are comparable between LATP and CTP. CTP offers shorter operative time without the need for laparoscopic instruments.

A 15-Year Experience with the One-Stage Surgery for Treatment of Hirschsprung's Disease in Newborns, Infants, and Young Children

The treatment of Hirschsprung's disease has changed over the past several years. Significant modifications occurred after the implementation of surgery without laparotomy, using transanal access. The type of this surgery depends on the condition and the age of a child. The aim of the study was to summarize our 15-year experience with one-stage surgery for the treatment of Hirschsprung's disease in the wider context of current clinical practice and to identify transanal endorectal pull-through-related factors influencing the surgery and hospitalization. The retrospective analysis of newborns, infants, and young children was performed between 2000 and 2014. Four girls and 29 boys were operated on. The parameters describing the surgery and the hospitalization were analyzed. The number of patients treated using transanal endorectal pull-through technique was 30, and Duhamel-Martin, 3. There were significant correlations (p < 0.05) between necessity of blood transfusion, length of resected intestine, operative time, the number of intraoperative histopathological assessments, and length of hospitalization. The time of one-step surgery is extended because of waiting for repeated intraoperative histopathological assessment of the level of resection. More extended bowel resection is connected with longer length of hospitalization and, more often, necessity of blood transfusion.

Late diagnosis of Hirschsprung disease--patient characteristics and results

PURPOSE

The aim of the present study was to describe the characteristics and the postoperative results of children diagnosed as having Hirschsprung disease (HD) after the age of 3 years.

METHODS

All patients with HD diagnosed after the age of 3 years in our hospital from 1998 to 2011 were included. Patient characteristics and postoperative results were prospectively registered.

RESULTS

Eleven children were included. Age at diagnosis was 3.0 to 9.6 years. Ten patients had rectosigmoid disease, whereas 1 had total colonic aganglionosis. Three children were given a diverting ileostomy before the pull-through procedure, and all 3 had ileostomy-related complications. Early postoperative complications were seen in 5 children, of whom 2 had anastomotic leakage. At final follow-up, with a median of 3 years postoperatively, 7 had normal bowel function, 1 had frequent loose stools, and 3 were soiling.

CONCLUSIONS

Early postoperative complications, especially anastomotic leakage, occurred frequently in children with late-diagnosed HD. Therefore, a diverting stoma should be considered in these patients. The long-term functional results were comparable with those seen in children operated on as neonates.

10 years of experience with laparoscopic-assisted endorectal Soave pull-through procedure for Hirschsprung's disease in China

OBJECTIVE

To report early and late results of laparoscopic-assisted endorectal Soave pull-through (LAEPT) with a short and V-shaped partial resection muscular cuff for Hirschsprung's disease (HD) over a 10-year period.

METHODS

The clinical courses of 218 patients who underwent modified LAEPT for HD were reviewed. LAEPT was described by the Georgeson technique. The main modifications included less dissection of the bottom of the pelvis, rectal mucosa dissection with a long cuff, coloanal anastomosis with a short cuff, and a V-shaped partial resection in the posterior wall of the muscular cuff.

RESULTS

From September 1999 to July 2009, 218 patients were operated on by the same surgeon. Ages ranged from 15 days to 12 years old. The aganglionic segment was located in the rectum or sigmoid colon in 176 patients, in the left colon in 38 children, and in the transverse colon in 4 patients. The median operating time was 176 minutes. Conversion to open surgery was required in 2 patients. Bleeding of the left iliac vein occurred in 1 patient, and a 180° twist of the neorectum occurred in 2 cases. Median first bowel movement time was 23 hours, and median postoperative hospital stay was 10.4 days. Median daily defecation frequency was 4.6 within 2 weeks and 2.3 at 3 months postoperatively. The immediate postoperative complications included intestine herniation from the trocar site in 2 patients, perianal excoriation in 32 patients, and anastomotic leakage in 3 patients. Follow-up ranging from 6 to 120 months was obtained for 182 patients. Late postoperative complications included postoperative adhesive bowel obstruction (1.1%), enterocolitis (7.7%), anasomostic stenosis (2.2%), constipation (1.6%), and soiling (3.6%). Eighty-seven percent had excellent and good bowel function.

CONCLUSION

LAEPT with a short muscular cuff with a V-shaped partial resection in the posterior wall is a safe and effective procedure for HD.

Outcome comparison among laparoscopic Duhamel, laparotomic Duhamel, and transanal endorectal pull-through: a single-center, 18-year experience

PURPOSE

Transanal endorectal pull-through has changed the treatment of Hirschsprung's disease (HD) in the past decade. The aim of the study was to compare outcomes, obtained in a single center, with laparotomic Duhamel (LTD), laparoscopic Duhamel (LSD), and laparoscopic-assisted transanal endorectal pull-through (LTEPT).

MATERIALS AND METHODS

We retrospectively reviewed the charts of all patients operated on for HD since 1992. Preoperative, operative, and postoperative data were collected to compare short- and long-term outcomes among the three groups.

RESULTS

From 1992 to 2010, 70 children were treated for HD. Patients were divided into three groups based on the surgical technique used: 14 LTEPT, 32 LSD, and 24 LTD. Mean ages at surgery were 4.67, 14.61, and 13.28 months, respectively. Patients in the LTEPT group had significant shorter operating times (195 versus 257 versus 291 minutes, P=.03), earlier start of feeding (1.2 versus 3.1 versus 4.7 days, P<.01), and shorter length of hospital stay (4.4 versus 6.8 versus 9.7 days, P<.011). Overall complications rate was lower in the LTEPT (14%) than in the LSD (31.2%) and LTD (29.7%) groups. Postoperative enterocolitis incidence was 3%-4% in the Duhamel groups and none in LTEPT. Long-term outcome showed less constipation and better continence for age in the LTEPT group at the 1-year follow-up (P=.033).

CONCLUSIONS

This study further supports technical advantages, lighter impact of the surgical procedure on infants, lower incidence of complications, and better long-term outcome of the transanal pull-through compared to the Duhamel approaches.

Is the Rehbein procedure obsolete in the treatment of Hirschsprung’s disease?

PURPOSE

After 25 years of practice and positive results of the Rehbein-procedure (RB) for children with Hirschsprung Disease (HD), we changed to the less invasive transanal endorectal pull through (TERPT). The aim of this study was to compare short- and mid-term complications of these two procedures in our patients with HD.

METHODS

Retrospective data of 50 HD patients were analyzed. Of these patients, 25 underwent RB (2000-2006) and in 25 the TERPT was performed (2005-2009). Medical records were reviewed to score complications and outcomes. Differences were analyzed using Chi-Square and Mann-Whitney U tests.

RESULTS

All RB patients (100%) were given a colostomy compared with four patients (16%) in the TERPT group (p < 0.001). The average age at surgery in the RB group was 191 days whereas this was 72 days in the TERPT group (p < 0.01). The mean length of time of surgery in the RB group (158 min) was not significantly different from that in the TERPT group (183 min). Ganglion cells were located in all specimens at the proximal end of the specimens. The median time to first feeding significantly decreased from 2 days (range 1-11) in the RB group to 1 day (range 1-3) in the TERPT group (p < 0.01). The median length of hospital stay decreased in the TERPT group (8 days) compared with the RB group (10 days) (p < 0.001). There was a significant reduction in postoperative obstructive symptoms during the first 6 months in the TERPT group (48%) compared with the RB group (84%) (p = 0.016). Postoperative enterocolitis decreased from 40% in the RB group to 24% in the TERPT group although this was not statistically significant.

CONCLUSIONS

The introduction of TERPT reduced the need for colostomies; it shortened days to first feeding after surgery and reduced hospital stay. It also improved short-term outcome with less obstructive symptoms. We recommend TERPT surgery as a first choice in children with HD. we consider the RB now to be obsolete.

Systematic review and meta-analysis of enterocolitis after one-stage transanal pull-through procedure for Hirschsprung's disease

PURPOSE

The transanal one-stage pull-through procedure (TERPT) has gained worldwide popularity over open and laparoscopic-assisted one-stage techniques in children with Hirschsprung's disease (HD). It offers the advantages of avoiding laparotomy, laparoscopy, scars, abdominal contamination, and adhesions. However, enterocolitis associated with Hirschsprung's disease (HAEC) still remains to be a potentially life-threatening complication after pull-through operation. The reported incidence of HAEC ranges from 4.6 to 54%. This meta-analysis was designed to evaluate postoperative incidence of HAEC following TERPT procedure.

METHODS

A meta-analysis of cases of TERPT reported between 1998 and 2009 was performed. Detailed information was recorded regarding intraoperative details and postoperative complications with particular emphasis on incidence of HAEC. Diagnosis of HAEC in a HD patient was based on the clinical presentation of diarrhoea, abdominal distension, and fever.

RESULTS

Of the 54 published articles worldwide, 27 articles, including 899 patients were identified as reporting entirely TERPT procedure. Postoperative HAEC occurred in 92 patients (10.2%). Recurrent episodes of HAEC were reported in 18 patients (2%). Conservative treatment of HAEC was successful in 75 patients (81.5%), whereas in 17 patients (18.5%) surgical treatment was needed.

CONCLUSIONS

This systematic review reveals that TERPT is a safe and less-invasive procedure with a low incidence of postoperative HAEC.

Clinical experience with a new modified transanal endorectal pull-through for Hirschsprung's disease

Single-stage transanal endorectal pull-through (TEPT) procedure is now widely used for rectosigmoid Hirschsprung's disease (HD). However, this procedure is associated with some common complications like stricture, enterocolitis, constipation, anastomotic dehiscence and perianal excoriation. The aim of this study was to evaluate the clinical outcomes of a modified TEPT operation in the management of rectosigmoid HD. 45 patients with rectosigmoid HD admitted between August, 2004 and July, 2008 were included in this study. Pre-operative barium enema was done in all of them. Patients in whom the transition zone was well delineated were included in the study. Frozen section biopsy was done to confirm the presence of ganglion cells in the pull-through bowel. All odd number patients were included in group A, where conventional TEPT procedure was performed. All even number patients and the last five patients of the series were in group B. In this group, a modified transanal endorectal procedure was done. The initial part of submucosal dissection and mobilization of aganglionic rectum was the same as in the conventional procedure. The anorectal mucosa was anastomosed end-to-side to the seromuscular coat of the ganglionic bowel. Mobilized bowel was divided at about 2 cm distal to the anastomosis. Six hitching stitches were applied from the free edge of the bowel to the perianal skin so that the anastomosis remains outside the anal verge. The distal redundant bowel was excised on eighth post-operative day. Pre-operative bowel preparation was done in all patients in group A. The bowel preparation was not mandatory in group B patients. Post-operative results of both these groups were compared and analyzed using the Mann-Whitney U test. Mean operative time in group A was 86 min (range 75-95 min) versus 90 min (range 70-100 min) in group B. Average length of the bowel resected was 20 cm (range 10-26 cm) in group A and 22 cm (12-40 cm) in group B. Post-operative feeding was started after 48 h in group A and after 6 h in group B. Average hospital stay was about 8 days in both the groups. Median follow-up was 36 months in group A (range 14-54 months) and 32 months (range 12-52 months) in group B. Anastomotic stricture or stenosis was noted in two patients in group A and none in group B (p < 0.01). Partial anastomotic dehiscence was noted in two patients in group A and none in group B (p < 0.01). Average bowel movement in group A was 6-8 per day at 1 month and 2-6 per day at 6 months. In group B, it was 8-10 at 1 month and 2-8 at 6 months. Cuff narrowing causing constipation was noted in two patients in group A and none in group B (p < 0.01). Enterocolitis following pull-through was noted in two patients in group A and three patients in group B. Four patients in group A and one patient in group B had post-operative constipation. All of them responded to bowel management program: only one of them (group A) required enema; soiling was noted in one patient each in both the groups. Modified TEPT procedure is associated with excellent clinical outcome with fewer complications, and permits early post-operative feeding. Operating time, hospital stay and post-operative bowel movement were comparable with the conventional technique.

Functional outcome after Swenson's operation for Hirshsprung's disease

BACKGROUND/AIM

Hirschsprung's disease (HD) is one of the most common causes resulting in lower intestinal obstruction in children with atypical clinical symptoms and inconspicuous morphological findings by barium enema X-ray. Recently, this situation has been largely ameliorated by improvement of instrument for measurement of anorectal pressure. By now, anorectal manometry has been regarded as a routine means for functional assessment and diagnosis of HD. It is accurate in nearly all cases of HD with characteristic absence of rectoanal inhibitory reflex. Different surgical modalities of treatment are available and Swenson's operation is one of the surgical procedures done for HD. Anorectal manometric findings may change after Swenson's operation with improvement of rectoanal inhibitory reflex in some cases. We aimed to evaluate functional results after Swenson's operation for HD using anorectal manometry.

PATIENTS AND METHODS

Between 1996 and 2005, 52 patients were diagnosed with HD and operated upon by Swenson's operation in Gastroenterology Center, Mansoura University. There were 33 males (63.46%) and 19 females (36.54%) with a mean age of 3.29 +/- 1.6, (range 2-17 years). Anorectal manometry and rectal muscle biopsy were done preoperatively for diagnosis but after operation anorectal manometry was done after every six months and then yearly.

RESULTS

All of the 52 patients showed absent rectoanal inhibitory reflex on manometric study with relatively higher resting anal canal pressure and within normal squeeze pressure. Postoperatively, there were 35 continent patients (67.31%) with 11 patients (21.15%) showing minor incontinence and six (11.54%) with major incontinence. On the other side, there were five patients (9.62%) with persistent constipation after operation (three due to anal stricture and two due to residual aganglionosis). Postoperative manometric study showed some improvement in anal sensation with the rectoanal inhibitory reflex becoming intact in six patients (11.54%) four years after operation.

CONCLUSION

Anorectal manometry is a more reliable method for diagnosis of HD than barium enema X-ray but for final diagnosis, it is reasonable to combine anorectal manometry with tissue biopsy. Functional outcome after Swenson's operation for HD may improve in some patients complaining of incontinence or constipation. Anorectal manometry may show improvement of the parameters after Swenson's operation.

Early and late outcomes of primary laparoscopic endorectal colon pull-through leaving a short rectal seromuscular sleeve for Hirschsprung disease

AIM

To report early and late outcomes of laparoscopic colon pull-through leaving a short rectal sleeve for Hirschsprung disease.

METHODS

Laparoscopic endorectal colon pull-through was performed using 4 ports. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies obtained laparoscopically. The rest of the procedure was carried out according to Georgeson's technique. However, we left a short rectal seromuscular sleeve of 1.5 to 2 cm above the dentate line.

RESULTS

From January 2001 to December 2007, 200 patients were operated upon by the same surgeon. Ages ranged from 14 days to 36 months old. The aganglionic segment was located in the rectum in 112 patients, in the sigmoid colon in 80 children, and in the left colon in 8 patients. The median operating time was 152 minutes. There were no perioperative deaths. Conversion to open surgery was required in four patients. There was minimal blood loss during the surgery. Oral intakes of clear fluid were started 12 hours after surgery and advanced to formula on the second day. In 1 patient, a small intestinal perforation occurred 3 days after surgery, requiring a diverting ileostomy. The mean hospital stay was 6.6 days (range, 4-12 days). Follow-up ranging from 5 to 85 months was obtained in 157 patients; 124 patients (79%) had 1 to 4 defecations a day, 17 (11%) had 5 to 6, and 8 had more than 6. Fecal incontinence occurred in 3 patients (2.0%), constipation in 5 patients (3.0%), and enterocolitis in 15 patients (9.5%). Anastomotic fistula occurred in 2 patients.

CONCLUSION

Laparoscopic endorectal pull-through leaving a short rectal seromuscular sleeve is a safe and effective procedure for Hirschsprung disease.

Primary transanal Swenson pull-through operation for Hirschsprung's disease

OBJECTIVE

The authors describe an experience with a newly developed technique for the treatment of Hirschsprung's disease (HD)-transanal Swenson pull-through operation (TSPT).

METHODS

The records of 27 children (15 males and 12 females) with HD proven on the basis of rectal biopsy or barium enema who underwent primary TSPT between November 2003 and April 2008 were retrospectively reviewed. Rectosigmoidectomy begins at the level just above dentate line in neonates and approximately 1-cm above dentate line in older children. The full-thickness dissection is performed upward around the rectum. The colon is transected above transition zone and anastomosed to the anus. All patients had postoperative pathologic proof. Data are expressed as mean and SD.

RESULTS

Mean age at operation was 29.4 +/- 48.2 months (range, 1-155 months). The operative time averaged 153.5 +/- 85.9 min (range, 65-400 min). There was a statistically significant difference between those younger than 1 month (107.1 +/- 14.8 months) and those greater than 1 month (190.7 +/- 101.1 months). None did receive blood transfusion. Average length of hospital stay was 9.1 +/- 4.1 days (range, 4-21 days). Peri- and postoperative complications included anastomotic stricture (n = 6), enterocolitis (n = 3), and urethral injury (n = 1). Fecal continence (stooling frequency rate of 1-2 times per day) was noted in 70.8% (17/24) and 77.8% (14/18) at 1- and 2-year follow-up, respectively. There was no mortality in the series.

CONCLUSIONS

Primary TSPT would be an alternative, safe technique in children with HD. The technique is not difficult, and associated with acceptable short-term outcomes. A long-term follow-up will be necessary to assess the real benefit of the technique.

Stabilization period after 1-stage transanal endorectal pull-through operation for Hirschsprung disease

PURPOSE

The aim of this study was to evaluate postoperative outcomes and to find the period required for normal stooling pattern after the 1-stage transanal endorectal pull-through operation (TERPT).

METHOD

The authors retrospectively reviewed the clinical data and postoperative courses of 61 patients who had the aganglionic bowel confined to rectosigmoid and underwent TERPT between 2001 and 2007.

RESULTS

Thirty-three patients (54.1%) were neonates, and 56 patients (91.8%) were less than 6 months old at operation. The mean age at TERPT was 90 +/- 216 days, and the mean body weight at TERPT was 4.5 +/- 2.8 kg. The average operating time was 189 +/- 49 minutes, and mean length of bowel resection was 11.1 +/- 3.2 cm. The mean postoperative hospital stay was 8.0 +/- 3.6 days. Postoperatively, 5 (8.2%) patients were considered as failure of TERPT because of persistent problems in defecation. Fifty-six (91.8%) patients finally had normal stooling patterns and normal findings in abdominal radiography after 9.4 +/- 6.2 weeks of the mean postoperative stabilization period. Neonatal cases had significantly longer postoperative stabilization periods than nonneonatal cases (11.3 +/- 6.9 weeks vs 7.3 +/- 4.6 weeks, P = .016). The postoperative stabilization period significantly decreased by age at operation as the patient's age increased (P = .018).

CONCLUSION

Clinical outcomes after TERPT are satisfactory, but a postoperative stabilization period is required for a normal stooling pattern to develop. The outcome of TERPT should consider a postoperative stabilization period.

A NOTES modification of the transanal pull-through

Transanal endorectal pull-through (TAEPT) surgery is primarily performed for rectosigmoid aganglionosis, generally with excellent results. There is evidence that overstretching the anus and tension traction in the sigmoid during the procedure could impair the final continence of the patient. Many researchers suggest the use of small umbilical or laparoscopic access to aid in colon mobilization, thus preventing excessive handling within the anal canal. We assumed that transabdominal mobilization of the sigmoid could be prevented by utilizing the NOTES (natural orifices transluminal endoscopic surgery) technique. We performed a TAEPT with NOTES access of the sigmoid vascular pedicle, keeping the surgery exclusively transanal, which prevented scars in the abdomen and minimized the stretching of perineal structures.

Transanal one-stage endorectal technique for Hirschprung's disease--a preliminary report of 24 cases from a single institution

Numerous surgical techniques for Hirschprung's disease have been developed and modified, being associated with extensive surgical procedures involving laparotomy, resection of affected segment of colon and descensus of the functional bowel to the anus. Conventional surgery was followed by complications, although the incidence of early and late postoperative complications has significantly decreased. Transanal mucosectomy was practiced as a part of conventional and laparoscopic assisted pull through procedures. The latest promising achievement is entirely transanal pull-through procedure, described by De la Tore-Mondragon and Ortega-Salgado: entirely transanal endorectal pull-through, thus avoiding both laparotomy and laparoscopy. Due to minimal invasive surgery it offers excellent results. During a five year period (2003-2008), 24 patients were operated with this technique. The recovery was uneventful in all patients. This study adds valuable information of meticulous details of the new, still developing technique with the emphasis on controversies about surgical complications reported in multicentric studies.

Transanal endorectal pull-through in children with Hirschsprung's disease--technical refinements and comparison of results with the Duhamel procedure

PURPOSE

Transanal endorectal pull-through (TEPT) has drastically changed the treatment of Hirschsprung's disease (HD). A short follow-up of children submitted to TEPT reveals results that are similar to the classic transabdominal pull-through procedures. However, few reports compare the late results of TEPT with transabdominal pull-through procedures with respect to complication rates and the fecal continence. The aims of the present work are to describe some technical refinements that we introduced in the procedure and to compare the short and long-term outcome of TEPT with the outcomes of a group of patients with HD who previously underwent the Duhamel procedure.

METHODS

Thirty-five patients who underwent TEPT were prospectively studied and compared to a group of 29 patients who were treated with colostomy followed by a classical Duhamel pull-through. The main modifications introduced in the TEPT group were no preoperative colon preparation, operation conducted under general anesthesia in addition to regional sacral anesthesia, use of only one purse-string suture in the rectal mucosa before transanal submucosal dissection, and no use of retractors and electrocautery during the submucosal dissection.

RESULTS

The most frequent early complications of TEPT group were perineal dermatitis (22.8%) and anastomotic strictures (8.6%). The comparison with patients who underwent Duhamel procedure revealed no difference in the incidence of preoperative enterocolitis, the patients of the TEPT group were younger at the time of diagnosis and of surgery, they had shorter operating times, and they began oral feeding more quickly after the operation. The incidence of wound infection was lower in the TEPT group. Moreover, the TEPT and Duhamel groups showed no difference in the incidences of mortality, postoperative partial continence, and total incontinence. Although the incidences of complete continence and postoperative enterocolitis were not different, a tendency to the increased incidence in the TEPT group was observed.

CONCLUSIONS

This study further supports the technical advantages, the simplicity, and the decreased incidence of complications of a primary TEPT procedure when compared to a classical form of pull-through. Some technical refinements are described, and no preoperative colon preparation was necessary for the patients studied here. The results show that the long-term outcomes of the modified TEPT procedure are generally better than those obtained with classical approaches.

Transanal one-stage endorectal pull-through for Hirschsprung's disease: a comparison with the staged procedures

Transanal one-stage endorectal pull-through (TOSEPT) has been presented as the most recent progression in treatment of Hirschsprung's disease (HD), which may be able to replace various previous techniques. This prospective study was designed to compare the efficacy and probable complications of the commonly used open surgery with those of TOSEPT technique in management of HD. Forty-two children (35 boys and 7 girls) between 3 days and 12 years of age underwent surgical treatment for HD-all after being diagnosed by barium enema over an 18-month period. In a manner of systematic random selection, 21 patients were operated by TOSEPT and the other 21 by Swenson procedures. All patients were followed-up at least for 12 months after hospital discharge. The necessary data containing age, sex, length of the resected aganglionic segment, intraoperative details, duration of hospital stay and postoperative functional results or complications were collected during hospitalization and follow-up period. There was no significant difference in age at the first operation, sex distribution and length of resected bowel between the two groups. Rate of postoperative complications were significantly higher in Swenson procedure group (P < 0.01). Narcotics were needed in all patients of Swenson procedure group but only in two patients operated by TOSEPT also required laparotomy (P < 0.001). The hospitalization period of TOSEPT group was also less than that of Swenson group (P < 0.001). The total cost of treatment by Swenson procedure is considerably higher than by TOSEPT. TOSEPT can significantly diminish postoperative pain, surgical complications, hospital stay and cost burden caused by Hirschsprung's disease. Besides, this procedure is cosmetically preferable because no visible scar remains.

Analysis of problems, complications, avoidance and management with transanal pull-through for Hirschsprung disease

BACKGROUND

The primary aim of this study is to detail the problems, complications, their avoidance, and management with transanal pull-through developed from experience with 65 patients.

METHODS

A retrospective study of 65 patients who underwent transanal pull-through between January 2002 and December 2006 was conducted. Their medical charts and operative notes were reviewed for problems encountered during surgery, postoperative period, and follow-up.

RESULTS

In 46 patients, a primary transanal pull-through was performed, whereas in 19 with a prior colostomy, followed staged pull-through was done. The minimum follow-up was 6 months, with an average of 22 months after surgery (range, 6-47 months). Sixteen patients (25%) experienced at least 1 complication. These included inadvertent full-thickness mobilization of the rectum in 3 (4.6%), retraction and bleeding of colonic mesenteric vessels in 2 (3.7%), difficulty in mobilizing intraperitoneal colon in 1 (1.5%), and a false-positive frozen section in 2 patients (3%). Early postoperative complications occurred in 7 patients (11%), which included sphincter spasm in 3 (4.6%), anastomotic leak in 1 (1.5%), cuff abscess in 2 (3%), and enterocolitis in 1 (1.5%). Late postoperative complications in 46 patients (70%), occurring from 1 week till 3 months of follow-up included perianal excoriation in 22 (34%), increased stool frequency in 20 (31%), anal stenosis in 3 (4.6%), and enterocolitis in 2 patients (3%). Methodology is detailed for avoidance and management of problems and complications. Individual patient analysis, complications timing, and strategy for management are discussed.

CONCLUSION

Patient outcomes for transanal pull-through have improved significantly as a result of combination of experience and the ability to avoid and manage associated complications. Experience, avoidance, and interdiction are key factors in complication management.

Is high amplitude propagated contraction present after transanal endorectal pull-through for Hirschsprung's disease?

The transanal endorectal pull-through (TAEPT) procedure is now widely performed for Hirschsprung's disease (HD), however, the colorectal function after TAEPT has not yet been adequately assessed. We evaluated the postoperative clinical outcome and colorectal function based on lower colonic manometry after TAEPT. Twenty-one cases of HD underwent TAEPT from 1998 to 2005. We examined the clinical outcome based on the requirement of enemas/suppositories, the number of defecations per day, the severity of perianal erosion, and the incidence of enterocolitis requiring hospital stay. Using a three-channel Dentsleeve catheter and UPS-2020 measuring device, we performed postoperative colonic manometry at three locations: (1) the anal canal, (2) 5 cm proximal to the anal canal, and (3) 10 cm proximal to the anal canal, during defecation, and then we measured the appearance of high-amplitude contraction (HAC) (duration >/=10 s, amplitude >/=100 cmH(2)O). Four of 21 cases were treated with enemas/suppositories no longer than 1 year. The number of defecations decreased gradually from 4 to 5 per day in the early postoperative period, reaching 2 to 3 per day about 1 year postoperatively. Perianal erosion was noted in 3 of 21 cases but it disappeared within three postoperative years. Two cases had enterocolitis. Lower colon manometry was performed in eight cases. Manometry during defecation was successfully monitored in six cases. HAC occurred in five of six cases (83.3%). The clinical outcomes after TAEPT were satisfactory in almost all cases. These good outcomes were possibly due to the occurrence of HAC during defecation, though HAC did not fill the definition of high amplitude propagated contractions (HAPCs). The occurrence of HAC after TAEPT might be caused by keeping any damage to the mesenteric ascending cholinergic nerve to a minimum during surgery. Further long-term observations are still required to make an adequate assessment of such cases.

Duhamel operation vs neonatal transanal endorectal pull-through procedure for Hirschsprung disease: which are the changes for pathologists?

BACKGROUND

The aim of this study was to evaluate whether performing definitive surgery for Hirschsprung disease (HD) in neonatal period with a transanal endorectal pull-through (TEPT) procedure had modified our diagnostic relevance, particularly during intraoperative frozen sections (IOFS), compared to classic Duhamel (DH) surgery performed in older children.

METHODS

We collected pathologic data for 47 children who underwent surgery for neonatal nontotal HD over a 5-year period.

RESULTS

Twenty-nine patients underwent TEPT and 18 the DH operation. Mean age at operation was 19 days for TEPT and 4 months for DH operation. The mean number of IOFS was 2.6 for TEPT and 2.4 for DH operation. Gross examination could be fully completed in all TEPT cases, but was incomplete in 5 DH cases. The average total lengths of bowel, and aganglionic, transitional, and ganglionic segments were 12.3, 7.3, 3, and 2 cm for TEPT, and 17.6, 9.3, 3.5, and 4.8 cm for DH operation, respectively. Discordance between IOFS and paraffin-section analysis occurred in 5 cases (3 TEPT and 2 DH operation).

CONCLUSION

When TEPT was used, the gross examination and sampling was more accurate, leading to a clearer pathology report. The TEPT procedure facilitates the work of the pathologist without modifying the results of IOFS, if some precautions are taken.

Single-stage transanal endorectal pull-through for Hirschsprung's disease: perspective from a developing country

BACKGROUND/PURPOSE

The aim of this study was to evaluate the feasibility, results, and cost-effectiveness of totally transanal endorectal pull-through (TEPT) in the management of rectosigmoid and midsigmoid Hirschsprung's disease (HD) in a low-income country.

METHODS

Between March 2004 and December 2005, 19 children underwent totally TEPT procedure. The patients' ages ranged from 6 days to 13 years. The primary diagnosis in all 19 patients was HD confined to the rectosigmoid region in 15 and midsigmoid in 4. None had a preoperative colostomy. Follow-up period ranged from 4 to 20 months (mean, 8 months).

RESULTS

Ages ranged from 0.25 to 65 months, with a mean of 16.24 months. Weights ranged from 3.4 to 13 kg, with a mean of 6.5 kg. Mean time from diagnosis to pull-through procedure was 26 days (range, 6-39 days). The mean length of rectosigmoid resection was 30 cm (range, 20-50 cm). The mean operative time was 95 minutes (range, 75-140 minutes). Mean intraoperative blood loss was 25 mL (range, 15-40 mL). There was one death unrelated to the procedure. One patient had enterocolitis 3 months postoperatively. Average frequency of defecation was 3 (range, 1-6) stools per day. TEPT was associated with a shorter operating time, less blood loss, early return to feeds, and an overall reduced cost.

CONCLUSION

The safety and cost-effective benefits of transanal endorectal pull-through in the treatment of HD are of special interest for a developing country. Our data also suggest that functional outcome following TEPT is highly satisfactory and comparable with other established procedures.

Role of transanal endorectal pull-through in complicated Hirschsprung's disease: experience in 18 patients

BACKGROUND/PURPOSE

In Hirschsprung's disease (HD) redo pull-through (PT) is indicated for anastomotic complications and for persistent aganglionosis after previous definitive surgery. This study was undertaken to evaluate the role of transanal approach to redo PT procedure in the management of complicated cases of HD over the last 7 years.

PATIENTS AND METHODS

Between November 1998 and September 2005, 225 patients with HD were operated using the transanal endorectal PT (TEPT) approach. Eighteen patients had a redo PT owing to persistent aganglionosis. The present study evaluates the role of TEPT approach in patients with persistent aganglionosis (n = 18). Three patients needed a colostomy (n = 2) or ileostomy (n = 1) before the final operation. All the 18 patients underwent transanal mobilization (TEPT) of the colon. Six patients required additional mobilization of the proximal colon (n = 4) and the ileum (n = 2) during the redo PT operation.

RESULTS

Median follow-up was 43 months (range, 3-72 months). Sixteen patients have had a good outcome with stool pattern 1 to 4 times daily. One patient had obstructive symptoms for 4 months postoperatively but then settled. One patient has occasional soiling.

CONCLUSIONS

In this series, TEPT and posterior midline split of the muscle cuff were used with good results. This has the advantage of avoiding injury to the pelvic muscles and nerves. The TEPT approach is combined with transabdominal mobilization of the intestine depending on the length of the aganglionic segment. The outcome has been favorable, but long-term follow-up is necessary for full assessment of those patients.

Evolution of the technique in the transanal pull-through for Hirschsprung's disease: effect on outcome

BACKGROUND

The transanal pull-through has become the standard operation for Hirschsprung's disease in many pediatric surgical centers. Over the past 8 years, we have modified our technique by leaving a short-rather than a long-rectal cuff and by doing routine intraabdominal colonic biopsies through an umbilical incision before beginning the anal dissection. The aim of this study was to determine if these modifications have changed the outcome for children undergoing this operation.

METHODS

A retrospective cohort study of all patients who underwent transanal pull-through by a single surgeon between 1997 and 2005 was conducted.

RESULTS

There were 23 children who had a long cuff (10-15 cm) and 22 who had a short cuff (<2 cm). The short cuff group tended to be younger (25 +/- 23 vs 139 +/- 67 days; P < .05) and smaller (3.5 +/- 0.7 vs 6.0 +/- 2.7 kg; P < .05) at the time of surgery. The operating time was shorter (167 vs 186 minutes; P = .05) in the short cuff group. Outcomes were improved in the short cuff group, as evidenced by decreased hospital stay (1.9 +/- 0.6 vs 2.7 +/- 0.9; P < .05), decreased incidence of enterocolitis (9% vs 30%; P = .1), and lower incidence of narrowing requiring daily dilatations (5% vs 30%; P < .05). Preliminary colonic biopsy was performed on 18 of the 45 patients. This had no significant effect on narcotic use (66% vs 70%; P = .8) and did not increase operating time (174 +/- 31 vs 179 +/- 34 minutes; P = .6). Hospital stay was shorter in the umbilical biopsy group (1.9 +/- 0.6 vs 2.6 +/- 0.9 days; P = .006).

CONCLUSION

Results of the transanal pull-through have improved likely as a result of a combination of experience and use of a shorter rectal muscular cuff. The use of a preliminary colonic biopsy through an umbilical incision has not increased postoperative pain, prolonged operative time, or lengthened hospital stay.

Is there a hidden mortality after one-stage transanal endorectal pull-through for patients with Hirschsprung's disease?

One-stage transanal pull-through (TAP) has become a standard definitive procedure for the treatment of Hirschsprung's disease (HD). Short-term results of this operation seem to be excellent, but long-term outcome is still obscure. We evaluated the morbidity and mortality of our patients with one-stage TAP, and we reviewed the literature. We performed a TAP without a colostomy in 21 patients with HD. The primary outcome measures are age, sex, complications during surgery, enterocolitis (EC) attacks after surgery, postoperative stooling problems and mortality. All patients were called over telephone, and their clinical and functional outcomes were obtained. Case series of TAP in the literature were also reviewed in terms of postoperative problems. Twenty-one patients with full thickness rectal biopsy-proven HD underwent one-stage TAP. Average follow-up was 28 months. One early postoperative EC and three more late attacks of EC were observed. All survived patients had normal bowel habits. Three patients had perianal excoriations, three patients soiling, seven cases required anal dilatations and four patients experienced a diarrhea after surgery. We have been informed that four patients died after discharge from hospital. Two of them were a sudden death (one patient had metabolic problems, the other might have had an EC attack). The cause of death of one patient with an associated Down syndrome was a severe pneumonia, and one other case died of a septic shock of unknown etiology. None of these patients had a diarrhea or abdominal distention, which could have been an evidence of an EC attack prior to their deaths. We observed similar fatal cases, when reviewed the published series in the literature. There might be a hidden mortality within the long-term period after TAP for HD. Therefore, we recommend a close follow-up for all patients with any associated health problem and those from low socioeconomic regions after one-stage pull-through.

Prospective analysis of primary modified Georgeson's laparoscopy-assisted endorectal pull-through for Hirschsprung's disease: short- to mid-term results

The aim of this study was to analyze the short- to mid-term outcome of primary modified Georgeson's laparoscopy-assisted endorectal pull-through (PMGLEPT) for Hirschsprung's disease (HD). HD patients treated by PMGLEPT were evaluated prospectively by a single surgeon using a standard structured questionnaire to assess complications, incidence of enterocolitis, and evaluate continence (CE). CE involved scoring five parameters (frequency of motions, severity of staining/soiling, severity of perianal erosions, anal shape, and requirement for medications) on a 3-point scale (0, 1, and 2 for each parameter). Thus, scores for CE were: 10 = normal, 8-9 = good, 6-7 = fair, and 0-5 = poor. Our modifications include transanal rectal dissection starting below or on the dentate line, near total excision of the posterior rectal cuff, and intraoperative acetylcholinesterase staining to accurately identify normal colon. Patients with total colon aganglionosis or trisomy-21 were excluded, leaving 33 cases of PMGLEPT performed between 1997 and 2004. Mean operative age was 11.0 months. Follow-up ranged from 8 months to 7 years (mean 4.0 years). There were no intraoperative complications. Post-PMGLEP, bowel obstruction occurred in 1 subject who required middle colic division for pull-through (PT), and enterocolitis occurred in 3 (9.1%) of 33 patients. In 20 subjects aged over 3 years with a follow-up period of more than 12 months, final CE was normal in 5, good in 10, fair in 4, and poor in 1, despite staining/soiling being present in 12 (60%) of 20 subjects. None of the 33 had constipation. Our results suggest that PMGLEPT is safe with acceptable outcome in the short- to mid-term. However, careful long-term follow-up is mandatory as there appears to be a relatively high incidence of staining/soiling on short- to mid-term follow-up.

Stooling patterns and colonic motility after transanal one-stage pull-through operation for Hirschsprung's disease in children

BACKGROUND

The transanal one-stage endorectal pull-through operation for Hirschsprung's disease is relatively new and makes assessment of the functional outcome and colonic motility difficult. The aim of this study was to evaluate the stooling patterns and colonic motility after a one-stage transanal pull-through operation for Hirschsprung's disease in children.

METHODS

Twenty-two children who underwent a one-stage transanal pull-through operation for Hirschsprung's disease were followed up for at least 6 months. The children (17 boys and 5 girls) were from 12 months to 13 years of age (mean age, 4 years). All patients had an aganglionic segment confined to the rectosigmoid area (confirmed by preoperative barium enema and postoperative histology). Clinical outcome was assessed by interviews and questionnaires, and children were divided into symptomatic and nonsymptomatic groups. Contrast barium enema and defecography and determination of total and segmental colonic transit time (using radio-opaque markers) were performed on all 22 children.

RESULTS

The stooling patterns were considered satisfactory in 17 children. Of all the children, the mean stool times were 1 to 2 per day and only 2 were 8 to 10 per day; postoperative soiling was found in 4, constipation was observed in 2, and Hirschsprung-associated enterocolitis in 1. There was no incontinence, cuff infection, anastomotic leak, or mortality noted. Barium enema showed that the dilated and spastic colonic segment disappeared in all 22 children. The dilated sigmoid loops decreased in 17 (2 symptomatic, 15 nonsymptomatic) and disappeared in 5 (4 symptomatic, 1 nonsymptomatic). There was a significant difference between the decreasing and disappearing loop group in regard to stooling disorders (P < .05). Postoperative defecography showed that the anorectal angle of all children was open, fixed, and significantly larger than that of the preoperative and control groups (123.3 degrees +/- 15.1 degrees vs 84.7 degrees +/- 8.3 degrees vs 79.0 degrees +/- 11.6 degrees, P < .01) and larger in the symptomatic group when compared with the nonsymptomatic group (135.6 degrees +/- 15.9 degrees vs 111.0 degrees +/- 14.3 degrees, P < .05). Postoperatively, the total gastrointestinal transit time, left colonic transit time, and rectosigmoid colonic transit time of all the children were shorter than preoperatively (26.8 +/- 8.2 vs >188 hours, P < .01; 6.3 +/- 4.1 vs >60 hours, P < .01; 11.8 +/- 4.4 vs >120 hours, P < .01) and similar to controls. The total gastrointestinal transit time and rectosigmoid colonic transit time of the symptomatic group were significantly shorter than the nonsymptomatic group (25.2 +/- 5.6 vs 28.1 +/- 10.1 hours, P < .05; 12.2 +/- 6.7 vs 9.8 +/- 4.0 hours, P < .05).

CONCLUSIONS

The stooling pattern and colonic motility are satisfactory in most children after the one-stage transanal pull-through operation for Hirschsprung's disease. Normalization of colon appearance and total and segmental colonic transit time are signs of recovery of colonic motility. Stooling disorders were noted in a few cases and may be related to decrease or disappearance of the sigmoid loop, dysfunction of the "neorectosigmoid", an open and fixed anorectal angle, and ischemia of the pull-through segment.

Experimental model for transanal endorectal pull-through surgery. Technique of De la Torre and Ortega

BACKGROUND

We describe an experimental model for transanal endorectal pull-through surgery using the method of de la Torre and Ortega that can be used for training purposes in experimental laboratories.

METHODS

Ten rabbits were submitted to the transanal endorectal pull-through technique of de la Torre and Ortega. Animals were randomly selected in the Botucatu School of Medicine experimental laboratory. Animals weighted between 2800 and 4400 g. Colons were not prepared, and antibiotic therapy was not used; dipyrone was administered postoperatively for analgesic purposes. We standardized resected segment size, recorded surgical time, and observed survival and possible complications for 1 month.

RESULTS

All animals survived the initial follow-up period without infection. Bowel movements returned quickly, and all animals were evacuating regularly within the first 24 hours. Mean surgical time was 48.6 minutes.

CONCLUSIONS

The experimental model proposed in this study is very useful for training and improving surgical techniques using the method of de la Torre and Ortega. The rabbit is an excellent animal for this surgery because of its size and postoperative resistance.

Clinical outcome in children after transanal 1-stage endorectal pull-through operation for Hirschsprung disease

BACKGROUND/PURPOSE

Recently, the transanal 1-stage pull-through operation has been widely used in Hirschsprung disease (HD), and it is obviously superior to traditional approach in early term for its noninversion. However, the procedure is relatively so new that it makes assessment of the functional outcome and stooling patterns difficult. The aim of this study was to evaluate the clinical outcomes of the transanal 1-stage endorectal pull-through operation in the management of rectosigmoid HD.

METHODS

Fifty-eight children (39 boys and 19 girls) aged 12 months to 13 years (mean, 2 years) who underwent transanal 1-stage endorectal pull-through operation for HD were followed up from 6 to 24 months. Clinical outcome was assessed by interviews and questionnaires. All patients had an aganglionic segment confined to the rectosigmoid area which was confirmed by the preoperative barium enema and postoperative pathological examination.

RESULTS

Forty-six patients had satisfactory results without complications. In all the children, the mean stool times were 1 to 2 per day; only 4 had mean stool times of 8 to 10 per day. Postoperative soiling was present in 9, constipation in 5, and HD-associated enterocolitis in 3. There were no incontinence, cuff infection, anastomotic leak, and mortality in any of the patients. In the 12 symptomatic patients, there were 4 children with length of aganglionic segment less than 30 cm, and 8 had 30 cm or more. In the 46 asymptomatic patients, 42 had length of aganglionic segment less than 30 cm, and 4 had 30 cm or more. There was a significant difference between the group with less than 30 cm and the group with 30 cm or more of aganglionic segment. For statistical analysis, the Fisher exact test showed P < .05.

CONCLUSIONS

The transanal 1-stage endorectal pull-through is a feasible and safe procedure in children with rectosigmoid HD. The clinical outcome is satisfactory. A gradual recovery could be noted in the stooling patterns along with the time after surgery. The younger the patient operated on and the shorter the aganglionic segment, the lower do the stooling disorders occur and the faster does the stooling function recover.

Transanal pull-through for Hirschsprung disease

Hirschsprung (HSCR) disease is a relatively common neonatal developmental disorder of the enteric nervous system and is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses of the distal intestine. This results in absent peristalsis in the affected bowel, and the development of a functional intestinal obstruction. The pathogenesis and genetic basis of the disease is yet unclear. The surgical treatment of HSCR has evolved significantly since 1949 when Swenson first proposed a trans-abdominal pull-through procedure. The transanal pull-through consists of a rectal mucosectomy, resection of the aganglionic bowel and a colo-anal anastomosis. Recent literature and clinically controversies of this minimally invasive one-stage procedure are reviewed. Although follow up is still relatively short the preliminary results appear very favorable and cost effective.

Long-term results of treatment of Hirschsprung's disease

Many children with Hirschsprung's disease (HD) have a good outcome following surgical treatment, but long-term follow-up studies have identified a number of concerns. Analysis of long-term function in children after surgical management is difficult. The most commonly encountered problems include constipation, incontinence, enterocolitis and the overall impact of the disease on lifestyle (quality of life). Other complications are less frequent. Each of these problems will be discussed.