Surgical treatment of total colonic aganglionosis: efficacy of aganglionic patch enteroplasty in the rat

Long-term results of total colonic agangliosis patients treated by preservation of the aganglionic right hemicolon and the ileo-cecal valve

PURPOSE

In 1989, Sauer introduced a technique to treat patients with total colonic aganglionosis (TCA) where he preserved the ileo-cecal valve and the right hemicolon to retain water and electrolyte absorption. This report examines the long-term outcome of patients who underwent this technique.

METHODS

All TCA patients treated between 1981 and 2005 according to Sauer were invited in 2013 to participate in a questionnaire survey to assess their long-term outcome focusing on bowel function and quality of life (QoL), using standardized scores.

RESULTS

Of eight TCA patients (2 females, 6 males), seven participated in the follow-up survey (median follow-up time 13.5 years (range 8-31.6). Early postoperative complications involving bouts of enterocolitis in 3 and anal strictures in 5 patients ceased with age. Bowel movements ranged from median 3-4 times a day (range 1-8). Bowel-function score (BFS) was reduced in 6 patients (median 16 points, range 8-19, max 20), who also reported soiling incidences with the need for night-time protective aids in two. QoL assessment, however, documented a good outcome with a median score of 10 points (range 7-13, max 13).

CONCLUSION

This long-term investigation of TCA patients treated according to Sauer's technique documented a good QoL despite a reduced BFS.

Total colonic aganglionosis and Hirschsprung's disease: a review

Total colonic aganglionosis is a relatively uncommon form of Hirschsprung's disease (HSCR). It occurs in approximately 2-13 % of HSCR cases and involves the entire colon which is aganglionic but may extend proximally into varying lengths of small bowel. As a result, it should be separated into Total colonic aganglionosis (TCA) [defined as aganglionosis extending from the anus to at least the ileocaecal valve but no more than 50 cm small bowel proximal to the ileocaecal valve] and total colonic and small bowel aganglionosis (TCSA) which may involve very long segments of small bowel aganglionosis. Clinically, TCA appears to represent a different spectrum of disease in terms of presentation and difficulties which may be experienced in diagnosis suggesting a different pathophysiology from the more common forms of HSCR. It is therefore not yet clear whether TCA merely represents a long form of HSCR or a different expression of the disease. A number of differences exist between TCA and other forms of HSCR which require explanation if its ubiquitous clinical features are to be understood. In addition to the usual explanations for the aganglionosis of HSCR, there is some evidence suggesting that in place of being purely congenital, it may represent certain different pathophysiologic mechanisms, some of which may continue to be active after birth. This study reviews what is known about the clinical, radiological and histopathologic differences between TCA and the more frequently encountered recto-sigmoid (or short-segment; S-HSCR) and correlates them with what is currently known about the genetic and molecular biologic background to find possible pathogenetic mechanisms.

Total colonic aganglionosis in Hirschsprung disease

Total colonic aganglionosis (TCA) is a relatively uncommon form of Hirschsprung disease (HSCR), occurring in approximately 2%-13% of cases. It can probably be classified as TCA (defined as aganglionosis extending from the anus to at least the ileocecal valve, but not >50 cm proximal to the ileocecal valve) and total colonic and small bowel aganglionosis, which may involve a very long segment of aganglionosis. It is not yet clear whether TCA merely represents a long form of HSCR or a different expression of the disease. There are many differences between TCA and other forms of HSCR, which require explanation if its ubiquitous clinical features are to be understood. Clinically, TCA appears to represent a different spectrum of disease in terms of presentation and difficulties that may be experienced in diagnosis, suggesting a different pathophysiology from the more common forms of HSCR. There is also some evidence suggesting that instead of being purely congenital, it may represent certain different pathophysiologic mechanisms. This study, in addition to reviewing current understanding and differences between TCA and the more frequently encountered rectosigmoid (or short-segment) expression, correlates them with what is currently known about the genetic and molecular biological background. Moreover, it reviews current outcomes to find consensus on management.

Total colonic aganglionosis and Hirschsprung's disease: shades of the same or different?

Total colonic aganglionosis is a relatively uncommon form of Hirschsprung's disease (HSCR) occurring in approximately 2-13% of cases. It can probably be divided into total colonic aganglionosis (TCA; defined as aganglionosis extending from the anus to at least the ileocaecal valve, but no more than 50 cm proximal to the ileocaecal valve) and total colonic and small bowel aganglionosis, which may involve a very long segment of aganglionosis. Clinically, they appear to represent a different spectrum of disease in terms of presentation and difficulties in diagnosis which may be experienced, suggesting a different pathophysiology from the more common forms of HSCR. It is not yet clear whether TCA merely represents a long form of HSCR or a different expression of the disease. There are a number of differences between TCA and other forms of HSCR, which require an explanation if its ubiquitous clinical features are to be understood. There is some evidence suggesting that instead of being purely congenital, it may represent certain different pathophysiologic mechanisms, some of which may continue to be active after birth. This study reviews all that is known about the clinical, radiological and histopathologic differences between TCA and the more frequently encountered recto-sigmoid (or short-segment) and correlates them with what is currently known about the genetic and molecular biologic background to find possible pathogenetic mechanisms.

Long-term outcomes in total colonic aganglionosis: a 32-year experience

BACKGROUND/METHODS

A 32-year retrospective review from 1972 to 2004 analyzed complications and long-term outcomes in children with total colonic aganglionosis (TCA) as they relate to the procedure performed.

RESULTS

Thirty-six patients (27 boys, 9 girls) had TCA. The level of aganglionosis was distal ileum (26), mid-small bowel (8), midjejunum (1), and entire bowel (1). Enterostomy was performed in 35 of 36. Eight developed short bowel syndrome. Twenty-nine (81%) had a pull-through at 15 +/- 6 months (modified Duhamel 20, Martin long Duhamel 4, and Soave 5). Six had a Kimura patch. Postoperative complications (including enterocolitis) were more common after long Duhamel and Soave procedures. Seven (19%; 2 with Down's syndrome) died (3 early, 4 late) from pulmonary emboli (1), sepsis (1), fluid overload (1), viral illness (1), liver failure (1), arrhythmia (1), and total bowel aganglionosis (1). Mean follow-up was 11 +/- 9 years (range, 6 months-29 years). Twenty-four (83%) of 29 patients exhibited growth by weight of 25% or more, 21 (91%) of 23 older than toddler age had 4 to 6 bowel movements per day, and 17 (81%) of 21 were continent. In 5 of 6, the Kimura patch provided functional benefit with proximal disease.

CONCLUSION

Long-term survival was 81%. The highest morbidity occurred with long Duhamel or Soave procedures. The modified Duhamel is our procedure of choice in TCA. Bowel transplantation is an option for TCA with unadapted short bowel syndrome.

The colon patch graft procedure for extensive aganglionosis: long-term follow-up

PURPOSE

During the last 17 years, the authors have used the colon patch graft (CPG) procedure to treat 11 patients with extensive aganglionosis. This study evaluates the effectiveness of the CPG procedure in treating patients with this disorder.

METHODS

An initial ileostomy was created during infancy in all 11 patients. At 1 to 21 months (mean, 5.5 months) of age, an 11- to 40-cm (mean, 18 cm) side-to-side ileocolostomy (CPG) was created between the ileum and aganglionic ascending colon, (including aganglionic ileum in three patients). Ten patients later underwent a Swenson-type definitive operation, the CPG segment being brought down to the anus at 9 to 30 months (mean, 19 months) of age. These 10 patients have been followed up for growth, development, and bowel habit patterns for the subsequent 5 to 17 years (mean, 12 years).

RESULTS

Within 1 month after the CPG was created, intravenous nutrition could be discontinued and the patients treated at home until time for the definitive procedure. During this period, one patient died of aspiration. After the definitive operation, body weight for age returned to a normal range in 2 to 4 years. Currently, seven older patients have one to three bowel movements per day, whereas three younger patients have explosive diarrheal defecations. None are incontinent of stool. Iron deficiency anemia developed in four patients. Two are mentally retarded, but the others are doing well in school.

CONCLUSIONS

(1) The colon patch graft procedure effectively reduces "ileostomy diarrhea," shortening the period of intravenous nutrition to 1 month, (2) bowel habit patterns improve with the advance of time, (3) body weight for age returns to normal 2 to 4 years after the definitive procedure, and (4) during long term follow-up, patients must be evaluated for iron deficiency anemia.

Long-term follow-up of patients treated with ileoendorectal pull-through and right colon onlay patch for total colonic aganglionosis

BACKGROUND/PURPOSE

This study was performed to assess the long-term follow-up of five patients who underwent one-stage ileoendorectal pull-through with right colon onlay patch for total colonic aganglionosis (TCA) at Kaiser Permanente Medical Center.

METHODS

A retrospective review of inpatient and outpatient charts and telephone follow-up of all patients were conducted to obtain current data regarding growth, development, bowel function, and postoperative and late complications.

RESULTS

Follow-up has ranged from 2 to 11 years. All patients are at or above the 50th percentile for weight by age and are continent with 1 to 5 daily bowel movements. Only two patients required reoperation. A perirectal abscess developed in one patient 2 months postoperatively. In the second patient a functional obstruction was relieved by sphincterotomy.

CONCLUSIONS

Ileoendorectal pull-through with right colon onlay patch is associated with few early and late postoperative complications; it appears to be superior to other procedures in the early postoperative period because of the more rapid return to acceptable stooling patterns. This method of reconstruction provides an excellent opportunity for normal growth, development, and long-term bowel function.

Early definitive surgery for total colon aganglionosis: Duhamel procedure with right colon patch graft using GIA stapler

A report is presented of an infant with total colon aganglionosis (TCA) with ileal involvement in whom a modified Duhamel procedure was used accompanied by a right colon patch graft 12 cm in length using a GIA-90 stapler at 3 months of age. The patient with TCA is usually treated by an initial diverting ileostomy followed by a definitive operation performed several months later. However, the management during the ileostomy period is associated with a variety of problems. In to minimize the resulting complications, we developed a procedure to allow a much earlier definitive operation.

Motor activity of refashioned colorectoanus in patients with total colonic aganglionosis

An ano-recto-sigmoid colon pressure study was designed to evaluate the characteristics of the motor activity of refashioned colorectoanus in patients with total colonic aganglionosis (TCA) in comparison to patients with rectosigmoid Hirschsprung's disease (HD) and healthy children (HC), and to elucidate the pathophysiology of the pulled-through ileum, with aganglionic colon as an onlay patch, in coordination with the anal sphincter. The study group consisted of six patients with TCA, six with HD who underwent endorectal colonic pull-through, and six HC. Pressure studies were performed using a triple-lumen catheter; recording sites were 15 and 9 cm from the anal verge, and at the anal canal. The following were measured and compared: (1) anal canal pressure profile, (2) resting pattern of activity at the refashioned colorectum and anal canal, and (3) changes in motor activity after stimulation with cold water and glycerin. The motor activities of the refashioned colorectoanus of TCA and HD patients differed greatly from those of HC. All six HC had no isolated high-amplitude contraction (IHAC) in the colorectum during the 45-minute study period; they complained of a strong urge to defecate after glycerin enema and actually did so. In contrast, IHAC appeared 2.0 +/- 1.3 times per 10 minutes, with maximal amplitude of 60.3 +/- 24.9 cm H2O in TCA, and 5.6 +/- 3.7 per 10 minutes with maximal amplitude of 79.5 +/- 11.7 cm H2O in HD. After glycerin enema, IHAC increased to 0.5 +/- 0.2 per minute and 69.3 +/- 44.6 cm H2O in TCA and to 0.8 +/- 0.4 per minute and 93.0 +/- 12.8 cm H2O in HD. Defecation was postponed for more than 10 minutes in two HD and all TCA patients. The mean motility index per minute was least for TCA patients (76.9 +/- 98.2); it was 406.5 +/- 197.1 (P < .05) for HD patients and 159.2 +/- 84.2 (P < .01) for HC. TCA patients had the lowest amplitude of maximal resting anal pressure, and hypoactivity of the colorectum during rest and after stimulation; this suggests that motor dysfunction involves even the ganglionic ileum, concomitant with suppressed signals to the higher integrating center for defecation.

Long-term results of surgical treatment in infants with total colonic aganglionosis

The authors describe the long-term results of the surgical treatment of total colonic aganglionosis (TCA) in nine boys who have been treated since 1975. The principal operative procedure was endorectal pull-through of the ganglionic ileum, with the aganglionic colon as an onlay patch. The procedure was employed in five infants, using the right or left colon. Ileorectostomy with an onlay patch was used in two patients; ileoanostomy without the patch was used in two. The distal end of the pulled-through ileum was, on average, 39 cm from the ileocecal junction. The average follow-up period was 11.0 years. Diarrhea and distension were temporary after the pull-through, and all patients ultimately tolerated normal feeding. Considering the variation in operative techniques, we were unable to demonstrate any advantage of one procedure over another. Z scores for height and weight at the last follow-up examination correlated with the weight gain before the definitive surgery and inversely correlated with the length of resected distal ileum at the time of operation.

Sequential intestinal lengthening procedures for refractory short bowel syndrome

Better understanding of the long-term delivery of parenteral nutrition (PN) in neonates and children has increased the survival for patients who have neonatal short bowel syndrome. Most infants with short bowel syndrome experience progressive enteral adaptation and are weaned from PN. This report describes the authors' clinical experience with nine infants and children who had refractory short bowel syndrome; single or sequential procedures were performed to lengthen the small bowel. Gut lengthening procedures used included a small bowel nipple valve constructed distally, to provide temporary partial obstruction and thereby induce dilatation and lengthening of the proximal small intestine (six patients). Bianchi's technique was used in three patients primarily and in six others after the bowel had been dilated and lengthened by the nipple valve. Kimura's gut lengthening technique was used in one patient after the small bowel had spontaneously become dilated subsequent to a Bianchi procedure. In all, 16 lengthening procedures were performed on the nine patients. Preoperatively, the nine patients tolerated less than 10% of their caloric intake enterally, with no evidence of improvement for a minimum of 6 months. Small bowel segments ranged from 6 to 92 cm originally and were increased an average of 2 1/2 times the original length. Two patients have been totally weaned from PN. For the patients whose lengthening procedure was performed more than 1 year ago, the percentage of enteral caloric intake averages 50%. One of the patients was profoundly impaired neurologically and was not resuscitated from an apneic episode. Another patient died in his sleep of unknown causes 1 year after intestinal lengthening.(ABSTRACT TRUNCATED AT 250 WORDS)

Preservation of the ileocecal valve and right colon in total colonic aganglionosis

A new surgical technique for the treatment of total colonic aganglionosis is described. Preservation of the right colon and the ileocecal valve is possible by performing an end-to-back anastomosis between a prececal short ileum segment and the uneffected ileum, and by creating a side-to-side anastomosis between an isolated ileal loop and the right colon. The ileorectal anastomosis is performed with a curved EEA 21 circular stapler (USSC, Norwalk, CT). After a neonatal ileostomy, the operation is performed as a one-stage procedure. The advantage of preserving the right colon and the ileocecal valve is discussed.

The isolated bowel segment (Iowa Model II): absorption studies for glucose and leucine

A model of the isolated bowel segment (IBS, Iowa Model II) was successfully created in experimental animals using a new surgical technique we developed. The IBS is completely free of its mesenteric attachment, yet its viability is preserved. The technique consists of two staged procedures: (1) initial enteropexy between the anterior margin of the liver and the antimesenteric border of the IBS with its ends forming cutaneous stomas; and (2) division of the IBS mesentery 5 weeks later. The IBS is nourished by vascular collaterals that form at the hepatoenteropexy during the interval between these two procedures. Our previous studies demonstrated preserved viability and motility in the IBS. This study was undertaken to test absorption in the IBS. In 25 rats (experimental group), the IBS (Iowa Model II) was created using an 8-cm-long isolated segment of jejunum. In 15 rats (control group), an 8-cm-long segment of jejunum was arranged to form a Thiry-Vella loop. Five weeks later, the IBS mesentery was divided in the experimental group, and sham laparotomy was performed in the control group animals. Absorption of glucose and leucine was studied in 13 rats of the experimental group and 6 of the control group using a constant single perfusion technique at 3, 8, and 11 weeks after the initial operation. The results were compared between the two groups. There was a 25% to 35% reduction in absorption of glucose and leucine in both groups with the advance of time, but no significant difference was observed between the groups except in leucine absorption at 11 weeks after the initial operation. This study concludes that absorption of glucose and leucine is preserved in the IBS after its mesentery is divided, suggesting that the IBS can be used as a functioning bowel for bowel reconstruction.

The effect of a neurotoxin (benzalkonium chloride) on the lower esophagus

Achalasia of the esophagus may be associated with abnormalities of the myenteric plexus (hypo- and anganglionosis). This report evaluates this relationship by studying the effect of benzalkonium chloride (BK, a topical neurotoxin) on the lower esophagus. Following midline laparotomy, topical BK (0.5%) was applied to the muscularis of the lower 1.0 cm of the esophagus for 30 min in 38 Sprague-Dawley rats (200 g). Thirty-eight additional rats acted as controls (unoperated, n = 19; sham laparotomy, n = 19). At 1 and 3 months animals were evaluated for weight gain, daily food intake (g/100 gm body wt), lower esophageal sphincter (LES) manometry, and contrast esophagram. At 3 months, the esophagus was evaluated for histologic study and acetylcholinesterase staining. Esophagram showed distal narrowing with proximal dilatation in BK rats (inner diameter 4.71 +/- 0.61 vs 6.17 +/- 0.58 in controls, P less than 0.001). Daily food intake was significantly less in BK rats (5.57 +/- 0.41 g vs controls 7.69 +/- 0.33 g P less than 0.001). Daily weight gain was also less in BK rats (1.13 +/- 0.34 vs controls 1.83 +/- 0.25, P less than 0.001). An increased LES pressure was noted in BK rats (5.45 +/- 0.89 mmHg vs controls 4.04 +/- 1.04 mmHg; P less than 0.1). A histologic study showed aganglionosis in BK rats with positive cholinesterase staining fibers compared to controls. Topical BK results in distal esophageal aganglionosis characterized by distal narrowing, proximal dilatation, decreased food intake, and limited weight gain when compared to controls. These findings are similar to those observed in achalasia and support a primary neurogenic cause for its etiology.

A proposal to preserve the ileocecal valve and right colon in total colonic aganglionosis

We report two cases of total colonic aganglionosis in which the ileocecal valve and right colon were preserved. The aganglionic ileal segment is removed leaving behind only a very short prececal remnant, which is anastomosed end-to-back to the remaining ileum. An ileal loop (of approximately 20 cm in length) is isolated and interposed between the right colon and rectum. The operation can be performed as a staged procedure. The advantage of preserving the ileocecal valve with respect to physiology is discussed.

Ideal treatment for total colonic Hirschsprung's disease

Five children were treated for total colonic Hirschsprung's disease between 1982 and 1986. Three girls and two boys underwent total colectomy and straight ileoanal endorectal pull-through, with creation of a suprapelvic side-to-side anastomosis of 10 cm of cecum and ascending colon to ileum (Boley procedure). All patients have been followed for periods of greater than 1 year, and they have been free of any postoperative complication. Stool frequency on an unrestricted diet has been between one and five semiformed per day. Their growth and development have been excellent. An advantage of this procedure is excellent water absorption without the risks of mechanical problems encountered with a variety of pelvic pouch creations in the young growing child.

Extensive aganglionosis: further experience with the colonic patch graft procedure and long-term results

During the period from 1979 to 1986, seven patients have been treated for extensive aganglionosis involving the colon and distal ileum (5 to 40 cm) employing the colonic patch graft (CPG) procedure. This consists of (1) ileostomy; (2) creation of a longitudinal side-to-side ileocolostomy between normal ileum and aganglionic ascending colon, forming a CPG; and (3) the definitive pull-through procedure. In all patients, the initial course after ileostomy was complicated by severe diarrhea, which was significantly improved by creation of the CPG. At the definitive operation several months later, the mesocolon attached to the CPG was severed to mobilize the ileocolostomy segment to the distal pelvis. Four patients in this series have been followed for 5 to 8 years. No patient has developed enterocolitis requiring hospitalization. Body weight became normal for age in all patients within 4 years of the definitive operation.

Alternative operative procedure for total colonic aganglionosis

The authors have utilized a technique recently described by Boley as the corrective procedure in two patients with complex long segment aganglionosis. The one-stage operation combines a right colon onlay patch for enhanced absorptive and reservoir purposes with an ileoendorectal pull-through. Both patients had only 3 to 4 stools per day by the end of the first postoperative month. The obligatory period of intestinal adaptation needed to achieve an acceptable stooling pattern is significantly reduced in comparison with results obtained with other commonly used procedures.

Is preserving the entire aganglionic colon reasonable in the surgical treatment of total colonic aganglionosis?

Clinical reports describe an increased incidence of severe enterocolitis in infants with total colonic aganglionosis (TCA) following the Martin extended Duhamel procedure using the entire aganglionic colon. This study evaluates the efficacy of this procedure in an experimental model of TCA in comparison with an antimesenteric aganglionic colon patch in rats. TCA was produced by serosal application of 0.1% benzalkonium chloride in 18 Sprague-Dawley rats (250 g). Five additional rats served as operated controls. Ileoanal pull-through was performed in 18 TCA rats, in conjunction with the Martin extended Duhamel procedure using the entire colon in six rats, with an aganglionic colon patch in nine (using the right [3 rats], transverse [3 rats] and left [3 rats] colon), and without other procedures in three rats. Animals were evaluated for survival, weight change, food intake, stool consistency and volume, barium enema, complete blood cell count (CBC), total protein, and serum electrolytes at 4 and 12 weeks. Survival was 83% (5/6) rats with the Martin procedure, 100% in the nine rats with various colon patches, zero in three rats with ileoanal pull-through alone, and 100% in controls. Rats with the Martin procedure gained 2.2 +/- 3.27% of preoperative weight, while controls gained 11.2 +/- 0.52% at 4 weeks. All other rats showed an early weight loss. At 12 weeks, right and transverse colon patched rats had weight gain. Blood count and laboratory studies were similar in each group. Barium enema showed rapid transit in rats with ileoanal pull-through, and slower transit in rats with colon patches or the Martin procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Chemically induced bowel denervation improves survival in short bowel syndrome

This study evaluates the effect of chemically induced bowel denervation on survival, weight gain or loss, transit time, and d-xylose absorption in rats following 80% small bowel resection. Forty-three male Sprague-Dawley rats (150 g) underwent 80% midsmall bowel resection and anastomosis. Twenty rats were short bowel controls (group I). In 23 rats (group II), a 2.0 cm segment of jejunum proximal to the anastomosis was denervated by application of 0.1% benzalkonium chloride (BK) for 30 minutes. Ten additional rats underwent sham laparotomy without bowel resection. Five remained untreated (group III) and in 5 (BK) denervation was added (group IV). Bowel denervation was confirmed by histologic study in all (BK) rats. Weight and daily food and water intake were measured for 30 days and the groups compared. Weight in group I was 43.8 +/- 52.9 g, group II 95.0 +/- 50.1, (P less than .005), group III 177 g, and group IV 175 g. Food intake was greater in group I than II (P less than .05) and was similar to groups III and IV. Water intake calculated as animal weight (g)/mL H2O ingested was lowest in group I (P less than .05). Mortality was 30% in group I (6/20) and only 8.6% in group II (2/23). No deaths were observed in unresected controls (III and IV). Twenty-four additional rats were evaluated for d-xylose absorption and transit time by bringing out a loop enterostomy 10.0 cm from the Ligament of Treitz. Twelve rats were ostomy controls (group V).(ABSTRACT TRUNCATED AT 250 WORDS)