1
|
Eeftinck Schattenkerk LD, Musters GD, de Jonge WJ, van Heurn L(E, Derikx JPM. Should primary anastomosis be considered more? A retrospective analysis of anastomotic complications in young children. WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000565. [PMID: 37671119 PMCID: PMC10476123 DOI: 10.1136/wjps-2023-000565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/26/2023] [Indexed: 09/07/2023] Open
Abstract
Objective Little is known about intestinal anastomotic leakage and stenosis in young children (≤3 years of age). The purpose of this study is to answer the following questions: (1) what is the incidence of anastomotic stenosis and leakage in infants? (2) which surgical diseases entail the highest incidence of anastomotic stenosis and leakage? (3) what are perioperative factors associated with anastomotic stenosis and leakage? Methods Patients who underwent an intestinal anastomosis during primary abdominal surgery in our tertiary referral centre between 1998 and 2018 were retrospectively included. Both general incidence and incidence per disease of anastomotic complications were determined. Technical risk factors (location and type of anastomosis, mode of suturing, and suture resorption time) were evaluated by multivariate Cox regression for anastomotic stenosis. Gender and American Society of Anaesthesiology (ASA) score of ≥III were evaluated by χ2 test for anastomotic leakage. Results In total, 477 patients underwent an anastomosis. The most prominent diseases are intestinal atresia (30%), Hirschsprung's disease (29%), and necrotizing enterocolitis (14%). Anastomotic stenosis developed in 7% (34/468) of the patients with highest occurrence in necrotizing enterocolitis (14%, 9/65). Colonic anastomosis was associated with an increased risk of anastomotic stenosis (hazard ratio (HR) =3.6, 95% CI 1.8 to 7.5). No technical features (type of anastomosis, suture resorption time and mode of suturing) were significantly associated with stenosis development. Anastomotic leakage developed in 5% (22/477) of the patients, with the highest occurrence in patients with intestinal atresia (6%, 9/143). An ASA score of ≥III (p=0.03) and male gender (p=0.03) were significantly associated with anastomotic leakage. Conclusions Both anastomotic stenosis and leakage are major surgical complications. Identifying more patient specific factors can result in better treatment selection, which should not solely be based on the type of disease.
Collapse
Affiliation(s)
- Laurens D. Eeftinck Schattenkerk
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gijsbert D. Musters
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Wouter J. de Jonge
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - L.W. (Ernest) van Heurn
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joep PM Derikx
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Kwon YJ, Kwon H, Namgoong JM, Kim SC, Kim DY. Redo pull-through for postoperative complications following pull-through in Hirschsprung disease: a single center experience. Ann Surg Treat Res 2023; 105:57-62. [PMID: 37441321 PMCID: PMC10333807 DOI: 10.4174/astr.2023.105.1.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/15/2023] [Accepted: 06/14/2023] [Indexed: 07/15/2023] Open
Abstract
Purpose Although surgical management of Hirschsprung disease (HD) is effective in most patients, some patients experience long-term postoperative complications, and require redo pull-through (PT). The present study evaluated clinical outcomes of redo PT in HD patients at a single center. Methods Patients with HD who underwent redo PT procedures between 2003 and 2019 were retrospectively reviewed. Results Thirteen patients were included. Five (38.5%) had undergone initial PT surgery at our center and 8 (61.5%) at other centers. Redo PT procedures were transanal endorectal PT in 12 patients (92.3%) and the posterior sagittal approach in 1 patient (7.7%). Indications for redo PT included pathologic misdiagnosis in 8 patients (61.5%); stricture in 2 (15.4%); and rectal stenosis, obstructing Duhamel pouch and remnant septum in 1 each (7.7%). At a median follow-up of 68 months (range, 3-227 months) after redo PT, 8 patients (61.5%) had normal bowel function, 2 (15.4%) had incontinence, and 1 (7.7%) had constipation. Conclusion Redo PT procedures could be an effective approach for improving obstructive symptoms in HD patients with anatomic or pathologic reasons following primary PT. Careful selection of patients and discreet indications for redo PT are crucial.
Collapse
Affiliation(s)
- Yong Jae Kwon
- Department of Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Hyunhee Kwon
- Division of Pediatric Surgery, Asan Medical Center Children’s Hospital, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Man Namgoong
- Division of Pediatric Surgery, Asan Medical Center Children’s Hospital, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Cheol Kim
- Division of Pediatric Surgery, Asan Medical Center Children’s Hospital, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Yeon Kim
- Division of Pediatric Surgery, Asan Medical Center Children’s Hospital, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
3
|
Li Q, Zhang Z, Xiao P, Ma Y, Yan Y, Jiang Q, Low Y, Li L. Surgical approach and functional outcome of redo pull-through for postoperative complications in Hirschsprung's disease. Pediatr Surg Int 2021; 37:1401-1407. [PMID: 34417631 DOI: 10.1007/s00383-021-04965-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
AIM To review our surgical experience and outcome of redo pull-through for various postoperative complications of Hirschsprung's disease. METHODS A retrospective study was performed on children who underwent redo pull-through from 2016 to 2019. Operative methods and functional outcomes were compared between those with anastomotic complications (stricture and fistula, n = 12) and patients without anastomotic complications (n = 24) such as residual aganglionosis/transition zone, twisted pull-through and tight soave cuff. RESULT 36 Patients (29 male and 7 female) were included with median age 6 (0.1-54) months at primary and 36 (9-144) months at redo pull-through. A transanal rectal mucosectomy and partial internal anal sphincterectomy (TRM-PIAS) pull-through with laparoscopic (n = 10, 27.8%) or laparotomy (n = 26, 72.2%) assisted techniques were performed for all patients during redo procedure. Patients with anastomotic complications had lower incidence of successful laparoscopic pull-through (0%), higher postoperative complications (25%) after redo surgery, but similar functional outcomes compared to those without anastomotic complications (41.6% underwent laparoscopic surgery, 4.2% complications). Patients with partial colectomy had significantly less soiling (36.4%) and enterocolitis (0%) compared to those with subtotal/total colectomy (79.2% soiling and 58.3% enterocolitis). CONCLUSION TRM-PIAS with/without laparoscopic-assisted redo pull-through was effective in treating various complications after primary pull-through. The functional outcome is strongly associated with the length of residual colon after redo pull-though.
Collapse
Affiliation(s)
- Qi Li
- Department of General Surgery, Capital Institute of Pediatrics, Beijing, China
| | - Zhen Zhang
- Department of General Surgery, Capital Institute of Pediatrics, Beijing, China
| | - Ping Xiao
- Department of Pathology, Capital Institute of Pediatrics, Beijing, China
| | - Ya Ma
- Department of Ultrasound, Capital Institute of Pediatrics, Beijing, China
| | - Yuchun Yan
- Department of Radiology, Capital Institute of Pediatrics, Beijing, China
| | - Qian Jiang
- Department of Medical Genetics, Capital Institute of Pediatrics, Beijing, China
| | - Yee Low
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Long Li
- Department of General Surgery, Capital Institute of Pediatrics, Beijing, China.
| |
Collapse
|
4
|
Demehri FR, Dickie BH. Reoperative techniques and management in Hirschsprung disease: a narrative review. Transl Gastroenterol Hepatol 2021; 6:42. [PMID: 34423163 DOI: 10.21037/tgh-20-224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/12/2020] [Indexed: 11/06/2022] Open
Abstract
The majority of children who undergo operative management for Hirschsprung disease have favorable results. A subset of patients, however, have long-term dysfunctional stooling, characterized by either frequent soiling or obstructive symptoms. The evaluation and management of a child with poor function after pull-through for Hirschsprung disease should be conducted by an experienced multidisciplinary team. A systematic workup is focused on detecting pathologic and anatomic causes of pull-through dysfunction. This includes an exam under anesthesia, pathologic confirmation including a repeat biopsy, and a contrast enema, with additional studies depending on the suspected etiology. Obstructive symptoms may be due to technique-specific types of mechanical obstruction, histopathologic obstruction, or dysmotility-each of which may benefit from reoperative surgery. The causes of soiling symptoms include loss of the dentate line and damage to the anal sphincter, which generally do not benefit from revision of the pull-through, and pseudo-incontinence, which may reveal underlying obstruction. A thorough understanding of the types of complications associated with various pull-through techniques aids in the evaluation of a child with postoperative dysfunction. Treatment is specifically tailored to the patient, guided by the etiology of the patient's symptoms, with options ranging from bowel management to redo pull-through procedure. This review details the workup and management of patients with complications after pull-through, with a focus on the perioperative management and technical considerations for those who require reoperation.
Collapse
Affiliation(s)
- Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
5
|
Peng C, Chen Y, Pang W, Zhang T, Wang Z, Wu D, Wang K. Redo Transanal Soave Pull Through with or without Assistance in Hirschsprung Disease: An Experience in 46 Patients. Eur J Pediatr Surg 2021; 31:182-186. [PMID: 32455444 DOI: 10.1055/s-0040-1710028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Transanal Soave pull through (PT) with or without assistance can be performed as a redo procedure for Hirschsprung disease (HD). In this study, we reviewed the indications and clinical outcomes of redo transanal Soave with or without assistance. MATERIALS AND METHODS A retrospective analysis was performed on patients who underwent redo transanal Soave with or without assistance in our hospital from 2004 to 2016, and did not have rectourethral fistula or rectovaginal fistula. The Krickenbeck classification system was used to evaluate postoperative bowel function. We analyzed the associated factors of the two main indications. RESULTS In this study, 46 patients were included, representing 5.6% of all HD PTs; 42 patients were initially operated elsewhere and 4 at our hospital. Primary PT surgeries included 38 transanal Soave, 2 Rehbein, 1 Martin, and 5 unknown procedures. The indications for redo PT were residual aganglionosis/transition zone PT (RA/TZPT) (27, 58.7%), anastomotic complication (14, 30.4%), and dilated distal segment (5, 10.9%). The median age of these 46 patients at primary and redo PT was 7.0 months (range, 0.4-137 months) and 45.5 months (range, 7-172 months), respectively. All 46 patients underwent redo transanal Soave PT; 43 patients (93.5%) underwent transanal Soave with laparotomy (n = 42) or laparoscopy (n = 1), and another 3 patients underwent transanal Soave PT. Six patients (13%) experienced complications within 30 days after redo surgery. A total of 43 patients were followed up, and the median follow-up period was 100 months (range, 35-180 months). Two patients could not hold back defecation in some inconvenient conditions. Sixteen patients (37.2%) had soiling, and 8 (18.6%) of 16 patients complained frequent soiling occurrence (more than 1/week). Only one patient complained of constipation (grade 1). Patients with anastomotic complication had more early postoperative complication and higher rate of soiling than patients with RA/TZPT, but there was no statistical difference (p = 0.672 and p = 0.105). CONCLUSION Transanal Soave PT with or without assistance was effective in resolving different problems after initial PT, while soiling was the most common postoperative problem, especially patients with anastomotic complication.
Collapse
Affiliation(s)
- Chunhui Peng
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yajun Chen
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wenbo Pang
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Tingchong Zhang
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zengmeng Wang
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Dongyang Wu
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Kai Wang
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
6
|
Kyrklund K, Sloots CEJ, de Blaauw I, Bjørnland K, Rolle U, Cavalieri D, Francalanci P, Fusaro F, Lemli A, Schwarzer N, Fascetti-Leon F, Thapar N, Johansen LS, Berrebi D, Hugot JP, Crétolle C, Brooks AS, Hofstra RM, Wester T, Pakarinen MP. ERNICA guidelines for the management of rectosigmoid Hirschsprung's disease. Orphanet J Rare Dis 2020; 15:164. [PMID: 32586397 PMCID: PMC7318734 DOI: 10.1186/s13023-020-01362-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/18/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hirschsprung's disease (HSCR) is a serious congenital bowel disorder with a prevalence of 1/5000. Currently, there is a lack of systematically developed guidelines to assist clinical decision-making regarding diagnostics and management. AIMS This guideline aims to cover the diagnostics and management of rectosigmoid HSCR up to adulthood. It aims to describe the preferred approach of ERNICA, the European Reference Network for rare inherited and congenital digestive disorders. METHODS Recommendations within key topics covering the care pathway for rectosigmoid HSCR were developed by an international workgroup of experts from 8 European countries within ERNICA European Reference Network from the disciplines of surgery, medicine, histopathology, microbiology, genetics, and patient organization representatives. Recommendation statements were based on a comprehensive review of the available literature and expert consensus. AGREE II and GRADE approaches were used during development. Evidence levels and levels of agreement are noted. RESULTS Thirty-three statements within 9 key areas were generated. Most recommendations were based on expert opinion. CONCLUSION In rare or low-prevalence diseases such as HSCR, there remains limited availability of high-quality clinical evidence. Consensus-based guidelines for care are presented.
Collapse
Affiliation(s)
- Kristiina Kyrklund
- Department of Pediatric Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ivo de Blaauw
- Department of Surgery, Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Kristin Bjørnland
- Department of Pediatric Surgery, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Udo Rolle
- Department of Pediatric Surgery and Pediatric Urology, University Hospital Frankfurt, Frankfurt/M, Germany
| | - Duccio Cavalieri
- Department of Biology, University of Florence, A.Mor.Hi, The Italian Association for Hirschsprung's disease, Florence, Italy
| | - Paola Francalanci
- Pathology Unit, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Fabio Fusaro
- Neonatal Surgery Unit - Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Annette Lemli
- SoMA, The German patient support organization for anorectal malformations and Hirschsprung Disease, Munich, Germany
| | - Nicole Schwarzer
- SoMA, The German patient support organization for anorectal malformations and Hirschsprung Disease, Munich, Germany
| | - Francesco Fascetti-Leon
- Pediatric Surgery, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health; Department of Pediatric Gastroenterology, Great Ormond Street Hospital for Children, London, UK
| | | | - Dominique Berrebi
- Department of Pediatric Pathology, Hôpital Universitaire Robert Debré, Paris Diderot University, Paris, France
| | - Jean-Pierre Hugot
- Department of Pediatric Gastroenterology, Hôpital Universitaire Robert Debré, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Célia Crétolle
- Department of Pediatric Surgery, University Hospital Necker-Enfants Malades, APHP centre, Paris University, Paris, France
| | - Alice S Brooks
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert M Hofstra
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Tomas Wester
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
7
|
Kapur RP, Smith C, Ambartsumyan L. Postoperative Pullthrough Obstruction in Hirschsprung Disease: Etiologies and Diagnosis. Pediatr Dev Pathol 2020; 23:40-59. [PMID: 31752599 DOI: 10.1177/1093526619890735] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Some patients continue to have obstructive symptoms and/or incontinence after pullthrough surgery for Hirschsprung disease. Incontinence can be due to injury to the anal sphincter and/or dentate line, abnormal colonic motility (nonretentive), or a chronic large stool burden (retentive). A diagnostic algorithm based on clinical and pathological evaluations can be applied to distinguish potential etiologies for obstructive symptoms, which segregate into anatomic (mechanical or histopathological) or physiologic subgroups. Valuable clinical information may be obtained by anorectal examination under anesthesia, radiographic studies, and anorectal or colonic manometry. In addition, histopathological review of a patient's original resection specimen(s) as well as postoperative biopsies of the neorectum usually are an important component of the diagnostic workup. Goals for the surgical pathologist are to exclude incomplete resection of the aganglionic segment or transition zone and to identify other neuromuscular pathology that might explain the patient's dysmotility. Diagnoses established from a combination of clinical and pathological data dramatically alter management strategies. In rare instances, reoperative pullthrough surgery is required, in which case the pathologist must be aware of histopathological features specific to redo pullthrough resection specimens.
Collapse
Affiliation(s)
- Raj P Kapur
- Department of Pathology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Caitlin Smith
- Department of Pediatric Surgery, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Lusine Ambartsumyan
- Department of Gastroenterology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| |
Collapse
|
8
|
Elsherbeny M, Abdelhay S. Obstructive complications after pull-through for Hirschsprung’s disease: different causes and tailored management. ANNALS OF PEDIATRIC SURGERY 2019. [DOI: 10.1186/s43159-019-0003-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Most children have a successful outcome after a pull-through for Hirschsprung’s disease. Some may have persisting symptoms after the pull-through. They could be managed conservatively, need minor surgical procedures, or a redo pull-through will be required. In this study, we presented our results in the management of the obstructive complications after pull-through for Hirschsprung’s disease.
Results
During the specified time period from January 2011 to December 2015, 21 patients presented to our department with persistent constipation or recurrent enterocolitis after a pull-through for Hirschsprung’s disease. Their age ranged between 4 months and 5 years (mean 2 years, median 2.5 years). They were 13 males and 8 females. Eleven patients underwent initial trans-anal endorectal pull-through, 4 underwent Duhamel procedure, and 6 underwent abdominal Soave technique. Three of the 11 patients with initial trans-anal endorectal pull-through had a tight anastomotic stricture which responded well to dilatation, 2 had a long muscular cuff which was incised laparoscopically, 4 had spasm of the internal anal sphincter which was relieved by sphincterotomy, and 2 had residual aganglionosis which required a redo pull-through. Two of the 4 patients who underwent initial Duhamel procedure had a long spur which was divided using a stapler, and the other 2 patients had residual aganglionosis which required a redo pull-through. One of the 6 patients who underwent abdominal Soave technique developed a long tight stricture and required a redo pull-through; in 1 patient, biopsy confirmed hypoganglionosis of the whole colon and was managed medically, and 4 patients had spasm of the internal anal sphincter which was relieved in 1 of them by sphincterotomy and in 2 by botulinum toxin injection while the remaining patient did not improve by either sphincterotomy or botulinum toxin injection.
Conclusion
Persistent constipation or recurrent enterocolitis after pull-through for Hirschsprung’s disease should be managed according to the cause; they could be managed medically by simple surgical procedures, or a redo pull-through may be required.
Collapse
|
9
|
Ralls MW, Fallon BP, Ladino-Torres M, Ehrlich PF, Jarboe MD. Salvage Laparoscopic-Assisted Anorectoplasty after Failed Vestibular Fistula Repair Using Magnetic Resonance Image Guidance. European J Pediatr Surg Rep 2019; 7:e12-e15. [PMID: 31131185 PMCID: PMC6533101 DOI: 10.1055/s-0039-1688486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/23/2019] [Indexed: 01/02/2023] Open
Abstract
Patients with vestibular fistula have a good functional outcome after posterior sagittal anorectoplasty (PSARP). While continence is often preserved, close follow-up and management of constipation are often required. Redo anorectal surgery has been associated with worse functional outcomes compared with primary procedures, possibly due to injury and scarring of the pelvic floor musculature and sphincter complex. Our group has a growing experience in the use of intraoperative real-time magnetic resonance imaging (MRI) for anorectal malformation repairs. We present a case of salvage operation of a failed PSARP for vestibular fistula.
Collapse
Affiliation(s)
- Matthew W Ralls
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Brian P Fallon
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Maria Ladino-Torres
- Section of Pediatric Radiology, Department of Radiology, University of Michigan Medical School and C.S. Mott Children's Hospital, Ann Arbor, Michigan, United States
| | - Peter F Ehrlich
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, United States
| | - Marcus D Jarboe
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, United States.,Division of Interventional Radiology, Department of Radiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, United States
| |
Collapse
|
10
|
Gupta DK, Khanna K, Sharma S. Experience with the Redo Pull-Through for Hirschsprung's Disease. J Indian Assoc Pediatr Surg 2019; 24:45-51. [PMID: 30686887 PMCID: PMC6322179 DOI: 10.4103/jiaps.jiaps_52_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aim: This study aims to evaluate the need of Redo pull-through (Re PT) procedures for Hirschsprung's disease (HD) and suggest preventive strategies. Materials and Methods: Patients who underwent redo procedures for HD from 1980 to 2016 by a single surgeon were retrospectively reviewed. Results: Of 167 patients operated for HD, 32 underwent Re PT; 7 were previously operated by the same surgeon, while 25 were referred from outside. Indication for Re PT included residual disease including the rectal pouch following-Duhamel (12), false-negative biopsy (3), retraction of bowel (5), anorectal stricture (2), bowel twist (1), cuff inversion (2), postmyectomy continued symptoms after primary PT (1), fecal fistula (1), Re PT after surgery for adhesive intestinal obstruction (3), bleeding (1), and combination of causes, including scarred perineum (1). Age at follow-up ranged from 2.5 to 26 years. Proximal diversion was performed in 19 and 14 underwent open Scott Boley's/Soave PT and 5 ileoanal anastomosis. Of the remaining, nondiverted 13 patients, 5 underwent transanal endorectal PT and 8 underwent PT of colostomy. Conclusions: Most patients of Re PT came after an initial Duhamel's procedure. Retraction of bowel, inversion of cuff, twist, distal bowel stricture, and perianal fibrosis were found after Scott Boley procedure. Proper planning with an initial diversion, nutritional buildup, barium study evaluation, frozen section facility, experienced pathologist, and an expert surgeon are prerequisites for a successful outcome after an initial as well as Re PT.
Collapse
Affiliation(s)
- Devendra K Gupta
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Kashish Khanna
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shilpa Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
11
|
Jiang M, Li CL, Cao GQ, Tang ST. Laparoscopic Redo Pull-Through for Hirschsprung Disease Due to Innervation Disorders. J Laparoendosc Adv Surg Tech A 2018; 29:424-429. [PMID: 30461345 DOI: 10.1089/lap.2018.0551] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Reoperations in Hirschsprung disease (HD) may be required due to pathological problems. We conducted this retrospective study to determine the incidence and outcomes of innervation disorders among HD patients following pull-through operation. MATERIALS AND METHODS We retrospectively reviewed the data of patients who underwent pull-through procedure from 2005 to 2017. Only patients who underwent reoperation due to histological disorders were analyzed. Patients with mechanical obstruction that caused recurrent constipation were excluded. RESULTS There were 836 patients who got treated for HD in our department during the study period, and of these, 72 (8.6%) had redo operation. Thirty-one out of the 72 patients (43.1%) showed abnormal histological findings on full-thickness biopsies. Primary operations included totally transanal endorectal pull-through (18), laparoscopic-assisted Duhamel (5) and Soave (8) techniques. The full-thickness biopsies before the reoperation showed aganglionosis (n = 8, 1 was residual resulted from false-positive intraoperative frozen sections and 7 were acquired aganglionosis), transition-zone (3), intestinal neuronal dysplasia B (IND B, n = 15), and hypoganglionosis (5). The final diagnoses according to the resection specimens of the initial and second operations were HD (11), Hirschsprung-associated IND B (15), and Hirschsprung-associated hypoganglionosis (5). Reoperation consisted of laparoscopic-assisted Duhamel (14) and Soave procedures (17). In these patients, 77.4% had excellent/good bowel function, 16.1% were fair, and 6.5% were poor. CONCLUSIONS Innervation disorders are still the underlying causes of recurrent constipation in almost half of all HD patients requiring redo pull-through operation. Most patients have a satisfactory outcome after redoing laparoscopic-assisted Duhamel or Soave operation.
Collapse
Affiliation(s)
- Meng Jiang
- 1 Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China.,2 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chang-Li Li
- 3 Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Wuhan, China
| | - Guo-Qin Cao
- 2 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shao-Tao Tang
- 2 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
12
|
Xiao SJ, Zhu XC, Deng H, Zhou WP, Yang WY, Yuan LK, Zhang JY, Tian S, Xu L, Zhang L, Xia HM. Gene expression profiling coupled with Connectivity Map database mining reveals potential therapeutic drugs for Hirschsprung disease. J Pediatr Surg 2018; 53:1716-1721. [PMID: 29605259 DOI: 10.1016/j.jpedsurg.2018.02.060] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 02/12/2018] [Accepted: 02/27/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hirschsprung disease (HD) is a congenital intestinal anomaly resulting from a failure to form enteric ganglia in the lower bowel. Surgery is the main therapeutic strategy, although neural stem cell transplantation has recently shown promise. However, HD remains a challenging disorder to treat. Our aim was to identify drugs that could counteract the dysregulated pathways in HD and could thus be potential novel therapies. METHODS We used microarray analysis to identify genes differentially expressed in ganglionic and aganglionic bowel samples from eight children with HD. The signature of differentially expressed genes was then used as a search query to explore the Connectivity Map (cMAP), a transcriptional expression database that catalogs gene signatures elicited by chemical perturbagens. RESULTS We uncovered several dysregulated signaling pathways, and in particular regulation of neuron development, in HD. The cMAP search identified some compounds with the potential to counteract the effects of the dysregulated molecular signature in this disease. One of these, pepstatin A, was recently shown to rescue the migration defects observed in a mouse model of HD, providing strong support for our findings. CONCLUSIONS This study advances our understanding of the molecular changes in HD and identifies several potential pharmacological interventions. Further testing of the identified compounds is warranted.
Collapse
Affiliation(s)
- Shang-Jie Xiao
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Xiao-Chun Zhu
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Hua Deng
- Translational Medicine Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Wei-Ping Zhou
- Translational Medicine Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Wen-Yi Yang
- Department of Neonatology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Li-Ke Yuan
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Jiang-Yu Zhang
- Department of Pathology, Guangdong Women and Children Hospital, Guangzhou, China
| | - Song Tian
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Lu Xu
- Department of Neonatal Surgery, Guangdong Women and Children Hospital, Guangzhou, China
| | - Liang Zhang
- Translational Medicine Center, Guangdong Women and Children Hospital, Guangzhou, China.
| | - Hui-Min Xia
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| |
Collapse
|
13
|
The anal canal is the fine line between "fecal incontinence and colitis" after a pull-through for Hirschsprung disease. J Pediatr Surg 2017; 52:2011-2017. [PMID: 28941931 DOI: 10.1016/j.jpedsurg.2017.08.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 08/28/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND/PURPOSE Fecal incontinence after a pull-through is associated with different factors, although damage to the anal canal seems to be the most important. The objective of this article is to identify the variables related to the presence of fecal control and colitis in a homogeneous group of children after pull-through. METHODS A retrospective cross-sectional study was performed in patients with HD for evaluation of post-operative problems from May 2014 to November 2016. The patients (39) had a transanal approach and were divided into two groups: Group 1 patients with fecal continence and Group 2 patients with fecal incontinence. RESULTS Group 1 patients (13) had the anastomosis in the rectum, no damage to the anal canal, and a positive history of colitis. Group 2 (26) had the anastomosis at the skin, anoderm, pectinate line, or a combination of these and a negative history of colitis. CONCLUSIONS We demonstrated that patients with a technical error in the anastomosis have fecal incontinence, but not colitis. Preservation of the anal canal is associated with fecal control and colitis because it is a high-pressure zone. Education for proper identification of the anal canal during a pull-through is an absolute necessity. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.
Collapse
|
14
|
Dingemans A, van der Steeg H, Rassouli-Kirchmeier R, Linssen MW, van Rooij I, de Blaauw I. Redo pull-through surgery in Hirschsprung disease: Short-term clinical outcome. J Pediatr Surg 2017; 52:1446-1450. [PMID: 27765267 DOI: 10.1016/j.jpedsurg.2016.09.059] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 09/19/2016] [Indexed: 01/19/2023]
Abstract
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.
Collapse
Affiliation(s)
- Ajm Dingemans
- Department of Surgery - Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Hjj van der Steeg
- Department of Surgery - Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - R Rassouli-Kirchmeier
- Department of Surgery - Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - M W Linssen
- Department of Surgery - Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Ialm van Rooij
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - I de Blaauw
- Department of Surgery - Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands.
| |
Collapse
|
15
|
Abstract
Pullthrough procedures for Hirschsprung diseases typically have favorable results. However, some children experience long-term postoperative complications comprising stooling disorders, such as intermittent enterocolitis, severe stool retention, intestinal obstruction, as well as incontinence. Reoperative Hirschsprung Disease surgery is complex. This begins with the workup after the initial presentation following primary pullthrough, continues with the definitive surgical correction with redo pullthrough, and ends with long-term follow-up of individuals. The decision tree can be varied with each patient. The operating pediatric surgeon must be able to utilize different operations and treatment options available. While lesser procedures may provide relief in a select population, those with residual aganglionosis or transition zone pathology or mechanical problems will likely require a redo pullthrough. Thus, the diagnostic workup, treatment plan, and definitive surgical care should be coordinated, and executed by an experienced, specialized team at a pediatric referral center.
Collapse
Affiliation(s)
- Matthew W Ralls
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, 1540 East Hospital Drive, Ann Arbor, Michigan, 48109-4211, USA
| | - Arnold G Coran
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, 1540 East Hospital Drive, Ann Arbor, Michigan, 48109-4211, USA.
| | - Daniel H Teitelbaum
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, 1540 East Hospital Drive, Ann Arbor, Michigan, 48109-4211, USA
| |
Collapse
|
16
|
Abstract
Colorectal pediatric surgery is a diverse field that encompasses many different procedures. The pullthrough for Hirschsprung disease, the posterior sagittal anorectoplasty for anorectal malformations including complex cloaca reconstructions and the ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis present some of the most technically challenging procedures pediatric surgeons undertake. Many children prevail successfully following these surgical interventions, however, a small number of patients suffer from complications following these procedures. Anticipated postoperative problems are discussed along with medical and surgical strategies for managing these complications.
Collapse
Affiliation(s)
- Jason S Frischer
- Colorectal Center for Children, Division of Pediatric General & Thoracic Surgery, Cincinnati Children׳s Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Ave, MLC-2023, Cincinnati, Ohio 45229.
| | - Beth Rymeski
- Colorectal Center for Children, Division of Pediatric General & Thoracic Surgery, Cincinnati Children׳s Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Ave, MLC-2023, Cincinnati, Ohio 45229
| |
Collapse
|
17
|
Zimmer J, Tomuschat C, Puri P. Long-term results of transanal pull-through for Hirschsprung's disease: a meta-analysis. Pediatr Surg Int 2016; 32:743-9. [PMID: 27385111 DOI: 10.1007/s00383-016-3908-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2016] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Several operative techniques have been developed for the treatment of Hirschsprung's disease (HD) in the past decades. Since one-stage transanal pull-through (TAPT) was first performed in 1998, multiple studies have shown favourable short-and midterm results compared to other techniques with shorter operation length, shorter hospital stay and lower complication rates. The aim of this meta-analysis was to determine the longterm results following TAPT for HD. METHODS A systematic literature search for relevant articles was performed in four databases using the following terms "Hirschsprung/Hirschsprung's disease", "aganglionosis", "transanal", "pullthrough/pull-through", "longterm/long-term" "results", "follow-up" and "outcome". A meta-analysis was conducted for relevant articles for one-stage transanal pull-through for HD with a minimal follow-up of median 36 months regarding constipation, incontinence/soiling, enterocolitis and secondary operations. Odds ratio (OR) with 95 % confidence intervals (CI) were calculated. RESULTS Six studies with 316 patients matched the set criteria and were included in this analysis. Overall 45 (14.2 %) patients had disturbances of bowel function (OR 0.05, 95 % CI 0.03-0.07, p < 0.00001). Of these, 24 (53.3 %) patients experienced constipation, 8 (17.8 %) incontinence/soiling and 13 (28.9 %) enterocolitis. 10 (3.2 %) patients developed complications requiring secondary surgery. Most patients had a daily defecation frequency of 1-3 bowel movements 3 years postoperatively, resembling the stooling patterns of healthy controls. CONCLUSION Nearly 15 % of all patients operated with TAPT for HD continue to experience persistent bowel symptoms with constipation as the main problem. Further studies on the long-term outcome of children operated with this technique for HD are necessary to evaluate stooling patterns, urinary and sexual function as well as general quality of life during adolescence and adulthood.
Collapse
Affiliation(s)
- J Zimmer
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - C Tomuschat
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - P Puri
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.
- School of Medicine and Medical Science and Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland.
| |
Collapse
|
18
|
Li Q, Li L, Jiang Q, Zhang Z, Xiao P. The mid-term outcomes of TRM-PIAS, proctocolectomy and ileoanal anastomosis for total colonic aganglionosis. Pediatr Surg Int 2016; 32:477-82. [PMID: 26833313 DOI: 10.1007/s00383-016-3870-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 11/29/2022]
Abstract
AIMS The present study aimed to evaluate the mid-term outcomes of total colonic aganglionosis (TCA) after transanal rectal mucosectomy and partial internal anal sphincterectomy (TRM-PIAS), proctocolectomy and ileoanal anastomosis. PATIENTS AND METHODS From 2012 to 2014, 12 patients (7 boys; 58.3 %) diagnosed with TCA and treated with the TRM-PIAS, proctocolectomy and ileoanal anastomosis. Seven TCA patients who underwent laparotomy-assisted endorectal pull-through (LEPT) between 2010 and 2012 were used as control group. Demographic features and complication of the two groups were evaluated. The functional outcomes were assessed by using a score system. RESULTS The procedure was successfully performed in all patients. The incidence of postoperative HAEC in the TRM-PIAS group was significantly lower (25.0 vs 85.7 %; p < 0.05) than control group within the second postoperative year. The number of bowel movement after 3, 12 and 24 months postoperatively, was 8.5 ± 3.5, 5.3 ± 2.9 and 3.1 ± 1.4 (p < 0.05) per day, respectively, in the TRM-PIAS group. The soiling was noted in 50.0 % (n = 6) of the patients in the 6th postoperative month, and 25.0 % (n = 3) in the 24th postoperative month in the TRM-PIAS group. There was no significant difference in overall functional outcome between two groups, but the TRM-PIAS group was better in terms of bowel movement and soiling. CONCLUSION TRM-PIAS, proctocolectomy and ileoanal anastomosis might be an effective treatment for TCA. More prospective studies evaluating the TRM-PIAS technique over longer period and with greater sample size are needed to confirm the findings in this study.
Collapse
Affiliation(s)
- Qi Li
- Department of General Surgery, Capital Institute of Pediatrics, No. 2 Yabao Rd, 100020, Beijing, China.
| | - Long Li
- Department of General Surgery, Capital Institute of Pediatrics, No. 2 Yabao Rd, 100020, Beijing, China
| | - Qian Jiang
- Department of Medical Genetics, Capital Institute of Pediatrics, No. 2 Yabao Rd, 100020, Beijing, China
| | - Zhen Zhang
- Department of General Surgery, Capital Institute of Pediatrics, No. 2 Yabao Rd, 100020, Beijing, China
| | - Ping Xiao
- Department of Pathology, Capital Institute of Pediatrics, No. 2 Yabao Rd, 100020, Beijing, China
| |
Collapse
|
19
|
Xia X, Li N, Wei J, Zhang W, Yu D, Zhu T, Feng J. Laparoscopy-assisted versus transabdominal reoperation in Hirschprung's disease for residual aganglionosis and transition zone pathology after transanal pull-through. J Pediatr Surg 2016; 51:577-81. [PMID: 26651281 DOI: 10.1016/j.jpedsurg.2015.10.085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 09/26/2015] [Accepted: 10/29/2015] [Indexed: 12/11/2022]
Abstract
INTRODUCTION This study aims to describe laparoscopic reoperation (LSR) and compare its outcomes with transabdominal reoperation (TAR) for treating Hirschsprung's disease (HD). PATIENTS AND METHODS Eighteen patients with HD underwent reoperation for recurring constipation due to residual aganglionosis and transition zone pathology after an initial transanal procedure (LSR, n=10; TAR, n=8). Preoperative, operative and postoperative data were collected through patient follow-ups ranging from 13 to 75months to compare operative characteristics and postoperative outcomes between the two groups. RESULTS Ten patients underwent laparoscopic reoperation in our institution without major complications. On average, blood loss was significantly lower in the LSR group (mean±standard deviation, 83±32.7mL) than in the TAR group (185±69mL) (P=0.001). The LSR group had a shorter hospitalization time (12±2days) than the TAR group (15±2.1days) (P=0.02). There was no statistically significant difference in incidence of postoperative complications between the two groups. CONCLUSIONS LSR is safe and technically feasible in HD for recurring constipation due to residual aganglionosis and transition zone pathology, when initial transanal procedure fails. Although RA and TZP can be cured by reoperation, great efforts should be made to diminish the necessity of reoperation.
Collapse
Affiliation(s)
- Xue Xia
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China.
| | - Ning Li
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Jia Wei
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Wen Zhang
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Donghai Yu
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Tianqi Zhu
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China.
| |
Collapse
|
20
|
Redo pullthrough for Hirschsprung disease: a single surgical group's experience. J Pediatr Surg 2014; 49:1394-9. [PMID: 25148745 DOI: 10.1016/j.jpedsurg.2014.04.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 03/24/2014] [Accepted: 04/18/2014] [Indexed: 11/23/2022]
Abstract
INTRODUCTION This study presents our surgical experience for redo-pullthrough (RedoPT) for Hirschsprung disease (HD). It reviews the patient's clinical outcomes and assesses stooling patterns after RedoPT. METHODS A retrospective review of our institution's RedoPTs as well as one author's overseas cases was performed. Stooling scores were tabulated using an established survey tool and compared to primary PT matched patients. RESULTS Between 1974 and 2012, 46 individuals (52% males) underwent RedoPT, representing 3 percent of all HD pullthroughs. Median age at primary PT and RedoPT was 1year (range 1week-18years) and 3.5years (range 8weeks-41years), respectively. Indications for RedoPT were predominately for aganglionosis/transition zone pathology (71%); followed by stricture or an obstructing Duhamel pouch (19%), tight cuff (8%) and a twisted PT (4%). None were performed for an isolated clinical diagnosis of repeated bouts of enterocolitis. RedoPT surgical approach depended upon the initial pullthrough technique and any previous complications. Stooling scores were significantly (P<0.05) worse in the RedoPT patients compared to the historically-matched group of children undergoing a primary PT for HD (5.5±1.2 vs. 12.2±1.4, primary PT versus RedoPT, respectively). When breaking down this total score into individual parameters, stooling pattern scores (1.0±0.2 vs. 4.1±0.4, P=0.001) and enterocolitis scores (2.0±0.4 vs. 4.2±0.4, P=0.001) were statistically worse in the RedoPT group. Patients in both groups had similar overall continence rates. CONCLUSION Appropriately selected children undergoing a RedoPT can achieve good results, with comparable continence rates to those undergoing a primary PT.
Collapse
|
21
|
Bag MJ, Sáez T, Varas J, Vallejos H, Meléndez D, Salas S, Quiroga Y, Villagrán F, Montedonico S. Surgical acquired aganglionosis: myth or reality? Pediatr Surg Int 2014; 30:797-802. [PMID: 25023942 DOI: 10.1007/s00383-014-3539-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE A number of patients operated on for Hirschsprung disease continue to have constipation and abdominal distension for years after surgery. Some authors have proposed that ischemia during surgery may induce secondary aganglionosis. The aim of the present study was to study the effects of ischemia on the enteric nervous system of sigmoid colon in an animal model. METHODS A surgical model of colonic ischemia was created. 34 adult Sprague-Dawley rats underwent a laparotomy where the marginal arterioles of the sigmoid colon were ligated. After that, a section in the middle segment of the sigmoid colon was performed followed by an anastomosis. The presence of ischemia was assessed by measurement of visible light spectroscopy tissue oximetry and histological examination. Colonic function was assessed by evaluation of stool weight. Rats were killed at 1, 8 and 12 weeks after the operation. 12 rats were sham-operated. Enteric nervous system was evaluated by means of immunohistochemistry with NGFR p75. Quantitative analysis of the number of ganglia and ganglion cells in the myenteric plexus was performed. RESULTS The surgical model of colonic ischemia significantly decreased tissue oxygenation (pre-surgical = 54.69 ± 7.32 %; post-surgical = 27.37 ± 9.2 %; p < 0.001). There was no disturbance in body-weight gaining in experimental groups and daily stool output did not vary after surgery (pre-surgical = 4.24 ± 0.94 g; post-surgical = 3.82 ± 1 g; p = 0.09). All experimental groups showed persistent ganglia. However, there was a significant decrease in the number of ganglia in all the experimental groups compared to control (1w: 45.91 ± 7.66; 8w: 44.17 ± 10.56; 12w: 36.17 ± 15.06 vs control: 56.88 ± 8.66; p < 0.01). The number of total ganglion cells was significantly reduced only in the experimental group killed at week 12 compared to control (1w: 539 ± 167.58; 8w: 488.58 ± 154.41; 12w: 343.94 ± 161.91 vs control: 513.96 ± 126.97; p < 0.01). The rate of ganglion cells per ganglia was significantly higher in the groups killed at week 1 and 8 versus control group (1w: 11.63 ± 2.53; 8w: 11.11 ± 2.56; 12w: 9.34 ± 1.16 vs control: 9.02 ± 1.81; p < 0.05). CONCLUSION Long-term follow-up after surgically induced colonic ischemia in the rat showed a decreased number of ganglion cells and ganglia. Nevertheless, it did not produce aganglionosis.
Collapse
Affiliation(s)
- M J Bag
- Departamento de Ciencias Biomédicas, Edificio Bruno Günther, Escuela de Medicina, Universidad de Valparaíso, Hontaneda, 2664, Valparaiso, Chile
| | | | | | | | | | | | | | | | | |
Collapse
|