Laparoscopic-Assisted Transanal Endorectal Coloanal Anastomosis for Hirschsprung's Disease

Minimally invasive surgery in older children with Hirschsprung's disease in a North African Country

Introduction

Hirschsprung's disease (HSD) is a bowel congenital anomaly affecting mainly the enteric nervous system of the rectosigmoid region. Surgical resection of the aganglionic segment and restoration of bowel continuity via coloanal anastomosis is the main stay of treatment. In 1999, Georgeson et al. introduced a new minimally invasive approach as a standard for the pull-through mechanism. This study aims to evaluate the safety and possibility of the use of a laparoscope in older children with HSD with various techniques for HSD surgery.

Methods

This study was performed based on 20 patients diagnosed with HSD. The patients are older children, whose mean age is 3 years. The cases showing enterocolitis or obstruction were excluded from the study. We divided these cases into two groups: Group A, consisting of 10 cases where laparoscopic-aided transanal pull-through was done, and group B, in which the laparoscopic Duhamel procedure was done.

Results

We compared between two groups for the first year follow-up period. In Group A, there were two cases of stenosis that respond to regular dilation: one case of enterocolitis and one case of fecal incontinence. In Group B, we had two cases of constipation and three cases of enterocolitis. There was no anastomotic leak in both groups.

Conclusion

Minimally invasive surgery is safe in management of HSD in older children in one stage, either by using the Duhamel or transanal Swenson procedure.

Risk factors for short-term complications graded by Clavien-Dindo after transanal endorectal pull-through in patients with Hirschsprung disease

BACKGROUND

Transanal endorectal pull-through (TERPT) is a common surgical procedure in Hirschsprung disease (HD). Aim of this study was to gain insight in the prevalence and severity of postoperative complications within 30-days after TERPT and to identify patient and perioperative characteristics, associated with the development of short-term postoperative complications.

METHODS

This study retrospectively analyzed data of children with HD and treated with TERPT in our center between 2005 and 2020. Complications emerging within 30-days after surgery were assessed using Clavien-Dindo (CD). Patient and perioperative characteristic as predictor of a complication were tested using (multivariable) logistic regression analysis.

RESULTS

Twenty-two of 106 (21%) included patients (17 transanal only; 77 laparoscopic-assisted; 12 laparotomy-assisted) developed 35 complications, including two patients (1.8%) that deceased. We suspect postoperative rectal irrigation leading to perforation as cause of death in both patients. Six patients (6%) had a minor (CD<3) and 16 patients (15%) a major (CD≥3) complication. Anastomotic leakage (n = 4, 11%), abdominal abscess (n = 3, 9%) and anastomotic stricture (n = 3,9%) occurred most frequently. Predictive factors for developing a complication were older age at time of surgery (OR 1.03 1.00-1.01, p = 0.041), laparotomy-assisted surgery (OR 12.65, CI 1.712-93.07, p = 0.013) and long-segment HD (OR 4.09 CI 1.09-15.39, p = 0.037).

CONCLUSIONS

We found a CD-graded short-term postoperative complication rate of 21% following TERPT, reporting anastomotic complications most frequently. In patients at risk a diverting stoma should be considered. We suspect postoperative rectal irrigation being the cause of two lethal perforations. Therefore, we recommend to place a rectal transanastomotic tube in all patients receiving TERPT.

LEVEL OF EVIDENCE

Level III.

Laparoscopic-assisted duhamel for hirschsprung's children older than 3 years

CONTEXT

Hirschsprung's disease (HD) is a congenital anomaly affecting the enteric nervous system commonly the rectosigmoid region. Treatment is surgical where the aganglionic segment is resected, and bowel continuity is achieved by a colo-anal anastomosis. In 1999, Georgeson et al. proposed a new technique of primary laparoscopic-assisted pull through for HD as a new gold standard.

AIM OF THE STUDY

To evaluate the outcome of the laparoscopic Duhamel procedure for the management of HD in children older than 3 years.

METHODS

This study was performed on 8 patients who were more than 3-year-old, with confirmed diagnoses of HD. Patients who initially presented with enterocolitis or obstruction were excluded from this study. In all cases, laparoscopic-assisted Duhamel was done.

RESULTS

We reported our results for the 1^st year follow-up period and divided our results into early outcome for the first 3 months postoperative during which we had 2 cases complaining of enterocolitis that responded to conservative treatment, we observed 2 cases of perianal excoriation that responded to medical treatment while the late outcome was reported after 3 months postoperative: We had two cases with attacks of enterocolitis at 6 months and 9 months postoperatively that needed conservative treatment in the hospital in the form of parenteral antibiotics, rectal irrigation, intravenous fluids and NP0. There was neither anastomotic leak nor stenosis.

CONCLUSION

Laparoscopic Duhamel for the management of HD in children older than 3 years is safe and useful procedure.

ERNICA guidelines for the management of rectosigmoid Hirschsprung's disease

BACKGROUND

Hirschsprung's disease (HSCR) is a serious congenital bowel disorder with a prevalence of 1/5000. Currently, there is a lack of systematically developed guidelines to assist clinical decision-making regarding diagnostics and management.

AIMS

This guideline aims to cover the diagnostics and management of rectosigmoid HSCR up to adulthood. It aims to describe the preferred approach of ERNICA, the European Reference Network for rare inherited and congenital digestive disorders.

METHODS

Recommendations within key topics covering the care pathway for rectosigmoid HSCR were developed by an international workgroup of experts from 8 European countries within ERNICA European Reference Network from the disciplines of surgery, medicine, histopathology, microbiology, genetics, and patient organization representatives. Recommendation statements were based on a comprehensive review of the available literature and expert consensus. AGREE II and GRADE approaches were used during development. Evidence levels and levels of agreement are noted.

RESULTS

Thirty-three statements within 9 key areas were generated. Most recommendations were based on expert opinion.

CONCLUSION

In rare or low-prevalence diseases such as HSCR, there remains limited availability of high-quality clinical evidence. Consensus-based guidelines for care are presented.

Pathologically assessed grade of Hirschsprung-associated enterocolitis in resected colon in children with Hirschsprung's disease predicts postoperative bowel function

PURPOSE

The aim of this study was to investigate the relationship between the grade of enterocolitis on pathological assessment of resected colon and postoperative bowel function in children with Hirschsprung's disease (HD).

METHODS

Children with HD who were seen at a large tertiary center from January 2012 to December 2013 were enrolled into this study. Resected colon was assessed using the histopathologic grade scoring system for Hirschsprung-associated enterocolitis (HAEC), and the relationship of these scores to postoperative bowel function was assessed. Time of recovery to normal defecation was the primary outcome measure. The t-test, analysis of variance, and Kaplan-Meier, univariate, and multiple regression analyses were performed.

RESULTS

Eighty children with HD (median age at repair 7.9months; range 1.3months to 9years) were included in the study. Nineteen children dropped out of the study and were considered as providing censored data, giving a follow-up rate of 76.3%. A total of 21 children (34.4%) were admitted to hospital with at least one episode of enterocolitis. Multivariate Cox proportional hazards models showed that compared with patients with a normal proximal colon, those with an inflamed proximal segment had a 1.5-fold higher risk of a poor recovery. Logistic regression analyses suggested that postoperative HAEC admissions increased by 57% with each HAEC pathological grade of the transitional segment and by 50% with each grade of the overall segment. Compared with normal bowel in the transitional segment, the detection of grade ≥3 HAEC in the transitional area increased the incidence of postoperative HAEC by 4.75-fold.

CONCLUSIONS

Children whose resected proximal colon showed inflammation on pathological assessment were at risk of poor recovery after surgery. A higher pathological HAEC score for the sum of the overall three segments suggested an increased risk for the subsequent development of enterocolitis. Among three segments, the severity of enterocolitis in the transitional segment was the most significant factor in predicting postoperative HAEC.

TYPE OF STUDY

Clinical study.

LEVEL OF EVIDENCE

Moderate.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic-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.

Outcome comparison among laparoscopic Duhamel, laparotomic Duhamel, and transanal endorectal pull-through: a single-center, 18-year experience

PURPOSE

Transanal endorectal pull-through has changed the treatment of Hirschsprung's disease (HD) in the past decade. The aim of the study was to compare outcomes, obtained in a single center, with laparotomic Duhamel (LTD), laparoscopic Duhamel (LSD), and laparoscopic-assisted transanal endorectal pull-through (LTEPT).

MATERIALS AND METHODS

We retrospectively reviewed the charts of all patients operated on for HD since 1992. Preoperative, operative, and postoperative data were collected to compare short- and long-term outcomes among the three groups.

RESULTS

From 1992 to 2010, 70 children were treated for HD. Patients were divided into three groups based on the surgical technique used: 14 LTEPT, 32 LSD, and 24 LTD. Mean ages at surgery were 4.67, 14.61, and 13.28 months, respectively. Patients in the LTEPT group had significant shorter operating times (195 versus 257 versus 291 minutes, P=.03), earlier start of feeding (1.2 versus 3.1 versus 4.7 days, P<.01), and shorter length of hospital stay (4.4 versus 6.8 versus 9.7 days, P<.011). Overall complications rate was lower in the LTEPT (14%) than in the LSD (31.2%) and LTD (29.7%) groups. Postoperative enterocolitis incidence was 3%-4% in the Duhamel groups and none in LTEPT. Long-term outcome showed less constipation and better continence for age in the LTEPT group at the 1-year follow-up (P=.033).

CONCLUSIONS

This study further supports technical advantages, lighter impact of the surgical procedure on infants, lower incidence of complications, and better long-term outcome of the transanal pull-through compared to the Duhamel approaches.

Older age at diagnosis of Hirschsprung disease decreases risk of postoperative enterocolitis, but resection of additional ganglionated bowel does not

PURPOSE

This study was conducted to determine the effect of age at diagnosis and length of ganglionated bowel resected on postoperative Hirschsprung-associated enterocolitis (HAEC).

METHODS

Children who underwent endorectal pull-through (ERPT) between January 1993 and December 2004 were retrospectively reviewed. t Test, analysis of variance, Kaplan-Meier, and Cox's proportional hazards analyses were performed.

RESULTS

Fifty-two children with Hirschsprung disease (median age, 25 days; range, 2 days-16 years) were included. Nineteen (37%) had admissions for HAEC. Proportional hazards regression showed that HAEC admissions decreased by 30% with each doubling of age at diagnosis (P = .03) and increased 9-fold when postoperative stricture was present (P < .01), after controlling for type of ERPT, trisomy 21, transition zone level, and preoperative enterocolitis. Thirty-six children, with age at initial operation less than 6 months, were grouped based on length of ganglionated bowel excised (A [5 cm] and B [>5 cm]). No significant difference in the number of HAEC admissions during initial 2 years post-ERPT was seen between groups A (n = 18) and B (n = 18). The study had a power of 0.8 to detect a difference of 1 admission over 2 years.

CONCLUSIONS

Children diagnosed with Hirschsprung disease at younger ages are at a greater risk for postoperative enterocolitis. Excising a longer margin of ganglionated bowel (>5 cm) does not seem to be beneficial in decreasing HAEC admissions.

INLINE RADIOFREQUENCY ABLATION-ASSISTED LAPAROSCOPIC LIVER RESECTION: FIRST EXPERIMENT WITH STAPLING DEVICE

BACKGROUND

In liver surgery, the increase in advancement of laparoscopic equipment has allowed the feasibility and safety of complex laparoscopic liver resection. However, blood loss and the potential risk of gas embolism seem to be the main obstacles. In this study, we successfully used the InLine radiofrequency ablation (RFA) device to carry out laparoscopic hand-assisted liver resection in pigs.

METHODS

Under general anaesthesia with tracheal intubation, pigs underwent InLine RFA-assisted laparoscopic liver resection. After installation of Hand Port and trocars, the InLine RFA device was introduced through Hand Port system and inserted into the premarked resection line. Then the generator was turned on and the power was applied according to the power setting. The resection was finally carried out using diathermy or stapler. For the control group, resection was simply carried out by diathermy or stapler.

RESULTS

Eight Landrace pigs underwent 23 liver resections. Blood loss was reduced significantly in the InLine group (P<0.001) when compared with control group in both surgical methods (diathermy and stapler).

CONCLUSION

In this study, we successfully carried out InLine RFA-assisted laparoscopic liver resection in both stapled and diathermy group. We showed that there was a highly significant difference between InLine and other liver resection techniques laparoscopically.

Application of a plain abdominal radiograph transition zone (PARTZ) in Hirschsprung's disease

Background

A standard contrast enema for Hirschsprung's disease can sometimes be inconclusive in delineating a transition zone especially in neonates and infants. The aim of this study was to determine the utility and diagnostic accuracy of a plain abdominal radiograph transition zone (PARTZ) in predicting the level of aganglionosis.

Methods

A prospective observational study of neonates and infants with biopsy proven Hirschsprung's disease was carried out from March 2004 through March 2006. All patients underwent a plain abdominal radiograph and a contrast enema followed by a rectal biopsy. The transition zone on a plain radiograph (PARTZ) and contrast enema (CETZ) were compared with operative and pathology reports. Results were analyzed by chi square test and expressed as their p values and 95% confidence intervals.

Results

PARTZ and CETZ suggestive of Hirschsprung's disease was seen in 24(89%) and 18(67%) patients respectively. The PARTZ and CETZ matched with the pathologic level of transition zone in 22(92%) and 13(72%) patients, p = 0.001, 95% CI (-1.87 to -0.79). In the 9 (33%) patients in whom contrast enema failed to reveal a transition zone, PARTZ was seen in 6/9(66%) patients and correlated with the pathological level of aganglionosis in 4/6(67%) patients, p = 0.001 95% CI (-1.87 to -0.79). The overall accuracy of PARTZ and CETZ was 96% and 84% respectively, p = 0.008, 95% CI (-6.09 to -3.6).

Conclusion

A plain abdominal radiographic transition zone is reliable in predicting the level of transition zone in cases of inconclusive contrast enema. It may be particularly helpful developing countries where laparoscopic techniques are not available to accurately identify the transition zone.

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.