Limited surgery for lower-segment Hirschsprung's disease

Initial experience with per-rectal endoscopic myotomy for Hirschsprung's disease: medium and long term outcomes of the first case series of a novel third-space endoscopy procedure

INTRODUCTION

Hirschsprung's disease (HSCR) is congenital aganglionosis affecting the hindgut and presents with constipation. Surgical pull-through is the current standard treatment but causes morbidity. Per-rectal endoscopic myotomy is a novel third-space endoscopy technique for treating short-segment (SS)-HSCR.

METHODS

Retrospective study of SS-HSCR patients diagnosed on history, contrast enema, rectal biopsies, and anorectal manometry, and treated by PREM. The aganglionic segment was mapped before PREM was performed using third-space endoscopy principles. Stool frequency and laxative usage before and after PREM were compared.

RESULTS

Nine patients (age 7.5 [± 5.2] years; 7 male) underwent PREM during a 4-year period. Mean aganglionic segment length was 6.3 cm, mean procedure time 96.1 minutes, and mean length of hospital stay 2.5 days. Median follow-up was 17 months (range 9-58 months). Stool frequency was 1/4.4 days before vs. 1/1.2 days after PREM (P = 0.0004). Mean laxative usage was 5.4 units of laxative (UL) before vs. 0.4 UL after PREM (P = 0.0002). No laxatives were used by 6/9 patients after PREM. The single adverse effect seen (anal stenosis) was treated with dilatation.

CONCLUSIONS

PREM is a safe and effective minimally invasive procedure to treat SS-HSCR and results in long-term response.

RESULTS OF POSTERIOR MYECTOMY FOR THE TREATMENT OF CHILDREN WITH CHRONIC CONSTIPATION

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the result of posterior myectomy in children with chronic constipation who underwent to this surgery.

METHODS

Forty eight children with chronic constipation who did not respond to diet, laxative, or enema were included. Children with abnormal barium enema showing transitional zone were excluded. Children with documented metabolic disease diabetes, and hypothyroidism were also excluded. All patients underwent posterior myectomy. Children were followed during 1 year after surgery regarding frequency of fecal evacuation, fecal consistency, straining during defecation, and diameter of feces. Data was analyzed using SPSS version 13.0 (Chicago, IL, USA).

RESULTS

Of 48 cases that underwent surgery, 21 were male and 27 were female. Age range was 1.5 to 11 years old. Mean duration of constipation before surgery was 22.79±17.08 (range 6-48 months). Mean duration of medical treatment was 14.90±10.31 (range= 6-48 months). Fecal consistency, feces diameter, number of bowel movements and straining during defecation were compared before and after surgery. The results were statistically significant ( P <0.001). Of all cases, 52% continued treatment of constipation after surgery for 1 year. Ganglion cells were absent in 32 cases. Ganglion cells were present in seven children. Proximal ganglion cell was found in nine cases Treatment response was not different between cases according to status of ganglion cell in biopsy.

CONCLUSION

Fecal consistency, feces diameter, number of bowel movements, and straining for defecation were improved after posterior myectomy. Another study with more sample is required for better evaluation of treatment.

Posterior myotomy/myectomy for persistent stooling problems in Hirschsprung's disease

BACKGROUND

Hirschsprung's disease (HD) patients after pull-through (PT) may have recalcitrant constipation or recurrent enterocolitis (EC). Posterior myotomy/myectomy (POMM) are possible options for these problems. This study analyzed the outcome of POMM in HD patients post-PT.

METHODS

Records of 348 HD patients were reviewed, and 32 were found to have undergone a POMM post-PT (1981 to 2002). Outcomes after this procedure were assessed. Statistics used linear and logistic regression.

RESULTS

Of the 32 patients, 29 had complete records for analysis. Of those with pure constipation (12), 6 had aganglionosis post-PT. Of those with recurrent EC (17) only 1 had aganglionosis post-PT. POMM was performed at a mean of 3.1 years post-PT (11 myotomy, 18 myectomy). Average follow-up was 8.6 years (range, 0.7 to 21). Type of POMM had no correlation with overall functional outcome (P =.44). Of those with chronic constipation, 60% had good results after POMM; the remainder required a redo-PT or colostomy. Interestingly, most patients with retained aganglionosis and chronic constipation did not respond after POMM (83%). Of those with recurrent EC, 75% became free of symptoms; none of the patients not responding have required redo-PT.

CONCLUSIONS

POMM to treat chronic constipation or recurrent EC in patients with HD post-PT is moderately successful. Because of the unsuccessful outcome with POMM in patients with a combination of constipation and aganglionosis, one should defer to a redo-PT in this group.