How the cause and cure of Hirschsprung's disease were discovered

Dr. Orvar Swenson and the Pull-Through

Dr. Orvar Swenson is best remembered for developing the Swenson pull-through, a technique he developed to treat Hirschsprung's disease. After graduating from Harvard Medical School and beginning his residency at Peter Bent Brigham Hospital, Dr. Swenson observed that patients with Hirschsprung's disease and toxic megacolon resumed normal bowel function after placement of transverse colostomies. His observation led to studying the patency of his patients’ colons using barium enema contrast studies. At the collapsed portion of the colon, he performed rectal biopsies leading to the discovery that the cause of Hirschsprung's disease is that the collapsed portion of the colon lacks the Auerbach plexus. The Swenson pull-through removes this aganglionic portion of the colon and cures the patient. His career grew from there as he traveled to academic institutions teaching his technique. He is remembered fondly for his contributions to pediatric surgery through the restructuring of pediatric surgery departments, pediatric surgery research, and writing and editing multiple volumes of Pediatric Surgery, the standard textbook for pediatric surgeons. He died peacefully in 2012 at the age of 103 years.

Hirschsprung's disease: A bridge for science and surgery

BACKGROUND/PURPOSE

Understanding the true nature of the disease provided the basis for appropriate surgery for Hirschsprung's disease some 60 years ago. Nevertheless, surgical outcome remains unsatisfactory. Advances in diagnosis and treatment will depend on the elucidation of the pathogenesis and disease heterogeneity.

METHODS

This lecture outlines the author's attempt in the past 30 years to bridge some of the gaps of knowledge in Hirschsprung's disease.

RESULTS

Studies of human fetal gut and aganglionic gut gave insight into the complexity of the human enteric nervous system, but the more fruitful studies came from genetic studies in which disease-causing genes were discovered, and the importance of noncoding mutations conferring disease susceptibility was unraveled. Animal models and pluripotent stem cell studies allowed elucidation of the interacting gene-cell-microenvironment signaling pathways for neural crest proliferation, migration, and differentiation.

CONCLUSION

Hirschsprung's disease has been a bridge for science and surgery. An integrative approach could provide breakthroughs in the diagnosis and treatment strategies of this complex condition, leading to improved outcome.

One-stage transanal endorectal pull-through for treatment of hirschsprung's disease in adolescents and adults

BACKGROUND

One-stage pull-through operation has become increasingly popular for treatment of Hirschsprung's disease. The one-stage transanal pull-through was introduced in the late 1990s and has rapidly replaced traditional procedures in infants and young children in many surgical centers.

OBJECTIVE

The aim of this study is to determine feasibility and safety of transanal primary repair in adolescent and adults.

METHODS

Fifteen patients who underwent transanal endorectal pull-through were prospectively studied. All patients presented by chronic refractory constipation with the age ranged from 11 to 22 years. The patients were followed up for a mean of 18 months. Anal continence and postoperative complication were evaluated.

RESULTS

Incomplete continence in the form of soiling occurred in four patients (26.6%) and improved gradually with conservative management. No patients suffered from complete incontinence. Anastomotic strictures occurred in two patients and were successfully treated with regular dilatations. One patient had continued outlet obstruction and revision was considered for him. One patient complicated with low perianal fistula which needed fistulectomy. There was no impotence in adults.

CONCLUSION

These findings indicate that one-stage transanal endorectal pull-through operation in adolescent and adults is feasible and safe.

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.

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.