Duhamel pull-through for Hirschsprung disease: a comparison of open and laparoscopic techniques

PurposeVarious pull-through techniques, both open and laparoscopic, have been performed for Hirschsprung disease. Our study compares open and laparoscopic Duhamel pull-through.MethodsAfter ethical approval, we reviewed all children (n = 181) with Hirschsprung disease admitted to our institution between 1999 and 2009. We excluded total colonic aganglionosis (n = 14), previous pull-through done elsewhere (n = 33), or follow-up performed abroad (n = 58). Open and laparoscopic pull-through were done in the same period according to surgeon preference. Data were analyzed using χ² or Mann-Whitney U test.ResultsSeventy-six children had a Duhamel pull-through for rectosigmoid aganglionosis. Operative time, time to full feeds, and length of hospital stay were similar in each group.Open (n = 41)Fifteen children (37%) required 33 further procedures. Fourteen had procedures for persistent constipation, including redo Duhamel (n = 2), stoma formation (n = 2), spur division (n = 2), and dilatation/stretch/Botox/rectal biopsy/manual evacuation (n = 23). Three children had other procedures (adhesiolysis [n = 2] and incisional hernia repair [n = 1]).Laparoscopic (n = 35)Fourteen children (40%) required 30 further procedures. Eleven had procedures for persistent constipation, including redo Duhamel (n = 1), stoma formation (n = 4), spur division (n = 9), and dilatation/stretch/rectal biopsy (n = 8). Three children had other procedures (adhesiolysis [n = 1] and incisional hernia repair [n = 2]). There were 4 conversions.ConclusionOpen and laparoscopic Duhamel pull-through have similar outcomes. We show that the techniques have comparable operative times and hospital stay.     

Duhamel operation vs. 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.

Clinical outcome in children after transanal 1-stage endorectal pull-through operation for Hirschsprung disease

Background/Purpose

Recently, the transanal 1-stage pull-through operation has been widely used in Hirschsprung disease (HD), and it is obviously superior to traditional approach in early term for its noninversion. However, the procedure is relatively so new that it makes assessment of the functional outcome and stooling patterns difficult. The aim of this study was to evaluate the clinical outcomes of the transanal 1-stage endorectal pull-through operation in the management of rectosigmoid HD.

Methods

Fifty-eight children (39 boys and 19 girls) aged 12 months to 13 years (mean, 2 years) who underwent transanal 1-stage endorectal pull-through operation for HD were followed up from 6 to 24 months. Clinical outcome was assessed by interviews and questionnaires. All patients had an aganglionic segment confined to the rectosigmoid area which was confirmed by the preoperative barium enema and postoperative pathological examination.

Results

Forty-six patients had satisfactory results without complications. In all the children, the mean stool times were 1 to 2 per day; only 4 had mean stool times of 8 to 10 per day. Postoperative soiling was present in 9, constipation in 5, and HD-associated enterocolitis in 3. There were no incontinence, cuff infection, anastomotic leak, and mortality in any of the patients. In the 12 symptomatic patients, there were 4 children with length of aganglionic segment less than 30 cm, and 8 had 30 cm or more. In the 46 asymptomatic patients, 42 had length of aganglionic segment less than 30 cm, and 4 had 30 cm or more. There was a significant difference between the group with less than 30 cm and the group with 30 cm or more of aganglionic segment. For statistical analysis, the Fisher exact test showed P < .05.

Conclusions

The transanal 1-stage endorectal pull-through is a feasible and safe procedure in children with rectosigmoid HD. The clinical outcome is satisfactory. A gradual recovery could be noted in the stooling patterns along with the time after surgery. The younger the patient operated on and the shorter the aganglionic segment, the lower do the stooling disorders occur and the faster does the stooling function recover.     

Transanal one-stage endorectal pull-through for Hirschsprung's disease in infants and children

Purpose: This report presents the technique and results of transanal one-stage endorectal pull-through procedure in children with rectosigmoid lesions from Hirschsprung's disease. Methods: Eight children aged one month to 6 years with frozen section biopsy[ndash ]proven Hirschsprung's disease underwent transanal one-stage endorectal pull-through procedures during a 12-month period. A rectosigmoid transitional zone was suggested by contrast enema in 7 patients; rectal manometry was done to confirm the diagnosis in one patient. Preoperative colonic irrigation to evacuate feces out of the dilated colon was done in the hospital. Bowel preparation was the same as conventional colorectal surgery. Full-thickness rectal biopsy at 1 to 2 cm above the dentate line was submitted for pathologic diagnosis. A rectal mucosectomy dissection was started 0.5 cm proximal to the dentate lines and was extended into the intraperitoneal rectum. The muscular sleeve was divided circumferentialy at 3 to 4 cm proximal to the dentate line, exposing the intraperitoneal rectum and allowing full-thickness mobilization of the rectosigmoid colon out of the anus. Aganglionic colon segment was resected, and the normal colon was pull down to anastomose with the distal end of anorectal mucosa. Results: Operating time, including taking frozen sections, ranged from 110 to 180 minutes. The length of bowel resections ranged from 9 to 25 cm. The length of hospital stay depended on the amount of fecal impaction in the colon. Older children with substantial fecal impaction required 2 weeks of preoperative saline enema. One infant needed 3 days for bowel preparation, the same as for conventional colorectal surgery. The hospital stay ranged from 6 to 7 days in children younger than 2 years and 10 to 28 days in older children. There were no intraoperative or postoperative complications related to the pull-through procedure. One case of colitis occurred in the 6-year-old child, which required rectal tube decompression one week after the operation. Seven patients passed stool within 24 hours after surgery. All patients had normal bowel movements within 3 weeks. There was no rectal cuff stricture or enterocolitis during one year of follow-up. Conclusions: Transanal one-stage endorectal pull-through operations for rectosigmoid lesions from Hirschsprung's disease can be performed successfully in all ages of children with good results, avoiding transabdominal exploration. The early postoperative enterocolitis in the older children might occur and should be treated urgently. The partial coloanal anastomosis obstruction found in older children could be treated by placing a rectal tube into the anus to decompress the dilated pull-through colon. The limitation of this approach is that retroperitoneal fixation of the descending colon could not be dissected by the transanal route. J Pediatr Surg 38:184-187.     

经脐腹腔镜结肠肛门拖出术治疗儿童神经节细胞减少症

目的探讨经脐腹腔镜结肠肛门拖出术用于儿童神经节细胞减少症的治疗效果。方法回顾性分析2009年6月至2010年6月间在华中科技大学同济医学院附属同济医院接受经脐腹腔镜肛门拖出手术的12例神经节细胞减少症患儿的临床资料。结果手术使用特制的弯曲手柄型加长器械进行操作,无一例患儿中转开腹或改行传统腹腔镜手术。术中无腹部血管、肠管、输尿管或输精管损伤．平均手术时间140min．平均术中失血量45ml,平均切除病变肠管长度40cm。术后无吻合口瘘、吻合口狭窄、便秘、污粪、排粪失禁等并发症出现,平均术后住院时间9d。术后1个月复诊时均未见明显手术瘢痕。术后经10～22（中位时间16）个月的随访,无一例复发。结论经脐腹腔镜肛门拖出术治疗神经节细胞减少症简单、安全并有效。     

Single-stage versus multi-stage pull-through for Hirschsprung's disease: Practice trends and outcomes in infants

PurposeThe aim of this study was to evaluate surgical treatments and outcomes in a multi-institutional cohort of neonates with Hirschsprung's disease (HD).MethodsUsing the Pediatric Health Information System (PHIS) from 1999 to 2009, neonates diagnosed with HD were identified and classified as having a single stage pull-through (SSPT) or multi-stage pull-through (MSPT). Diagnosis and classification algorithms and clinical variables and outcomes were validated by multi-institutional chart review. Groups were compared using logistic regression modeling and propensity-score matched analysis to account for baseline differences between groups.Results1555 neonates with HD were identified; 77.2% underwent SSPT and 22.8% underwent MSPT. Misclassification of disease or surgical treatment was < 2%. Rates of SSPT increased over time (p = 0.03). Compared to SSPT, patients undergoing MSPT had significantly lower birth weights and higher rates of prematurity, non-HD gastrointestinal anomalies, enterocolitis, and preoperative mechanical ventilation. Patients undergoing MSPT had significantly higher rates of readmissions (58.5 vs. 37.9%) and additional operations (38.7 vs. 26%). Results were consistent in the propensity-score matched analysis.ConclusionMost neonates with HD undergo SSPT. In patients with similar observed baseline characteristics, MSPT was associated with worse outcomes suggesting that some infants currently selected to undergo MSPT may have better outcomes with SSPT. However, there remains a subgroup of MSPT patients who were too ill to be adequately compared to SSPT patients; for this subgroup of severely ill infants with HD, MSPT may be the best option.     

Early and late outcomes of primary laparoscopic endorectal colon pull-through leaving a short rectal seromuscular sleeve for Hirschsprung disease

Aim

To report early and late outcomes of laparoscopic colon pull-through leaving a short rectal sleeve for Hirschsprung disease.

Methods

Laparoscopic endorectal colon pull-through was performed using 4 ports. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies obtained laparoscopically. The rest of the procedure was carried out according to Georgeson's technique. However, we left a short rectal seromuscular sleeve of 1.5 to 2 cm above the dentate line.

Results

From January 2001 to December 2007, 200 patients were operated upon by the same surgeon. Ages ranged from 14 days to 36 months old. The aganglionic segment was located in the rectum in 112 patients, in the sigmoid colon in 80 children, and in the left colon in 8 patients. The median operating time was 152 minutes. There were no perioperative deaths. Conversion to open surgery was required in four patients. There was minimal blood loss during the surgery. Oral intakes of clear fluid were started 12 hours after surgery and advanced to formula on the second day. In 1 patient, a small intestinal perforation occurred 3 days after surgery, requiring a diverting ileostomy. The mean hospital stay was 6.6 days (range, 4-12 days). Follow-up ranging from 5 to 85 months was obtained in 157 patients; 124 patients (79%) had 1 to 4 defecations a day, 17 (11%) had 5 to 6, and 8 had more than 6. Fecal incontinence occurred in 3 patients (2.0%), constipation in 5 patients (3.0%), and enterocolitis in 15 patients (9.5%). Anastomotic fistula occurred in 2 patients.

Conclusion

Laparoscopic endorectal pull-through leaving a short rectal seromuscular sleeve is a safe and effective procedure for Hirschsprung disease.     

先天性巨结肠经肛-期直肠内拖出手术疗效与术后排粪情况研究

目的探讨经肛-期直肠内拖出术（TOSEPT）治疗先天性巨结肠的安全性、有效性及术后排粪情况。方法回顾性分析2005年4月至2011年4月间在广州医学院第三附属医院接受TOSEPT的56例先天性巨结肠患儿的临床资料。将患儿按手术年龄分为新生儿组（2l例,手术年龄在出生后1个月以内）和非新生儿组（45例）,比较两组患儿的术中及术后情况。结果56例患儿手术时间（121．5±39．2）min,切除肠段（17．6±4．2）cm,术中出血（34．6±5．2）ml,术后住院时间（7．2±3．6）d．术后6例（10．6％）患儿出现并发症（小肠结肠炎4例,便秘复发2例）,其中接受再次手术的2例和长期便秘尚未解决的1例患儿视为手术失败。手术成功的53例患儿术后经（9．2±5．8）周的排粪过渡期均最终恢复正常排粪。与非新生儿组相比．新生儿组患儿手术时间和术后住院时间均明显缩短,但术后排粪过渡期显著延长（均P〈0．05）;两组患儿术中出血量和术后并发症发生率的差异无统计学意义（P〉0．05）。结论TOSEPT治疗先天性巨结肠安全、有效,但术后需要一个排粪过渡期来恢复正常排粪。尽管相对于婴幼患儿．新生患儿手术时间和术后住院时间均明显缩短．但在疗效评价时应同时考虑其显著延长的排粪过渡期。     

Comparison of clinical outcomes after total transanal and laparoscopic assisted endorectal pull-through in patients with rectosigmoid Hirschsprung disease

BackgroundTotal transanal (TERPT) and laparoscopic endorectal pull-through (LERPT) are the most common procedures to treat rectosigmoid Hirschsprung's disease (HD). Since few studies have compared the two methods, we aimed to assess clinical outcomes after TERPT and LERPT in this cross-sectional study.Methods and PatientsAll patients with rectosigmoid HD operated with TERPT and LERPT between 2001 and 2018 were eligible. Peri-operative data were registered from patients’ records, and bowel function was assessed according to the Krickenbeck classification.Results91/97 (94%) patients were included; 46 operated with TERPT and 45 with LERPT. Bowel function was assessed in 80 patients at median seven (4–17) years. There was no difference in functional outcome between the procedures. Unplanned procedures under general anesthesia were frequent; 28% after TERPT and 49% after LERPT (p = 0.04). 11% of TERPT and 29% of LERPT patients got botulinum toxin injections (p = 0.03). In the TERPT group, patients operated in the neonatal period had poorer outcome (78%) than those operated later (24%) (p = 0.005). No difference in operative time, length of hospital stay, and rate of early and late complications was found between the procedures.ConclusionThere was no difference in long-term bowel function in patients with rectosigmoid HD operated with TERPT or LERPT. More LERPT patients had an unplanned procedure under general anesthesia, mostly due to obstructive symptoms.Level of evidenceIII.     

Robotic Swenson pull-through for Hirschsprung's disease in infants

It has been demonstrated that infants with Hirschsprung's disease can be treated with a one-stage laparoscopic resection and coloanal pull-through. However, the feasibility and benefits of performing this operation using robotic technology have not yet been evaluated. We reviewed our experience with 12 infants diagnosed with Hirschsprung's disease and treated with laparoscopic-robotic assisted colonic resection with proctectomy and pull-through using the da Vinci robotic system. Patients were treated at a mean age/weight of 16 weeks/5.5 kg. The average operative time for the robotic procedure was 230 minutes, and average length of stay was 3 days. At discharge, all patients were having regular bowel movements and tolerating a completely oral diet. All patients received early postoperative anorectal dilation and six patients required dilations for an average of 12 weeks after surgery for management of minor rectal strictures. Only two patients developed postoperative enterocolitis with a mean follow-up of 36 months. A robotic approach for performing a Swenson-type resection and pull-through procedure can be performed safely and successfully in young infants. Robotic technology provided superior dexterity and visualization, essential in performing a more complete rectal dissection, thus allowing for a complete proctectomy and eliminating the risk of leaving a segment of aganglionic rectum behind.     

Results of the treatment of Hirschsprung disease using the Duhamel operation

The Duhamel operation was performed on 136 children with Hirschsprung's disease. Eight patients died. Results of the operation were studied in 121 patients within the terms of from 1 to 17 years. Late complications were noted in 7 patients. In the other 114 patients remote results of the treatment were good.     

Stabilization period after 1-stage transanal endorectal pull-through operation for Hirschsprung disease

Purpose

The aim of this study was to evaluate postoperative outcomes and to find the period required for normal stooling pattern after the 1-stage transanal endorectal pull-through operation (TERPT).

Method

The authors retrospectively reviewed the clinical data and postoperative courses of 61 patients who had the aganglionic bowel confined to rectosigmoid and underwent TERPT between 2001 and 2007.

Results

Thirty-three patients (54.1%) were neonates, and 56 patients (91.8%) were less than 6 months old at operation. The mean age at TERPT was 90 ± 216 days, and the mean body weight at TERPT was 4.5 ± 2.8 kg. The average operating time was 189 ± 49 minutes, and mean length of bowel resection was 11.1 ± 3.2 cm. The mean postoperative hospital stay was 8.0 ± 3.6 days. Postoperatively, 5 (8.2%) patients were considered as failure of TERPT because of persistent problems in defecation. Fifty-six (91.8%) patients finally had normal stooling patterns and normal findings in abdominal radiography after 9.4 ± 6.2 weeks of the mean postoperative stabilization period. Neonatal cases had significantly longer postoperative stabilization periods than nonneonatal cases (11.3 ± 6.9 weeks vs 7.3 ± 4.6 weeks, P = .016). The postoperative stabilization period significantly decreased by age at operation as the patient's age increased (P = .018).

Conclusion

Clinical outcomes after TERPT are satisfactory, but a postoperative stabilization period is required for a normal stooling pattern to develop. The outcome of TERPT should consider a postoperative stabilization period.     

腹腔镜辅助手术与开腹手术治疗先天性巨结肠的比较

目的　比较先天性巨结肠改良Swenson腹腔镜辅助与开腹根治手术的临床效果 ,。　方法　回顾性分析 39例改良Swenson根治手术患儿的临床资料 ,其中 2 0例开腹为开腹组 ,19例在腹腔镜辅助下进行为腹腔镜组。比较两组特殊器械的应用、手术时间、出血量、住院时间、住院总费用及术后并发症等。　结果　患儿肠蠕动时间开腹组为 (78± 2 8)小时 ,腹腔镜组为 (2 7± 7)小时 (t=2 .87P <0 .0 1) ,术后住院时间分别为 (13± 3)天 ,(7± 1)天 (t=2 .4 8P <0 .0 5 ) ;住院总费用开腹组为 (12 5 0 0± 15 0 0 )元 ,腹腔镜组为 (110 0 0± 130 0 )元 (t=0 .78P >0 .0 5 ) ;术后肠粘连肠梗阻两组分别为 3例 ,O例 ;术后小肠结肠炎为 2例 ,0例 ;尿潴留分别为 0例 ,2例。两组在年龄、体重、性别、手术时间、术中出血、术后吻合口漏等并发症无明显差异。　结论　腹腔镜辅助下巨结肠根治术疗效好 ,治疗费用适中 ,有微创优势 ,能减轻患儿痛苦、缩短术后恢复时间 ,没有增加术中和术后并发症 ,对有适应证的患儿应推广使用     

腹腔镜结合肛门外离断术治疗先天性巨结肠的疗效分析

目的:探讨腹腔镜结合肛门外离断术治疗先天性巨结肠的临床疗效。方法:回顾分析2014年5月至2017年5月收治的60例先天性巨结肠患儿的临床资料,均行腹腔镜结合肛门外离断术,观察术后疗效、并发症及预后。结果:60例均顺利完成手术,手术时间平均(235.36±40.25)min,出血量平均(79.36±6.25)ml,肠蠕动恢复时间平均(28.69±5.24)h,恢复正常排便时间平均(3.69±0.12)个月,均未发生结肠缺血坏死、腹盆腔大出血、直肠肌鞘感染等严重并发症,术后3个月内发生2例(3.33%)切口感染,3例(5.00%)粘连性肠梗阻、2例(3.33%)直肠黏膜脱垂,1例(1.67%)小肠结肠炎;术后3~12个月发生2例污粪,2例小肠结肠炎。患者经药物、扩肛、抗炎输液等治疗均明显好转,逐渐恢复正常的排便频率,每日1~3次,平均排便频率(2.36±0.05)次。结论:腹腔镜结合肛门外离断术治疗先天性巨结肠安全、有效,操作简便,并发症发生率低。     

三个月内婴儿巨结肠症腹腔镜Soave改良根治术探讨

目的:总结腹腔镜Soave改良根治术治疗3个月内婴儿巨结肠症的临床经验。方法:为45例巨结肠患儿施行腹腔镜Soave改良根治术并对术后发生并发症的21例进行分析。结果:45例均治愈出院,术后随访3个月至4年,患儿生长发育良好,食欲及大小便正常,无污粪。结论:腹腔镜下巨结肠Soave改良根治术对婴儿打击小,创伤轻,手术风险低,安全系数高,手术效果好。在腹腔镜辅助下可将巨结肠患儿的手术年龄提前至新生儿和小婴儿期,早期治愈有利于患儿身心健康及发育。     

Results of a mechanical Duhamel pull-through for the treatment of Hirschsprung's disease and intestinal neuronal dysplasia

Background/purpose

The authors analyzed the results of a modified entirely mechanical Duhamel pull-through for the treatment of Hirschsprung’ disease or type B intestinal neuronal dysplasia. The aim of the follow-up was to evaluate results of a Duhamel procedure entirely performed with the use of staplers.

Methods

Fifty-six patients were followed up to detect complications and outcome. Patients were evaluated clinically, and, when symptoms were present, a suction biopsy with histochemical analysis, an x-ray contrast enema, or an endoscopy was performed.

Results

Early complications developed in 4 cases (7%) including a case of leakage (1.8%). No patient experienced recurrence. During a mean follow-up of 49 months, further complications occurred in 16 other patients: 4 adhesive obstructions requiring surgery, 3 strictures, 5 chronic bleeding, 4 fecaloma formation, 2 urinary problems, and 13 postoperative enterocolitis.Four patients (7%) had more than 3 passages of liquid stools per day, and 3 of them who had an ileal pull-through had constant soiling. Thirty-seven children (68.5%) had 1 to 2 bowel movements per day and were continent. Seven (13%) had less than 3 bowel movements per week. Three children who underwent total colectomy were incontinent (5.5%). Three more children (5.5%) have not yet reached the age for continence. Forty-nine parents (87%) judged the outcome satisfactory.

Conclusions

Follow-up of mechanical Duhamel pull-through showed an acceptable long-term outcome. An increased risk of incontinence is present in case of ileal pull-through, whereas constipation is more frequent after partial colon resection, regardless of the type of intestinal neuronal malformation.     

Transanal versus open endorectal pull-through for Hirschsprung's disease

PURPOSE: Transanal endorectal resection and pull-through technique (TERPT) for Hirschsprung's disease (HD) was described in 1998. It offers the advantages of avoiding laparotomy, laparoscopy, scars, abdominal contamination, and adhesions. The authors compared TERPT with 2 open standard endorectal pull-through approaches. METHODS: Twenty-eight HD patients operated on by endorectal pull-through were compared in 3 groups. Group I had 10 patients with preliminary colostomy approached by laparotomy; group II, 8 by laparotomy; and group III, 10 patients treated by TERPT. Age, operating time and bleeding, complications, follow-up, and functional results were analyzed. Mean, standard deviation, and median were calculated. Groups were compared by 1-way analysis of variance (ANOVA) using the Kruskal-Wallis test. RESULTS: Age and length of follow-up were not statistically different (P = .12 and .07, respectively). Operating time and bleeding were less in group III (P = .03 for both). An intestinal obstruction secondary to adhesions and a subhepatic abscess occurred in group I and II, respectively. Minimal complications occurred in group III. Good functional results were obtained in 80% to 90% of the patients in all groups. CONCLUSION: TERPT minimizes blood loss in this study, was expeditious, uncomplicated, and as effective as the open standard techniques.