Treatment of classic-type Hirschsprung's disease: rectoplasty with posterior triangular colonic flap versus transanal endorectal pull-through with rectoanal myotomy

Risk factors for Hirschsprung disease-associated enterocolitis: a systematic review and meta-analysis

BACKGROUND

The incidence of Hirschsprung disease (HSCR) is nearly 1/5000 and patients with HSCR are usually treated through surgical intervention. Hirschsprung disease-associated enterocolitis (HAEC) is a complication of HSCR with the highest morbidity and mortality in patients. The evidence on the risk factors for HAEC remains inconclusive to date.

METHODS

Four English databases and four Chinese databases were searched for relevant studies published until May 2022. The search retrieved 53 relevant studies. The retrieved studies were scored on the Newcastle-Ottawa Scale by three researchers. Revman 5.4 software was employed for data synthesis and analysis. Stata 16 software was employed for sensitivity analysis and bias analysis.

RESULTS

A total of 53 articles were retrieved from the database search, which included 10 012 cases of HSCR and 2310 cases of HAEC. The systematic analysis revealed anastomotic stenosis or fistula [ I2 =66%, risk ratio (RR)=1.90, 95% CI 1.34-2.68, P <0.001], preoperative enterocolitis ( I2 =55%, RR=2.07, 95% CI 1.71-2.51, P <0.001), preoperative malnutrition ( I2 =0%, RR=1.96, 95% CI 1.52-2.53, P <0.001), preoperative respiratory infection or pneumonia ( I2 =0%, RR=2.37, 95% CI 1.91-2.93, P <0.001), postoperative ileus ( I2 =17%, RR=2.41, 95% CI 2.02-2.87, P <0.001), length of ganglionless segment greater than 30 cm ( I2 =0%, RR=3.64, 95% CI 2.43-5.48, P <0.001), preoperative hypoproteinemia ( I2 =0%, RR=1.91, 95% CI 1.44-2.54, P <0.001), and Down syndrome ( I2 =29%, RR=1.65, 95% CI 1.32-2.07, P <0.001) as the risk factors for postoperative HAEC. Short-segment HSCR ( I2 =46%, RR=0.62, 95% CI 0.54-0.71, P <0.001) and transanal operation ( I2 =78%, RR=0.56, 95% CI 0.33-0.96, P =0.03) were revealed as the protective factors against postoperative HAEC. Preoperative malnutrition ( I2 =35 % , RR=5.33, 95% CI 2.68-10.60, P <0.001), preoperative hypoproteinemia ( I2 =20%, RR=4.17, 95% CI 1.91-9.12, P <0.001), preoperative enterocolitis ( I2 =45%, RR=3.51, 95% CI 2.54-4.84, P <0.001), and preoperative respiratory infection or pneumonia ( I2 =0%, RR=7.20, 95% CI 4.00-12.94, P <0.001) were revealed as the risk factors for recurrent HAEC, while short-segment HSCR ( I2 =0%, RR=0.40, 95% CI 0.21-0.76, P =0.005) was revealed as a protective factor against recurrent HAEC.

CONCLUSION

The present review delineated the multiple risk factors for HAEC, which could assist in preventing the development of HAEC.

Feasibility of home and hospital colorectal irrigation with continuous tube placement for Hirschsprung’s disease in neonates and infants: a comparative retrospective study

Background

Since the length of the affected colon widely varies, the preoperative management of Hirschsprung’s disease varies from one hospital to another. For our cases in which the length of the aganglionic colon cannot be managed by enema, anal bougienage, or rectal irrigation, colorectal irrigation is used along with the placement of a transanal catheter for these patients as home or hospital management, until one-stage definitive surgery can be performed. No comparative studies have been conducted on the continuous tube placement method, and no study has utilized this method as home management. Thus, this study aimed to analyze the efficacy and feasibility of our proposed continuous tube placement management for patients with Hirschsprung’s disease in the hospital or even at home.

Results

We included 22 infants with Hirschsprung’s disease between 2008 and 2018. The patients were divided into two groups: those who were managed with enema, bougienage, and rectal irrigation (n = 6), and those who were managed with the placement of a continuous transanal tube and colorectal irrigation (n = 16). The group with continuous transanal tube placement was further divided into two groups: those who were preoperatively managed with a continuous anorectal tube at home (n = 7), and those at a hospital (n = 9). Preoperative demographic information and clinical details were retrospectively examined and compared between the two groups. Univariate analysis showed no significant differences in the backgrounds and clinical status between the enema, bougienage, and rectal irrigation group and the colorectal irrigation group. The patients in the home group were older and weighed more at the time of radical surgery than those in the hospital group (p = 0.0267, p = 0.0377, respectively). The total duration of hospitalization until radical surgery was significantly decreased in the home group (p = 0.0315).

Conclusions

The total duration of hospitalization was significantly reduced in patients undergoing home colorectal irrigation which was as effective as the conventional method, with no impact on the preoperative condition or postoperative outcomes. Hence, our home-based preoperative management for patients with Hirschsprung’s disease may be effective and potentially feasible for the management of patients with Hirschsprung’s disease.

Forty-Year Experience Alleviating Postoperative Hirschsprung-Associated Enterocolitis by Complete Full-Thickness Posterior Rectal Cuff Excision. The Anorectal Line Eliminates Problematic Anastomoses

Introduction: A modified pull-through (PT) distinguished by complete full-thickness removal of the posterior rectal cuff, initially developed as an open procedure in 1980, has been performed with laparoscopic assistance since 1997. Postoperative bowel dysfunction improved when the anatomic landmark for PT surgery was revised from the dentate line (DL) to the anorectal (or Herrmann's) line (ARL) in 2007. A 40-year (1980-2019) review of 153 consecutive rectal/rectosigmoid type Hirschsprung's disease (HD) patients is presented. Methods: Data for postoperative bowel dysfunction and Hirschsprung-associated enterocolitis (HAEC) classified according to the American Pediatric Surgical Association (APSA) scale were obtained retrospectively. Results: PT was open (n = 43) and laparoscopic (n = 110). Dissection was DL (n = 57) and ARL (n = 96). Over 40 years, 5/153 patients (3.3%) had postoperative obstructive symptoms (POS), and 10/153 patients (6.5%) had 13 episodes of postoperative HAEC; APSA grades were: I (n = 4); II (n = 8); and III: (n = 1) presenting with explosive diarrhea (10/13; 76.9%), fever (10/13; 76.9%), abdominal distension (9/13; 69.2%), or bloody stools/shock (1/13 with grade III; 7.7%). The grade III case had histologically-proven transitional zone PT. Postoperative HAEC developed in 3/5 (60.0%) POS+ patients and 7/148 (4.7%) POS- patients (P = .002). Symptom duration and treatment were not correlated with APSA grades. Conclusions: Complete full-thickness posterior rectal cuff excision and using the ARL reduced postoperative HAEC significantly in this series. Despite being anatomically distinct, the DL is inadequate as a precise landmark for PT surgery because it lacks functional relevance. The APSA scale could benefit from timely review to improve its clinical and prognostic value.

Predictive factors for the development of postoperative Hirschsprung-associated enterocolitis in children operated during infancy

PURPOSE

The risk factors for postoperative Hirschsprung-associated enterocolitis (HAEC) are still incompletely understood, especially age at which surgery is performed. Therefore, the aim of this study was to identify the risk factors for the development of postoperative HAEC in children operated during infancy.

METHODS

Thirty-five children who had undergone radical surgery for Hirschsprung disease (HD) during infancy were included in the study. They were divided into two groups; those who developed postoperative HAEC (HAEC, 14 patients) and those who did not (no HAEC, 21 patients). Their medical records were retrospectively reviewed for clinical details.

RESULTS

Developing postoperative HAEC was significantly associated with long-segment HD (p = 0.020) and the age at radical surgery (p = 0.0241). No other factors had a significant association with postoperative HAEC. In the patients who developed postoperative HAEC (n = 14), those with Trisomy 21 had significantly longer hospitalizations than those without. Patients with long-segment HD had a higher hospitalization rate than those with short-segment HD.

CONCLUSION

This study clearly showed that long-segment HD and older age at radical surgery are risk factors for developing postoperative HAEC.