Diagnosis and surgical approach of adult Hirschsprung's disease: About two observations and review of the literature. Case series

Introduction

Hirschsprung's disease (HD) is uncommon in adulthood. In this study, we describe the management of two cases of adult Hirschsprung's disease treated with transanal colonic pull-through procedure followed by a delayed coloanal anastomosis.

Patients and methods

This was a retrospective (December 2016 to Jun 2019) study included two cases of adult HD with confirmed Hirschsprung disease who underwent surgery at Zinder National hospital, Niger. The registration number is researchregistry 5174.

Results

These were two patients aged 21 years (male) and 22 years (female) admitted to the emergency department with an acute bowel obstruction. The history finds a delayed passage of meconium at birth with a history of long-standing recurrent constipation since early childhood for the 2 patients. A lateral colostomy was performed urgently in both patients and the barium enema revealed a disparity of the sigmoid colon with corn shaped transition zone. Histologic examination of the biopsy specimen confirmed the diagnosis of HD. Surgery was done according to transanal endorectal pull-through procedure followed by delayed coloanal anastomosis. Patients were regularly followed over a period of 16 months. Constipation was gone, no continence problem was reported and quality of life was rated satisfactory.

Conclusion

The discovery of Hirschsprung's disease is rare in adulthood. Transanal endorectal pull-through procedure followed by delayed coloanal anastomosis with conventional surgery is a suitable option for the treatment of HD and gives a good result.

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More than 90% of cases, diagnosis and treatment of Hirschsprung’s disease are made in the first 5 years of life; as a result, the diagnosis of HD in adulthood is rare.

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Surgical treatment in adulthood is more laborious because of anatomical changes.

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Many surgical procedures have been described, the best known of which are Swenson, Duhamel, Soave and Lynn. Modifications of these techniques have been proposed.

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The goal of surgical treatment is to resect or exclude the aganglionic segment and to lower the healthy colon, normally innervated at the anus.

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Transanal colonic pull-through procedure followed by a delayed coloanal anastomosis with conventional surgery and manual anastomosis, gives satisfactory results and remains well adapted to the adult Hirschsprung’s disease in context of limited resources.

transanal endorectal pull-through procedure for Hirschsprung disease: A systematic review and meta-analysis

OBJECTIVE

To compare treatment outcomes in children with Hirschsprung's disease who underwent treatment using the Duhamel or TERPT surgical procedures.

METHODS

Medline, Cochrane, EMBASE, and Google Scholar databases were searched through December 26, 2016. Search strings included Hirschsprung's disease, fecal incontinence, transanal endorectal pull-through, and Duhamel operation. Randomized controlled studies (RCTs) and retrospective studies that compared the treatment of Hirschsprung's disease in with TERPT or Duhamel surgical procedures in neonates, infants, or children were included.

RESULTS

The study included six studies with a total of 280 patients. The meta-analysis indicated that the Duhamel and TERPT interventions were similar with respect to rate of postoperative fecal incontinence (OR=0.85, 95% CI=0.37 to 1.92, P=0.692) and operation time (difference in means=46.68min, 95% CI=-26.96 to 114.31, P=0.226). The Duhamel procedure was associated with longer postoperative hospital stay (Difference in means=3.14days, 95% CI=1.46 to 4.82, P<.001) and a lower rate of enterocolitis (OR=0.21, 95%=0.07 to 0.68, P=0.009) compared with the TERPT procedure.

CONCLUSIONS

The study found that Duhamel and TERPT procedures showed similar benefit in treating Hirschsprung's disease, although differences exist with respect to length of postoperative hospital stay and the incidence of enterocolitis.

THE TYPE OF STUDY

Meta-analysis.

LEVEL OF EVIDENCE

Level II.

Long-term outcome of bowel function for 110 consecutive cases of Hirschsprung's disease: Comparison of the abdominal approach with transanal approach more than 30years in a single institution - is the transanal approach truly beneficial for bowel function?

BACKGROUND

We compared the long-term outcomes of the bowel function (BF) in Hirschsprung's disease (HD) patients who underwent transanal endorectal pull-through (TA) with those who underwent the Soave-Denda (SD) procedure.

METHODS

Patient data were collected from 1984 to 2015 from 110 HD patients who underwent definitive diagnosis and operation. The follow-up data were analyzed retrospectively. BF was evaluated according to the evacuation score (ES) of the Japan Society of Anorectal Malformation Study Group at 3, 5, 7, 9, and 11years of age.

RESULTS

The operative procedures performed were as follows: SD: 71 (64.5%), TA: 38 (34.5%), and Duhamel: 1 (1.0%). We compared SD with TA. The ES improved chronologically after both procedures, and patients achieved satisfactory results at least 10years after operation. There was no significant difference in the total ES at all ages. The incontinence and frequency of bowel movement scores of TA patients were significantly lower than those of SD patients at several points.

CONCLUSION

TA is simple, less invasive, and adaptive for neonates and small infants. However, regarding the bowel function, TA is not always superior to SD. The surgical technique of TA must be improved according to a detailed understanding of the anatomy.

LEVEL OF EVIDENCE

Retrospective study - level III.