ACQUIRED MEGACOLON AS A COMPLICATION OF RECTO-SIGMOIDECTOMY FOR HIRSCHSPRUNG'S DISEASE

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.

Laparoscopic Redo Pull-Through for Hirschsprung Disease Due to Innervation Disorders

BACKGROUND

Reoperations in Hirschsprung disease (HD) may be required due to pathological problems. We conducted this retrospective study to determine the incidence and outcomes of innervation disorders among HD patients following pull-through operation.

MATERIALS AND METHODS

We retrospectively reviewed the data of patients who underwent pull-through procedure from 2005 to 2017. Only patients who underwent reoperation due to histological disorders were analyzed. Patients with mechanical obstruction that caused recurrent constipation were excluded.

RESULTS

There were 836 patients who got treated for HD in our department during the study period, and of these, 72 (8.6%) had redo operation. Thirty-one out of the 72 patients (43.1%) showed abnormal histological findings on full-thickness biopsies. Primary operations included totally transanal endorectal pull-through (18), laparoscopic-assisted Duhamel (5) and Soave (8) techniques. The full-thickness biopsies before the reoperation showed aganglionosis (n = 8, 1 was residual resulted from false-positive intraoperative frozen sections and 7 were acquired aganglionosis), transition-zone (3), intestinal neuronal dysplasia B (IND B, n = 15), and hypoganglionosis (5). The final diagnoses according to the resection specimens of the initial and second operations were HD (11), Hirschsprung-associated IND B (15), and Hirschsprung-associated hypoganglionosis (5). Reoperation consisted of laparoscopic-assisted Duhamel (14) and Soave procedures (17). In these patients, 77.4% had excellent/good bowel function, 16.1% were fair, and 6.5% were poor.

CONCLUSIONS

Innervation disorders are still the underlying causes of recurrent constipation in almost half of all HD patients requiring redo pull-through operation. Most patients have a satisfactory outcome after redoing laparoscopic-assisted Duhamel or Soave operation.

Surgical acquired aganglionosis: myth or reality?

PURPOSE

A number of patients operated on for Hirschsprung disease continue to have constipation and abdominal distension for years after surgery. Some authors have proposed that ischemia during surgery may induce secondary aganglionosis. The aim of the present study was to study the effects of ischemia on the enteric nervous system of sigmoid colon in an animal model.

METHODS

A surgical model of colonic ischemia was created. 34 adult Sprague-Dawley rats underwent a laparotomy where the marginal arterioles of the sigmoid colon were ligated. After that, a section in the middle segment of the sigmoid colon was performed followed by an anastomosis. The presence of ischemia was assessed by measurement of visible light spectroscopy tissue oximetry and histological examination. Colonic function was assessed by evaluation of stool weight. Rats were killed at 1, 8 and 12 weeks after the operation. 12 rats were sham-operated. Enteric nervous system was evaluated by means of immunohistochemistry with NGFR p75. Quantitative analysis of the number of ganglia and ganglion cells in the myenteric plexus was performed.

RESULTS

The surgical model of colonic ischemia significantly decreased tissue oxygenation (pre-surgical = 54.69 ± 7.32 %; post-surgical = 27.37 ± 9.2 %; p < 0.001). There was no disturbance in body-weight gaining in experimental groups and daily stool output did not vary after surgery (pre-surgical = 4.24 ± 0.94 g; post-surgical = 3.82 ± 1 g; p = 0.09). All experimental groups showed persistent ganglia. However, there was a significant decrease in the number of ganglia in all the experimental groups compared to control (1w: 45.91 ± 7.66; 8w: 44.17 ± 10.56; 12w: 36.17 ± 15.06 vs control: 56.88 ± 8.66; p < 0.01). The number of total ganglion cells was significantly reduced only in the experimental group killed at week 12 compared to control (1w: 539 ± 167.58; 8w: 488.58 ± 154.41; 12w: 343.94 ± 161.91 vs control: 513.96 ± 126.97; p < 0.01). The rate of ganglion cells per ganglia was significantly higher in the groups killed at week 1 and 8 versus control group (1w: 11.63 ± 2.53; 8w: 11.11 ± 2.56; 12w: 9.34 ± 1.16 vs control: 9.02 ± 1.81; p < 0.05).

CONCLUSION

Long-term follow-up after surgically induced colonic ischemia in the rat showed a decreased number of ganglion cells and ganglia. Nevertheless, it did not produce aganglionosis.

Surgical evaluation and management of refractory constipation in older children

Chronic constipation is a common childhood problem that accounts for 3% to 5% of pediatric visits and 10% to 25% of referrals to pediatric gastroenterologists. The etiology of constipation can be elusive, and extensive investigation often fails to identify a specific cause. The authors conducted a 5-year retrospective review of the patients referred for deep transanal rectal biopsy to determine the usefulness of this procedure in the evaluation and subsequent surgical management of refractory constipation. Specimens obtained by transanal rectal biopsy established a diagnosis for 30 of the 70 patients, and 17 of these 30 had subsequent procedures in the treatment of their constipation. The authors conclude that transanal rectal biopsy identifies a significant number of patients with previously unidentified neuroenteric disorders who may benefit from additional surgery in the treatment of constipation refractory to medical management.

Colonic atresia combined with Hirschsprung's disease: a diagnostic and therapeutic challenge

Three new cases of patients with co-occurrence of colonic atresia and Hirschsprung's disease and a review of the literature (n = 5) are presented in this report. All patients (n = 8) except one were full-term infants who had no other significant anomalies. The preterm infant had associated tetralogy of Fallot in addition to Hirschsprung's disease and colonic atresia. Six patients had atresia of the ascending colon, and two had atresia of the colon to splenic flexure. All colonic atresias were diagnosed neonatally; however, there was mean delay of 15.4 months (range, 1 mo to 5 years) in diagnosing associated Hirschsprung's disease. There were two deaths. A careful examination of the resected specimen to rule out Hirschsprung's disease is recommended. Performing a rectal biopsy must be considered for patients who initially were treated for colonic atresia and who have a slow return of normal gut function.

Acquired aganglionosis following surgery for Hirschsprung's disease: a report of five cases during a 33-year experience with pull-through procedures

Acquired Hirschsprung's disease is a rare and controversial form of colonic aganglionosis. Little is known about its aetiology and pathogenesis. We report five cases encountered amongst 173 long-term follow-up patients treated for classical Hirschsprung's disease between 1957 and 1990 at the Red Cross Children's Hospital, Cape Town, and review the current literature. The clinical and pathological findings of the cases have been studied to explore possible aetiological mechanisms. Our cases, like most of those previously reported, developed obstructive symptoms and acquired aganglionosis in pulled-through bowel which had been previously confirmed as ganglionated. Two patients had histological evidence of hyaline fibrosis of blood vessels in the segment of bowel with acquired aganglionosis. Such fibrosis and other features attributable to regional hypoxia were not found in the other three cases. It is suggested that ischaemia with fibrosis may have a pathogenetic role in some, but not all, cases of acquired Hirschsprung's disease. A plea is made for patients developing recurrent symptoms of Hirschsprung's disease, after adequate surgical correction, to be fully studied with repeated sequential biopsies in order to gain a better understanding of the entity.

Complications of endorectal pull-through for Hirschsprung's disease

In 10 years, 57 infants with Hirschsprung's disease underwent endorectal pull-through (ERPT). Postoperatively, 3 patients died. Of the 44 survivors with an intact endorectal anastomosis aged more than 3 years, 23 (52%) had an excellent result, and of the 28 children more than 5 years old, 23 (82%) had a satisfactory result. Of the 53 known survivors of all ages, 18% suffered from diarrhea with intermittent incontinence and 5 (9.4%) had undergone a Duhamel procedure within 4 years of ERPT.

Ileal atresia with long-segment Hirschsprung's disease in a neonate

A newborn female had ileal atresia without mesenteric continuity associated with a small, shortened colon but without "malrotation." After correction by an ileocolostomy the infant remained obstructed, requiring an ileostomy at 24 days; subsequently, at 13 months, a Martin-Duhamel operation was done. since associated anomalies are uncommon in each of these conditions, since no cause and effect relationship has been developed, and since no prior survival has been clearly documented, this report is important. The recommendation of distal bowel biopsy is stressed to establish an early diagnosis and, thereby, correct treatment.

Hirschsprung's disease. A clinical review

Experience with 38 cases of Hirschsprung's disease seen over a 20-year period is described. Only 24 per cent of cases presented with a combination of symptoms and signs such as to suggest the correct diagnosis on clinical grounds. Barium-enema examination carries a high ‘true-positive’ rate, but cases reported as negative must be viewed critically. A radiological diagnosis of idiopathic megacolon should not be accepted without supplementary rectal biopsy and/or anorectal pressure studies. Survival without surgery is compatible with Hirschsprung's disease, but the dangers of enterocolitis must be acknowledged. Rectosigmoidectomy, which includes resection to an area of normal innervation proximally and excision of part of the internal sphincter of the rectum distally, produces a satisfactory late functional result at an acceptable mortality-rate. A colostomy prior to rectosigmoidectomy is advisable when there is a history of repeated attacks of subacute obstruction and one or more episodes of enterocolitis. A colostomy after rectosigmoidectomy is advisable in those cases which are submitted to laparotomy for intestinal obstruction in the period following operation, even when no mechanical cause for obstruction is demonstrable. Patients with problems relating to coprostasis following treatment of congenital anorectal disorders should be submitted to rectal biopsy, since a proportion of these patients reveal a deficiency of innervation of the distal large bowek which approximate to that seen in Hirschsprung's disease.