Population-based study shows that Hirschsprung disease does not have a negative impact on education and income

Epidemiology and Surgical Management of Hirschsprung's Disease in France: A 12-Year Retrospective Analysis (2012-2023)

AIM

Hirschsprung's disease (HSCR) is a congenital disorder of the enteric nervous system, leading to functional intestinal obstruction in neonates and young children. This study aimed to assess the epidemiology and surgical management of HSCR in France over a 12-year period using nationwide data.

METHODS

We conducted a retrospective cohort study using the French National Hospital Discharge Database (PMSI), including patients aged 0 to 3 years diagnosed and surgically treated for HSCR between 2012 and 2023.

RESULTS

Among 1512 patients, the average incidence was 17.26 per 100 000 live births. Short-segment disease accounted for 70% of cases, and 78.6% were male. A progressive shift toward minimally invasive techniques was observed, with laparoscopic surgery increasing significantly. Mortality was low (0.3%). Long-segment disease was associated with higher reoperation rates and lower reoperation-free survival.

CONCLUSION

This study confirms the stable incidence of HSCR in France and highlights the increasing use of minimally invasive surgery. Regional disparities in care and the higher surgical burden in long-segment cases underline the need for ongoing surveillance, equitable access and improved follow-up strategies.

A systematic review of school functioning in pediatric patients with Hirschsprung disease

To better target future educational outcomes of pediatric patients with Hirschsprung disease (HSCR), we conducted a systematic review without meta-analysis on the impact of HSCR on school functioning (SF). PubMed, Embase, Scopus, Web of Science, Cochrane, PsycINFO, and ERIC were searched from inception to December 2023, following the systematic reviews of PRISMA guidelines. Original studies where SF was measured as one of the outcomes were identified by searching relevant databases and manual searching. Data describing the impact of HSCR on SF were extracted. Screening, data extraction, and quality assessment were performed by at least two authors. 2042 articles were identified, 1300 records were screened after removal of duplicates. Forty records were assessed for eligibility and twelve studies which evaluated the SF in children between the ages of 6 and 17 with HSCR were analyzed. Among the twelve studies, five were retrospective cohort studies, one prospective cohort study, one longitudinal cohort study, and five case-control studies. Five studies measured general SF including attention, memory, schoolwork, and missing school. Among these five studies, three showed domain scores for SF lower than matched healthy controls or the reference normative population. Additionally, peer relationship problems/peer rejection/bullying as a specific area of SF were reported in another five studies using three different assessment instruments. Other specific aspects of SF such as school absences, school environment, school attitude, school performance, interpersonal relationships, and education services were assessed by different generic or disease-specific scales in the included studies. The lack of data measuring individual aspects made it hard to conclude the effects of HSCR in these aspects. HSCR negatively impacted general SF, especially in peer relationships. Due to the lack of studies utilizing standardized measures of SF on HSCR children, a multicenter larger sample size and longitudinal study is urgently needed, to provide robust evidence and to help inform targeted strategies to optimize educational outcomes for students with HSCR.

Educational outcomes in school age children with a history of isolated Hirschsprung disease are equivalent to their peers

PURPOSE

The aim of this study was to assess real-world educational outcomes and developmental disorders in patients with a history of Hirschsprung disease compared to an age-matched control group.

METHODS

With ethics approval (H2016:014) a retrospective cohort study of all children diagnosed with Hirschsprung disease at a single centre from 1992 to 2017 was performed. A 10:1 date-of-birth matched control cohort was constructed from a population-based directory. The educational outcomes were compared using the following measures: Early Developmental Instrument, Grades 3, 7, and 8 assessments, Grade 9 completion, Grade 9 performance, and high school graduation. Fisher's exact tests were used to compare the odds of failure between cases to controls. Only children who reached 4 years of age were included.

RESULTS

A total of 75 cases with Hirschsprung disease patients were identified. Patients with Hirschsprung disease were at increased risk of failing to meet expectations on the Early Development Instrument. After entering elementary school, Hirschsprung patients were at no greater risk than their peers of failing to meet expectations on standardized testing or failing to graduate from high school.

CONCLUSION

Using real-world measures of academic success as a surrogate for neurodevelopmental status, our study demonstrates that patients with a history of Hirschsprung disease demonstrated poor neurodevelopmental performance in pre-school, but the educational achievements of patients did not differ from controls once they started school. These promising data can be used to mitigate preconceived notions that patients with Hirschsprung disease require special education, which may be isolating and psychosocially damaging.

Attention deficit hyperactivity disorder and educational level in adolescent and adult individuals after anesthesia and abdominal surgery during infancy

AIM

Several studies in animal models have found that exposure to anesthetics in early life can cause cognitive dysfunction. Human studies show conflicting results and studies of cognitive function after anesthesia and neonatal surgery are scarce. The aim of this study was to investigate whether exposure to anesthesia and abdominal surgery during infancy was associated with cognitive dysfunction from the perspective of educational level, disposable income and attention deficit hyperactivity disorders (ADHD) in adolescent and adult individuals.

METHODS

A cohort study with patients born 1976 to 2002 that underwent abdominal surgery during infancy at a pediatric surgical center were matched by age, sex, and gestational age to ten randomly selected individuals from the Swedish Medical Birth Register. Individuals with chromosomal aberrations were excluded. Data on highest level of education and annual disposable income were attained from Statistics Sweden and the diagnosis of ADHD were retrieved from the Swedish National Patient Register.

RESULTS

485 individuals and 4835 controls were included. Median gestational age was 38 weeks (24-44) and median age at surgery was seven days (0-365). Three hundred sixty-six individuals (70.0%) underwent surgery during the neonatal period (< 44 gestational weeks). Median operating time was 80 minutes (10-430). The mean age at follow-up was 28 years. Fisher's exact test for highest level of education for the exposed and unexposed groups were respectively: university 35% and 33%, upper secondary 44% and 47%, compulsory 21% and 20% (p = 0.6718). The median disposable income was 177.7 versus 180.9 TSEK respectively (p = 0.7532). Exposed individuals had a prevalence of ADHD of 5.2% and unexposed 4.4% (p = 0.4191).

CONCLUSIONS

This study shows that exposure to anesthesia and abdominal surgery during infancy is not associated with cognitive dysfunction from the perspective of educational level, disposable income and ADHD in adolescent and adult individuals. Further studies in larger cohorts at earlier gestational ages are needed to verify these findings.

Quality of life and neuropsychological development at school age in Hirschsprung's disease

PURPOSE

To determine the quality of life and neuropsychological development of school-aged children with Hirschsprung's disease.

METHODS

In this observational monocentric study, a multidisciplinary team prospectively assessed quality of life, neuropsychometric development and bowel functional outcomes. This study was registered on ClinicalTrial.gov (NCT03406741). Kidscreen and VSP-A questionnaires assessed the quality of life and were compared to the reference population (Eurostat database). Intelligence, attention and executive functions, perceptual organization and memory were evaluated using the Wechsler Children's Intelligence Scale, the NEuroPSYchological assessment, and the Rey figure test. Bowel functional outcomes were obtained using the Krickenbeck score.

RESULTS

Fifteen patients were included, with a mean age of 10.25 years. The children's Kidscreen-assessed quality of life index was higher than the reference population (p = 0.01). The Full-Scale Intelligent Quotient was dissociated in 64% of children. The Perceptional Reasoning Index and the Processing Speed Index were observed at lower levels. There were no disturbances in executive functions. A satisfactory bowel functional outcome was noted in 46.7% of children.

CONCLUSION

Children with Hirschsprung's disease have been shown to have subtle decreased performances in some areas of intelligence. Performing a neuropsychological assessment upon entering elementary school could help to detect these specific learning disabilities.

LEVELS OF EVIDENCE

Level II, prognosis study.

Diagnosis of Hirschsprung Disease

Diagnosis or exclusion of Hirschsprung disease (HSCR) is a frequent exercise in any pediatric hospital. Although HSCR may present at different ages and with varied clinical findings, the most common presentation is a neonate with severe constipation or signs of intestinal obstruction. A variety of diagnostic tests including contrast enema and anorectal manometry may be used as diagnostic screens, but diagnosis ultimately rests upon histopathological evaluation of a rectal biopsy. For the experienced pathologist, conventional hematoxylin-and-eosin-stained sections often suffice to exclude HSCR or establish the diagnosis. However, ancillary diagnostic tests such as acetylcholinesterase histochemistry or calretinin immunohistochemistry are complementary and extremely helpful in some cases. In this Perspectives article, we review the clinical and pathological features of HSCR, highlight those that are found in most patients, and discuss how to address particularly challenging aspects of the diagnostic workup.

No increased risk of attention deficit hyperactivity disorders in patients with Hirschsprung disease

PURPOSE

Hirschsprung disease (HSCR) has previously been associated with increased need of special education services despite normal intelligence. The aim of this study was to assess the risk of attention deficit hyperactivity disorders (ADHD) in individuals with HSCR in a population-based cohort.

METHODS

This was a nationwide, population-based cohort study. The study exposure was HSCR and the study outcome was ADHD. The cohort included all individuals with HSCR registered in the Swedish National Patient Register between 1964 and 2013 and ten age- and sex-matched controls per patient, randomly selected from the Population Register.

RESULTS

The cohort comprised 739 individuals with HSCR and 7390 controls. Twenty-six of the 739 individuals with HSCR and 202 of the 7390 controls were diagnosed with ADHD, Odds ratio (OR) 1.30, Confidence interval (CI) 95% 0.84-1.93, indicating no difference in risk for ADHD. The mean age at diagnosis of ADHD was not different between the groups; 18.1 years (SD 8.4) vs 16.7 years (SD 7.8), p = 0.39. Down syndrome did not affect the risk for ADHD, OR 2.26 (CI 95% 0.68-5.53). Female gender decreased the risk for ADHD, OR 0.58 (CI 95% 0.40-0.83).

CONCLUSIONS

There is no increased risk of ADHD in patients with Hirschsprung disease.

LEVEL OF EVIDENCE

Prognosis study, level of evidence: Level I.

Long-term Outcome of Hirschsprung Disease: Impact on Quality of Life and Social Condition at Adult Age

BACKGROUND

Hirschsprung disease is a rare congenital disease typically requiring surgical treatment during childhood. Quality of life and social condition at adult age can be impaired by disease-specific sequelae.

OBJECTIVE

This study aimed to assess the quality of life and social outcome of adult patients operated on for Hirschsprung disease during childhood.

DESIGN

Patients operated on for Hirschsprung disease during childhood were identified and specific questionnaires were sent to them.

SETTINGS

Data from 2 referral centers were used.

PATIENTS

Patients who completed the questionnaires regarding quality of life and social condition were included.

MAIN OUTCOME MEASURES

The Hirschsprung's Disease and Anorectal Malformations Quality of Life disease-specific questionnaire (8 dimensions explored; each scored from 0 to 100 maximum score) and a sociodemographic questionnaire were sent to identified patients. Sociodemographic data were compared with those of the French general population.

RESULTS

Thirty-four patients had Hirschsprung disease (men, 76%; mean age, 32 years) were included in the study. Mean total Hirschsprung's Disease and Anorectal Malformations Quality of Life score was 611 of 800 (maximum score 800). The 2 most impaired dimensions were "physical symptoms" and "diarrhea" (62.9/100 and 73.6/100). Fecal continence was only marginally affected (mean score, 89/100). Patients with Hirschsprung disease achieved better educational levels than the French general population. Parental and marital status did not differ between the 2 groups.

LIMITATIONS

This study had the limitations inherent to a retrospective study.

CONCLUSION

The quality of life of adult patients with Hirschsprung disease sequelae is marginally impaired in this study. Despite the consequences of this congenital abnormality, the condition eventually achieved can be considered as satisfactory. See Video Abstract at http://links.lww.com/DCR/A917.

Hirschsprung disease-Bowel function beyond childhood

Hirschsprung disease is a developmental defect of the enteric nervous system characterized by lack of enteric neurons in the distal hindgut. There are numerous reports on short-term outcomes indicating that impaired bowel function is common. Recently, several controlled studies show that bowel function outcomes are affected beyond childhood, in adolescents and adults, compared with healthy control subjects. Constipation and fecal incontinence are common. The impaired bowel function appears to have a negative impact on quality of life, although, a majority of patients have adapted to their symptoms. On the other hand, Hirschsprung disease seems to have limited impact on education and occupation in adult life. The aim of this review was to summarize current knowledge of bowel function outcome beyond childhood in patients with Hirschsprung disease.

Long-term psychosocial consequences of surgical congenital malformations

Surgical congenital malformations often represent years of treatment, large number of hospital stays, treatment procedures, and long-term functional sequels affecting patients' psychosocial functioning. Both functional defects and psychosocial difficulties that occur commonly in childhood may pass through adolescence on to adulthood. This overview presents reports published over the past 3 decades to elucidate the long-term psychosocial consequences of surgical congenital malformations. Literature searches conducted on PubMed database revealed that less than 1% of all the records of surgical congenital malformations described long-term psychosocial consequences, but with diverse findings. This inconsistency may be due to methodological differences or deficiencies; especially in study design, patient sampling, and methods. Most of the studies revealed that the functional deficits may have great impact on patients' mental health, psychosocial functioning, and QoL; both short- and long-term negative consequences. Factors other than functional problems, e.g., repeated anesthesia, multiple hospitalization, traumatic treatment procedures, and parental dysfunctioning, may also predict long-term mental health and psychosocial functioning. Through multidisciplinary approach, pediatric surgeons should also be aware of deficits in emotional and psychosocial functioning. To achieve overall optimal psychosocial functioning, the challenge is to find a compromise between physically optimal treatment procedures and procedures that are not psychologically detrimental.