Transanal endorectal pull-through for Hirschsprung's disease: experience with 68 patients

Background/purpose: The aim of this study was to evaluate the indications, results, and complications of transanal endorectal pull-through (TEPT) in the management of recto-sigmoid Hirschsprung’s disease (HD).Methods: Between November 1998 and March 2002, 68 TEPT procedures were performed in infants and children. The patients’ ages ranged from 6 days to 13 years. The primary diagnosis in all 68 patients was Hirschsprung’s disease confined to the recto-sigmoid region. All children had their operations done without construction of preoperative colostomy except for one. Follow-up period ranged from 3 to 39 months (mean, 21 months).Results: The mean operating time was 90 minutes, and average length of bowel resected was 25 cm. Sixty-two patients had satisfactory results without complications. Blood transfusion was needed in only 11 patients. Recovery was very fast, and patients often were hungry within 24 hours. Feeding was resumed within 48 hours. One patient required laparotomy during the procedure owing to injury to the urethra. Two patients required colostomy 3 and 5 days after surgery respectively, because of delayed leakage. Three patients suffered from attacks of enterocolitis 6 to 9 months postoperatively. There was increased frequency of defecation (5 to 15 times daily) for 4 to 6 weeks after surgery in all the patients. There was no constipation, no incontinence, no cuff abscess, and no mortality in any of the patients. Average frequency of defecation was 1 to 3 times daily after 3 months. The cost of the TEPT technique was almost half that of the open surgery.Conclusions: TEPT takes less time, has less bleeding, shorter hospital stay, less morbidity, and earlier recovery than similar open pull-through procedures. The hazards and morbidities associated with laparotomy and colostomy may be avoided with a one-stage technique in Hirschsprung’s disease confined to the recto-sigmoid region. Careful long-term follow-up is required to assess continence and sexual function.     

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.     

经肛门拖出术治疗先天性巨结肠23例

长期以来采用Ｓｏａｖｅ手术治疗小儿先天性巨结肠[1] ,近来我们采用不开腹 ,经肛门一期根治术治疗 ,创伤小 ,术后恢复快 ,并发症少。1　材料与方法小儿先天性巨结肠 2 3例 ,男 15例 ,女 8例 ,年龄 2 6天～ 4岁。以病史、体征、肛诊和钡灌肛等初步诊断 ,选择其降结肠无明显扩张的病儿 ,常规消毒腹部及会阴皮肤 ,插尿管。肛门扩张后 ,缝 4针牵引线。在齿状线上 4ｃｍ处直肠后壁取全层活检进一步确诊。齿状线以上粘膜下注入肾上腺素盐水 ,以利于止血和剥离。在齿线上 0 2ｃｍ处环行切开直肠粘膜 ,剥离直肠粘膜 6～ 8ｃｍ ,见直肠肌层随粘膜牵…     

Role of transanal endorectal pull-through in complicated Hirschsprung's disease: experience in 18 patients

Background/Purpose

In Hirschsprung's disease (HD) redo pull-through (PT) is indicated for anastomotic complications and for persistent aganglionosis after previous definitive surgery. This study was undertaken to evaluate the role of transanal approach to redo PT procedure in the management of complicated cases of HD over the last 7 years.

Patients and Methods

Between November 1998 and September 2005, 225 patients with HD were operated using the transanal endorectal PT (TEPT) approach. Eighteen patients had a redo PT owing to persistent aganglionosis.The present study evaluates the role of TEPT approach in patients with persistent aganglionosis (n = 18). Three patients needed a colostomy (n = 2) or ileostomy (n = 1) before the final operation. All the 18 patients underwent transanal mobilization (TEPT) of the colon. Six patients required additional mobilization of the proximal colon (n = 4) and the ileum (n = 2) during the redo PT operation.

Results

Median follow-up was 43 months (range, 3-72 months). Sixteen patients have had a good outcome with stool pattern 1 to 4 times daily. One patient had obstructive symptoms for 4 months postoperatively but then settled. One patient has occasional soiling.

Conclusions

In this series, TEPT and posterior midline split of the muscle cuff were used with good results. This has the advantage of avoiding injury to the pelvic muscles and nerves. The TEPT approach is combined with transabdominal mobilization of the intestine depending on the length of the aganglionic segment. The outcome has been favorable, but long-term follow-up is necessary for full assessment of those patients.     

Primary laparoscopic endorectal colon pull-through for Hirschsprung's disease: early results of 61 cases

OBJECTIVE: To report early results after a one-stage laparoscopic endorectal colon pull-through for Hirschsprung's disease (HD). METHODS: Between January 2002 and June 2004, 61 patients underwent primary laparoscopic-assisted endorectal colon pull-through procedure for HD. Ages ranged from 21 days to 36 months. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies obtained laparoscopically. The rest of the procedure was performed according to Georgeson's technique. We left a short rectal seromuscular sleeve 2 cm from the dentate line. RESULTS: The aganglionic segment was located in the rectum in 33 patients, in the sigmoid colon in 27 patients and in the left colon in one patient. The median operating time was 140 minutes. There were no operative complications or deaths. No conversion was required. There was minimal blood loss during surgery. Clear fluids were given 12 hours after surgery and milk was given on the 2nd day. In one patient, small intestinal perforation occurred 3 days after surgery and required ileostomy. The median hospital stay was 6 days, excluding one patient with intestinal perforation. Spontaneous defaecation occurred in all patients before discharge. CONCLUSION: One-stage laparoscopic-assisted colon pull-through is a safe and effective procedure for HD.     

Reappraisal of the endorectal pull-through operation for Hirschsprung's disease

With proper operative technique the endorectal pull through is a safe and effective procedure for the treatment of Hirschsprung's disease which can be utilized in both infants and older children with a minimum of complications. The use of a colostomy at the time of the pullthrough procedure may endanger rather than protect the pulled-through colonic segment. Postoperative drainage of the rectal cuff is indicated for 2–4 days to prevent the occurrence of cuff abscesses.     

Submucosal pressure-air insufflation facilitates endorectal mucosectomy in transanal endorectal pull-through procedure in patients with Hirschsprung's disease

Background: Most children with Hirschsprung's disease (HD) can be treated with a transanal endorectal pull-through (TEP) procedure. The authors have developed a simple technique of submucosal pressure-air insufflation (SI) to facilitate the submucosal dissection, which is one of the crucial parts of the operation. Methods: Six patients with HD were treated by using TEP in one year. After adequate positioning and exposure, anal mucosa was incised 1 cm above the dentate line, and 4-quadrant SI with a simple system of scalp-vein needle connected to a 20-mL syringe was used in all of the patients. Submucosal proctectomy, aganglionic and dilated segment colectomy, and coloanal anastomosis were completed transanally, but, in 2 of the patients, laparoscopic assistance to release the colon was required. Results: There were no intraoperative and postoperative complications related to SI. Submucosal dissections were completed smoothly in all of the patients with negligible amount of bleeding. The only complication during the submucosal dissection was mucosal perforation at the site of previous rectal biopsy in 2 patients. Average operating time was 2.7 hours (range, 90-180 min), and mean length of resected bowel was 22.5 cm (range, 12 to 42 cm). Follow-up is 8 to 14 months. Frequent bowel movements ([gt ]8 times per day) and perianal dermatitis were observed in 2 patients but returned to acceptable limits in 3 months. One patient had to undergo reoperation for adhesive intestinal obstruction. Conclusions: SI is simple, and offers a safe and faster dissection with minimum amount of bleeding during the endorectal mucosectomy in TEP procedure. J Pediatr Surg 38:188-190.     

经肛门Ⅰ期先天性巨结肠根治术临床观察

目的 探讨经肛门Ⅰ期先天性巨结肠根治术的治疗方法和临床效果.方法 对12例已证实为短段型或普通型先天性巨结肠患儿行经肛门Ⅰ期先天性巨结肠根治术.年龄3月至5岁,平均1.8岁.结果 全组手术顺利,无死亡.术后1周左右出院,随访半年,术后有1例出现轻度排便困难,经保守治疗痊愈.有3例出现不同程度的污粪,3-6月后痊愈.无严重并发症,生长发育良好.结论 经肛门Ⅰ期巨结肠根治术适用于患短段型或普通型先天性巨结肠症的婴幼儿,手术创伤小,不需开腹,合并症少、手术时间短,效果满意.     

经肛门I期先天性巨结肠根治术临床观察

目的 探讨经肛门I期先天性巨结肠根治术的治疗方法和临床效果。方法 对12例已证实为短段型或普通型先天性巨结肠患儿行经肛门I期先天性巨结肠根治术。年龄3月至5岁，平均1．8岁。结果 全组手术顺利，无死亡。术后1周左右出院，随访半年，术后有1例出现轻度排便困难，经保守治疗痊愈。有3例出现不同程度的污粪，3-6月后痊愈。无严重并发症，生长发育良好。结论 经肛门I期巨结肠根治术适用于患短段型或普通型先天性巨结肠症的婴幼儿，手术创伤小，不需开腹，合并症少、手术时间短，效果满意。     

Outcome of transanal endorectal vs. transabdominal pull-through in patients with Hirschsprung’s disease

Introduction  

Various outcomes have been reported in patients with Hirschsprung’s disease (HD) following transanal endorectal (TERPT) or conventional transabdominal (ABD) pull-through procedures. This study examined postoperative complications and the long-term outcome of TERPT vs. ABD pull-through for HD.     

Favorable ten-year experience with valve procedures for active infective endocarditis

We have reviewed our 1972 to 1982 experience with valve procedures for infective endocarditis in 52 consecutive patients to evaluate the results of an interdisciplinary policy of early operation for uncontrolled complications. There were 47 patients with native valve endocarditis and five with prosthetic valve endocarditis. Twenty-seven were drug addicts and 25 were not. Thirty-seven (71%) required operation during the active phase of the disease and 15 during the inactive phase. Ninety-three percent of the addicts, 41% of the nonaddicts, and all patients with prosthetic valve endocarditis were in the active group. The distribution of infected valves was as follows: aortic, 21 active and 10 inactive; mitral, six active and three inactive; aortic and mitral, five active and two inactive; aortic and tricuspid, one active and none inactive; and tricuspid, four active and none inactive. Streptococcus was the most common infecting organism in both groups--predominantly group D in addicts and non-D in nonaddicts. Staphylococcus, gram-negative rods, and fungi occurred only in the active group. Indications for operation were congestive heart failure alone (19 active and 15 inactive), congestive heart failure and refractory infection or major emboli (nine active and none inactive), and resistant or refractory infection alone or with emboli (nine active and none inactive). Periannular abscess or aneurysm formation was most frequent at the aortic valve site in patients with native valve endocarditis; it occurred in 13 of 25 patients (52%) in the active group and in one of 12 patients (8%) in the inactive group. Six patients with preoperative stroke syndromes underwent operation without neurological deterioration; two patients had rupture of cerebral mycotic aneurysms postoperatively. Hospital mortality was 8% (3/7) in the active group and 0% in the inactive group. The late actuarial survival rate was 64% at 5 years and 54% at 10 years. Seven of nine deaths in the addict group were related to continued drug use, with five deaths occurring in the first 18 months. These results support a policy of early operation for uncontrolled complications with attention to the particular problems of active endocarditis.