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Zhang Y, Liu Z, Li S, Yang S, Zhao J, Yang T, Li S, Chen Y, Guo W, Hou D, Li Y, Huang J. One-stage transanal endorectal pull-through for Hirschsprung disease: experience with 229 neonates. Pediatr Surg Int 2022; 38:1533-1540. [PMID: 36030350 DOI: 10.1007/s00383-022-05198-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of transanal endorectal pull-through (TEPT) and the long-term outcomes in newborns with Hirschsprung disease (HD). METHODS A total of 229 newborns with HD underwent one-stage TEPT between 2007 and 2020, and the diagnoses were confirmed by rectal biopsy. The perioperative clinical course for all patients was reviewed, and the postoperative short- and long-term outcomes were assessed. RESULTS A total of 229 neonates (187 male and 42 female) had a median age at TEPT of 17 days (range 6-28 days). Sixty-eight patients (29.7%) underwent TEPT combined with an abdominal approach or laparoscopy. Early postoperative complications (using the Clavien-Dindo grading system) were documented in 36 patients (15.7%), and late postoperative complications were noted in 9 patients (3.9%). The follow-up period in the remaining 165 children ranged from 1.2 to 14.0 years (median 5.0 years). A total of 106 of the patients older than four years old took part in an interview about bowel function, and 85 patients (80.2%) had bowel function scores (BFS) ≥ 18. CONCLUSION TEPT is effective and safe for HD in the neonatal period and presents with a low rate of complications and an acceptable outcome.
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Affiliation(s)
- Yanan Zhang
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Zhaozhou Liu
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Shuangshuang Li
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Shen Yang
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Jiawei Zhao
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Ting Yang
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Siqi Li
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Yongwei Chen
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Weihong Guo
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Dawei Hou
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Yingzi Li
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China
| | - Jinshi Huang
- Department of Neonatal Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Road, Beijing, 100045, China.
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Did Age at Surgery Influence Outcome in Patients With Hirschsprung Disease? A Nationwide Cohort Study in the Netherlands. J Pediatr Gastroenterol Nutr 2022; 75:431-437. [PMID: 35830738 DOI: 10.1097/mpg.0000000000003550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Hirschsprung disease (HD) requires surgical resection of affected bowel, but the current evidence is inconclusive regarding the optimal age for resection. The aim of this study was to assess whether age at resection of the aganglionic segment is a determinant for surgical outcomes. METHODS A cross-sectional cohort study was done including all consecutive patients with HD between 1957 and 2015, aged 8 years or older (n = 830), who were treated in 1 of the 6 pediatric surgical centers in the Netherlands. Outcome measures were mortality, postoperative complications, stoma rate and redo surgery rate, retrieved from the medical records. Additionally, constipation and fecal incontinence rate in long term were assessed with the Defecation and Continence Questionnaire (DeFeC and P-DeFeC). RESULTS The medical records of 830 patients were reviewed, and 346 of the 619 eligible patients responded to the follow-up questionnaires (56%). There was a small increase in the risk of a permanent stoma [odds ratio (OR) 1.01 (95% confidence interval {CI}: 1.00-1.02); P = 0.019] and a temporary stoma [OR 1.01 (95% CI: 1.00-1.01); P = 0.022] with increasing age at surgery, regardless of the length of the aganglionic segment and operation technique. Both adjusted and unadjusted for operation technique, length of disease, and temporary stoma, age at surgery was not associated with the probability and the severity of constipation and fecal incontinence in long term. CONCLUSIONS In this study, we found no evidence that the age at surgery influences surgical outcomes, thus no optimal timing for surgery for HD could be determined.
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Comparison of clinical outcomes after total transanal and laparoscopic assisted endorectal pull-through in patients with rectosigmoid Hirschsprung disease. J Pediatr Surg 2022; 57:69-74. [PMID: 35123788 DOI: 10.1016/j.jpedsurg.2022.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Total transanal (TERPT) and laparoscopic endorectal pull-through (LERPT) are the most common procedures to treat rectosigmoid Hirschsprung's disease (HD). Since few studies have compared the two methods, we aimed to assess clinical outcomes after TERPT and LERPT in this cross-sectional study. METHODS AND PATIENTS All patients with rectosigmoid HD operated with TERPT and LERPT between 2001 and 2018 were eligible. Peri-operative data were registered from patients' records, and bowel function was assessed according to the Krickenbeck classification. RESULTS 91/97 (94%) patients were included; 46 operated with TERPT and 45 with LERPT. Bowel function was assessed in 80 patients at median seven (4-17) years. There was no difference in functional outcome between the procedures. Unplanned procedures under general anesthesia were frequent; 28% after TERPT and 49% after LERPT (p = 0.04). 11% of TERPT and 29% of LERPT patients got botulinum toxin injections (p = 0.03). In the TERPT group, patients operated in the neonatal period had poorer outcome (78%) than those operated later (24%) (p = 0.005). No difference in operative time, length of hospital stay, and rate of early and late complications was found between the procedures. CONCLUSION There was no difference in long-term bowel function in patients with rectosigmoid HD operated with TERPT or LERPT. More LERPT patients had an unplanned procedure under general anesthesia, mostly due to obstructive symptoms. LEVEL OF EVIDENCE III.
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Westfal ML, Okiemy O, Chung PHY, Feng J, Lu C, Miyano G, Tam PKH, Tang W, Wong KKY, Yamataka A, Guyer RA, Doody DP, Goldstein AM. Optimal timing for Soave primary pull-through in short-segment Hirschsprung disease: A meta-analysis. J Pediatr Surg 2022; 57:719-725. [PMID: 34330420 PMCID: PMC8776908 DOI: 10.1016/j.jpedsurg.2021.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/15/2021] [Accepted: 07/07/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal age for endorectal pull-through (ERPT) surgery in infants with short-segment Hirschsprung disease varies, with a trend toward earlier surgery. However, it is unclear if the timing of surgery impacts functional outcomes. We undertook the present study to determine the optimal timing of ERPT in infants with short-segment Hirschsprung disease. METHODS The NCBI PubMed database was searched for English-language manuscripts published between 2000 and 2019 analyzing functional outcomes for patient following the initial Soave ERPT for short-segment Hirschsprung disease. Raw data from these studies was obtained from the corresponding author for each manuscript. We combined data from these papers with our own institutional data and performed a meta-analysis. RESULTS A total of 780 infants were included in our meta-analysis. Constipation occurred in 1.0-31.7%, soiling 1.3-26.0%, anastomotic stricture 0.0-14.6%, and anastomotic leak 0.0-3.4%. Regarding age at ERPT, younger infants at the time of initial corrective surgery had higher rates of soiling, stricture, and leak. On sub-group analysis, patients <2.5 months at their initial corrective surgery had higher rates of soiling (25.9% vs. 11.4%, p<0.01), as well as stricture (10.0% vs 1.7%, p<0.01) and leak (5.5% vs 1.3%, p<0.01). CONCLUSION While age at Soave endorectal pull-through for short-segment Hirschsprung disease has decreased over time, functional outcomes associated with this trend have only recently been examined. Our findings suggest that patients <2.5 months old at the time of endorectal pull-through may have worse functional outcomes, emphasizing the need to consider further study of the timing of surgery in this population.
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Affiliation(s)
- Maggie L Westfal
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Warren 1151, Boston, Massachusetts MA 02114, United States
| | - Ongoly Okiemy
- Department of Pediatric Surgery, American Memorial Hospital, Reims-Champagne-Ardennes University, Reims, France
| | | | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, Wuhan, China
| | - Changgui Lu
- Department of Pediatric Surgery, Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Go Miyano
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | | | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | | | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Richard A Guyer
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Warren 1151, Boston, Massachusetts MA 02114, United States
| | - Daniel P Doody
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Warren 1151, Boston, Massachusetts MA 02114, United States
| | - Allan M Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Warren 1151, Boston, Massachusetts MA 02114, United States.
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Kastenberg ZJ, Taylor MA, Durham MM, Calkins CM, Rentea RM, Wood RJ, Avansino JR, Levitt MA, van Leeuwen KD, Lewis KE, Reeder RW, Rollins MD. Perioperative and long-term functional outcomes of neonatal versus delayed primary endorectal pull-through for children with Hirschsprung disease: A pediatric colorectal and pelvic learning consortium study. J Pediatr Surg 2021; 56:1465-1469. [PMID: 34052005 DOI: 10.1016/j.jpedsurg.2021.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE the timing of endorectal pull-through for Hirschsprung disease (HD) is controversial. Neonatal primary endorectal pull-through theoretically prevents preoperative enterocolitis. Delayed primary endorectal pull-through offers the surgeon the benefit of more robust perineal anatomy and allows primary caregivers the time to emotionally process the diagnosis and to gain experience with rectal irrigations. We hypothesized that delayed primary endorectal pull-through would be associated with equivalent perioperative morbidity compared to the neonatal repair and would lead to improved long-term functional outcomes. METHODS we analyzed all patients in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry who had a primary endorectal pull-through for HD and at least three-and-one-half years of follow up in a specialty colorectal clinic. We evaluated patient demographics, operative outcomes, perioperative episodes of enterocolitis, and long-term functional outcomes for the neonatal (<31 days) and delayed (≥31 days) pull-through cohorts. RESULTS eighty-two patients were identified of whom 49 were operated upon in the neonatal period and 33 in a delayed fashion. The median age at operation was 11 days [IQR 7 - 19 days] for the neonatal cohort and 98 days [IQR 61 - 188 days] for the delayed cohort. Thirty-four (69.4%) of the neonatal and 22 (66.7%) of the delayed cohort patients had rectosigmoid transition zones. Four of 49 patients (8.1%) in the neonatal cohort were diagnosed with enterocolitis preoperatively compared to two of 33 (6.0%) in the delayed cohort (p = 0.89). Eighteen of 49 patients (36.7%) in the neonatal cohort and 16 of 33 (48.5%) in the delayed cohort had at least one postoperative episode of enterocolitis (p = 0.38). Fifteen of 49 patients (30.6%) in the neonatal cohort were receiving bowel management for fecal incontinence at most recent follow up compared to five of 33 (15.2%) in the delayed cohort (p = 0.13). CONCLUSION delayed primary endorectal pull-through offers a safe alternative to operation in the neonatal period and appears to have, at least, equivalent functional outcomes. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Zachary J Kastenberg
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, Primary Children's Hospital, 100N. Mario Cappecchi Dr., Suite 3800, Salt Lake City, UT 84113, United States.
| | - Mark A Taylor
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, Primary Children's Hospital, 100N. Mario Cappecchi Dr., Suite 3800, Salt Lake City, UT 84113, United States
| | - Megan M Durham
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Casey M Calkins
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | - Rebecca M Rentea
- Division of Pediatric Surgery, Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, United States
| | - Richard J Wood
- Division of Pediatric Surgery, Department of Surgery, Ohio State College of Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Jeffrey R Avansino
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle Children's, WA, United States
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC, United States
| | | | - Katelyn E Lewis
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, United States
| | - Ron W Reeder
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, United States
| | - Michael D Rollins
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, Primary Children's Hospital, 100N. Mario Cappecchi Dr., Suite 3800, Salt Lake City, UT 84113, United States
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Mpody C, Shepherd EG, Thakkar RK, Dairo OO, Tobias JD, Nafiu OO. Synergistic effects of sepsis and prematurity on neonatal postoperative mortality. Br J Anaesth 2020; 125:1056-1063. [PMID: 32868040 DOI: 10.1016/j.bja.2020.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Compared with term neonates, preterm babies are more likely to die from sepsis. However, the combined effects of sepsis and prematurity on neonatal postoperative mortality are largely unknown. Our objective was to quantify the proportion of neonatal postoperative mortality that is attributable to the synergistic effects of preoperative sepsis and prematurity. METHODS We performed a multicentre, propensity-score-weighted, retrospective, cohort study of neonates who underwent inpatient surgery across hospitals participating in the United States National Surgical Quality Improvement Program-Pediatric (2012-2017). We assessed the proportion of the observed hazard ratio of mortality and complications that is attributable to the synergistic effect of prematurity and sepsis by estimating the attributable proportion (AP) and its 95% confidence interval (CI). RESULTS We identified 19 312 neonates who realised a total of 321 321 person-days of postsurgical observations, during which 683 died (mortality rate: 2.1 per 1000 person-days). The proportion of mortality risk that is attributable to the synergistic effect of prematurity and sepsis was 50.5% (AP=50.5%; 95% CI, 28.8-72.3%; P < 0.001). About half of mortality events among preterm neonates with sepsis occurred within 24 h after surgery. Just over 45% of postoperative complications were attributable to the synergistic effect of prematurity and sepsis when both conditions were present (AP=45.8; 95% CI, 13.4-78.1%; P<0.001). CONCLUSION Approximately half of postsurgical mortality and complications were attributable to the combined effect of sepsis and prematurity among neonates with both exposures. These neonates typically died within a few days after surgery, indicating a very narrow window of opportunity to predict and prevent mortality. CLINICAL TRIAL NUMBER AND REGISTRY Not applicable.
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Affiliation(s)
- Christian Mpody
- Department of Anaesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Edward G Shepherd
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rajan K Thakkar
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Olamide O Dairo
- Department of Anaesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anaesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Olubukola O Nafiu
- Department of Anaesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
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Bawazir OA. Laparoscopic-Assisted Transanal Pull-Through in Hirschsprung Disease: Does Laparoscopic Dissection Minimize Anal Overstretching? J Laparoendosc Adv Surg Tech A 2020; 30:338-343. [PMID: 31934817 DOI: 10.1089/lap.2019.0524] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Introduction: Surgical treatment for Hirschsprung disease (HD) has evolved from a staged repair to a primary operation but is still associated with significant complications. Extensive transanal dissection may overstretch the sphincter and cause partial tear; however, laparoscopic dissection can decrease rectal overstretching. Thus, this study aimed to evaluate the outcome of surgical management of HD and the efficacy of laparoscopic-assisted transanal endorectal pull-through in infants and children in our center. Patients and Methods: We reviewed the medical records of 74 patients who underwent surgical repair of HD from 2006 to 2019. However, we excluded 42 patients with HD (patients with stoma [n = 33] and total colonic aganglionosis [n = 9]). The remaining 32 patients were divided into two groups. Group A included patients who had transanal pull-through with laparoscopic assistance only to visualize the transition zone, take a biopsy, and check for twisting or bleeding. Group B included patients who had laparoscopic-assisted transanal pull-through with dissection of the rectum. All patients had Soave repair with an approximate cuff length of 5 cm. Results: Group A included 18 patients, whereas group B included 14 patients. Demographic data were comparable between the two groups with no significant difference in age or gender (P = .12 and .67, respectively). Patients in group A had longer operative time (210 ± 20.75 minutes versus 178 ± 18.92 minutes; P < .001) and hospital stay (6 ± 1.33 days versus 5 ± 1.24 days; P = .033). No significant difference was observed in postoperative complications between both groups (anastomotic site stricture, P = .295; persistent soiling, P = .238). Conclusion: Laparoscopic rectal dissection for managing HD is associated with less operative time and hospital stay. In addition, all procedures required for the repair can be safely performed using laparoscopy.
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Affiliation(s)
- Osama A Bawazir
- Pediatric Surgery and Pediatric Urology, Umm Al-Qura University Faculty of Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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