Primary pull-through for Hirschsprung’s disease

Post-surgical Outcomes of Different Surgical Techniques in Hirschsprung's Disease: A Literature Review

Hirschsprung's disease (HD) is a rare condition that affects newborns and is characterized by the lack of ganglion cells in the colon. Typical symptoms include difficulty passing stool, vomiting, and trouble feeding. Various surgical methods are available to manage the condition. The aim of the study is to investigate and compare the post-surgical outcomes of different surgical techniques used in the treatment of HD. A thorough literature search was conducted using various electronic databases to identify relevant studies to be referred to. Double-blinded screening of the identified articles led to the final selection of 40 out of 440 HD, including transanal endorectal pull-through (TERPT), laparoscopic approaches, and modified techniques. Several studies have investigated surgical procedures for HD, including TERPT, laparoscopic methods, and modified techniques. These have shown positive outcomes, with fewer complications, improved bowel function, and favorable cosmetic results. Individual patient characteristics and surgeon expertise should guide procedure selection. Surgery for HD aims to restore normal bowel function, but post-surgical outcomes can include constipation or fecal incontinence. Complications like enterocolitis, anastomotic stricture, and sphincter damage may occur. Laparoscopic approaches have shorter hospital stays. However long-term follow-up is essential to assess quality of life, psychological well-being, and potential side effects.

Reoperation for Hirschsprung Disease: Two cases of Vanishing Ganglion Cells and Review of the Literature

Hirschsprung disease (HD) is characterized by circumferential aganglionosis of the rectum with variable proximal bowel involvement. The underlying pathogenesis is due to failure of caudal migration of neural crest cells during pre-natal development, causing functional bowel obstruction. Definitive therapy is surgical resection; however, a subset of patients will require reoperation. An important cause of reoperation is the rare but distinct entity described as the ganglion cell "vanishing" phenomenon. In this phenomenon, affected patients have normal circumferential ganglion cells present at the proximal margin during primary resection. They undergo a variable asymptomatic period post-primary resection but ultimately develop recurrent symptoms. Upon reoperation, ganglion cells seemingly vanish and are no longer present in the previously functioning and ganglionated bowel proximal to the initial anastomotic site. To further characterize and investigate this poorly understood pathology, here we present 2 cases of HD patients who required reoperation. Our small series implicates that an immune component may contribute as patient 2 had a brisk neurotrophic eosinophilic infiltrate only present in the reoperation specimen. However, this was not observed in patient 1. Other possible etiologies include post-operative ischemia/hypoxia, visceral neuropathy, or signaling abnormalities within the residual ganglion cells themselves.

The Technique of Mobilization of the Colon for Pull-Through Procedure in Hirschsprung’s Disease

Background

In patients with Hirschsprung's disease (HD), persistent obstructive symptoms may develop after surgery. The causes of mechanical obstruction may be a retraction of the pulled-through bowel due to insufficient mobilization of the mesentery or impaired blood supply in the area of the coloanal anastomosis in the case of excessive ligation of the supplying vessels. Leakage and stenosis are formidable complications and require repeated surgical intervention.

Objective

The purpose of this study is to describe our experience and short-term results of the developed method: mobilization of the descending colon for its pull-through during the surgical treatment of the children with HD, which allows ensuring good mobility to the descending colon and maintaining blood supply at the same time.

Methods

The medical records of 20 patients with rectosigmoid HD, who underwent parietal mobilization of the descending colon with preservation of the marginal artery, sigmoid arteries, and ligation of the left colon artery, were reviewed. This method is aimed at increasing the mobility of the brought-down bowel and maintaining the blood supply to the distal part of the brought-down bowel not only from the superior mesenteric artery but also from the lower one.

The SPSS Statistics 26.0 package was used for statistical analysis. To describe the analyzed data with a normal distribution, the mean values and the error of the mean were used. To determine the differences, Student’s t-test was used, and the differences were considered significant at a significance level of p < 0.05.

Results

In all patients, the postoperative period was uneventful, without complications. The patients were discharged for outpatient treatment on average on the seventh day after the surgery. In all cases, there were no signs of anastomotic leakage or stricture on follow-up after 6–12 months.

Conclusion

The method of mobilization of the colon in the rectosigmoid form of HD, parietal mobilization of the descending part of the colon preserving the marginal artery, sigmoid arteries, and ligating the left colon artery, can reduce the risk of complications by eliminating the tension of the descending colon.

Evaluation and treatment of the post pull-through Hirschsprung patient who is not doing well; Update for 2022

After operative intervention for Hirschsprung disease (HD) a child should thrive, be fecally continent, and avoid recurrent episodes of abdominal distention and enterocolitis. This is unfortunately not the case for a significant number of patients who struggle following their pull-through procedure. Many clinicians are puzzled by these outcomes as they can occur in patients who they believe have had a technically satisfactory described operation. This review presents an organized approach to the evaluation and treatment of the post HD pull-through patient who is not doing well. Patients with HD who have problems after their initial operation can have: (1) fecal incontinence, (2) obstructive symptoms, and (3) recurrent episodes of enterocolitis (a more severe subset of obstructive symptoms). After employing a systematic diagnostic approach, successful treatments can be implemented in almost every case. Patients may need medical management (behavioral interventions, dietary changes, laxatives, or mechanical emptying of the colon), a reoperation when a specific anatomic or pathologic cause is identified, or botulinum toxin when non-relaxing sphincters are the cause of the obstructive symptoms or recurrent enterocolitis.

Evaluation and Management of Persistent Problems After Surgery for Hirschsprung Disease in a Child

PURPOSE OF REVIEW

Ideally, after operative intervention, a child born with Hirschsprung disease (HD) should thrive, achieve fecal continence, and avoid recurrent episodes of abdominal distention and enterocolitis. However, a significant number of patients continue to struggle following their pull-through procedure. The purpose of this review is to present an organized and practical approach to the evaluation and management of the symptomatic patient post pull-through operation for HD.

RECENT FINDINGS

Children diagnosed with HD who are not doing well after their initial operation can be categorized in three distinct groups: (1) those that have fecal incontinence, (2) those with obstructive symptoms, and (3) those with recurrent episodes of enterocolitis. It is important to have a systematic diagnostic approach for these patients based on a comprehensive protocol. All three of these patient groups can be treated with a combination of either medical management, reoperation when a specific anatomic or pathologic etiology is identified, or botulinum toxin for non-relaxing sphincters contributing to the obstructive symptoms or recurrent enterocolitis. For patients not doing well after their initial pull-through, a systematic workup should be employed to determine the etiology. Once identified, a multidisciplinary and organized approach to management of the symptomatic patients can alleviate most post pull-through symptoms.

Transanal, full-thickness, Swenson-like approach for Hirschsprung disease

PURPOSE

Swenson's procedure for Hirschsprung disease (HD) was thought to disturb fecal, urinary, and ejaculatory functions leading to other approaches including the Soave and Duhamel techniques. Given our Center's experience with a full-thickness rectal dissection for anorectal malformations, and using the new transanal concept, we chose to apply these ideas to the primary treatment of HD, and describe technical aspects and impact on fecal, urinary, and sexual function.

METHODS

We reviewed our series of HD patients who underwent a transanal, Swenson-like rectosigmoid dissection, assessing for postoperative stricture, anastomotic leak, enterocolitis, and long-term results for bowel, urinary, and sexual function.

RESULTS

Of 67 patients, 28 had a transanal resection, 5 had transanal plus laparoscopy, and 34 had transanal plus laparotomy, of those, 28 patients had a leveling colostomy prior to referral. The average length of resection was 27 cm ± 12.7 cm. Mean follow-up was 17.2 months (range 1-96 months). 44 patients were at least three years old at follow-up and were assessed for urinary and fecal continence; all (100%) had voluntary bowel movements and urinary continence. Enterocolitis occurred in 9 patients (14%) and constipation (requiring laxatives) occurred in 21 (32%). Of 24 male patients, 21 (88%) reported the occurrence of spontaneous erections post-operatively.

CONCLUSION

Our data support the fact that a modification of Swenson's original transabdominal dissection concept using the recently described transanal approach is an excellent technique for Hirschsprung, and produces excellent long-term outcomes for fecal and urinary continence, and seems to preserve erectile function.

The Hirschsprungs patient who is soiling after what was considered a "successful" pull-through

After surgery for Hirschsprungs disease, most children thrive, have few if any episodes of abdominal distention and enterocolitis, and are fecally continent. However, there exists a small group of patients who do not do well. Either they suffer from persistent distension and enterocolitis or they experience soiling after their pull-through procedure. These patients can be systematically evaluated and successfully treated with a combination of bowel management, dietary changes, and laxatives, and, in certain circumstances, a reoperation.

Outcome of transanal endorectal vs. transabdominal pull-through in patients with Hirschsprung's disease

INTRODUCTION

Various outcomes have been reported in patients with Hirschsprung's disease (HD) following transanal endorectal (TERPT) or conventional transabdominal (ABD) pull-through procedures. This study examined postoperative complications and the long-term outcome of TERPT vs. ABD pull-through for HD.

METHODS

Records were reviewed for 53 patients over 3 years of age in whom a pull-through procedure was performed for HD (TERPT, n = 24; ABD, n = 29) between 1992 and 2007 at the Departments of Pediatric Surgery, University of Heidelberg and University Hospital of Mannheim, and their families were interviewed and scored via a thorough 15-item, post-pull-through, long-term outcome questionnaire. Total scores ranged from 0 to 40: 0 to 10, excellent; 11 to 20, good; 21 to 30, fair; and 31 to 40, poor. Two-sided Fisher's exact test and analysis of variance were used to compare different variables in patients in the two groups with significance set at p < 0.05. Results are expressed as mean and standard deviation (SD).

RESULTS

Overall scores were similar (TERPT, n = 16, 7.3 +/- 6.6 vs. ABD, n = 23, 4.6 +/- 3.5, p = 0.11) and showed mainly excellent or good long-term outcome for TERPT (93.8%) and ABD (99.7%) pull-through procedures. The incidence of incontinence in children older than 3 years was insignificantly lower in ABD group (TERPT 18.7% vs. ABD 4.3 %, p = 0.15). Regarding the soiling score, however, the soiling tended to be significantly more severe after TERPT than ABD. For the TERPT procedure, the appearance of postoperative constipation, enterocolitis, anastomotic dehiscence, and symptomatic anastomotic stricture was lower but this was not statistically significant. After TERPT, patients started to feed sooner (TERPT 2.8 days vs. ABD 4.4 days, p = 0.005) and operating time (TERPT 133.2 min vs. ABD 204 min, p < 0.001) and hospital stay (TERPT 9.8 days vs. ABD 17.7 days, p < 0.001) were significantly shorter.

CONCLUSION

We employ the TERPT procedure as the first choice in children with rectosigmoid HD.

Evaluation and treatment of the patient with Hirschsprung disease who is not doing well after a pull-through procedure

Ideally, after operative management of Hirschsprung disease, a child should thrive, avoid recurrent episodes of abdominal distention and enterocolitis, and be fecally continent. However, there is a small group of patients that do not do well after their pull-through procedure. The purpose of this article is to describe our algorithm for the work-up and management of the post pull-through patient with Hirschsprung disease who is not doing well. These children can be categorized into 2 distinct groups: (1) those who are soiling, and (2) those who suffer from distention and enterocolitis. Both of these patient types can be systematically treated with a combination of bowel management, dietary changes, and laxatives, and, potentially, a redo operation, with the goal of having a clean, and happy child.

Hirschsprung disease and fecal incontinence: diagnostic and management strategies

PURPOSE

Ideally, fecal incontinence after operative management for Hirschsprung disease should not occur. If it does, it presents a formidable challenge. The purpose of this study was to describe the causes of fecal incontinence and present our algorithm for its treatment.

METHODS

We reviewed 68 patients with Hirschsprung disease and fecal incontinence referred to us after surgery at other institutions. Patients were evaluated by contrast enema and by an examination under anesthesia to look specifically for the integrity of the anal canal. They were designated as having a dilated colon and constipation or a nondilated colon and a tendency to diarrhea based on their stooling pattern and the appearance of the contrast enema. Medical management was started that included laxatives for those patients with a dilated colon and constipation. For those with a nondilated colon and tendency to diarrhea, the management included loperamide, pectin, and a special dietary regimen (constipating diet, 3 meals per day, and no snacks). Those patients who responded to medical management were retrospectively considered to have been pseudoincontinent. Those who did not respond were considered truly incontinent. The truly incontinent group was treated with enemas alone for those with a dilated colon, or enemas, loperamide, pectin, and a constipating diet for those with a nondilated colon and tendency to diarrhea.

RESULTS

Fifty-six patients had true incontinence and 12 had pseudoincontinence. Of the true incontinent group, 27 had a dilated colon and 29 had a nondilated colon. Five of these patients had a damaged or absent anal canal (anastomosis at the anal skin) and all of them had true incontinence. In the dilated colon group with true incontinence, 23 (85%) patients were clean after treatment. In the nondilated colon group with true incontinence, 23 (79%) were successfully treated. All patients in the pseudoincontinent groups had no soiling after treatment. Of 55 in the truly incontinent group, 39 (70%) had had an endorectal (Soave type) pull-through.

CONCLUSION

Fecal incontinence after operative management of Hirschsprung disease represents a serious problem. Poor surgical technique may be a contributing factor in some of the cases. Successful management depends on the appropriate evaluation, which determines whether the incontinence is true or pseudo, and the type of colon the patient has. Each category can be well treated, leading most of the time to a clean child.

Comparing cost and complications of primary and staged surgical repair of neonatally diagnosed Hirschsprung's disease

BACKGROUND/PURPOSE

We questioned whether primary surgical correction of neonatally diagnosed Hirschsprung's Disease (HD) incurs higher costs or increased incidence of adverse events (AE) when compared with staged repair.

METHODS

We reviewed the medical records of all neonates diagnosed with HD at our institution between 1997 and 2007. Sixty subjects fulfilled criteria for inclusion. Twenty-seven neonates had primary repair, and 33 had staged repair. We measured inflation-adjusted total costs, direct costs, and total charges and 6 AE between the 2 groups. A generalized linear model was used to examine differences between group variables.

RESULTS

We found no statistically significant difference in costs or AE between primary and staged repair. Inflation-adjusted median financial data for primary or staged repair were, respectively, as follows: total costs, $35,670 vs $38,538 (P = .617); direct costs, $18,453 vs $23,937 (P = .128); total charges, $107,315 vs $102,492 (P = .690). Adverse events occurred in 48% of primary repair subjects and 36% of staged repair subjects (P = .434); no single AE differed significantly between the two groups.

CONCLUSIONS

We found no statistical evidence that primary neonatal correction of HD adds cost or risk of AE when compared with a traditional staged approach in neonates who met inclusion criteria.

Ileocecal interposition for Hirschsprung's disease: a case report

An ileocecal interposition (ICI) between the descending colon and anus was performed in a girl, 14 months old, with congenital aganglionosis up to the sigmoid colon. The left colon could not safely be mobilised because the paracolic arcade had been interupted during a preceding colostomy construction. The functional result, 14 years after reconstruction, is excellent: 1-2 easy defecations per day with normal continence for flatus and stool. An ICI may be an appropriate rescue procedure, saving a maximum length of normally innervated bowel and providing a neorecta1 reservoir.

Laparotomic versus laparoscopic Duhamel pull-through for Hirschsprung disease in infants and children

PURPOSE

The aim of this study was to analyze the results from laparotomic and laparoscopic Duhamel pull-through in the treatment of Hirschsprung disease.

MATERIALS AND METHODS

In our department, the Duhamel pull-through technique was adopted in most patients and the laparoscopic technique used since 1999 follows the original Duhamel procedure. Patients were identified retrospectively and followed up in our outpatient clinic. Preoperative, operative, and postoperative data were collected and analyzed.

RESULTS

Between January 1992 and March 1999, 21 children with Hirschsprung disease underwent primary surgical correction using the classic open Duhamel pull-through. The mean age at operation was 14 months, the median operating time was 297 minutes, and the average postoperative stay was 10 days. From April 1999 to December 2003, 22 children underwent laparoscopic Duhamel pull-through. The mean age at operation was 14.6 months, the mean operative time was 253 minutes, and the mean postoperative stay was 6.8 days. The rates of early (4.7% vs. 4.7%) and late (19% vs. 23.8%) complications were similar in the two groups, but in the laparoscopic group the mean operative time and postoperative hospital stay were lower.

CONCLUSION

With these encouraging results, laparoscopic Duhamel pull-through has become our procedure of choice in the surgical management of Hirschsprung's disease.

Are the long-term results of the transanal pull-through equal to those of the transabdominal pull-through? A comparison of the 2 approaches for Hirschsprung disease

PURPOSE

The transanal endorectal pull-through (TERPT) is becoming the most popular procedure in the treatment of Hirschsprung disease (HD), but overstretching of the anal sphincters remains a critical issue that may impact the continence. This study examined the long-term outcome of TERPT versus conventional transabdominal (ABD) pull-through for HD.

METHODS

Records of 41 patients more than 3 years old who underwent a pull-through for HD (TERPT, n = 20; ABD, n = 21) were reviewed, and their families were thoroughly interviewed and scored via a 15-item post-pull-through long-term outcome questionnaire. Patients were operated on between the years 1995 and 2003. During this time, our group transitioned from the ABD to the TERPT technique. Total scoring ranged from 0 to 40: 0 to 10, excellent; 11 to 20 good; 21 to 30 fair; 31 to 40 poor. A 2-tailed Student t test, analysis of covariance, as well as logistic and linear regression were used to analyze the collected data with confidence interval higher than 95%.

RESULTS

Overall scores were similar. However, continence score was significantly better in the ABD group, and the stool pattern score was better in the TERPT group. A significant difference in age at interview between the 2 groups was noted; we therefore reanalyzed the data controlling for age, and this showed that age did not significantly affect the long-term scoring outcome between groups.

CONCLUSION

Our long-term study showed significantly better (2-fold) results regarding the continence score for the abdominal approach compared with the transanal pull-through. The stool pattern and enterocolitis scores were somewhat better for the TERPT group. These findings raise an important issue about the current surgical management of HD; however, more cases will need to be studied before a definitive conclusion can be drawn.