Further evidence on totally transanal one-stage pull-through procedure for Hirschsprung's disease

Endoscopic Decompression with a Transanal Drainage Tube for the Treatment of Hirschsprung's Disease in Newborns

Background: To evaluate the effectiveness and safety of endoscopic decompression with a transanal drainage tube (ED-TDT) in the treatment of neonatal Hirschsprung's disease (HD). Materials and Methods: Six newborns (4 boys and 2 girls; age at operation 9-29 days, median 24 days) were admitted to our hospital due to the delayed passage of meconium after birth, abdominal distension, and vomiting. HD was diagnosed by the retrograde enema radiography. All patients underwent ED-TDT for decompression of the dilated colon. During the operation, an endoscope was inserted through the anus to the ascending colon or ileocecal region, which was then used to insert a guidewire to the ascending colon. The endoscope was then removed, and a colorectal drainage tube was introduced over the guidewire. This drainage was placed until a pull-through procedure was performed. Results: The ED-TDT was successfully performed in all newborns. The intraoperative rectal biopsy confirmed the diagnosis of HD. The duration of the operation was 25-70 minutes (median 52.5 minutes). There were no perforations, bleeding, or other complications after surgery. After surgery, the abdominal distention was significantly relieved, and the babies could be fed with milk after 6 hours. These babies were discharged after 2-11 days (median 2.5 days) and underwent a pull-through procedure after 1-3 months (median 3 months). Conclusions: ED-TDT is a safe and effective treatment for neonatal HD before a pull-through procedure. It could be used as an alternative therapy to colostomy.

How to manage a late diagnosed Hirschsprung's disease

BACKGROUND

How to manage a late diagnosed Hirschsprung's disease (HD) and how to avoid calibre discrepancy?

SUBJECTS AND METHODS

A retrospective study of all patients diagnosed with HD over 2 years in our hospital from January 2009 to December 2012. Data were analysed for clinical presentations, investigations, surgical procedures and post-operative outcome.

RESULTS

Fifteen patients, operated by one single surgeon, were included in this study. The mean age was 6 years (2-16 years). Patients had an ultra-short segment type in 4 cases, rectosigmoid type in 9 cases and descending colonic aganglionosis in 2 cases. Rectal wash out was effective in 12 patients. A blowhole transverse colostomy was performed in 2 patients. Twelve patients underwent one single stage endorectal pull-through. Anastomosis incongruence was avoided by a plication procedure never described before. The assessment of post-operative outcomes by the paediatric incontinence and constipation scoring system revealed a normal continence function in all our patients, but 3 patients suffered from soiling secondary to constipation.

CONCLUSION

One single stage pull-through can be safe and effective in children with late diagnosed HD. Routine rectal washout is a good way to prepare the colon. In some cases, blowhole colostomy can be an option. Anastomosis incongruence is a challenge; we describe a plication procedure to avoid it.

Results of transanal endorrectal descent in Hirschprung's disease

OBJECTIVE

To present our experience of patients with Hirschsprung disease (HD) operated by transanal endorrectal descent (TED).

METHODS

A retrospective study performed of TEDs. We correlate fundamentally the aganglionic segment length with: Complications, need for colostomy and surgical approach.

RESULTS

Between 2003 and 2012 we performed 73 TED (57 men), 78.6% diagnosed in the neonatal period. The aganglionic segment length evidenced in the enema was correlated with surgical findings in 68.9% of cases, being higher in the short forms than in the long segments (80.9 vs. 44%, P<.001). Four patients required preoperative colostomy. The mean age of surgery was 6.3 months (4.5 to 33.7). Short forms represented 64.4% of cases. The abdominal approach was necessary in 10 patients, 9 of these were long/total colonic aganglionic segment. Postoperative enterocolitis presented in 10,9% (9 patients), with no relation with the length of aganglionic or the existence of residual dysplasia. Obstructions occurred in 19.2% of the long form or pancolonic forms. Currently, of the evaluable patients, 5 present constipationand 12 present occasional leakage.

CONCLUSIONS

TED is the surgery of choice for patients with HD. The majority can be handled by preoperative «nursing» without colostomy. The diagnostic tests of choice are manometry with suction biopsy. No significant correlation was found between enterocolitis and length of aganglionic segment, although we observed a drastic reduction of postoperative enterocolitis, since the introduction of technical changes, such as the use of postoperative rectal tubes and the posterior section of the cuff muscles.

Laparoscopic-assisted transanal pull-through for Hirschsprung's disease: Comparison between partial and near total laparoscopic mobilization of rectum

Background:

Transanal pull-through with laparoscopic assistance is gaining popularity. How much rectal dissection to do laparoscopically and how much transanally is not clear. Laparoscopic rectal mobilization is akin to open pelvic dissection of Swenson's operation — the most physiological procedure. Through this comparative study, we aim to evolve a technique that maximizes the benefits of Swenson's technique and minimizes the problems of a transanal procedure.

Materials and Methods:

Twenty patients (19 boys and one girl, newborn to 6 years) with Hirschsprung's disease (HD) were randomized for laparoscopic-assisted transanal pull-through (LATAPT) either by near complete (Group A) or partial (Group B) laparoscopic mobilization of rectum. Patients were followed up for at least 3 months. Demographic profile; operative details (time taken, blood loss, operative difficulty, and complications); postoperative course (duration of urinary catheter, oral feeding, and hospital stay); and follow-up stooling pattern, consistency, and continence were compared in the two groups.

Results:

The time taken for laparoscopic mobilization was marginally higher in group A, but the time taken for transanal dissection in this group was significantly less than in group B. All other comparisons showed no significant difference in the two groups. Stool frequency and continence improved with time in both groups.

Conclusion:

Extent of laparoscopic mobilization of rectum does not appear to be a factor deciding the outcomes. No recommendations could be made in view of the small number of cases. However, it shows that laparoscopic assistance can be used to maximize the benefits of Swenson type of operation and a transanal pull-through.

10 years of experience with laparoscopic-assisted endorectal Soave pull-through procedure for Hirschsprung's disease in China

OBJECTIVE

To report early and late results of laparoscopic-assisted endorectal Soave pull-through (LAEPT) with a short and V-shaped partial resection muscular cuff for Hirschsprung's disease (HD) over a 10-year period.

METHODS

The clinical courses of 218 patients who underwent modified LAEPT for HD were reviewed. LAEPT was described by the Georgeson technique. The main modifications included less dissection of the bottom of the pelvis, rectal mucosa dissection with a long cuff, coloanal anastomosis with a short cuff, and a V-shaped partial resection in the posterior wall of the muscular cuff.

RESULTS

From September 1999 to July 2009, 218 patients were operated on by the same surgeon. Ages ranged from 15 days to 12 years old. The aganglionic segment was located in the rectum or sigmoid colon in 176 patients, in the left colon in 38 children, and in the transverse colon in 4 patients. The median operating time was 176 minutes. Conversion to open surgery was required in 2 patients. Bleeding of the left iliac vein occurred in 1 patient, and a 180° twist of the neorectum occurred in 2 cases. Median first bowel movement time was 23 hours, and median postoperative hospital stay was 10.4 days. Median daily defecation frequency was 4.6 within 2 weeks and 2.3 at 3 months postoperatively. The immediate postoperative complications included intestine herniation from the trocar site in 2 patients, perianal excoriation in 32 patients, and anastomotic leakage in 3 patients. Follow-up ranging from 6 to 120 months was obtained for 182 patients. Late postoperative complications included postoperative adhesive bowel obstruction (1.1%), enterocolitis (7.7%), anasomostic stenosis (2.2%), constipation (1.6%), and soiling (3.6%). Eighty-seven percent had excellent and good bowel function.

CONCLUSION

LAEPT with a short muscular cuff with a V-shaped partial resection in the posterior wall is a safe and effective procedure for HD.

What is the most common complication after one-stage transanal pull-through in infants with Hirschsprung's disease?

BACKGROUND

Hirschsprung's disease (HD) is a relatively common congenital disease that could be suspected by clinical symptoms, abdominal plain X-ray, and finally diagnosed by rectal biopsy. In 80% cases, rectosigmoid junction is involved. Recently, one-stage transanal pull-through (TAPT) procedure has been popular and may have several complications.

METHODS AND PATIENTS

During a 4-year period, 86 infants (28 girls, 58 boys) with mean age 8 days (3-33) and clinically suspected to HD were admitted in our center. HD was proved by rectal biopsy. All patients after full bowel preparation and rectal washout were candidates for TAPT operation. A Swenson-like procedure was performed and the anastomosis was done between the well blood supply ganglionic colon and the rectum at 1 cm above dentate line. Interrupted suture with 5-0 Vicryl was used. Nelaton tube (12 F) inserted in the pelvis via transprineal for drainage of blood or collection. From February 2008 in 30 cases, prophylactic Hegar dilatation was performed 2 weeks after operation.

RESULTS

Anal stricture in 12 cases (14%) was treated by anal dilation in 10 cases and 2 cases corrected by surgical management. Entrocolitis in 4 cases (5%) was treated by medical management. In two cases, retrocolic abscess had spontaneous drainage via tube drain. There was no anastomotic stricture after starting prophylactic anal bouginage.

CONCLUSION

TAPT has many advantages, low complications and the results are excellent. It seems the most common complication is anastomotic stricture that responds well to prophylactic bouginage. We recommend prophylactic anal bouginage with Hegar probe at 2 weeks after operation. Long-term follow-up is needed to evaluate the outcomes of our operations.

Clinical experience with a new modified transanal endorectal pull-through for Hirschsprung's disease

Single-stage transanal endorectal pull-through (TEPT) procedure is now widely used for rectosigmoid Hirschsprung's disease (HD). However, this procedure is associated with some common complications like stricture, enterocolitis, constipation, anastomotic dehiscence and perianal excoriation. The aim of this study was to evaluate the clinical outcomes of a modified TEPT operation in the management of rectosigmoid HD. 45 patients with rectosigmoid HD admitted between August, 2004 and July, 2008 were included in this study. Pre-operative barium enema was done in all of them. Patients in whom the transition zone was well delineated were included in the study. Frozen section biopsy was done to confirm the presence of ganglion cells in the pull-through bowel. All odd number patients were included in group A, where conventional TEPT procedure was performed. All even number patients and the last five patients of the series were in group B. In this group, a modified transanal endorectal procedure was done. The initial part of submucosal dissection and mobilization of aganglionic rectum was the same as in the conventional procedure. The anorectal mucosa was anastomosed end-to-side to the seromuscular coat of the ganglionic bowel. Mobilized bowel was divided at about 2 cm distal to the anastomosis. Six hitching stitches were applied from the free edge of the bowel to the perianal skin so that the anastomosis remains outside the anal verge. The distal redundant bowel was excised on eighth post-operative day. Pre-operative bowel preparation was done in all patients in group A. The bowel preparation was not mandatory in group B patients. Post-operative results of both these groups were compared and analyzed using the Mann-Whitney U test. Mean operative time in group A was 86 min (range 75-95 min) versus 90 min (range 70-100 min) in group B. Average length of the bowel resected was 20 cm (range 10-26 cm) in group A and 22 cm (12-40 cm) in group B. Post-operative feeding was started after 48 h in group A and after 6 h in group B. Average hospital stay was about 8 days in both the groups. Median follow-up was 36 months in group A (range 14-54 months) and 32 months (range 12-52 months) in group B. Anastomotic stricture or stenosis was noted in two patients in group A and none in group B (p < 0.01). Partial anastomotic dehiscence was noted in two patients in group A and none in group B (p < 0.01). Average bowel movement in group A was 6-8 per day at 1 month and 2-6 per day at 6 months. In group B, it was 8-10 at 1 month and 2-8 at 6 months. Cuff narrowing causing constipation was noted in two patients in group A and none in group B (p < 0.01). Enterocolitis following pull-through was noted in two patients in group A and three patients in group B. Four patients in group A and one patient in group B had post-operative constipation. All of them responded to bowel management program: only one of them (group A) required enema; soiling was noted in one patient each in both the groups. Modified TEPT procedure is associated with excellent clinical outcome with fewer complications, and permits early post-operative feeding. Operating time, hospital stay and post-operative bowel movement were comparable with the conventional technique.

Transanal endorectal pull-through in children with Hirschsprung's disease--technical refinements and comparison of results with the Duhamel procedure

PURPOSE

Transanal endorectal pull-through (TEPT) has drastically changed the treatment of Hirschsprung's disease (HD). A short follow-up of children submitted to TEPT reveals results that are similar to the classic transabdominal pull-through procedures. However, few reports compare the late results of TEPT with transabdominal pull-through procedures with respect to complication rates and the fecal continence. The aims of the present work are to describe some technical refinements that we introduced in the procedure and to compare the short and long-term outcome of TEPT with the outcomes of a group of patients with HD who previously underwent the Duhamel procedure.

METHODS

Thirty-five patients who underwent TEPT were prospectively studied and compared to a group of 29 patients who were treated with colostomy followed by a classical Duhamel pull-through. The main modifications introduced in the TEPT group were no preoperative colon preparation, operation conducted under general anesthesia in addition to regional sacral anesthesia, use of only one purse-string suture in the rectal mucosa before transanal submucosal dissection, and no use of retractors and electrocautery during the submucosal dissection.

RESULTS

The most frequent early complications of TEPT group were perineal dermatitis (22.8%) and anastomotic strictures (8.6%). The comparison with patients who underwent Duhamel procedure revealed no difference in the incidence of preoperative enterocolitis, the patients of the TEPT group were younger at the time of diagnosis and of surgery, they had shorter operating times, and they began oral feeding more quickly after the operation. The incidence of wound infection was lower in the TEPT group. Moreover, the TEPT and Duhamel groups showed no difference in the incidences of mortality, postoperative partial continence, and total incontinence. Although the incidences of complete continence and postoperative enterocolitis were not different, a tendency to the increased incidence in the TEPT group was observed.

CONCLUSIONS

This study further supports the technical advantages, the simplicity, and the decreased incidence of complications of a primary TEPT procedure when compared to a classical form of pull-through. Some technical refinements are described, and no preoperative colon preparation was necessary for the patients studied here. The results show that the long-term outcomes of the modified TEPT procedure are generally better than those obtained with classical approaches.

Analysis of problems, complications, avoidance and management with transanal pull-through for Hirschsprung disease

BACKGROUND

The primary aim of this study is to detail the problems, complications, their avoidance, and management with transanal pull-through developed from experience with 65 patients.

METHODS

A retrospective study of 65 patients who underwent transanal pull-through between January 2002 and December 2006 was conducted. Their medical charts and operative notes were reviewed for problems encountered during surgery, postoperative period, and follow-up.

RESULTS

In 46 patients, a primary transanal pull-through was performed, whereas in 19 with a prior colostomy, followed staged pull-through was done. The minimum follow-up was 6 months, with an average of 22 months after surgery (range, 6-47 months). Sixteen patients (25%) experienced at least 1 complication. These included inadvertent full-thickness mobilization of the rectum in 3 (4.6%), retraction and bleeding of colonic mesenteric vessels in 2 (3.7%), difficulty in mobilizing intraperitoneal colon in 1 (1.5%), and a false-positive frozen section in 2 patients (3%). Early postoperative complications occurred in 7 patients (11%), which included sphincter spasm in 3 (4.6%), anastomotic leak in 1 (1.5%), cuff abscess in 2 (3%), and enterocolitis in 1 (1.5%). Late postoperative complications in 46 patients (70%), occurring from 1 week till 3 months of follow-up included perianal excoriation in 22 (34%), increased stool frequency in 20 (31%), anal stenosis in 3 (4.6%), and enterocolitis in 2 patients (3%). Methodology is detailed for avoidance and management of problems and complications. Individual patient analysis, complications timing, and strategy for management are discussed.

CONCLUSION

Patient outcomes for transanal pull-through have improved significantly as a result of combination of experience and the ability to avoid and manage associated complications. Experience, avoidance, and interdiction are key factors in complication management.

The effect of dilated ganglionic segment on anorectal and urinary functions during 1-stage transanal endorectal pull through for Hirschsprung's disease

BACKGROUND/PURPOSE

During a 1-stage transanal endorectal pull through (OS-TERP) for Hirschsprung's disease (HD), dilated ganglionic segment (DGS) may pose a problem during coloanal anastomosis. Apart from the anorectal problems occurring after the HD operations, lower urinary tract problems may also be encountered. The anorectal and lower urinary tract system functions of the patients that underwent OS-TERP in the presence of DGS were evaluated.

METHOD

From 2000 to 2005, 15 patients (14 boys and 1 girl) underwent OS-TERP for HD. During the presence of DGS, the coloanal anastomosis of the DGS was completed without any tapering or excision. Hospital and digital video records of all the patients who underwent OS-TERP were evaluated, and the operation time, complications, and follow-up periods of the patients were compared. Standard urodynamic studies were performed after at least 6 months. Bladder capacity; mean bladder capacity ratio; maximum filling pressure; the number of contractions during the filling phase; intraabdominal, intravesical, and detrusor pressures; residual urinary volume; and electromyography activities of the pelvic floor muscles were evaluated.

RESULTS

Six patients had ganglionic segment of normal caliber, whereas 9 patients had DGS. Duration of the operation was significantly longer in the DGS group. One patient in DGS group experienced a single episode of enterocolitis in the postoperative period. Transient urinary retention occurred in another patient in DGS group. In ganglionic segment of normal caliber group, one patient experienced 2 episodes of enterocolitis in the postoperative period. Urodynamic study of the 7 patients in the DGS group had postvoiding urine volume of less than 20 mL. The detrusor activities of all the patients were found to be normal. None of the patients had developed urinary tract problems during the follow-up period.

CONCLUSION

With the coloanal anastomosis technique, we have described that narrowing the DGS to anal caliber step by step without any excision or tapering enables DGS to fit to the anus easily. Although further clinical studies with larger sample sizes are necessary, present study may imply that OS-TERP performed in the presence of a DGS may not increase morbidity and affect anorectal functions. The normal urodynamic study results obtained in this study may imply that OS-TERP procedure may be performed safely in the presence of DGS.

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.

Is there a hidden mortality after one-stage transanal endorectal pull-through for patients with Hirschsprung's disease?

One-stage transanal pull-through (TAP) has become a standard definitive procedure for the treatment of Hirschsprung's disease (HD). Short-term results of this operation seem to be excellent, but long-term outcome is still obscure. We evaluated the morbidity and mortality of our patients with one-stage TAP, and we reviewed the literature. We performed a TAP without a colostomy in 21 patients with HD. The primary outcome measures are age, sex, complications during surgery, enterocolitis (EC) attacks after surgery, postoperative stooling problems and mortality. All patients were called over telephone, and their clinical and functional outcomes were obtained. Case series of TAP in the literature were also reviewed in terms of postoperative problems. Twenty-one patients with full thickness rectal biopsy-proven HD underwent one-stage TAP. Average follow-up was 28 months. One early postoperative EC and three more late attacks of EC were observed. All survived patients had normal bowel habits. Three patients had perianal excoriations, three patients soiling, seven cases required anal dilatations and four patients experienced a diarrhea after surgery. We have been informed that four patients died after discharge from hospital. Two of them were a sudden death (one patient had metabolic problems, the other might have had an EC attack). The cause of death of one patient with an associated Down syndrome was a severe pneumonia, and one other case died of a septic shock of unknown etiology. None of these patients had a diarrhea or abdominal distention, which could have been an evidence of an EC attack prior to their deaths. We observed similar fatal cases, when reviewed the published series in the literature. There might be a hidden mortality within the long-term period after TAP for HD. Therefore, we recommend a close follow-up for all patients with any associated health problem and those from low socioeconomic regions after one-stage pull-through.

A new modification of transanal Soave pull-through procedure for Hirschsprung's disease

BACKGROUND

One stage transanal Soave pull-through procedure (TSPP) is a recent popular operation in the treatment of Hirschsprung's disease (HD). With no visible scar and a short hospital stay, it is well accepted by surgeons and mothers. In the conventional Soave procedure, a long rectal muscular cuff left for anocolic anastomosis might increase the incidence of postoperative enterocolitis and constipation. This study presents a modified transanal Soave pull-through procedure (MTSPP) which includes an oblique mucosectomy and an oblique anastomosis with a short split muscular cuff.

METHODS

A review of two groups of HD patients was made: 112 underwent conventional transanal Soave procedure from 1999 to 2001 (group 1) and 140 underwent modified transanal Soave procedure from 2002 to 2004 (group 2). A comparison was made between the two groups on operative data and postoperative complications. The data included: age at the operation, operating time, blood loss, time to feeds and hospital stay, occurrence of postoperative enterocolitis or constipation, need for anal dilatation, postoperative bowel function and perianal skin problems.

RESULTS

There was no significant difference between two groups with respect to age, gender, length of colon resected, operating time, blood loss and hospital stay. However occurrence of postoperative enterocolitis, constipation, anastomotic stricture and time needed for anal dilatation were evidently less in group 2 (MTSPP). The mean operating time in group 1 was (106 +/- 39) minutes with a range of 60 to 170 minutes; in group 2 was (101 +/- 36) minutes with a range of 66 to 190 minutes. The average length of the bowel resected in group 1 was (24 +/- 7) cm, range 15 to 58 cm; in group 2 was (26 +/- 8) cm, range 15 to 70 cm. Two patients, one in each group, required laparoscopic assistance because of long aganglionic colon. Another patient in group 2 required laparotomy because of total colonic aganglionosis. Postoperative complications in group 1 included: temporary perianal excoriation in 34 patients (26 were < 3 months of age), enterocolitis in 21, anastomotic stricture in 11, recurrent constipation in 12, cuff abscess in 1, anastomosis leak in 1, soiling in 3 and rectal prolapse in 1. In group 2 post operative complications included: transient perianal excoriation in 37 patients (30 were < 3 months of age), enterocolitis in 13, anastomotic stricture in 5, recurrent constipation in 6, anastomotic leak in 1, adhesive bowel obstruction in 1 and soiling in 4. Complete bowel continence was found in 97 children (86.6%) in group 1 and in 129 children (92.1%) in group 2 at one year followup after operation.

CONCLUSIONS

Modified transanal Soave pull-through procedure for HD with oblique mucosectomy and anastomosis and a short split muscular cuff is a safe and feasible operation with low incidence of postoperative complication. It is an encouraging improvement of the conventional transanal Soave pull-through procedure. MTSPP is a preferable choice in the surgery of HD.