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Balela N, Fauzi AR, Nugroho N, Dwihantoro A, Gunadi. Prognostic factors for persistent obstructive symptoms in patients with Hirschsprung disease following pull-through. PLoS One 2023; 18:e0290430. [PMID: 37682877 PMCID: PMC10490837 DOI: 10.1371/journal.pone.0290430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/09/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Although most patients with Hirschsprung disease (HSCR) improve after pull-through, some patients still have persistent obstructive symptoms. Most previous studies reported persistent obstructive symptoms after pull-through in HSCR patients from developed countries. Our study determined the prognostic factors of persistent obstructive symptoms in patients with HSCR following pull-through from a particular developing country. METHODS A cross-sectional study was conducted using medical records of patients with HSCR at our institution from January 2017 to January 2022. RESULTS We ascertained 114 patients with HSCR: 79 males and 35 females. Most of them (90.4%) showed a short aganglionosis and underwent transanal endorectal pull-through (55.3%). Twenty-two percent of patients showed persistent obstructive symptoms following pull-through. Operative technique and age at definitive surgery were significantly associated with the persistent obstructive symptoms after pull-through (p = 0.011 and 0.019, respectively), while sex, aganglionic segment length, presence of global developmental delay, and Down syndrome were not (p = 0.873, 0.525, 0.647, and 0.301, respectively). Multivariate analysis revealed that age at pull-through was a significant independent factor for persistent obstructive symptoms after pull-through, with an odds ratio of 3.41 (95% CI = 1.18-9.91; p = 0.02). CONCLUSIONS Our study shows a moderate frequency of persistent obstructive symptoms after pull-through in our institution. In addition, patients who underwent pull-throughs at a younger age might have persistent obstructive symptoms following a definitive surgery. Our study provides new data on persistent obstructive symptoms after pull-through from a particular population that might be beneficial for pediatric surgeons' consideration before performing definitive surgery on patients with HSCR.
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Affiliation(s)
- Naisya Balela
- Faculty of Medicine, Department of Surgery, Pediatric Surgery Division, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Aditya Rifqi Fauzi
- Faculty of Medicine, Department of Surgery, Pediatric Surgery Division, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Ninditya Nugroho
- Faculty of Medicine, Department of Surgery, Pediatric Surgery Division, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Andi Dwihantoro
- Faculty of Medicine, Department of Surgery, Pediatric Surgery Division, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Gunadi
- Faculty of Medicine, Department of Surgery, Pediatric Surgery Division, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
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Moesch M, Usemann J, Bruder E, Romero P, Schwab C, Niesler B, Tapia-Laliena MA, Khasanov R, Nisar T, Holland-Cunz S, Keck S. Associations of Mucosal Nerve Fiber Innervation Density with Hirschsprung-Associated Enterocolitis: A Retrospective Three-Center Cohort Study. Eur J Pediatr Surg 2022. [PMID: 35777734 DOI: 10.1055/a-1889-6355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Hirschsprung's disease (HSCR) is a congenital intestinal neurodevelopmental disorder characterized by the absence of enteric ganglion cells in the distal colon. Although Hirschsprung-associated enterocolitis (HAEC) is the most frequent life-threatening complication in HSCR, to date reliable biomarkers predicting the likelihood of HAEC are yet to be established. We established a three-center retrospective study including 104 HSCR patients surgically treated between 1998 and 2019. MATERIALS AND METHODS Patient-derived cryopreserved or paraffin-preserved colonic tissue at surgery was analyzed via βIII-tubulin immunohistochemistry. We subsequently determined extrinsic mucosal nerve fiber density in resected rectosigmoid specimens and classified HSCR patients accordingly into nerve fiber-high or fiber-low groups. We compared the distribution of clinical parameters obtained from medical records between the fiber-high (n = 36) and fiber-low (n = 68) patient groups. We assessed the association between fiber phenotype and enterocolitis using univariate and multivariate logistic regression adjusted for age at operation. RESULTS Enterocolitis was more prevalent in patients with sparse mucosal nerve fiber innervation (fiber-low phenotype, 87%) compared with the fiber-high phenotype (13%; p = 0.002). In addition, patients developing enterocolitis had a younger age at surgery (3 vs. 7 months; p = 0.016). In the univariate analysis, the odds for enterocolitis development in the fiber-low phenotype was 5.26 (95% confidence interval [CI], 1.67-16.59; p = 0.005) and 4.01 (95% CI, 1.22-13.17; p = 0.022) when adjusted for age. CONCLUSION Here, we showed that HSCR patients with a low mucosal nerve fiber innervation grade in the distal aganglionic colon have a higher risk of developing HAEC. Consequently, histopathologic analysis of the nerve fiber innervation grade could serve as a novel sensitive prognostic marker associated with the development of enterocolitis in HSCR patients.
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Affiliation(s)
- Michèle Moesch
- Department of Pediatric Surgery, University Children's Hospital Basel, Basel, BS, Switzerland
| | - Jakob Usemann
- Department of Pediatric Pulmonology, UKBB Ringgold Standard Institution, Basel, BS, Switzerland
| | - Elisabeth Bruder
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Philipp Romero
- Division of Pediatric Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Constantin Schwab
- Institute of Pathology, University Hospital Heidelberg Institute of Pathology Ringgold Standard Institution, Heidelberg, Baden-Württemberg, Germany
| | - Beate Niesler
- Department of Human Molecular Genetics, University Hospital Heidelberg Institute of Human Genetics Ringgold Standard Institution, Heidelberg, Baden-Württemberg, Germany
| | | | - Rasul Khasanov
- Department of Pediatric Surgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Tauseef Nisar
- Department of Pediatric Surgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Stefan Holland-Cunz
- Department of Pediatric Surgery, University Children's Hospital Basel, Basel, BS, Switzerland
| | - Simone Keck
- Department of Pediatric Surgery, University Children's Hospital Basel, Basel, BS, Switzerland
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Yang W, Pham J, King SK, Newgreen DF, Young HM, Stamp LA, Hao MM. A Novel Method for Identifying the Transition Zone in Long-Segment Hirschsprung Disease: Investigating the Muscle Unit to Ganglion Ratio. Biomolecules 2022; 12:biom12081101. [PMID: 36008996 PMCID: PMC9406109 DOI: 10.3390/biom12081101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/01/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
Hirschsprung disease (HSCR) is characterised by the absence of enteric ganglia along variable lengths of the distal bowel. Current gold standard treatment involves the surgical resection of the defective, aganglionic bowel. Clear and reliable distinction of the normoganglionated bowel from the transition zone is key for successful resection of the entire defective bowel, and the avoidance of subsequent postoperative complications. However, the intraoperative nature of the tissue analysis and the variability of patient samples, sample preparation, and operator objectivity, make reproducible identification of the transition zone difficult. Here, we have described a novel method for using muscle units as a distinctive landmark for quantifying the density of enteric ganglia in resection specimens from HSCR patients. We show that the muscle unit to ganglion ratio is greater in the transition zone when compared with the proximal, normoganglionated region for long-segment HSCR patients. Patients with short-segment HSCR were also investigated, however, the muscle unit to ganglion ratio was not significantly different in these patients. Immunohistochemical examination of individual ganglia showed that there were no differences in the proportions of either enteric neurons or glial cells through the different regions of the resected colon. In addition, we identified that the size of enteric ganglia was smaller for patients that went on to develop HSCR associated enterocolitis; although the density of ganglia, as determined by the muscle unit to ganglia ratio, was not different when compared with patients that had no further complications. This suggests that subtle changes in the enteric nervous system, even in the “normoganglionated” colon, could be involved in changes in immune function and subsequent bacterial dysbiosis.
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Affiliation(s)
- Wendy Yang
- Department of Anatomy and Physiology, The University of Melbourne, Parkville 3010, Australia
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei 10663, Taiwan
| | - Jenny Pham
- Department of Anatomy and Physiology, The University of Melbourne, Parkville 3010, Australia
| | - Sebastian K. King
- Murdoch Children’s Research Institute, Parkville 3052, Australia
- Department of Paediatric Surgery, The Royal Children’s Hospital, Parkville 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville 3010, Australia
| | | | - Heather M. Young
- Department of Anatomy and Physiology, The University of Melbourne, Parkville 3010, Australia
| | - Lincon A. Stamp
- Department of Anatomy and Physiology, The University of Melbourne, Parkville 3010, Australia
- Correspondence: (L.A.S.); (M.M.H.)
| | - Marlene M. Hao
- Department of Anatomy and Physiology, The University of Melbourne, Parkville 3010, Australia
- Correspondence: (L.A.S.); (M.M.H.)
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Bilal R, Ospanov M, Dzhenalayev D, Olkhovik Y, Khamitov M, Kozhakhmetov A, Satbekov R, Abetova D. The Technique of Mobilization of the Colon for Pull-Through Procedure in Hirschsprung’s Disease. Front Surg 2022; 9:921789. [PMID: 35865043 PMCID: PMC9294277 DOI: 10.3389/fsurg.2022.921789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIn 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.ObjectiveThe 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.MethodsThe 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.ResultsIn 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.ConclusionThe 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.
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Affiliation(s)
- Ruslan Bilal
- Department of Medicine, School of Medicine, Nazarbayev University, Nur-Sultan, Kazakhstan
- Correspondence: Ruslan Bilal
| | - Marat Ospanov
- Department of Pediatric Surgery, National Research Mother and Child Center, Nur-Sultan, Kazakhstan
| | - Damir Dzhenalayev
- Department of Pediatric Surgery, National Research Mother and Child Center, Nur-Sultan, Kazakhstan
| | - Yuri Olkhovik
- Department of Pediatric Surgery, National Research Mother and Child Center, Nur-Sultan, Kazakhstan
| | - Medet Khamitov
- Department of Pediatric Surgery, Medical University Astana, Nur-Sultan, Kazakhstan
| | - Arman Kozhakhmetov
- Department of Medicine, School of Medicine, Nazarbayev University, Nur-Sultan, Kazakhstan
| | - Rauan Satbekov
- Department of Medicine, School of Medicine, Nazarbayev University, Nur-Sultan, Kazakhstan
| | - Dina Abetova
- Department of Medicine, School of Medicine, Nazarbayev University, Nur-Sultan, Kazakhstan
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Bhagwat AD, Jadhav P, Vaze D. Novel Method of Managing Residual Rectal Spur, Post Modified Duhamel's Operation. J Indian Assoc Pediatr Surg 2021; 26:276-277. [PMID: 34385778 PMCID: PMC8323574 DOI: 10.4103/jiaps.jiaps_1_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/10/2021] [Accepted: 03/24/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Aniruddha D Bhagwat
- Department of Paediatric Surgery, Dr. D.Y. Patil Medical College Hospital and Research Center, Pune, Maharashtra, India
| | - Pranav Jadhav
- Department of Paediatric Surgery, Dr. D.Y. Patil Medical College Hospital and Research Center, Pune, Maharashtra, India
| | - Dhananjay Vaze
- Department of Paediatric Surgery, Dr. D.Y. Patil Medical College Hospital and Research Center, Pune, Maharashtra, India
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Apte A, McKenna E, Levitt MA. Image of the Month: Enterocolitis Following a Pull-through for Total Colonic Hirschsprung Disease in a 2-Year-Old Boy. European J Pediatr Surg Rep 2021; 8:e102-e104. [PMID: 33437565 PMCID: PMC7796827 DOI: 10.1055/s-0040-1721050] [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: 05/29/2020] [Accepted: 08/18/2020] [Indexed: 12/04/2022] Open
Abstract
We present a case of a 2-year-old boy with total colonic Hirschsprung disease (HD) who underwent an ileostomy as a newborn, and then colectomy and pull-through at 10 months of age. Since then he has presented four times with enterocolitis. The case is presented with a focus on evaluating patients with HD who present with obstructive symptoms following corrective surgery. A key image is presented along with questions formatted as a quiz to guide readers through critically evaluating the case.
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Affiliation(s)
- Anisha Apte
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
| | - Elise McKenna
- Department of General and Thoracic Surgery, Children's National Medical Center, Washington, District of Columbia, United States
| | - Marc A Levitt
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States.,Department of General and Thoracic Surgery, Children's National Medical Center, Washington, District of Columbia, United States.,Division of Colorectal and Pelvic Reconstruction Surgery, Children's National Medical Center, Washington, District of Columbia, United States
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Mandelia A, Sharma MS, Siddiqui Y, Mishra A. Division of Long Residual Spur after Duhamel's Pull through with Endo-GIA Stapler under Colonoscopic Guidance. J Indian Assoc Pediatr Surg 2021; 26:69-70. [PMID: 33953522 PMCID: PMC8074821 DOI: 10.4103/jiaps.jiaps_281_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/02/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ankur Mandelia
- Department of Pediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Moinak Sen Sharma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Yousuf Siddiqui
- Department of Pediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ashwani Mishra
- Department of Pediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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