Long-term follow-up of redo pull-through procedures for Hirschsprung's disease: efficacy of the endorectal pull-through

Reoperation for Hirschsprung Disease: Two cases of Vanishing Ganglion Cells and Review of the Literature

Hirschsprung disease (HD) is characterized by circumferential aganglionosis of the rectum with variable proximal bowel involvement. The underlying pathogenesis is due to failure of caudal migration of neural crest cells during pre-natal development, causing functional bowel obstruction. Definitive therapy is surgical resection; however, a subset of patients will require reoperation. An important cause of reoperation is the rare but distinct entity described as the ganglion cell "vanishing" phenomenon. In this phenomenon, affected patients have normal circumferential ganglion cells present at the proximal margin during primary resection. They undergo a variable asymptomatic period post-primary resection but ultimately develop recurrent symptoms. Upon reoperation, ganglion cells seemingly vanish and are no longer present in the previously functioning and ganglionated bowel proximal to the initial anastomotic site. To further characterize and investigate this poorly understood pathology, here we present 2 cases of HD patients who required reoperation. Our small series implicates that an immune component may contribute as patient 2 had a brisk neurotrophic eosinophilic infiltrate only present in the reoperation specimen. However, this was not observed in patient 1. Other possible etiologies include post-operative ischemia/hypoxia, visceral neuropathy, or signaling abnormalities within the residual ganglion cells themselves.

Transanal full-thickness pull-through approach in the treatment of anastomotic leakage after operation for Hirschsprung disease

BACKGROUND

Anastomotic leakage (AL) is one of the most perplexing complications that can occur following a radical operation to treat Hirschsprung disease (HSCR). The purpose of this study was to document our experience with anastomotic leakage following radical HSCR surgery to enhance therapeutic effect and prognosis.

METHODS

Between January 2007 and April 2021, a retrospective study was conducted on 12 children who developed anastomotic leakage following radical surgery for HSCR. Medical records were analyzed to determine the clinical manifestations, primary surgical procedures, evaluation methods, surgical plans, and outcomes of the patients. To assess postoperative bowel function, the Rintala score was used.

RESULTS

The Soave procedure was used as the primary surgical method in seven cases (58.3%), the Swenson procedure was used in four cases (33.3%), and the Rehbein procedure was used in one case (8.3%). Enterostomy (10, 83.3%) and conservative treatment (2, 16.7%) were performed when anastomotic leakage was diagnosed. Two patients who directly closed stoma without redoing pull-through both accepted enterostomy within 48 h. One female with anastomotic fistula who was closed leakage or fistula in situ had to endure lifelong stoma. Other patients who underwent redo pull-through procedures had normal bowel function. Seven patients underwent a redo pull-through procedure. Three of them preferred the transanal full-thickness pull-through (FTPT) approach, while four preferred the Soave technique. Three children had mild postoperative soiling, which improved with conservative treatment. Bowel function score was 17.5 ± 1.1.

CONCLUSION

Enterostomy should be performed immediately if anastomotic leakage occurs. After leakage, it is necessary to redo the pull-through procedure in an anastomotic fistula or anastomotic stricture. Transanal FTPT reconstruction is an effective method for repairing anastomoses and leakage.

Current understanding of Hirschsprung-associated enterocolitis: Pathogenesis, diagnosis and treatment

Hirschsprung-associated enterocolitis (HAEC) was described in 1886 by Harald Hirschsprung and is a potentially deadly complication of Hirschsprung Disease. HAEC is classically characterized by abdominal distension, fever, and diarrhea, although there can be a variety of other associated symptoms, including colicky abdominal pain, lethargy, and the passage of blood-stained stools. HAEC occurs both pre-operatively and post-operatively, is the presenting symptom of HSCR in up to 25% of infants and varies in overall incidence from 20 to 60%. This article reviews our current understanding of HAEC pathogenesis, diagnosis, and treatment with discussion of areas of ongoing research, controversy, and future investigation.

Long-term surgical and patient-reported outcomes of Hirschsprung Disease

BACKGROUND

Information is needed regarding the complex relationships between long-term functional outcomes and health-related quality of life (HRQoL) in Hirschsprung's Disease (HSCR). We describe long-term outcomes across multiple domains, completing a core outcome set through to adulthood.

METHODS

HSCR patients operated at a single center over a 35-year period (1978-2013) were studied. Patients completed detailed questionnaires on bowel and urologic function, and HRQOL. Patients with learning disability (LD) were excluded. Outcomes were compared to normative data. Data are reported as median [IQR] or mean (SD).

RESULTS

186 patients (median age 28 [18-32] years; 135 males) completed surveys. Bowel function was reduced (BFS 17 [14-19] vs. 19 [19-20], p < 0•0001;η² = 0•22). Prevalence and severity of fecal soiling and fecal awareness improved with age (p < 0•05 for both). Urinary incontinence was more frequent than controls, most of all in 13-26y females (65% vs. 31%,p = 0•003). In adults, this correlated independently with constipation symptoms (OR 3.18 [1.4-7.5],p = 0.008). HRQoL outcomes strongly correlated with functional outcome: 42% of children demonstrated clinically significant reductions in overall PedsQL score, and poor bowel outcome was strongly associated with impaired QOL (B = 22•7 [12•7-32•7],p < 0•001). In adults, GIQLI scores were more often impacted in patients with extended segment disease. SF-36 scores were reduced relative to population level data in most domains, with large effect sizes noted for females in General Health (g = 1.19) and Social Wellbeing (g = 0.8).

CONCLUSION

Functional impairment is common after pull-through, but bowel function improves with age. Clustering of poor functional outcomes across multiple domains identifies a need for early recognition and long-term support for these patients.

Reoperative techniques and management in Hirschsprung disease: a narrative review

The majority of children who undergo operative management for Hirschsprung disease have favorable results. A subset of patients, however, have long-term dysfunctional stooling, characterized by either frequent soiling or obstructive symptoms. The evaluation and management of a child with poor function after pull-through for Hirschsprung disease should be conducted by an experienced multidisciplinary team. A systematic workup is focused on detecting pathologic and anatomic causes of pull-through dysfunction. This includes an exam under anesthesia, pathologic confirmation including a repeat biopsy, and a contrast enema, with additional studies depending on the suspected etiology. Obstructive symptoms may be due to technique-specific types of mechanical obstruction, histopathologic obstruction, or dysmotility-each of which may benefit from reoperative surgery. The causes of soiling symptoms include loss of the dentate line and damage to the anal sphincter, which generally do not benefit from revision of the pull-through, and pseudo-incontinence, which may reveal underlying obstruction. A thorough understanding of the types of complications associated with various pull-through techniques aids in the evaluation of a child with postoperative dysfunction. Treatment is specifically tailored to the patient, guided by the etiology of the patient's symptoms, with options ranging from bowel management to redo pull-through procedure. This review details the workup and management of patients with complications after pull-through, with a focus on the perioperative management and technical considerations for those who require reoperation.

Redo pull-through in total colonic aganglionosis due to residual aganglionosis: a single center's experience

BACKGROUND

Reoperation for total colonic aganglionosis (TCA) may be required for residual aganglionosis after an initial radical operation. We aimed to investigate the symptoms, management, and outcomes of patients who required a redo pull-through (Redo PT).

METHODS

Nine TCA patients underwent Redo PT at our center between 2007 and 2017. Their medical records were reviewed. Parental telephone interviews that included disease-specific clinical outcomes were conducted, and post-operative complications and long-term outcomes (including height-for-age/weight-for-age and bowel-function score) were compared to those of single-pull-through (Single PT) patients (n = 21).

RESULTS

All the nine Redo PT patients suffered obstruction within 1 month after the initial operation that could not be alleviated by conservative treatment. All abdominal X-ray/contrast barium enemas showed proximal bowel dilatation, indicating residual aganglionosis. The median ages at the initial operation and Redo PT were 200 and 509 days, respectively. Reoperation consisted of an intraoperative frozen biopsy and a modified laparotomic Soave procedure in all patients. Post-operative complications included perianal excoriation (n = 3), intestinal obstruction (n = 2), enterocolitis (n = 2), and rectovestibular fistula (n = 1). Seven Redo PT patients were followed up for a mean time of 7.1 ± 2.3 years; six (85.7%) had good growth and four (57.1%) had good bowel-function recovery. Post-operative complications and long-term outcomes were almost equal between the Redo PT and Single PT groups (all P > 0.05).

CONCLUSION

TCA patients with recurrent obstructive symptoms and dilated proximal bowel may have residual aganglionosis after an initial operation. Redo PT is effective and provides good long-term outcomes comparable to those of patients who benefited from Single PT.

Redo Transanal Soave Pull Through with or without Assistance in Hirschsprung Disease: An Experience in 46 Patients

INTRODUCTION

 Transanal Soave pull through (PT) with or without assistance can be performed as a redo procedure for Hirschsprung disease (HD). In this study, we reviewed the indications and clinical outcomes of redo transanal Soave with or without assistance.

MATERIALS AND METHODS

 A retrospective analysis was performed on patients who underwent redo transanal Soave with or without assistance in our hospital from 2004 to 2016, and did not have rectourethral fistula or rectovaginal fistula. The Krickenbeck classification system was used to evaluate postoperative bowel function. We analyzed the associated factors of the two main indications.

RESULTS

 In this study, 46 patients were included, representing 5.6% of all HD PTs; 42 patients were initially operated elsewhere and 4 at our hospital. Primary PT surgeries included 38 transanal Soave, 2 Rehbein, 1 Martin, and 5 unknown procedures. The indications for redo PT were residual aganglionosis/transition zone PT (RA/TZPT) (27, 58.7%), anastomotic complication (14, 30.4%), and dilated distal segment (5, 10.9%). The median age of these 46 patients at primary and redo PT was 7.0 months (range, 0.4-137 months) and 45.5 months (range, 7-172 months), respectively. All 46 patients underwent redo transanal Soave PT; 43 patients (93.5%) underwent transanal Soave with laparotomy (n = 42) or laparoscopy (n = 1), and another 3 patients underwent transanal Soave PT. Six patients (13%) experienced complications within 30 days after redo surgery. A total of 43 patients were followed up, and the median follow-up period was 100 months (range, 35-180 months). Two patients could not hold back defecation in some inconvenient conditions. Sixteen patients (37.2%) had soiling, and 8 (18.6%) of 16 patients complained frequent soiling occurrence (more than 1/week). Only one patient complained of constipation (grade 1). Patients with anastomotic complication had more early postoperative complication and higher rate of soiling than patients with RA/TZPT, but there was no statistical difference (p = 0.672 and p = 0.105).

CONCLUSION

 Transanal Soave PT with or without assistance was effective in resolving different problems after initial PT, while soiling was the most common postoperative problem, especially patients with anastomotic complication.

Rectourethral and rectovesical fistula as serious and rare complications after Hirschsprung disease operation: Experience in seven patients

AIM

To present the features and treatment of rectourethral fistula (RUF) and rectovesical fistula (RVF) after Hirschsprung disease (HD) operation.

METHODS

A retrospective analysis was performed on patients with RUF and RVF after HD operation, who received repair surgery from a single surgeon between January 2005 and December 2019. Bowel function was assessed using the Rintala score.

RESULTS

Seven patients were included. Six patients were referred to us after transanal endorectal pull-through (TEPT) in other centers; one RVF patient had fecal diversion at admission. Bladder-neck injury was detected during redo TEPT in our hospital in the remaining one patient and instant repair was given. 11 days later, RVF and sepsis were detected. Fecal and urine diversion was performed immediately. The fistula openings were prostatic urethra (3), membranous urethra (2), bladder triangle (1), and bladder-neck (1). Anastomotic stricture (4), bladder stone (3), hydronephrosis and ureterovesical junction obstruction (2), pelvic infection (2), distal colonic dilatation (1) and other fistulas (1) were identified before repair surgery. Fecal and urine diversion was performed before repair surgery in one RUF and one RVF patient respectively, to treat pelvic infection owing to fecal or urine leaks and accompanying problems. Five RUFs were repaired by transperineal approach, and two RVFs were repaired using the transabdominal and transanal approach respectively. Four patients with anastomotic stricture underwent redo TEPT with simultaneous fistula repair. Aside from one RUF patient, the fistula in all patients successfully resolved. Median follow up time was 81 months (range, 5-116 months). No recurrence was observed. Median bowel function score was 17.5 (range, 17-18).

CONCLUSION

The location of fistula, presence of anastomotic stricture and the association of urinary complications have significant impacts on the treatment strategy in such rare complications after TEPT for HD.

THE TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

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.

Redo pullthrough for Hirschsprung disease

Pullthrough procedures for Hirschsprung diseases typically have favorable results. However, some children experience long-term postoperative complications comprising stooling disorders, such as intermittent enterocolitis, severe stool retention, intestinal obstruction, as well as incontinence. Reoperative Hirschsprung Disease surgery is complex. This begins with the workup after the initial presentation following primary pullthrough, continues with the definitive surgical correction with redo pullthrough, and ends with long-term follow-up of individuals. The decision tree can be varied with each patient. The operating pediatric surgeon must be able to utilize different operations and treatment options available. While lesser procedures may provide relief in a select population, those with residual aganglionosis or transition zone pathology or mechanical problems will likely require a redo pullthrough. Thus, the diagnostic workup, treatment plan, and definitive surgical care should be coordinated, and executed by an experienced, specialized team at a pediatric referral center.

Usefulness of posterior sagittal anorectoplasty for redo pull-through in complicated and recurrent Hirschsprung disease: Experience with a single surgical group

AIM

To retrospectively examine 12 patients with Hirschsprung disease (HD) who underwent posterior sagittal anorectoplasty (PSARP) for various complications.

METHODS

This study included patients with HD who underwent redo pull-through (PT) via PSARP at our institute between 2005 and 2014. The type of initial procedure, clinical presentations, indications, and functional results were analyzed. Postoperative excretory function was assessed using the Krickenbeck classification.

RESULTS

The study group comprised 9 boys and 3 girls (total, 12). Five patients were diagnosed with rectosigmoid aganglionosis, 5 with long segment aganglionosis, and 2 with total colonic aganglionosis. The primary operations performed on these patients included the Soave, Duhamel, Swenson, Rehbein, and Ikeda-Soper procedures. The interval between the primary operations and reoperation ranged from 5months to 8years (median, 3years). The indications for PSARP were rectocutaneous fistulae (6 cases), frozen pelvis (5 cases), severe anastomotic stricture (3 cases), rectovaginal fistulae (2 cases), and hemorrhagic proctitis with an inflammatory polyp (1 case). All fistulae were repaired using PSARP; only one rectocutaneous fistula recurred and required two additional surgeries. Stricture and hemorrhagic proctitis were cured in all involved cases. Nine patients were followed up for 8months to 10years after PSARP surgery (average, 5.1years). All 9 patients had voluntary bowel movements within 6months after the last PSARP and stoma closure: 3 had normal bowel movement, while 6 had varying degrees of soiling, depending on the length of residual colon. None complained of constipation.

CONCLUSION

PSARP is useful for treating severe complications of failed PT in HD. Complex and recurrent rectocutaneous fistulae and frozen pelvis are the main indications for PSARP, while soiling is the most common surgical complication.

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.

Redo pullthrough for Hirschsprung disease: a single surgical group's experience

INTRODUCTION

This study presents our surgical experience for redo-pullthrough (RedoPT) for Hirschsprung disease (HD). It reviews the patient's clinical outcomes and assesses stooling patterns after RedoPT.

METHODS

A retrospective review of our institution's RedoPTs as well as one author's overseas cases was performed. Stooling scores were tabulated using an established survey tool and compared to primary PT matched patients.

RESULTS

Between 1974 and 2012, 46 individuals (52% males) underwent RedoPT, representing 3 percent of all HD pullthroughs. Median age at primary PT and RedoPT was 1year (range 1week-18years) and 3.5years (range 8weeks-41years), respectively. Indications for RedoPT were predominately for aganglionosis/transition zone pathology (71%); followed by stricture or an obstructing Duhamel pouch (19%), tight cuff (8%) and a twisted PT (4%). None were performed for an isolated clinical diagnosis of repeated bouts of enterocolitis. RedoPT surgical approach depended upon the initial pullthrough technique and any previous complications. Stooling scores were significantly (P<0.05) worse in the RedoPT patients compared to the historically-matched group of children undergoing a primary PT for HD (5.5±1.2 vs. 12.2±1.4, primary PT versus RedoPT, respectively). When breaking down this total score into individual parameters, stooling pattern scores (1.0±0.2 vs. 4.1±0.4, P=0.001) and enterocolitis scores (2.0±0.4 vs. 4.2±0.4, P=0.001) were statistically worse in the RedoPT group. Patients in both groups had similar overall continence rates.

CONCLUSION

Appropriately selected children undergoing a RedoPT can achieve good results, with comparable continence rates to those undergoing a primary PT.

Management of Recurrent Post Redo Pull-Through Stricture - What is the Option?

Redo pull-through procedures are not without their complications and have results that are satisfactory only in 70 % to 80 % of cases. Persistent obstructive symptoms due to anastomotic stricture are a common indication for redo operation in 30 % to 50 % of cases. Management of stricture following a redo operation can still be a complicated issue with limited available options. One such case is presented and management discussed.

Reoperative surgery for Hirschsprung disease

Despite most children undergoing a successful pull through for Hirschsprung disease, a small portion of children are left with persistent stooling issues. Most of these stooling issues can be addressed by nonoperative approaches. However, in a small group of remaining children, a reoperation may be necessary. Most children who may need a redo pull-through procedure may have a persistent area of aganglionosis, unremitting enterocolitis, or a torsion or stricture of the pull-through segment. Each of these influences the approach the surgeon must take to correct the presenting problem. The chapter details the diagnostic approach as well as the operative techniques, which best deal with each of these complications.

Re-operation for Hirschsprung's disease: experience in 24 patients from China

PURPOSE

The aim of this study is to review the authors' 12-year experience with re-operative surgery for Hirschsprung's disease (HD) including indications of re-operation and surgical technique.

METHODS

We retrospectively reviewed the data of 24 patients who underwent re-operation from 1998 to 2010. The type of initial procedure, clinical presentations, indications and details of redo surgery, and the functional results were analyzed.

RESULTS

The primary operations performed on these patients included Duhamel (nine cases), Soave (12 cases), Swenson (one case) and Rehbein (two cases). The indications for re-operation were recurrent constipation due to severe anastomotic stricture (five cases), residual aganglionic segments (five cases) and gate syndrome after Duhamel procedure (five cases); fistula formation including rectocutaneous fistula (six cases), rectovaginal fistula (one case), complex fistula (two cases). The redo procedure ranged from posterior sagittal approach combined with laparotomy (seven cases), Soave procedure (seven cases, six conventional Soave + one transanal Soave), Duhamel procedure (one case), Rehbein procedure (three cases), re-using the stapling device (five cases), repairing the rectovaginal fistula via laparotomy (one case). We have followed up the patients for 7 months to 6 years (mean 2.5 years). After re-operation, in 22 patients older than 3 years, 19 (86.4%) have normal or near normal bowel habits with a stool frequency of 1-5 times per day, two have voluntary bowel movements but occasional soiling (once or twice per week) and without significant incontinence, one presented rectosacral fistula due to careless dilatation. There were no deaths.

CONCLUSION

Re-operation can work out the anatomical or pathological problems resulted from failed initial procedure and improve the patient's quality of life. Posterior sagittal approach, Soave and Duhamel are all safe and effective, but we still need to try our best to diminish the necessity of re-operation.

Residual aganglionosis after pull-through operation for Hirschsprung's disease: a systematic review and meta-analysis

PURPOSE

Most patients with Hirschsprung's disease (HD) have a satisfactory outcome after pull-through (PT) operation. However, some children continue to have persistent bowel symptoms after the initial operation and may require redo PT. Redo PT operation in HD is usually indicated for anastomotic strictures or residual aganglionosis (RA). We designed this meta-analysis to determine the incidence and outcome of RA among patients with HD following PT operation.

METHODS

A meta-analysis of redo PT operations for HD reported in the literature between 1985 and 2011 was performed. Detailed information was recorded in patients with RA and transition-zone bowel (TZB), including recurrent bowel problems, histological findings on repeat rectal biopsy, type of redo PT operation and outcome.

RESULTS

Twenty-nine articles reported 555 patients with redo PT operations. 193 (34.8%) patients demonstrated abnormal histological findings on rectal biopsy with 144 patients showing RA and 49 patients showing TZB. These 193 patients presented with persistent constipation (n = 135), recurrent enterocolitis (n = 45) and abnormal histology of the pulled-through bowel (n = 13). Mean age at redo PT was 4.4 years (range 4 months-17 years). Redo procedures were Duhamel (n = 57), transanal endorectal PT (n = 40), Soave (n = 35), Swenson (n = 10), posterior sagittal approach (n = 1) and not reported (n = 50). Follow-up information after redo PT was available in 134 (69.4%) patients and not available in 59 patients. Of the 134 patients, 99 (73.9%) patients had normal bowel habits, 19 patients had persistent constipation/soiling and 16 patients had recurrent enterocolitis.

CONCLUSION

This meta-analysis reveals that RA and TZB are the underlying causes of persistent bowel symptoms in one-third of all patients with HD requiring redo PT operation. Most patients have a satisfactory outcome after redo operation. Rectal biopsy should be performed in all patients with recurrent bowel problems after PT operation.

Redo pull-through in Hirschsprung's [corrected] disease for obstructive symptoms due to residual aganglionosis and transition zone bowel

BACKGROUND

Reoperations in Hirschsprung disease may be required for residual aganglionosis or transition-zone bowel found at the distal pull-through. We aimed to review the management of patients who had this complication and offer suggestions on how to avoid it.

METHODS

Ninety-three patients with Hirschsprung disease were referred to our institution with recurrent problems after a pull-through done elsewhere. All required reoperations with a variety of indications, and of these, 25 had residual aganglionosis/transition-zone histology. This was the only indication for redo in 16 children.

RESULTS

Children (range, 2-17 years) presented 6 to 66 months after the initial pull-through. The predominant symptoms were enterocolitis (n = 9 [56%]), constipation (n = 7 [44%]), failure to thrive (n = 5 [31%]), and impaction (n = 4 [25%]). The rectal biopsy performed as part of their post pull-through work up showed hypertrophic nerves (n = 16), absent ganglion cells (n = 6), and normal ganglion cells (n = 10). The original frozen-section biopsy, determining the level of the pull-through, only sampled the seromuscular layer in 3 children, leading to misdiagnosis. Reoperations involved a transanal resection (n = 15) and a posterior sagittal approach (n = 1). In all cases, obstructive symptoms were resolved, and no patient has had recurrent enterocolitis.

CONCLUSION

Patients' post pull-through with recurrent obstructive symptoms may have residual aganglionosis or transition-zone bowel. Reoperation can result in the resolution of these symptoms. A full-thickness biopsy at the time of the initial pull-through to include the mucosa and submucosa may increase the possibility of identifying hypertrophic nerves.

Redo surgery in Hirschsprung disease: what did we learn? Unicentric experience on 70 patients

PURPOSE

This article is aimed at describing a series of 70 patients who underwent a redo pull-through in the period between January 1991 and January 2007 and to compare them with a series of consecutive patients with Hirschsprung disease who underwent a single pull-through.

METHODS

The notes were reviewed, and a comprehensive interview based on a disease-specific questionnaire for continence and quality of life was submitted to all eligible patients. We used a number of consecutive patients who underwent a single pull-through for Hirschsprung disease as control group.

RESULTS

Seventy patients were included. Residual aganglionosis in pulled-through bowel or retained aganglionic rectum represented the indications to reoperation in most cases. Intestinal obstruction represented the leading symptom in more than 60% of patients. We adopted either the endorectal pull-through, the Duhamel, or the Swenson procedure. Thirty-six patients were assessed for long-term outcome. One third experienced complications. Long-term continence was satisfactory in 70%. Enterocolitis, soiling, and perineal excoriations were complained by 30%. Excellent to good perspectives were described by 94%, and excellent to good cosmetic results by 22%. The only significant difference with control group (109 patients) involved cosmetic appearance, whereas soiling, although more frequent, could not be considered significantly increased.

CONCLUSIONS

Patients who experience failure of a pull-through must go through multiple procedures to achieve definitive results. Although overall outcome does not significantly differ from that of a single effective pull-through, great efforts should be made to minimize complications and avoid the need for a redo, which requires experienced surgeons and highly committed families for a longer course of the disease.

Hirschsprung disease: do risk factors of poor surgical outcome exist?

INTRODUCTION

Long-term results after surgical treatment of Hirschsprung disease (HSCR) are not always as good as a surgeon may perceive. Several studies have tried to correlate preoperative features to the surgical outcome of HSCR, but none came to definitive conclusions. Our study is aimed at identifying risk factors of poorer long-term outcome after surgery for HSCR.

MATERIALS AND METHODS

One hundred two patients with HSCR were included. Eighty had rectosigmoid aganglionosis and 22 had total colonic aganglionosis (TCSA). Preoperative variables were sex, associated anomalies, delayed meconium passage, preoperative enterocolitis, preoperative bowel obstruction, age at surgery, and number of pull-through procedures performed. Outcome measures were surgical complications, postoperative enterocolitis, perineal excoriations, constipation, continence, psychological self acceptance, and patients' perspectives. These were evaluated with regard to preoperative features and length of aganglionosis.

RESULTS

Results of patients with TCSA proved to be significantly worse than those of patients with classic HSCR (constipation and poor continence excluded). Male patients with TCSA proved to have a significantly higher incidence of complications (100% vs 38.5%) and poor psychological self acceptance (100% vs 46.2%). Patients with associated anomalies (central nervous system) experienced a significantly higher incidence of postoperative constipation (43% vs 13%). Patients who described failure or delayed meconium passage complained of significantly worse continence (28.3% vs 7.1% of fair to poor continence). Preoperative enterocolitis proved to be significantly correlated to postoperative enterocolitis (16.4% vs 37.1%) and perineal excoriations (13.7% vs 30.9%). Patients with preoperative intestinal obstructions complained of significantly worse psychological self acceptance (37.8% vs 12.5%).

CONCLUSIONS

Length of aganglionosis has the greatest impact on overall surgical outcome of HSCR. Other minor risk factors have been identified, namely, male sex, associated central nervous system anomalies, failure to pass meconium, and preoperative enterocolitis occurrences. Age at surgery and redo procedures proved not to significantly interfere with the outcome. Our study provides comprehensive and useful data to inform parents and families of a baby with HSCR with regard to expected results and long-term outcomes of surgery basing on preoperative features. Further studies on larger series are strongly recommended.

Role of transanal endorectal pull-through in complicated Hirschsprung's disease: experience in 18 patients

BACKGROUND/PURPOSE

In Hirschsprung's disease (HD) redo pull-through (PT) is indicated for anastomotic complications and for persistent aganglionosis after previous definitive surgery. This study was undertaken to evaluate the role of transanal approach to redo PT procedure in the management of complicated cases of HD over the last 7 years.

PATIENTS AND METHODS

Between November 1998 and September 2005, 225 patients with HD were operated using the transanal endorectal PT (TEPT) approach. Eighteen patients had a redo PT owing to persistent aganglionosis. The present study evaluates the role of TEPT approach in patients with persistent aganglionosis (n = 18). Three patients needed a colostomy (n = 2) or ileostomy (n = 1) before the final operation. All the 18 patients underwent transanal mobilization (TEPT) of the colon. Six patients required additional mobilization of the proximal colon (n = 4) and the ileum (n = 2) during the redo PT operation.

RESULTS

Median follow-up was 43 months (range, 3-72 months). Sixteen patients have had a good outcome with stool pattern 1 to 4 times daily. One patient had obstructive symptoms for 4 months postoperatively but then settled. One patient has occasional soiling.

CONCLUSIONS

In this series, TEPT and posterior midline split of the muscle cuff were used with good results. This has the advantage of avoiding injury to the pelvic muscles and nerves. The TEPT approach is combined with transabdominal mobilization of the intestine depending on the length of the aganglionic segment. The outcome has been favorable, but long-term follow-up is necessary for full assessment of those patients.

Repeated pull-through surgery for complicated Hirschsprung's disease--principles derived from clinical experience

BACKGROUND

In some patients, an initial pull-through procedure for Hirschsprung's disease fails, and obstructive symptoms persist or recur. Then a repeated pull-through operation may be necessary.

METHODS

Seventeen patients with Hirschsprung's disease aged 2 to 9 years (median, 4.6 years) have undergone a repeated pull-through procedure because of unresponsive symptoms after an initial operation. The initial procedure was Soave in 3 patients, Rehbein in 13 patients, and Duhamel in 1 patient. Surgical revision was indicated by incomplete resection of the transition zone in 16 patients, anastomotic strictures in 9 patients, and fistulas in 2 patients. All 17 patients have undergone Redo Duhamel pull-through procedure. Median follow-up after Redo operation was 9 years (range, 1-23 years).

RESULTS

In 15 patients, the stooling pattern normalized immediately after Redo procedure. Two, including 1 with Down's syndrome, are prone to constipation with occasional use of laxatives. Soiling is seen in the patient with Down's syndrome, but only with episodes of diarrhea. In spite of large formation of scars surrounding the neoanorectum in most patients, Duhamel pull-through reconstruction was possible in all children of this series.

CONCLUSIONS

The predominant cause for persistent or recurrent unresponsive obstructive symptoms after initial pull-through procedure is incomplete resection of the transition zone. Less frequently, anastomotic strictures, rigidity of the anorectal cuff, and fistulas cause obstruction. Preoperative workup must focus on these complications. The courses after initial pull-through procedure show that laxatives, Malone procedure, dilatations of the anorectum, myectomy, V-Y-plasty, and injections of botulinum toxin cannot eliminate the mechanical or functional obstruction. Although a large formation of scars in the pelvis resulting from the initial operation, myectomies, dilatations, and other surgical modalities render a Redo revision more difficult, Redo Duhamel pull-through procedure is able to provide the definitive solution to the problem.

Redo transanal endorectal pull-through: a preliminary study

The aim of this study is to evaluate the safety and efficacy of the redo transanal endorectal pull-through (TEPT) for patients with persistent symptoms after pull-through for Hirschsprung's disease (HD). Seven children were included in the study, their ages ranged from 2.5 to 6 years (four males and three females). They presented with persistent obstructive symptoms after pull-through for HD, which was remediated with redo TEPT. Indications were persistent constipation, anastomotic stricture unresponsive to dilatation with or without attacks of enterocolitis. Mean follow-up period was 12 months (ranged from 8 to 16 months). Obstructive symptoms were relieved in all patients with no soiling throughout the period of follow-up. Enterocolitis developed once in two patients who responded to conservative management after hospitalization. There were no deaths and anastomotic leakage, persistent stricture and cuff abscess did not develop in our series. EMG mapping of the external anal sphincter showed a good resting and powerful squeezing pressure curve. Redo TEPT is a useful alternative procedure for persistent symptoms of HD, and it appears to be safe and effective.

Obstruction due to rectal cuff after laparoscopy-assisted transanal endorectal pull-through for Hirschsprung's disease

We report a case of persistent obstruction after laparoscopy-assisted transanal endorectal pullthrough for Hirschsprung's disease in a 4-week-old boy with biopsy-proven HD. Before pull-through, the posterior rectal cuff was split along its entire length cranially, starting from the dentate line. Initial recovery was uneventful; however, signs of obstruction developed 3 weeks postoperatively. Reoperation through a posterior sagittal approach confirmed a residual rectal cuff surrounding the neo-rectum circumferentially. The dorsal side of the residual rectal cuff was removed completely. At follow-up 5 years later, he defecates 2 to 4 times a day with occasional staining. We hypothesize that the persistent postoperative obstruction was caused by a long residual rectal cuff that spontaneously reapproximated and/or became folded during pull-through. Therefore, a shorter cuff with near-total posterior excision should be strongly considered during laparoscopy-assisted transanal endorectal pull-through for Hirschsprung's disease.

New insights into the pathogenesis of Hirschsprung's associated enterocolitis

The management of Hirschsprung's disease (HD) has made dramatic strides over the last 20 years. Research into the embryological development and migration of ganglion cell has enabled a greater understanding of the pathogenesis of the disease. Coupled with new techniques in surgery, such as laparoscopy-assisted pull-through and the transanal pull-through, this knowledge has led to improved outcomes for children with HD. However, although our appreciation of Hirschsprung's associated enterocolitis and its aetiology has increased, there are continued references in the literature to a multitude of theories of pathogenesis. The purpose of this review is to delineate the theories and demonstrate the evidence supporting or otherwise contradicting each other.

Long-term results of treatment of Hirschsprung's disease

Many children with Hirschsprung's disease (HD) have a good outcome following surgical treatment, but long-term follow-up studies have identified a number of concerns. Analysis of long-term function in children after surgical management is difficult. The most commonly encountered problems include constipation, incontinence, enterocolitis and the overall impact of the disease on lifestyle (quality of life). Other complications are less frequent. Each of these problems will be discussed.

Transanal endorectal pull-through for Hirschsprung's disease: experience with 68 patients

BACKGROUND/PURPOSE

The aim of this study was to evaluate the indications, results, and complications of transanal endorectal pull-through (TEPT) in the management of recto-sigmoid Hirschsprung's disease (HD).

METHODS

Between November 1998 and March 2002, 68 TEPT procedures were performed in infants and children. The patients' ages ranged from 6 days to 13 years. The primary diagnosis in all 68 patients was Hirschsprung's disease confined to the recto-sigmoid region. All children had their operations done without construction of preoperative colostomy except for one. Follow-up period ranged from 3 to 39 months (mean, 21 months).

RESULTS

The mean operating time was 90 minutes, and average length of bowel resected was 25 cm. Sixty-two patients had satisfactory results without complications. Blood transfusion was needed in only 11 patients. Recovery was very fast, and patients often were hungry within 24 hours. Feeding was resumed within 48 hours. One patient required laparotomy during the procedure owing to injury to the urethra. Two patients required colostomy 3 and 5 days after surgery respectively, because of delayed leakage. Three patients suffered from attacks of enterocolitis 6 to 9 months postoperatively. There was increased frequency of defecation (5 to 15 times daily) for 4 to 6 weeks after surgery in all the patients. There was no constipation, no incontinence, no cuff abscess, and no mortality in any of the patients. Average frequency of defecation was 1 to 3 times daily after 3 months. The cost of the TEPT technique was almost half that of the open surgery.

CONCLUSIONS

TEPT takes less time, has less bleeding, shorter hospital stay, less morbidity, and earlier recovery than similar open pull-through procedures. The hazards and morbidities associated with laparotomy and colostomy may be avoided with a one-stage technique in Hirschsprung's disease confined to the recto-sigmoid region. Careful long-term follow-up is required to assess continence and sexual function.

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.

Reoperative surgery for Hirschsprung's disease

Most patients who undergo a pull-through procedure for Hirschsprung's disease typically do well. A small number of patients have persistent stooling problems, often manifesting with either constipation or recurrent enterocolitis. A group of these patients will not respond to conservative medical management and may need to undergo another operative procedure. Reoperative surgery for Hirschsprung's disease typically falls into 2 categories, those who require a myectomy and those who need a redo pull-through. This article reviews the workup, indications, and techniques for these procedures and discusses previously published, as well as the authors' outcome, with these 2 procedures.

Combined abdominal and posterior sagittal approach for redo pull-through operation in Hirschsprung's disease

BACKGROUND/PURPOSE

In Hirschsprung's disease (HD) redo pull-through (PT) is indicated for anastomotic complications and retained aganglionosis after a previous operation. Duhamel or Swenson method is used commonly for redo operations. The pelvic dissection may be difficult, especially in Swenson's type of operation, because of fibrosis resulting from previous surgery or its complications. To overcome this, the authors used a combined abdominal and posterior sagittal approach to perform redo pull-through of Swenson's type in 4 children.

METHODS

Four boys (2.5 to 12 years) underwent redo pull-through for failed endorectal pull through (n = 2), persistent symptoms after 2 myectomies (n = 1) and late anastomotic disruption after Swenson's PT (n = 1). Abdominal dissection was done first to mobilize colon and resect aganglionic segment as far as the mid pelvis. The mobilized ganglionic colon was tacked to the pelvic rectal stump, hemostasis checked, and the abdomen closed. The lower pelvic dissection was done through the posterior sagittal route, under direct vision. The remainder of diseased rectum was excised, and the pull-through colon was retrieved and anastomosed to the anal stump. No covering colostomy was done.

RESULTS

A rectocutaneous fistula developed in one patient, which healed spontaneously. All patients had increased stool frequency in the early postoperative period but improved with time. All patients have attained normal voluntary bowel actions, but one child has infrequent minor soiling. There was no anastomotic narrowing in any case.

CONCLUSIONS

Posterior sagittal approach is a useful alternative in difficult redo pull-through surgery. It offers excellent exposure, precise dissection, and direct anastomosis. There are minimal chances of complications, and continence is retained.