Laparoscopic Duhamel procedure. Management of 30 cases

Current status of Hirschsprung's disease: based on a nationwide survey of Japan

PURPOSE

The diagnosis and surgical treatments of Hirschsprung's disease (HD) have undergone various changes in the last few decades because of establishment of laparoscopic procedures. A retrospective nationwide survey for 4 decades was performed to study the changing profile of HD in Japan.

METHODS

The patient data were collected in 4 phases: Group 1, between 1978 and 1982; Group 2, between 1988 and 1992; Group 3, between 1998 and 2002; and Group 4, between 2008 and 2012.

RESULTS

The incidence and the male/female ratio remained almost the same over time (1/4, 895 in newborns and 2.9:1 in Group 4). The patients with a family history increased to 7.1% in Group 4, in comparison to 2.8-6.0% in other groups. Regarding the extent of aganglionosis, sigmoid colon increased to 63.1% in Group 4, compared to 51.9% in Group 3. Manometry was performed less frequently in Group 4 (45.8%) than in Group 3 (66.1%). Transanal endorectal pull-through (TAEPT) was the most popular operation in Group 4 (49.6%). In addition, laparoscopy-assisted operations increased to 46.9% in Group 4, in comparison to 29.7% in Group 3. The incidence of preoperative enterocolitis and the mortality rate in Group 4 were 17.2% and 2.4%, respectively, and were markedly decreased in comparison to Group 1 (29.2% and 6.5%, respectively). The mortality rate decreased over time to 2.4% in Group 4. Over the last decade, there has been remarkable improvement in the mortality rate associated with the small intestine (aganglionosis extending orally to more than 30 cm of the terminal ileum). The rates were 25.5% in Group 4, 53.6% in Group 1, 33.3% in Group 2, and 35.5% in Group 3. In addition, the mortality rates of the remaining aganglionosis subgroups also improved.

CONCLUSION

Primary operations without laparotomy, including TAEPT and laparoscopy-assisted operations, have become the first choice for the definitive surgical treatment of HD in Japan. The mortality rate has decreased over time. However, the mortality rate of small intestinal aganglionosis is still relatively high. The development of new treatment strategy for small intestinal aganglionosis is called for.

Advances in minimally invasive neonatal colorectal surgery

Over the last two decades, advances in laparoscopic surgery and minimally invasive techniques have transformed the operative management of neonatal colorectal surgery for conditions such as anorectal malformations (ARMs) and Hirschsprung’s disease. Evolution of surgical care has mainly occurred due to the use of laparoscopy, as opposed to a laparotomy, for intra-abdominal procedures and the development of trans-anal techniques. This review describes these advances and outlines the main minimally invasive techniques currently used for management of ARMs and Hirschsprung’s disease. There does still remain significant variation in the procedures used and this review aims to report the current literature comparing techniques with an emphasis on the short- and long-term clinical outcomes.

Duhamel versus transanal endorectal pull through (TERPT) for the surgical treatment of Hirschsprung's disease

For the surgical treatment of Hirschsprung's disease, several surgical techniques are used to resect the distal aganglionic colon. Two frequently used techniques are the Duhamel procedure and the transanal endorectal pull-through procedure. During the '8th Pediatric Colorectal Course' in Nijmegen, November 2015, a workshop was organized to share experiences of both techniques by several experts in the field and to discuss (long term) outcomes. Specifically, the objective of the meeting was to discuss the main controversies in relation to the technical execution of both procedures in order to make an initial assessment of the limitations of available evidence for clinical decision-making and to formulate a set of preliminary recommendations for current clinical care and future research.

Laparoscopic-assisted transanal pull-through (LATP) versus complete transanal pull-through (CTP) in the surgical management of Hirschsprung's disease

BACKGROUND

It is unclear whether laparoscopic-assisted transanal pull-through (LATP) or complete transanal pull-through (CTP) is superior for the surgical management of Hirschsprung's disease. We compared outcomes between approaches.

METHODS

We retrospectively reviewed patients with Hirschsprung's disease who underwent LATP or CTP at our centre between 1995 and 2014. Patients were matched based on age, birth weight, and level of aganglionosis. A systematic literature review and meta-analysis were also performed.

RESULTS

From our data, LATP (n=24) took significantly longer than CTP (n=12; 3.9±1.1 vs. 2.6±0.6h, p=0.001). There was no difference in length of stay or incidence of postoperative complications. A literature search identified 17 published studies, of which 2 were comparative. Our pooled analysis of comparative studies including our results showed that operative time was significantly longer for the LATP group (OR 1.59, 95% CI 1.21-1.96, p<0.001). There was no significant difference in major complications (OR 1.75, 95% CI 0.76-4.04, p=0.19) or length of stay (OR 0.33, 95% CI -0.41 to 1.08, p=0.38).

CONCLUSION

Clinical outcomes are comparable between LATP and CTP. CTP offers shorter operative time without the need for laparoscopic instruments.

3D high-definition manometry in evaluation of children after surgery for Hirschsprung's disease: A pilot study

PURPOSE

Anorectal 3-dimensional high definition manometry (3D HRM) could be the best tool for postoperative assessment of restorative surgical procedures for Hirschsprung's disease. The aim of our study was to evaluate patients after surgery for Hirschsprung's disease using 3D HRM.

MATERIALS AND METHODS

Anorectal function was evaluated using solid state 3D HRM. We measured the length of the anal canal, mean resting squeeze pressures, the presence of rectoanal inhibitory reflex, cough reflex, ano-anal reflex and the bear down manoeuvre.

RESULTS

We studied 14 children operated on for Hirschsprung's disease. The mean values of pressure asymmetry were higher in patients after the Duhamel procedure than after the TEPT procedure (29.58% vs. 22.26% during resting and 26.1% vs. 14.01% during squeeze, respectively). No difference between the groups was observed in the measurement of all the manometric parameters except the presence of rectoanal inhibitory reflex (87.5% after TEPT vs. 33% after Duhamel).

CONCLUSIONS

Anorectal 3D HRM evaluation of patients with Hirschsprung's disease demonstrated that the asymmetry of the anal canal occurred in a similar percentage after both procedures.

Laparoscopic Duhamel Procedure for Hirschsprung's Disease: Systematic Review and Meta-analysis

INTRODUCTION

Since its introduction in 1956, the Duhamel procedure has been and remains one of the most widely performed for Hirschsprung's disease (HD). The most significant modification to this procedure has been the incorporation of laparoscopy, while the original principles of the method have been retained. This study compared long-term outcomes for open Duhamel (OD) and laparoscopic Duhamel (LD) procedures for HD, to identify any added advantage of the laparoscopic technique.

MATERIALS AND METHODS

We undertook a systematic review of all studies published over a period of 20 years (1994-2014) that assessed functional outcomes for OD and/or LD procedures. Odds ratios were calculated for dichotomous variables, and mean difference values were calculated for continuous variables.

RESULTS

From 11 articles 456 patients were included (253 OD, 203 LD), with no significant difference in age at surgery and length of follow-up (P > .05). The open group had a significantly greater incidence of soiling/incontinence (11% versus 4%; P = .02) and further surgery (25% versus 14%; P = .005), longer hospital stay (9.79 versus 7.3 days; P < .00001), and time to oral feed (4.05 versus 3.27 days; P < .00001). Operative time was significantly longer in the laparoscopic group (3.83 versus 4.09 hours; P = .004). There was no significant difference in incidence of enterocolitis (15% versus 10%; P = .14) and constipation (23% versus 30%; P = .12).

CONCLUSIONS

Our meta-analysis convincingly demonstrates the superiority of LD over OD pull-through for HD. Prospective, randomized control trials are required to overcome limitations in the current literature.

Laparoscopic assistance for primary transanal pull-through in Hirschsprung's disease: a systematic review and meta-analysis

OBJECTIVE

To compare outcomes following totally transanal endorectal pull-through (TTERPT) versus pull-through with any form of laparoscopic assistance (LAPT) for infants with uncomplicated Hirschsprung's disease.

DESIGN

Systematic review and meta-analysis.

SETTING

Five hospitals with a paediatric surgical service.

PARTICIPANTS

405 infants with uncomplicated Hirschsprung's disease.

INTERVENTIONS

TTERPT versus LAPT.

PRIMARY OUTCOMES

mortality, postoperative enterocolitis, faecal incontinence, constipation, unplanned laparotomy or stoma formation, and injury to abdominal viscera.

SECONDARY OUTCOMES

Haemorrhage requiring transfusion of blood products, abscess formation, intestinal obstruction, intestinal ischaemia, enteric fistula formation, urinary incontinence or retention, impotency and duration of procedure.

RESULTS

Five eligible studies comprising 405 patients were identified from 2107 studies. All studies were retrospective case series, with variability in outcome assessment quality and length of follow-up. Operative duration was 50.29 min shorter with TTERPT (95% CI 39.83 to 60.74, p<0.00001). There were no significant differences identified between TTERPT and LAPT for incidence of postoperative enterocolitis (OR=0.78, 95% CI 0.44 to 1.38, p=0.39), faecal incontinence (OR=0.44, 95% CI 0.09 to 2.20, p=0.32) or constipation (OR=0.84, 95% CI 0.32 to 2.17, p=0.71).

CONCLUSIONS

This meta-analysis did not find any evidence to suggest a higher rate of enterocolitis, incontinence or constipation following TTERPT compared with LAPT. Further long-term comparative studies and multicentre data pooling are needed to determine whether a purely transanal approach offers any advantages over a laparoscopically assisted approach to rectosigmoid Hirschsprung's disease.

TRIAL REGISTRATION NUMBER

PROSPERO registry- CRD42013005698.

Abdominal Cellulitis following a Laparoscopic Procedure: A Rare and Severe Complication

Advantages of laparoscopic approach in Hirschsprung disease have been already published decreasing the hospital stay and postoperative adhesions. To our knowledge, we report the first case of postoperative abdominal cellulitis after laparoscopic procedure. A laparoscopic Duhamel pull through was done on a 3-month-old child. Full-thickness biopsy under laparoscopy was performed with intraperitoneal inoculation. Large peritoneal irrigation was used. Abdominal necrotizing cellulitis starting from a port site occurred few days after the procedure requiring repeat surgical excision, broad spectrum antibiotics, and hyperbaric oxygen.

Laparoscopic and transanal pull-through for Hirschsprung disease

The surgical correction of Hirschsprung disease has undergone a complete evolution in the past decade. Refinements in the performance of both transanal and laparoscopic procedures have tremendously facilitated the advancement of these surgeries. This chapter presents the history of these procedures, and then discusses the various approaches and details of these techniques.

Duhamel pull-through for Hirschsprung disease: a comparison of open and laparoscopic techniques

PURPOSE

Various pull-through techniques, both open and laparoscopic, have been performed for Hirschsprung disease. Our study compares open and laparoscopic Duhamel pull-through.

METHODS

After ethical approval, we reviewed all children (n = 181) with Hirschsprung disease admitted to our institution between 1999 and 2009. We excluded total colonic aganglionosis (n = 14), previous pull-through done elsewhere (n = 33), or follow-up performed abroad (n = 58). Open and laparoscopic pull-through were done in the same period according to surgeon preference. Data were analyzed using χ(2) or Mann-Whitney U test.

RESULTS

Seventy-six children had a Duhamel pull-through for rectosigmoid aganglionosis. Operative time, time to full feeds, and length of hospital stay were similar in each group. OPEN (N = 41): Fifteen children (37%) required 33 further procedures. Fourteen had procedures for persistent constipation, including redo Duhamel (n = 2), stoma formation (n = 2), spur division (n = 2), and dilatation/stretch/Botox/rectal biopsy/manual evacuation (n = 23). Three children had other procedures (adhesiolysis [n = 2] and incisional hernia repair [n = 1]). LAPAROSCOPIC (N = 35): Fourteen children (40%) required 30 further procedures. Eleven had procedures for persistent constipation, including redo Duhamel (n = 1), stoma formation (n = 4), spur division (n = 9), and dilatation/stretch/rectal biopsy (n = 8). Three children had other procedures (adhesiolysis [n = 1] and incisional hernia repair [n = 2]). There were 4 conversions.

CONCLUSION

Open and laparoscopic Duhamel pull-through have similar outcomes. We show that the techniques have comparable operative times and hospital stay.

Fish mouth and parachute surgical technique for hirschsprung's disease: our experience in 254 cases with a modified form of Duhamel-Martin procedure

PURPOSE

This study examined the long-term therapeutic effect of fish mouth and parachute technique anastomosis for Hirschsprung's disease.

METHODS

From March 1992 to October 2002, we performed one-stage fish mouth and parachute technique anastomosis for 293 patients with Hirschsprung's disease. Two hundred and fifty-four patients (79 percent) were followed up for three to five years. The operative outcome and postoperative complications were retrospectively analyzed.

RESULTS

Two hundred ninety-three patients were included in the study, the majority of patients were male (n = 205, 70 percent) and ages ranged between 8 months and five years. Early complications were low (n = 7, 2.3 percent) and included urine retention (n = 2), enteritis (n = 2), and intestinal obstruction (n = 3). No infection of the abdominal cavity or wound, anastomotic leakage, or death occurred in any patients. Late complications were present in 10 cases (3.4 percent).

CONCLUSIONS

The fish mouth and parachute surgical technique procedure showed some practical benefits and fewer complications than traditional surgical techniques for the treatment of Hirschsprung' s disease.

Minimally invasive surgery

The field of Minimally Invasive Surgery or Minimally Access Surgery (MAS) as it is commonly known has grown remarkably over the past two decades. MAS has a steep learning curve and unexpected complications with MAS are not infrequent unless approached with great caution. However it leads to a shorter hospital stay, less analgesic use, rapid return to school and a better cosmetic outcome. MAS in children started in India a decade ago, and has a great impact on the way we manage pediatric surgical problems today. This article is a brief description of most of the procedures that are being done with the help of MAS. In addition to these, new techniques, procedures and innovations are always ongoing in this fast developing field. MAS is being practiced in limited centers in our country with expanding experience and indications. Its use in children as the first option for early appendicitis, intraabdominal testis, gall stone disease and a few other conditions is now proven beyond doubt. There are other indications and areas of application of MAS which are continuously evolving and needs institutional audit and validation at every step before moving to the next phase.

Laparotomic versus laparoscopic Duhamel pull-through for Hirschsprung disease in infants and children

PURPOSE

The aim of this study was to analyze the results from laparotomic and laparoscopic Duhamel pull-through in the treatment of Hirschsprung disease.

MATERIALS AND METHODS

In our department, the Duhamel pull-through technique was adopted in most patients and the laparoscopic technique used since 1999 follows the original Duhamel procedure. Patients were identified retrospectively and followed up in our outpatient clinic. Preoperative, operative, and postoperative data were collected and analyzed.

RESULTS

Between January 1992 and March 1999, 21 children with Hirschsprung disease underwent primary surgical correction using the classic open Duhamel pull-through. The mean age at operation was 14 months, the median operating time was 297 minutes, and the average postoperative stay was 10 days. From April 1999 to December 2003, 22 children underwent laparoscopic Duhamel pull-through. The mean age at operation was 14.6 months, the mean operative time was 253 minutes, and the mean postoperative stay was 6.8 days. The rates of early (4.7% vs. 4.7%) and late (19% vs. 23.8%) complications were similar in the two groups, but in the laparoscopic group the mean operative time and postoperative hospital stay were lower.

CONCLUSION

With these encouraging results, laparoscopic Duhamel pull-through has become our procedure of choice in the surgical management of Hirschsprung's disease.

Duhamel operation vs neonatal transanal endorectal pull-through procedure for Hirschsprung disease: which are the changes for pathologists?

BACKGROUND

The aim of this study was to evaluate whether performing definitive surgery for Hirschsprung disease (HD) in neonatal period with a transanal endorectal pull-through (TEPT) procedure had modified our diagnostic relevance, particularly during intraoperative frozen sections (IOFS), compared to classic Duhamel (DH) surgery performed in older children.

METHODS

We collected pathologic data for 47 children who underwent surgery for neonatal nontotal HD over a 5-year period.

RESULTS

Twenty-nine patients underwent TEPT and 18 the DH operation. Mean age at operation was 19 days for TEPT and 4 months for DH operation. The mean number of IOFS was 2.6 for TEPT and 2.4 for DH operation. Gross examination could be fully completed in all TEPT cases, but was incomplete in 5 DH cases. The average total lengths of bowel, and aganglionic, transitional, and ganglionic segments were 12.3, 7.3, 3, and 2 cm for TEPT, and 17.6, 9.3, 3.5, and 4.8 cm for DH operation, respectively. Discordance between IOFS and paraffin-section analysis occurred in 5 cases (3 TEPT and 2 DH operation).

CONCLUSION

When TEPT was used, the gross examination and sampling was more accurate, leading to a clearer pathology report. The TEPT procedure facilitates the work of the pathologist without modifying the results of IOFS, if some precautions are taken.

Transanal pull-through for Hirschsprung disease

Hirschsprung (HSCR) disease is a relatively common neonatal developmental disorder of the enteric nervous system and is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses of the distal intestine. This results in absent peristalsis in the affected bowel, and the development of a functional intestinal obstruction. The pathogenesis and genetic basis of the disease is yet unclear. The surgical treatment of HSCR has evolved significantly since 1949 when Swenson first proposed a trans-abdominal pull-through procedure. The transanal pull-through consists of a rectal mucosectomy, resection of the aganglionic bowel and a colo-anal anastomosis. Recent literature and clinically controversies of this minimally invasive one-stage procedure are reviewed. Although follow up is still relatively short the preliminary results appear very favorable and cost effective.

Pediatric laparoscopic surgery--Indian scenario

Laparpscopic Surgery/Minimally Invasive Surgery (MIS) in children have witnessed tremendous progress in the last decade. Presently, there are extensive applications of this novel technique and several advanced level intricate surgeries have been done safely in small children. This is a brief overview of the common indications and utility of MIS in pediatric practice in the Indian Scenario. We discuss some common clinical settings like recurrent abdominal pain, Impalpable testis, intersex disorders Empyema, Thoracis etc., where MIS has had a significant benefit. We also present our experience of MIS in children without using any sophisticated equipment like the harmonic scalpel, endo-staplers etc. MIS has come to stay and it will definitely have lasting impact on surgical problems in children.

Complications of mechanical suturing in pediatric patients

BACKGROUND/PURPOSE

Although it is widely accepted that staplers are effective in reducing operating time, potential complications related to their use in the pediatric population are not well defined yet. The aim of this study is to evaluate the safety of mechanical suturing.

METHODS

Between 1996 and 2001, 174 procedures were performed using circular staplers in gastrointestinal anastomosis, whereas linear staplers were used in gastrointestinal and lung resection. Intraoperative and early complications of each intervention were recorded.

RESULTS

Overall, 12 complications occurred (6.9%). Two were caused by technical problems: In one case the stapler broke, in the other the anvil detached from the instrument shaft. Ten (5.7%) were major complications: 2 cases of leakage and 3 of bleeding in gastrointestinal procedures, and one case of bronchopleural fistula and 4 cases of bleeding during lung surgery. There was a significant correlation (P <.05) between type of stapler used and development of complications, suggesting a safer use of endoscopic staplers compared with conventional linear ones.

CONCLUSIONS

Mechanical suturing in children is not used frequently, but some procedures could be used more widely because they are fast and safe.

Current concepts in minimal access surgery for children

Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.

Hirschsprung's Disease

Hirschsprung's disease (HSCR) is the most common congenital malformation of the enteric nervous system and requires early diagnosis and surgical repair for the best comprehensive outcome. The early diagnosis of this disorder permits the use of primary endorectal pull-through (PERPT), which is now the definitive surgical therapy for HSCR. PERPT has become the preferred method of treatment for HSCR, and large numbers of successfully treated patients have been described in the recent medical literature. The rate of postoperative complications is generally similar to that following a two-stage surgical repair, but PERPT patients may be at a slightly higher risk for Hirschsprung's-associated enterocolitis. Despite recent surgical advances in the treatment of HSCR, a two-stage surgical repair involving a temporary diverting colostomy may still be necessary in up to one third of patients. Candidates for a staged repair include those HSCR patients with long-segment or total colonic disease or when there has been a delay in diagnosis that results in a markedly dilated proximal colon or patient clinical instability. Internal anal sphincter hypertonicity, occurring either as isolated primary anal achalasia or as a postoperative complication, can be successfully managed by either botulinum toxin injections or anal myectomy. The measurement of colonic motility in surgically repaired patients with a long-standing postoperative abnormality of bowel function can identify several distinct motility disorders that are amenable to separate and individualized therapies. The single most important element in the management of HSCR remains the clinical judgement of the surgeon of record, who utilizes all discernible clinical data to elect the manner of surgical repair in a given patient.

[Minimally invasive surgery in the treatment of Hirschsprung disease]

STUDY AIM

The treatment of Hirschsprung's disease was improved by the laparoscopic approach. The study aim was to report the results of a short series.

PATIENTS AND METHOD

From December 1996 to January 2000, 13 children (7 boys and 6 girls) were operated for a Hirschsprung's disease with a laparoscopic approach. The mean age at the time of surgery was 6 months. A colostomy had been performed previously in 10 of them. The colostomy was closed and the colorectal anastomosis was performed with Duhamel's technique in 10 and Swenson's in 3. Location of aganglionnic bowel was rectum and sigmoid colon (n = 9) rectum (n = 2) left colon (n = 1), left colon and right transverse colon (n = 1).

RESULTS

The mean duration of the procedure was 160 minutes. One conversion to laparotomy was necessary. One postoperative leak required a temporary colostomy. One intestinal occlusion due to an incarceration of an intestinal loop behind the pulled through colon, required a reoperation. The mean 26 month-follow-up was too short to draw conclusions about functional results.

CONCLUSION

Laparoscopic approach was an important progress in the treatment of the Hirschsprung's disease but, more recently, the transanal approach that we used in the last five patients, seems to be another more important innovation.