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.

Transanal endorectal pull-through in children with Hirschsprung's disease—technical refinements and comparison of results with the Duhamel procedure

Purpose

Transanal endorectal pull-through (TEPT) has drastically changed the treatment of Hirschsprung's disease (HD). A short follow-up of children submitted to TEPT reveals results that are similar to the classic transabdominal pull-through procedures. However, few reports compare the late results of TEPT with transabdominal pull-through procedures with respect to complication rates and the fecal continence. The aims of the present work are to describe some technical refinements that we introduced in the procedure and to compare the short and long-term outcome of TEPT with the outcomes of a group of patients with HD who previously underwent the Duhamel procedure.

Methods

Thirty-five patients who underwent TEPT were prospectively studied and compared to a group of 29 patients who were treated with colostomy followed by a classical Duhamel pull-through. The main modifications introduced in the TEPT group were no preoperative colon preparation, operation conducted under general anesthesia in addition to regional sacral anesthesia, use of only one purse-string suture in the rectal mucosa before transanal submucosal dissection, and no use of retractors and electrocautery during the submucosal dissection.

Results

The most frequent early complications of TEPT group were perineal dermatitis (22.8%) and anastomotic strictures (8.6%). The comparison with patients who underwent Duhamel procedure revealed no difference in the incidence of preoperative enterocolitis, the patients of the TEPT group were younger at the time of diagnosis and of surgery, they had shorter operating times, and they began oral feeding more quickly after the operation. The incidence of wound infection was lower in the TEPT group. Moreover, the TEPT and Duhamel groups showed no difference in the incidences of mortality, postoperative partial continence, and total incontinence. Although the incidences of complete continence and postoperative enterocolitis were not different, a tendency to the increased incidence in the TEPT group was observed.

Conclusions

This study further supports the technical advantages, the simplicity, and the decreased incidence of complications of a primary TEPT procedure when compared to a classical form of pull-through. Some technical refinements are described, and no preoperative colon preparation was necessary for the patients studied here. The results show that the long-term outcomes of the modified TEPT procedure are generally better than those obtained with classical approaches.     

Repeated pull-through surgery for complicated Hirschsprung's disease--principles derived from clinical experience

Background

In some patients, an initial pull-through procedure for Hirschsprung's disease fails, and obstructive symptoms persist or recur. Then a repeated pull-through operation may be necessary.

Methods

Seventeen patients with Hirschsprung's disease aged 2 to 9 years (median, 4.6 years) have undergone a repeated pull-through procedure because of unresponsive symptoms after an initial operation. The initial procedure was Soave in 3 patients, Rehbein in 13 patients, and Duhamel in 1 patient. Surgical revision was indicated by incomplete resection of the transition zone in 16 patients, anastomotic strictures in 9 patients, and fistulas in 2 patients. All 17 patients have undergone Redo Duhamel pull-through procedure. Median follow-up after Redo operation was 9 years (range, 1-23 years).

Results

In 15 patients, the stooling pattern normalized immediately after Redo procedure. Two, including 1 with Down's syndrome, are prone to constipation with occasional use of laxatives. Soiling is seen in the patient with Down's syndrome, but only with episodes of diarrhea. In spite of large formation of scars surrounding the neoanorectum in most patients, Duhamel pull-through reconstruction was possible in all children of this series.

Conclusions

The predominant cause for persistent or recurrent unresponsive obstructive symptoms after initial pull-through procedure is incomplete resection of the transition zone. Less frequently, anastomotic strictures, rigidity of the anorectal cuff, and fistulas cause obstruction. Preoperative workup must focus on these complications. The courses after initial pull-through procedure show that laxatives, Malone procedure, dilatations of the anorectum, myectomy, V-Y-plasty, and injections of botulinum toxin cannot eliminate the mechanical or functional obstruction. Although a large formation of scars in the pelvis resulting from the initial operation, myectomies, dilatations, and other surgical modalities render a Redo revision more difficult, Redo Duhamel pull-through procedure is able to provide the definitive solution to the problem.     

Comparison of Hirschsprung-associated enterocolitis following Soave and Duhamel procedures

Background

Hirschsprung-associated enterocolitis (HAEC) represents the primary cause of high morbidity and mortality in Hirschsprung disease (HSCR) patients. The most common surgical methods for HSCR are the Soave and Duhamel procedures. Therefore, we aimed to compare the HAEC frequency following the Soave and Duhamel procedures.

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。     

Laparoscopic Duhamel procedure

Background: Between February 1995 and June 1998, 30 laparoscopic Duhamel pull-through procedures were performed in our department. Methods: Our main aim was to prove the feasibility of the laparoscopic abdominal Duhamel procedure for different localizations of Hirschsprung disease. We used one camera port and three working ports. The sigmoid colon and posterior rectum were mobilized laparoscopically. A standard posterior colo-anal anastomosis was fashioned and a stapler was used for the anterior anastomosis. The top of the rectum was then closed by endo stapler under laparoscopic vision. Results: Thirty patients underwent laparoscopic surgery for this procedure. Three laparoscopic procedures were converted because of technical difficulties. The operative time was 100–330 mn. Oral feeding was started at a mean postoperative time of 2.5 days. Mean postoperative hospitalization was 9 days. Early postoperative complications included 1 anastomotic leak, 1 retrorectal abscess, 2 urinary infections, and 1 evisceration (after conversion). No enterocolitis or enterocolitis-like symptoms were noted. All patients now have daily spontaneous bowel movements. Conclusion: The laparoscopic Duhamel procedure can be performed safely, giving good results. Received: 6 November 1998/Accepted: 12 February 1999     

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.     

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.     

Duhamel procedure: a comparative retrospective study between an open and a laparoscopic technique

Background Few studies are available comparing open with laparoscopic treatment of Hirschsprung’s disease. This study compares a laparoscopic series of 30 patients with a historical open series of 25 patients. Methods The charts of all patients having had a Duhamel procedure in the period from June 1987 through July 2003 were retrospectively reviewed. Open procedures were performed until March 1994. Patients with extended aganglionosis, pre-Duhamel ostomy, or syndrome were excluded from the study. End points were intraoperative complications, postoperative complications, time to first feeding, hospital stay, and outcome at follow-up such as stenosis, enterocolitis, constipation, fecal incontinence, and enuresis. Results Twenty-five patients had an open Duhamel (OD) and 30 had a laparoscopic one (LD). There were no differences in patient characteristics and there were no intraoperative complications in either group. Time to first oral feeds was significantly longer in the OD group as was the duration of hospital stay. No significant differences at follow-up were observed but there was a tendency for a higher enterocolitis rate in the LD group. In contrast, the adhesive obstruction and enuresis rates were higher in the OD group. Cosmetic results were superior in the LD group. Conclusions Except for a significantly shorter hospital stay and shorter time to first oral feeds in favor of LD, no significant differences could be observed. The cosmetic result was not an end point but there was no doubt that it was better in the LD group. Although not statistically significant different, there were no adhesive bowel obstructions in the LD group compared with 3 of 25 in the OD group. Fecal incontinence was not encountered in either group.     

改良Duhamel术在先天性巨结肠中的应用

目的:探讨根治先天性巨结肠的最佳方法。方法:本组32例,钡灌肠诊断:常见型23例,长段型5例,短段型4例;男26例,女6例;年龄1岁～8岁,平均年龄4.5岁。均采用改良Duhamel术式行手术治疗。结果:32例均痊愈,无吻合口狭窄和吻合口漏等并发症。结论:应用改良Duhamel术式,既可根治先天性巨结肠,又可减少并发症发生,提高患儿生存质量。     

腹腔镜先天性巨结肠根治术

目的　介绍腹腔镜巨结肠根治术的初步经验。方法　从 2 0 0 0年 5月起行腹腔镜辅助下先天性巨结肠根治术 2 5例 ,年龄最小 2 3d ,最大 6岁 ,平均 1.5岁。全部病人采用气管插管静脉复合麻醉 ,于脐上Varess针穿刺 ,慢速注入CO2 形成气腹 ,压力在 1.3 3～ 1.86kPa ,后于同一点置入内径 5mm腹腔镜 ,分别于左右下腹置入两只内径 5mm的操作钳 ,对准备切除肠管段肠系膜血管进行处理 ,肛门部的操作为改良Soave’s法 ,于齿环线上 0 .5～ 1.0cm水平结肠与肛管全层缝合。结果　手术时间最长 2 10min ,最短 12 0min ,平均时间 165min ,术后第 3天开始进食 ,住院时间 7～ 9d ,全部病儿术后无近期并发症。结论　腹腔镜先天性巨结肠根治术安全 ,损伤小 ,值得推广应用     

Early adult outcome of the Duhamel procedure for left-sided Hirschsprung disease--a prospective serial assessment study

Purpose

To assess both early adult functional outcome and change in long-term functional outcome over time after the Duhamel procedure (DP) for left-sided Hirschsprung disease (HSCR).

Methods

The study population consisted of 78 children (aged 19.9 ± 3.6 years) who previously underwent objective outcome assessment after DP was performed for HSCR during the period of 1980 to 1991. Inclusion criteria were previous evaluation of functional outcome and either rectosigmoid or left-sided HSCR. Outcome measures were assessed twice within the cohort, in 1997 and in 2005. The primary outcome measure was the Rintala (J Ped Surg. 1995;30:491-494) functional outcome score (FOS; maximum, 20). Controls consisted of 20 age-matched healthy children. Satisfactory functional score was defined as an FOS at or above the 10th percentile of controls (FOS, ≥17). Secondary outcome measures were the operation failure rate (defined by requirement for a stoma or major reoperative surgery), and enterocolitis rates (defined by intention to treat). Consecutive outcome scores were compared by paired t test. Data were expressed as mean ± SD, and P < .05 was considered significant.

Results

Operation failure occurred in 9 (11.5%) of 78. Consecutive FOSs were obtained in 40 (57%) of 69. A satisfactory functional score was observed in 23 (58%) of 40 adults as opposed to 33 (47%) of 70 children 8 years previously (P = .02). Satisfactory outcome (defined by satisfactory functional score and lack of enterostomy or major revision pull-through procedure) was observed in 23 (47%) of 49. Previously, this figure was 34 (44%) of 78. Individual paired FOSs showed a significant improvement with time (1997: 14.9 ± 4.1; 2005: 16.4 ± 2.8; P = .02).

Conclusions

At early adult follow-up, the operation failure rate has not changed from that of the same cohort 8 years earlier. However, a significant improvement in individual FOSs was demonstrated.     

Experimental model for transanal endorectal pull-through surgery. Technique of De la Torre and Ortega

Background

We describe an experimental model for transanal endorectal pull-through surgery using the method of de la Torre and Ortega that can be used for training purposes in experimental laboratories.

Methods

Ten rabbits were submitted to the transanal endorectal pull-through technique of de la Torre and Ortega. Animals were randomly selected in the Botucatu School of Medicine experimental laboratory. Animals weighted between 2800 and 4400 g. Colons were not prepared, and antibiotic therapy was not used; dipyrone¹ was administered postoperatively for analgesic purposes. We standardized resected segment size, recorded surgical time, and observed survival and possible complications for 1 month.

Results

All animals survived the initial follow-up period without infection. Bowel movements returned quickly, and all animals were evacuating regularly within the first 24 hours. Mean surgical time was 48.6 minutes.

Conclusions

The experimental model proposed in this study is very useful for training and improving surgical techniques using the method of de la Torre and Ortega. The rabbit is an excellent animal for this surgery because of its size and postoperative resistance.     

Analysis of problems, complications, avoidance and management with transanal pull-through for Hirschsprung disease

Background

The primary aim of this study is to detail the problems, complications, their avoidance, and management with transanal pull-through developed from experience with 65 patients.

Methods

A retrospective study of 65 patients who underwent transanal pull-through between January 2002 and December 2006 was conducted. Their medical charts and operative notes were reviewed for problems encountered during surgery, postoperative period, and follow-up.

Results

In 46 patients, a primary transanal pull-through was performed, whereas in 19 with a prior colostomy, followed staged pull-through was done. The minimum follow-up was 6 months, with an average of 22 months after surgery (range, 6-47 months). Sixteen patients (25%) experienced at least 1 complication. These included inadvertent full-thickness mobilization of the rectum in 3 (4.6%), retraction and bleeding of colonic mesenteric vessels in 2 (3.7%), difficulty in mobilizing intraperitoneal colon in 1 (1.5%), and a false-positive frozen section in 2 patients (3%). Early postoperative complications occurred in 7 patients (11%), which included sphincter spasm in 3 (4.6%), anastomotic leak in 1 (1.5%), cuff abscess in 2 (3%), and enterocolitis in 1 (1.5%). Late postoperative complications in 46 patients (70%), occurring from 1 week till 3 months of follow-up included perianal excoriation in 22 (34%), increased stool frequency in 20 (31%), anal stenosis in 3 (4.6%), and enterocolitis in 2 patients (3%). Methodology is detailed for avoidance and management of problems and complications. Individual patient analysis, complications timing, and strategy for management are discussed.

Conclusion

Patient outcomes for transanal pull-through have improved significantly as a result of combination of experience and the ability to avoid and manage associated complications. Experience, avoidance, and interdiction are key factors in complication management.     

Laparoscopy-assisted transanal pull-through at the time of suction rectal biopsy: a new approach to treating selected cases of Hirschsprung disease

Aim

We present a new approach to treating selected cases of Hirschsprung disease (HD) where suction rectal biopsy (SRBx) is performed in an operating room, and rapid acetylcholinesterase staining (RAST) is used to identify histopathology within 20 minutes, allowing primary laparoscopy-assisted transanal pull-through (PLTPT) to be commenced “immediately” (n = 7).

Materials and Methods

All subjects had an obvious caliber change in the rectum/sigmoid colon on barium enema and were strongly suspected of having HD.

Results

Rapid acetylcholinesterase staining clearly demonstrated acetylcholinesterase-positive hypertrophic nerve trunks and absence of ganglion cells in all SRBx specimens, indicating that all 7 patients had HD. All 7 proceeded to uneventful PLTPT. By taking this approach, SRBx results were available extremely quickly, and hospital stay was reduced by 2 to 4 days.

Discussion

Our approach enhanced the treatment of selected cases of HD by proceeding immediately to PLTPT after SRBx specimens were examined using RAST.     

Laparoscopic-assisted Duhamel procedure with ex-anal rectal transection for total colonic aganglionosis

Purpose

Laparoscopic-assisted Duhamel procedure has a larger anastomosis and a reservoir which allows early recovery of defecation frequency, but concerns have been raised regarding the long operative time, high incidence of pouchitis and Hirschsprung associated enterocolitis (HAEC). The purpose of this study was to evaluate the postoperative complications and functional outcomes for patients with TCA undergoing modified laparoscopic-assisted Duhamel procedure (MLDP) with ex-abdominal partial colectomy and ex-anal rectal transection.

改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型先天性巨结肠症

目的探讨改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型先天性巨结肠症(Hirschsprung disease,HD)的并发症和疗效。方法回顾分析2010年3月~2014年1月12例长段型HD资料,男7例,女5例,中位年龄8月(5月~6岁)。其中移行区位于降结肠近端8例,横结肠2例,结肠肝曲1例,升结肠1例。7例行结肠造瘘。手术主要改良之处:经肛门齿状线上方直肠后壁切口将结肠拖出至肛门外,用Endo-GIA肛门外切断并封闭,保留直肠残端4~5 cm。然后结合Deloyer技术将升结肠拖下与原直肠后壁端侧吻合,再将Endo-GIA切缝器两肢分别放入原直肠和新直肠,切开两段肠管间隔并行侧侧吻合。观察术中术后并发症及排便功能。结果 12例均在腹腔镜辅助下完成次全结肠切除升结肠Duhamel拖出术,平均手术时间170 min(125~240 min),未出现术中并发症,无吻合口漏。4例诉肛周疼痛,1例术后5天便血,保守治疗治愈。大便频率2周以内4~15次/天,恢复到正常排便频率(1~2次/天)时间平均3.5月(2.2~5个月)。平均随访时间32个月(3~46个月),2例术后小肠结肠炎,1例早期有便秘症状,均保守治疗治愈。无闸门综合征和粪石发生,无大便失禁。结论改良腹腔镜辅助Duhamel结肠次全切除术治疗长段型HD安全有效,排便频率恢复正常快。肛门外处理直肠盲端简单可靠,腹壁创伤小。     

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.     

内括约肌部分切除在经肛门Soave巨结肠根治术中的应用

目的探讨内括约肌部分切除对经肛门Soave巨结肠根治手术疗效的影响。方法前瞻性人组2003-2012年间广东省东莞市人民医院收治的153例先天性巨结肠患儿,均予以经肛门Soave巨结肠根治术治疗。按简单单双号法将患儿分为部分切除组（77例）和单纯切开组（76例）,分别于术中进行内括约肌部分切除或仅单纯切开直肠后壁肌鞘。比较两组患儿术后并发症及排粪控制功能的差异。结果部分切除组患儿较单纯切开组术后直肠肌鞘内感染[1．3％（1／77）比11．8％（9／76）,P〈0．05]、小肠结肠炎[2．6％（2／77）比13．2％（10／76）,P〈0．05]、吻合口狭窄[3．9％（3／77）比22．4％（17／76）,P〈0．01]及腹胀[10．4％（8／77）比25．0％（19／76）,P〈0．05]的发生率均明显降低。两组术后1年排粪控制功能比较差异无统计学意义（Kelly评分：5．1±0．5比5．2±0．6,P〉0．05）。结论与单纯切开直肠后壁肌鞘相比,内括约肌部分切除能明显降低经肛门Soave巨结肠根治术后直肠肌鞘内感染、腹胀、吻合口狭窄和小肠结肠炎的发生率,同时并不会加重术后远期排粪控制功能的损害。