Laparoscopic Soave procedure for long-segment Hirschsprung's disease - single-center experience

Quantitative evaluation of pediatric umbilical loop stomas: 2 decades of experience from a single institution

PURPOSE

Since pediatric stomas are often temporary, their creation, management, and closure should be simple, with minimal complications and excellent cosmetic results. We began employing umbilical stomas in 2000. This study aimed to characterize the ingenuity and utility of umbilical stomas and provide a quantitative evaluation of their cosmetic outcomes.

METHODS

We examined cases of stoma construction and closure surgery performed in our department from January 2000 to December 2022. The umbilical and non-umbilical stoma groups included 54 and 42 cases, respectively, and the findings for both groups were compared and analyzed.

RESULTS

The two groups showed no significant differences in the incidence of complications. The Manchester Scar Scale score for the umbilical stoma group (8.42 ± 1.85) was significantly better than that for the non-umbilical stoma group (16.31 ± 2.96; P < 0.01). Likewise, in Patient and Observer Scar Assessment Scale assessments, the umbilical stoma group showed significantly better scores in both the observer scale (9.48 ± 2.50 vs. 21.78 ± 7.26; P < 0.01) and the patient scale (10.5 ± 1.39 vs. 22.40 ± 7.35; P < 0.01).

CONCLUSIONS

Umbilical stomas are easy to manage and yield an inconspicuous closure incision with excellent cosmetic outcomes. Although patient selection is important, pediatric umbilical stomas are a valuable option that can be actively employed.

Bowel function at preschool and early childhood age in children with long-segment Hirschsprung disease

Bowel dysfunction has been proven to be the most typical complication of long-segment Hirschsprung disease (LSHD). Additionally, bowel dysfunction in preschool and early childhood should be properly assessed, because it may result in persistent bowel dysfunction, social issues, and depression in adolescence and adulthood. This study evaluated bowel function during preschool and early childhood in patients with LSHD. A cross-sectional bowel function score (BFS) questionnaire survey was conducted on 270 infants with short-segment Hirschsprung disease (SSHD) and LSHD who underwent pull-through (PT) between January 2014 and December 2019 at the Children's Hospital of Nanjing Medical University. One hundred ninety patients who consented to the survey were asked to complete the questionnaire and were divided into two groups: the LSHD group (n = 42) and the SSHD group (n = 148). Bowel function outcomes were assessed by using a questionnaire. The total BFS score in the LSHD group was significantly lower than that in the SSHD group (15.0 [14.0, 17.0] vs. 18.0 [16.0, 19.0], p < 0.05) and did not improve with age (p > 0.05). Independent BFS items with lower scores were discovered in LSHD than in SSHD, including the capacity to hold back defecation, feeling/reporting the urge to defecate, frequency, soiling, and accidents (all p < 0.05). After subgroup analysis of follow-up age (3-5 years, 5 ~ 7 years, and > 7 years), there was no difference between the score of ability to hold back defecation over 7 years old and feeling/reporting the urge to defecate over 5 years old (all p > 0.05). The frequency and soiling scores were lower in the LSHD group than in the SSHD group over 5 years of age (all p < 0.05). Fortunately, there was no difference in constipation scores and social problems between the LSHD and SSHD groups in every sub-follow-up group (all p > 0.05).  Conclusion: Overall, bowel function at preschool and early childhood age was poorer in LSHD than in SSHD and did not improve with age. However, the ability to hold back defecation and feeling/reporting the urge to defecate with age in LSHD may be similar to those in SSHD. Simultaneously, the frequency, soiling, and number of accidents were consistently worse in the LSHD group.  Trial registration: This study was retrospectively registered in the ClinicalTrials database.gov (NCT05461924) in August 2022. What is Known: • Bowel function in SSHD is satisfactory or near-normal, and the general consensus is that the longer the aganglionic segment, the worse the bowel function after surgery. • Bowel functional outcomes of LSHD were not defined, and the limited reports of bowel functional outcomes compared with SSHD were extensively varied. Bowel dysfunction at preschool and early childhood may lead to persistent bowel dysfunction, social problems, and depression in adolescence or adulthood. What is New: • Bowel function in preschool and early childhood in patients with LSHD has not been defined and should be thoroughly assessed in a larger group of patients with precise definitions of incontinence or soiling. • The present study was primarily designed to evaluate bowel function at preschool and early childhood age in LSHD compared with SSHD in a relatively large number of HD cases using BFS.

Effect of modified transanal Soave assisted by laparoscopy in the treatment of Hirschsprung's disease in children and its influencing factors

OBJECTIVE

To investigate the effect of modified transanal Soave assisted by laparoscopy in children with Hirschsprung's disease (HD).

METHODS

The clinical data of 120 children with Hirschsprung's disease admitted to Fujian Children's Hospital from January 2018 to November 2021 were retrospectively analyzed. Based on the surgical methods, 58 children treated with modified transanal Soave were regarded as the modified group and 62 children treated with modified transanal Soave assisted by laparoscopy were divided into the laparoscopic group. The operative indexes, anal function, quality of life and perianal pressure 6 months after surgery, complications within 1 month after surgery, and recovery within 6 months after surgery of the two groups were compared. The risk factors influencing the postoperative recovery of hirschsprung's disease in children were analyzed by univariate and logistic regression analysis.

RESULTS

The operation time, intraoperative blood loss, length of hospital stay and gastrointestinal recovery time in the laparoscopic group were lower than those in modified group (P < 0.05). The excellent and good rate of postoperative anal function in laparoscopic group was 87.10%, which was higher than that in modified group (68.97%) (P < 0.05). The proportion of patients with good quality of life in laparoscopic group (90.32%) was higher than that in modified group (74.14%) (P < 0.05). The anal resting pressure and systolic pressure in laparoscopic group were lower than those in modified group (all P < 0.05). The total complication rate of laparoscopic group (6.45%) was lower than that of modified group (22.41%) (P < 0.05). After 6 months, 64 cases (53.33%) were cured and 56 cases (46.67%) were not. After univariate analysis, there were statistically significant differences in enteritis, abdominal distension, and anastomotic stenosis between cured children and uncured children (all P < 0.05). There was no significant difference in other factors (P > 0.05). Logistic regression analysis showed that enteritis, abdominal distension and anastomotic stenosis were the risk factors affecting the recovery of hirschsprung's disease in children (all P < 0.05).

CONCLUSIONS

Modified transanal Soave assisted by laparoscopy can improve anal function and quality of life, relieve anal pressure, and have a low complication rate. Enteritis, abdominal distension, and anastomotic stenosis are the factors affecting the recovery of Hirschsprung's disease in children.

E. coli JM83 damages the mucosal barrier in Ednrb knockout mice to promote the development of Hirschsprung‑associated enterocolitis via activation of TLR4/p‑p38/NF‑κB signaling

Hirschsprung-associated enterocolitis (HAEC) is characterized by intestinal mucosal damage and an imbalance in the intestinal microbiota. Recent studies have indicated that the TLR4/p-p38/NF-κB signaling pathway in the intestine is of great importance to intestinal mucosal integrity. The present study aimed to investigate the role of TLR4/phosphorylated (p-)38/NF-κB signaling in the pathogenesis of HAEC in E. coli JM83-infected endothelin receptor B (Ednrb)^−/− mice. Ednrb^−/− mice were infected with E. coli JM83 by oral gavage to establish the HAEC model. Wild-type and Ednrb^−/− mice were randomly divided into uninfected and E. coli groups. The role of TLR4/p-p38/NF-κB signaling was further evaluated by in vivo and in vitro analyses. The activation of the TLR4/p-p38/NF-κB signaling pathway induced by E. coli JM83 resulted in HAEC in Ednrb^−/− mice, which was evidenced by a significant increase in the expression of TNF-α, TGF-β and IL-10, and a decreased density of F-actin protein expression. TLR4 knockdown reduced the severity of enterocolitis and attenuated the expression of IL-10, TNF-α and TGF-β, whilst increasing the density of F-actin protein in Ednrb^−/− mice after E. coli infection. These results indicated that E. coli JM83 activates TLR4/p-p38/NF-κB signaling in Ednrb^−/− to promote the development of HAEC. Thus, inhibition of this signaling pathway may benefit the treatment and prevention of HAEC.

Laparoscopic vs. Transabdominal Treatment for Overflow Fecal Incontinence Due to Residual Aganglionosis or Transition Zone Pathology in Hirschsprung's Disease Reoperation

Objective: The aim of this study was to describe the details of laparoscopic-assisted reoperative surgery for Hirschsprung's disease (HSCR) with overflow fecal incontinence, and to retrospectively compare laparoscopic-assisted surgery with transabdominal pull-through surgery. Methods: We retrospectively analyzed patients with HSCR with overflow fecal incontinence after the initial surgery in our center between January 2002 and December 2018. Pre-operative, peri-operative, and post-operative data were recorded for statistical analysis. Results: Thirty patients with overflow fecal incontinence after initial megacolon surgery [17 who underwent transanal pull-through (TA-PT) and 13 who underwent laparoscopic-assisted pull-through (LA-PT)] required a secondary surgery [reoperation with LA-PT (LAR-PT) (n = 16) or reoperation with transabdominal pull-through (TR-PT) (n = 14)]. Indications for reoperation were residual aganglionosis (RA) (7/30, 23.3%) or transition zone pathology (TZP) (23/17, 76.7%). Blood loss was significantly decreased in the LAR-PT group (75 ± 29.2 ml) compared to the TR-PT group (190 ± 51.4 ml) (P = 0.001). The length of hospital stay was significantly shorter in the LAR-PT group (10 ± 1.5 days) than that in the TR-PT group (13 ± 2.4 days). No significant differences were found between two groups in surgical methods, defecation function score, or post-operative complications except for wound infection (LAR-PT vs. TR-PT 0 vs. 28.6%, P < 0.05). Conclusions: It is necessary to make a comprehensive analysis of the causes of fecal incontinence after HSCR surgery and make an accurate judgment using appropriate methods. If a reoperation was inevitable for patients with overflow fecal incontinence due to RA or TZP, a comprehensive evaluation prior to the operation is required to maximize the benefit from reoperation. Although laparoscopic reoperation with heart-shaped anastomosis was safe and feasible for patients with failed initial Soave technique, unnecessary reoperation should be avoided as much as possible.