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Beltman L, Labib H, Masselink M, Backes M, Benninga MA, Roelofs JJTH, van der Voorn JP, van Schuppen J, Oosterlaan J, van Heurn LWE, Derikx JPM. Diagnosing Hirschsprung Disease in Children Younger than 6 Months of Age: Insights in Incidence of Complications of Rectal Suction Biopsy and Other Final Diagnoses. Eur J Pediatr Surg 2023; 33:360-366. [PMID: 36724825 DOI: 10.1055/s-0043-1760839] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The gold standard for diagnosing Hirschsprung disease (HD) in patients younger than 6 months is pathological examination of rectal suction biopsy (RSB). The aim of this study was to gain insight into the following: (1) complications following RSB, (2) final diagnosis of patients referred for RSB, and (3) factors associated with HD. METHODS Patients suspected of HD referred for RSB at our center were analyzed retrospectively. Severity of complications of RSB was assessed using Clavien-Dindo (CD) grading. Factors associated with HD were tested using multivariate logistic regression analysis. RESULTS From 2000 to 2021, 371 patients underwent RSB because of infrequent defecation, at a median age of 44 days. Three patients developed ongoing rectal bleeding (0.8%) graded CD1. Most frequent final diagnoses were: HD (n = 151, 40.7%), functional constipation (n = 113, 31%), idiopathic meconium ileus (n = 11, 3%), and food intolerance (n = 11, 3%). Associated factors for HD were male sex (odds ratio [OR], 3.19; confidence interval [CI], 1.56-6.53), presence of syndrome (OR, 7.18; CI, 1.63-31.69), younger age at time of RSB (OR, 0.98; CI, 0.85-0.98), meconium passage for more than 48 hours (OR, 3.15; CI, 1.51-6.56), distended abdomen (OR, 2.09; CI, 1.07-4.07), bilious vomiting (OR, 6.39; CI, 3.28-12.47), and failure to thrive (OR, 8.46; CI, 2.11-34.02) (model R 2 = 0.566). CONCLUSION RSB is a safe procedure with few and only minor complications. In the majority of patients referred for RSB under the age of 6 months, HD was found followed by a functional cause for the defecation problems. RSB should be obtained on a low threshold in all patients under the age of 6 months with the suspicion of HD.
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Affiliation(s)
- Lieke Beltman
- Department of Pediatric Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Department of Pediatrics, Emma Children's Hospital Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Hosnieya Labib
- Department of Pediatric Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Marit Masselink
- Department of Pediatric Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Manouk Backes
- Department of Pediatric Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Marc A Benninga
- Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands
- Department of Pediatric Gastroenterology and Nutrition, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - J Patrick van der Voorn
- Department of Pathology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Joost van Schuppen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Jaap Oosterlaan
- Department of Pediatrics, Emma Children's Hospital Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - L W Ernest van Heurn
- Department of Pediatric Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Joep P M Derikx
- Department of Pediatric Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
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Beltman L, Labib H, Ahmed H, Benninga M, Roelofs J, van der Voorn P, van Schuppen J, Oosterlaan J, van Heurn E, Derikx J. Transition Zone Pull-through in Patients with Hirschsprung Disease: Is Redo Surgery Beneficial for the Long-term Outcomes? J Pediatr Surg 2023; 58:1903-1909. [PMID: 36941171 DOI: 10.1016/j.jpedsurg.2023.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/17/2023] [Accepted: 02/08/2023] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Transition zone pull-through (TZPT) is incomplete removal of the aganglionic bowel/transition zone (TZ) in patients with Hirschsprung disease (HD). Evidence on which treatment generates the best long-term outcomes is lacking. The aim of this study was to compare the long-term occurrence of Hirschsprung associated enterocolitis (HAEC), requirement of interventions, functional outcomes and quality of life between patients with TZPT treated conservatively to patients with TZPT treated with redo surgery to non-TZPT patients. METHODS We retrospectively studied patients with TZPT operated between 2000 and 2021. TZPT patients were matched to two control patients with complete removal of the aganglionic/hypoganglionic bowel. Functional outcomes and quality of life was assessed using Hirschsprung/Anorectal Malformation Quality of Life questionnaire and items of Groningen Defecation & Continence together with occurrence of Hirschsprung associated enterocolitis (HAEC) and requirement of interventions. Scores between the groups were compared using One-Way ANOVA. The follow-up duration lasted from time at operation until follow-up. RESULTS Fifteen TZPT-patients (six treated conservatively, nine receiving redo surgery) were matched with 30 control-patients. Median duration of follow-up was 76 months (range 12-260). No significant differences between groups were found in the occurrence of HAEC (p = 0.65), laxatives use (p = 0.33), rectal irrigation use (p = 0.11), botulinum toxin injections (p = 0.06), functional outcomes (p = 0.67) and quality of life (p = 0.63). CONCLUSION Our findings suggest that there are no differences in the long-term occurrence of HAEC, requirement of interventions, functional outcomes and quality of life between patients with TZPT treated conservatively or with redo surgery and non-TZPT patients. Therefore, we suggest to consider conservative treatment in case of TZPT.
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Affiliation(s)
- Lieke Beltman
- Emma Children's Hospital Amsterdam, Amsterdam UMC Location University of Amsterdam, Department of Pediatric Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Emma Children's Hospital Amsterdam, Amsterdam UMC Location University of Amsterdam, Department of Pediatrics, Emma Children's Hospital Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands.
| | - Hosnieya Labib
- Emma Children's Hospital Amsterdam, Amsterdam UMC Location University of Amsterdam, Department of Pediatric Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Hafsa Ahmed
- Emma Children's Hospital Amsterdam, Amsterdam UMC Location University of Amsterdam, Department of Pediatric Surgery, Meibergdreef 9, Amsterdam, the Netherlands
| | - Marc Benninga
- Emma Children's Hospital Amsterdam, Amsterdam UMC Location University of Amsterdam, Department of Pediatric Gastroenterology and Nutrition, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands
| | - Joris Roelofs
- Amsterdam UMC Location University of Amsterdam, Department of Pathology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Patrick van der Voorn
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Pathology, Boelelaan 1117, Amsterdam, the Netherlands
| | - Joost van Schuppen
- Amsterdam UMC Location University of Amsterdam, Department of Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jaap Oosterlaan
- Emma Children's Hospital Amsterdam, Amsterdam UMC Location University of Amsterdam, Department of Pediatrics, Emma Children's Hospital Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Ernest van Heurn
- Emma Children's Hospital Amsterdam, Amsterdam UMC Location University of Amsterdam, Department of Pediatric Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
| | - Joep Derikx
- Emma Children's Hospital Amsterdam, Amsterdam UMC Location University of Amsterdam, Department of Pediatric Surgery, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism Research Institute, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands
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Beltman L, Labib H, Oosterlaan J, van Heurn E, Derikx J. Risk factors for complications in patients with Hirschsprung disease while awaiting surgery: Beware of bowel perforation. J Pediatr Surg 2022; 57:561-568. [PMID: 35354528 DOI: 10.1016/j.jpedsurg.2022.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 02/10/2022] [Accepted: 02/23/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with Hirschsprung disease (HD) mostly undergo surgery around the age of three to six months. While awaiting surgery, therapy to treat the obstruction such as transanal irrigation (TAI) or laxatives is applied. The aim of this study was to gain insight in the prevalence and severity of complications occurring while awaiting surgery and to identify patient characteristics associated with the development of these complications. METHODS This study retrospectively analyzed data of patients with HD operated in our center between 2000 and 2021. Complications emerging while awaiting surgery were graded using Clavien-Dindo (CD). Patient characteristics as predictor of a complication were tested using logistic regression analysis. RESULTS Twenty-two of 132 (17%) included patients (preoperative treatment: 94% TAI; 2% laxatives; 2% other therapy) developed 45 complications while awaiting surgery, including predominantly major complications (91%). Bowel perforation occurred most frequently (n = 9, 7%) wherefrom six caused by TAI (5%), including three patients with total colon aganglionosis (TCA) (2%) counting one life-threatening and one lethal perforation. The other perforations were caused by meconium ileus (n = 2) and Hirschsprung associated enterocolitis (HAEC) (n = 1). Other frequent complications were: sepsis (5%), ileus (4%) and persistent obstruction (4%). Predictive factor for developing complication was TCA (OR 9.905, CI 2.994-32.772, p < 0.001). CONCLUSION We found a complication rate of 17% in patients while awaiting surgery, reporting bowel perforation most frequently. We found this complication in patients with TCA being highly dangerous causing one life-threatening and one lethal perforation. Therefore, we advise in patients with (suspected) TCA to limit the time awaiting surgery. LEVEL OF EVIDENCE level III.
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Affiliation(s)
- Lieke Beltman
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam 1105 AZ, the Netherland; Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital Amsterdam UMC Follow-Me program and Emma Neuroscience Group, Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherland.
| | - Hosnieya Labib
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam 1105 AZ, the Netherland
| | - Jaap Oosterlaan
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital Amsterdam UMC Follow-Me program and Emma Neuroscience Group, Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherland
| | - Ernest van Heurn
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam 1105 AZ, the Netherland
| | - Joep Derikx
- Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, Amsterdam 1105 AZ, the Netherland
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Beltman L, Roorda D, Backes M, Oosterlaan J, van Heurn LWE, Derikx JPM. Risk factors for short-term complications graded by Clavien-Dindo after transanal endorectal pull-through in patients with Hirschsprung disease. J Pediatr Surg 2022; 57:1460-1466. [PMID: 34452757 DOI: 10.1016/j.jpedsurg.2021.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Lieke Beltman
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands; Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Department of Pediatrics, Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands.
| | - Daniëlle Roorda
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands; Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Department of Pediatrics, Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Manouk Backes
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Jaap Oosterlaan
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Department of Pediatrics, Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - L W Ernest van Heurn
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Joep P M Derikx
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
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Beltman L, Windster JD, Roelofs JJTH, van der Voorn JP, Derikx JPM, Bakx R. Diagnostic accuracy of calretinin and acetylcholinesterase staining of rectal suction biopsies in Hirschsprung disease examined by unexperienced pathologists. Virchows Arch 2022; 481:245-252. [PMID: 35513609 PMCID: PMC9343274 DOI: 10.1007/s00428-022-03334-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/24/2022]
Abstract
Rectal suction biopsy (RSB) is a gold standard for diagnosing Hirschsprung disease (HD). Calretinin staining of RSB is increasingly used by experienced pathologists due to non-complex examination and comparable diagnostic accuracy with acetylcholinesterase (AChE). However, the diagnostic accuracy of calretinin examined by unexperienced pathologists remains to be elucidated. Therefore, we aim to compare diagnostic accuracy of calretinin with AChE on RSB for diagnosing HD when examined by unexperienced pathologists. We prospectively analyzed sections from RSB stained with AChE + HE and calretinin. Blinded examination was done by five unexperienced pathologists (pathology residents) and three experienced pathologists (senior pediatric gastro-enterology pathologists) assessing for the presence of HD. Cases for the study included ones proven to be HD on resection specimens and cases without HD. Diagnostic accuracy was determined calculating area under the curve (AUC), sensitivity, specificity, likelihood ratio, and posttest probability. Fleiss’ kappa analysis was performed to assess interobserver agreement between reviewers. Eleven of 18 included patients (61%) were diagnosed with HD. Comparing the diagnostic accuracy of unexperienced pathologists, calretinin versus AChE + HE showed sensitivity of 80.0% versus 74.5% and specificity of 100% versus 65.4%, AUC of 0.87 (0.78–0.96) versus 0.59 (0.45–0.72). Unexperienced pathologists showed substantial agreement with calretinin (kappa 0.72 [0.61–0.84]) and fair agreement with AChE + HE (kappa 0.34 [0.23–0.44]). We found calretinin having higher diagnostic accuracy in diagnosing HD compared to AChE + HE when examined by unexperienced pathologists. Therefore, we recommend to use calretinin as the standard technique for staining RSB in diagnosing HD.
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Affiliation(s)
- L Beltman
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - J D Windster
- Department of Pediatric Surgery and Intensive Care, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J J T H Roelofs
- Department of Pathology, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - J P M Derikx
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - R Bakx
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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