Surgical acquired aganglionosis: myth or reality?

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

Background

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

Objective

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

Methods

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

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

Results

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

Conclusion

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

Postoperative Pullthrough Obstruction in Hirschsprung Disease: Etiologies and Diagnosis

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.

Laparoscopic Redo Pull-Through for Hirschsprung Disease Due to Innervation Disorders

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.