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Wang K, Xie C, Yan J, Chen Y. Total Transanal Endorectal Pull-through Versus Laparoscopic-Assisted Approach in Children with Rectosigmoid Hirschsprung's Disease: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2025; 35:80-88. [PMID: 38727572 DOI: 10.1089/lap.2023.0448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2025] Open
Abstract
Objective: To compare the clinical outcomes between total transanal endorectal pull-through (TTEPT) and laparoscopic-assisted transanal endorectal pull-through (LTEPT) in children with rectosigmoid Hirschsprung's disease. Methods: A retrospective study was conducted to compare patients with rectosigmoid Hirschsprung's disease who underwent TTEPT or LTEPT at Beijing Children's Hospital between January 2016 and June 2021. Clinical details were collected from medical records. Patients' parents completed the Krickenbeck questionnaire to evaluate the long-term bowel function (age >4 years) by telephone. A literature search was conducted by using the National Center for Biotechnology Information (NCBI) PubMed database. We combined data from our data with eligible articles and performed a meta-analysis. Result: From our data, there was no difference in the incidence of postoperative complications or long-term bowel function between the patients undergoing TTEPT and LTEPT. A meta-analysis, including five published articles and our data, was performed with a total of 414 patients (n = 236 with TTEPT and n = 178 with LTEPT). For postoperative complications, there were no significant differences between TTEPT and LTEPT for the incidence of HAEC (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.45-1.80; P = .77) or anastomotic leak (OR, 2.52; 95% CI, 0.40-15.80; P = .32). Regarding bowel function outcomes, the incidence of soiling (OR, 1.77; 95% CI, 0.84-3.71; P = .13) and constipation (OR, 1.20; 95% CI, 0.54-2.64; P = .66) were also similar for the two approaches. Conclusion: There was no significant difference in postoperative complications and bowel functional outcomes in patients with rectosigmoid HD undergoing TTEPT or LTEPT. Levels of Evidence: III.
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Affiliation(s)
- Kexin Wang
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Chuanping Xie
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jiayu Yan
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yajun Chen
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Xu TO, Levitt MA, Feng C. Controversies in Hirschsprung surgery. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000887. [PMID: 39346552 PMCID: PMC11429006 DOI: 10.1136/wjps-2024-000887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 07/31/2024] [Indexed: 10/01/2024] Open
Abstract
The treatment of Hirschsprung disease (HSCR) is surgical resection of aganglionic bowel and subsequent pull-through of ganglionated bowel. Despite many advances since the initial description of the disease and its surgical management more than half a century ago, there remain considerable controversies regarding the history of the surgical technique, the optimal timing of the primary and multistage pull-through, the best treatment for patients with a delayed diagnosis of HSCR, and the management of post pull-through complications such as soiling due to sphincter incompetence, the presence of a transition zone, and the prevention of enterocolitis. The following review will explore each of these controversies.
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Affiliation(s)
- Thomas O Xu
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, USA
| | - Christina Feng
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, USA
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Noviello C, Romano M, Trotta L, Umano GR, Papparella A. Are the complications after laparo-assisted endo-rectal pull-through for Hirschsprung disease related to the change of the anal tone? LA PEDIATRIA MEDICA E CHIRURGICA 2024; 46. [PMID: 38963345 DOI: 10.4081/pmc.2024.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/09/2024] [Indexed: 07/05/2024] Open
Abstract
The main advantage of the laparo-assisted transanal endorectal pull-through technique (LA - TERPT) for Hirschsprung Disease (HD) is the respect to the rectal-anal anatomy. Postoperative complications have been observed recently. The present study aims to determine how often these postoperative complications occur in these patients. From January 2009 to December 2018, a retrospective analysis was conducted on 36 children (25 males) with HD who underwent LA-TERPT. Data were collected on the age of diagnosis and surgery, sex, the presence of other pathologies, and cases of enterocolitis. In all cases, anorectal manometry (ARM) was performed to evaluate the anal tone. The median age at diagnosis was 2 months and the mean age at surgery was 5 months. Nine related pathologies were identified: five cases of Down syndrome, one case of hypertrophic stenosis of the pylorus, atresia of the esophagus, polydactyly, and anorectal malformation. A patient with total colonic aganglionosis was identified through laparoscopic serummuscular biopsies. Enterocolitis was diagnosed in 7 cases before and 6 after surgery. At follow-up, the complications recorded were: 5 cases of constipation (treated with fecal softeners), one case of anal stenosis (patient with anorectal malformation), 16 cases of soiling (treated with enemas) and 1 child with fecal incontinence (treated with a transanal irrigation system). The ARM was performed in all 36 cases and showed normal anal tone, except for one case with anal hypotonia. LA-TERPT is an important surgical technique for HD. According to the literature, soiling is the most main complication after HD surgery, probably due to "pseudo-incontinence" with normal anal sphincter tone.
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Affiliation(s)
- Carmine Noviello
- Pediatric Surgery Unit, Department of Woman, Child, General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples.
| | - Mercedes Romano
- Pediatric Surgery Unit, Department of Woman, Child, General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples.
| | - Letizia Trotta
- Pediatric Surgery Unit, Department of Woman, Child, General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples.
| | - Giuseppina Rosaria Umano
- Pediatric Unit, Department of Woman, Child, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples.
| | - Alfonso Papparella
- Pediatric Surgery Unit, Department of Woman, Child, General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples.
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Sun D, Zhang X, Xu Q, Li Y, Zhang Q, Wang D, Mu W, Hou P, Li A. Duhamel and transanal endorectal pull-throughs for Hirschsprung disease: a Bayesian network meta-analysis. BMC Surg 2024; 24:132. [PMID: 38702697 PMCID: PMC11067296 DOI: 10.1186/s12893-024-02416-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 04/17/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND To comprehensively compare the effects of open Duhamel (OD), laparoscopic-assisted Duhamel (LD), transanal endorectal pull-through (TEPT), and laparoscopic-assisted endorectal pull-through (LEPT) in Hirschsprung disease. METHODS PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, and VIP were comprehensively searched up to August 4, 2022. The outcomes were operation-related indicators and complication-related indicators. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence. Network plots, forest plots, league tables and rank probabilities were drawn for all outcomes. For measurement data, weighted mean differences (WMDs) and 95% credibility intervals (CrIs) were reported; for enumeration data, relative risks (RRs) and 95%CrIs were calculated. RESULTS Sixty-two studies of 4781 patients were included, with 2039 TEPT patients, 1669 LEPT patients, 951 OD patients and 122 LD patients. Intraoperative blood loss in the OD group was more than that in the LEPT group (pooled WMD = 44.00, 95%CrI: 27.33, 60.94). Patients lost more blood during TEPT versus LEPT (pooled WMD = 13.08, 95%CrI: 1.80, 24.30). In terms of intraoperative blood loss, LEPT was most likely to be the optimal procedure (79.76%). Patients undergoing OD had significantly longer gastrointestinal function recovery time, as compared with those undergoing LEPT (pooled WMD = 30.39, 95%CrI: 16.08, 44.94). The TEPT group had significantly longer gastrointestinal function recovery time than the LEPT group (pooled WMD = 11.49, 95%CrI: 0.96, 22.05). LEPT was most likely to be the best operation regarding gastrointestinal function recovery time (98.28%). Longer hospital stay was observed in patients with OD versus LEPT (pooled WMD = 5.24, 95%CrI: 2.98, 7.47). Hospital stay in the TEPT group was significantly longer than that in the LEPT group (pooled WMD = 1.99, 95%CrI: 0.37, 3.58). LEPT had the highest possibility to be the most effective operation with respect to hospital stay. The significantly reduced incidence of complications was found in the LEPT group versus the LD group (pooled RR = 0.24, 95%CrI: 0.12, 0.48). Compared with LEPT, OD was associated with a significantly increased incidence of complications (pooled RR = 5.10, 95%CrI: 3.48, 7.45). Patients undergoing TEPT had a significantly greater incidence of complications than those undergoing LEPT (pooled RR = 1.98, 95%CrI: 1.63, 2.42). For complications, LEPT is most likely to have the best effect (99.99%). Compared with the LEPT group, the OD group had a significantly increased incidence of anastomotic leakage (pooled RR = 5.35, 95%CrI: 1.45, 27.68). LEPT had the highest likelihood to be the best operation regarding anastomotic leakage (63.57%). The incidence of infection in the OD group was significantly higher than that in the LEPT group (pooled RR = 4.52, 95%CrI: 2.45, 8.84). The TEPT group had a significantly increased incidence of infection than the LEPT group (pooled RR = 1.87, 95%CrI: 1.13, 3.18). LEPT is most likely to be the best operation concerning infection (66.32%). Compared with LEPT, OD was associated with a significantly higher incidence of soiling (pooled RR = 1.91, 95%CrI: 1.16, 3.17). Patients with LEPT had the greatest likelihood not to develop soiling (86.16%). In contrast to LD, LEPT was significantly more effective in reducing the incidence of constipation (pooled RR = 0.39, 95%CrI: 0.15, 0.97). LEPT was most likely not to result in constipation (97.81%). LEPT was associated with a significantly lower incidence of Hirschprung-associated enterocolitis (HAEC) than LD (pooled RR = 0.34, 95%CrI: 0.13, 0.85). The OD group had a significantly higher incidence of HAEC than the LEPT group (pooled RR = 2.29, 95%CrI: 1.31, 4.0). The incidence of HAEC was significantly greater in the TEPT group versus the LEPT group (pooled RR = 1.74, 95%CrI: 1.24, 2.45). LEPT was most likely to be the optimal operation in terms of HAEC (98.76%). CONCLUSION LEPT may be a superior operation to OD, LD and TEPT in improving operation condition and complications, which might serve as a reference for Hirschsprung disease treatment.
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Affiliation(s)
- Dong Sun
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Xintao Zhang
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Qiongqian Xu
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Yang Li
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Qiangye Zhang
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Dongming Wang
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Weijing Mu
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Peimin Hou
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Aiwu Li
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China.
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Rossi D, Löf Granström A, Teunissen NM, Wijnen RMH, Wester T, Sloots CEJ. Bridging the Gap: A Systematic Review on Reporting Baseline Characteristics, Process, and Outcome Parameters in Rectosigmoid Hirschsprung's Disease. Eur J Pediatr Surg 2024; 34:189-198. [PMID: 37884061 DOI: 10.1055/a-2198-9050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
The variation in standardized, well-defined parameters in Hirschsprung's disease (HSCR) research hinders overarching comparisons and complicates evaluations of care quality across healthcare settings. This review addresses the significant variability observed in these parameters as reported in recent publications. The goal is to compile a list of commonly described baseline characteristics, process and outcome measures, and to investigate disparities in their utilization and definitions. A systematic review of literature on the primary care process for HSCR was performed according to PRISMA guidelines. Relevant literature published between 2015 and 2021 was obtained by combining the search term "Hirschsprung's disease" with "treatment outcome," "complications," "mortality," "morbidity," and "survival" in Medline, Embase, and the Cochrane Library. We extracted study characteristics, reported process and outcome parameters, and patient and disease characteristics. We extracted 1,026 parameters from 200 publications and categorized these into patient characteristics (n = 226), treatment and care process characteristics (n = 199), and outcomes (n = 601). A total of 116 parameters were reported in more than 5% of publications. The most frequently reported characteristics were sex (88%), age at the time of surgery (66%), postoperative Hirschsprung-associated enterocolitis (64%), type of repair (57%), fecal incontinence (54%), and extent of aganglionosis (51%). This review underscores the pronounced variation in reported parameters within HSCR studies, highlighting the necessity for consistent, well-defined measures and reporting systems to foster improved data interpretability. Moreover, it advocates for the use of these findings in the development of a Core Indicator Set, complementing the recently developed Core Outcome Set. This will facilitate quality assessments across pediatric surgical centers throughout Europe.
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Affiliation(s)
- Daniel Rossi
- Department of Pediatric Surgery, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Scientific Bureau, Dutch Institute for Clinical Auditing (DICA), Leiden, The Netherlands
| | - Anna Löf Granström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Nadine M Teunissen
- Department of Pediatric Surgery, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
- Scientific Bureau, Dutch Institute for Clinical Auditing (DICA), Leiden, The Netherlands
| | - René M H Wijnen
- Department of Pediatric Surgery, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Tomas Wester
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
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Zhang MX, Zhang X, Chang XP, Zeng JX, Bian HQ, Cao GQ, Li S, Chi SQ, Zhou Y, Rong LY, Wan L, Tang ST. Robotic-assisted proctosigmoidectomy for Hirschsprung’s disease: A multicenter prospective study. World J Gastroenterol 2023; 29:3715-3732. [PMID: 37398887 PMCID: PMC10311611 DOI: 10.3748/wjg.v29.i23.3715] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/29/2023] [Accepted: 05/22/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Robotic surgery is a cutting-edge minimally invasive technique that overcomes many shortcomings of laparoscopic techniques, yet few studies have evaluated the use of robotic surgery to treat Hirschsprung’s disease (HSCR).
AIM To analyze the feasibility and medium-term outcomes of robotic-assisted proctosigmoidectomy (RAPS) with sphincter- and nerve-sparing surgery in HSCR patients.
METHODS From July 2015 to January 2022, 156 rectosigmoid HSCR patients were enrolled in this multicenter prospective study. Their sphincters and nerves were spared by dissecting the rectum completely from the pelvic cavity outside the longitudinal muscle of the rectum and then performing transanal Soave pull-through procedures. Surgical outcomes and continence function were analyzed.
RESULTS No conversions or intraoperative complications occurred. The median age at surgery was 9.50 months, and the length of the removed bowel was 15.50 ± 5.23 cm. The total operation time, console time, and anal traction time were 155.22 ± 16.77, 58.01 ± 7.71, and 45.28 ± 8.15 min. There were 25 complications within 30 d and 48 post-30-d complications. For children aged ≥ 4 years, the bowel function score (BFS) was 17.32 ± 2.63, and 90.91% of patients showed moderate-to-good bowel function. The postoperative fecal continence (POFC) score was 10.95 ± 1.04 at 4 years of age, 11.48 ± 0.72 at 5 years of age, and 11.94 ± 0.81 at 6 years of age, showing a promising annual trend. There were no significant differences in postoperative complications, BFS, and POFC scores related to age at surgery being ≤ 3 mo or > 3 mo.
CONCLUSION RAPS is a safe and effective alternative for treating HSCR in children of all ages; it offers the advantage of further minimizing damage to sphincters and perirectal nerves and thus providing better continence function.
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Affiliation(s)
- Meng-Xin Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xi Zhang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xiao-Pan Chang
- Department of Pediatric Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, Guangdong Province, China
| | - Ji-Xiao Zeng
- Department of Pediatric Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, Guangdong Province, China
| | - Hong-Qiang Bian
- Department of General Surgery, Wuhan Children’s Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430019, Hubei Province, China
| | - Guo-Qing Cao
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Shuai Li
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Shui-Qing Chi
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Ying Zhou
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Li-Ying Rong
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Li Wan
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Shao-Tao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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Transanal endorectal or transabdominal pull-through for Hirschsprung's disease; which is better? A systematic review and meta-analysis. Pediatr Surg Int 2023; 39:89. [PMID: 36692536 DOI: 10.1007/s00383-023-05378-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/25/2023]
Abstract
AIM Hesitations concerning the long-term results of transanal endorectal pull-through (TEPT) due to prolonged anal stretching and resultant stricture and continence problems has been started to be questioned. This meta-analysis intended to compare long-term results between TEPT and transabdominal (TAB) pull-through techniques in the surgical management of Hirschsprung's disease. METHODS All publications between the years 1998-2021 in the PubMed, Medline, Google Scholar, Cochrane databases were reviewed. Retrospective and prospective comparative studies for TEPT, TAB as well as Laparoscopic-assisted TEPT (LTEPT) were included. Data included age at operation, postoperative constipation, enterocolitis, incontinence, stricture, and soiling rates. RESULTS Eighteen publications met the inclusion criteria for TAB and TEPT, and six for TEPT and LTEPT. Patients who underwent TEPT had significantly younger operation age than patients with TAB (SMD - 1.02, 95%Cl - 1.85 to - 0.18, p: 0.0168). Postoperative constipation (OR 0.39, 95% Cl 0.25-0.61 p < 0.0001) and enterocolitis (OR 0.65, 95% Cl 0.46-0.90, p: 0.0108) rates were significantly lower in TEPT groups. Postoperative incontinence (OR 1.06, 95% Cl 0.56-2.01, p: 0.8468), stricture (OR 1.97, 95% Cl 0.81-4.80, p: 0.1352) and soiling rates were similar between the two groups. Furthermore, when TEPT and LTEPT results were compared, incidence of incontinence (OR 7.01, 95% Cl 0.75-65.33, p: 0.0871), constipation (OR 1.95, 95% Cl 0.70-5.37, p: 0.199), enterocolitis (OR 3.16, 95% Cl 0.34-29.55 p: 0.3137), stricture (OR 1.33, 95% Cl 0.29-6.15, p: 0.7188) and soiling (OR 1.57, 95% Cl 0.57-4.31, p: 0.3778) were similar for both techniques. DISCUSSION TEPT is superior to TAB in terms of constipation and enterocolitis. Contrary to concerns, postoperative incontinence rates are not statistically different. However, further publications about long-term LTEPT results are necessary for more reliable conclusions.
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Gabr AA, Shalaby A, Elham Fares A, Hussein Bahaaeldin K, Nabhan Kaddah S, El Tagy G, Ahmed Gad M. Medium-term outcomes of antegrade continent enema (ACE): Cairo University Specialized Pediatric Hospital (CUSPH) experience. J Pediatr Surg 2022:S0022-3468(22)00769-2. [PMID: 36628693 DOI: 10.1016/j.jpedsurg.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/29/2022] [Accepted: 11/26/2022] [Indexed: 12/12/2022]
Abstract
AIM OF THE STUDY To assess the medium-term outcomes of ACE in children with fecal incontinence (FI). METHOD Eligible children were recruited from the colorectal clinic between December 2016 and January 2020 and were followed prospectively for 2-6 years. A series of questionnaires were used to assess QOL, patients and parent satisfaction, and to assess the outcomes of the ACE. RESULT 24 children aged 6-12 years (mean age 8.17 ± 1.95), including 18 males (75%) and 6 females (25% were studied. Cases included anorectal malformations (45.83%)., Hirschsprung disease (25%), neural tube defects (16.66%), sacrococcygeal teratoma (4.16%), and intractable pseudoincontinence (8.33%). QOL improved from (3) [3 -3] to (16) [16-16],p < 0.05. Fecal incontinence index showed significant improvement: 20 [20-20] versus 3 [0-4],p < 0.05. Bowel symptoms demonstrated improvement in the ability to decide when to pass stools and a decrease in soiling. Stooling survey showed lower scores representing better outcome. ACE questionnaire showed that the range of irrigation volumes used by parents is wide, and that all families recommend the ACE for children with similar condition. Postoperative complications were stenosis (16.66%), stomal prolapse (12.5%), leakage (4.16%), and false passage (4.16%). Satisfaction questionnaire showed a median score of 9 (range, 5-10). CONCLUSION ACE is an effective method to keep the child with FI clean, more socially active, and with a better QOL and FII in the medium-term. The reported complications were stenosis, false passage, and leakage. ACE mucosa prolapse is a novel complication picked up on medium-term follow up.
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Affiliation(s)
- Ahmed Adel Gabr
- Cairo University Specialized Pediatric Hospital, Cairo, Egypt.
| | - Aly Shalaby
- Cairo University Specialized Pediatric Hospital, Cairo, Egypt.
| | | | | | | | - Gamal El Tagy
- Cairo University Specialized Pediatric Hospital, Cairo, Egypt.
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9
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Evans-Barns HME, Swannjo JB, Trajanovska M, Safe M, Hutson JM, Dinning PG, King SK. Post-operative anorectal manometry in children with Hirschsprung disease: A systematic review. Neurogastroenterol Motil 2022; 34:e14311. [PMID: 34964199 DOI: 10.1111/nmo.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/30/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hirschsprung disease is commonly encountered by pediatric surgeons. Despite advances in the surgical management, these children may experience symptoms of bowel dysfunction throughout adulthood. Anorectal manometry may be used to assess post-operative anorectal structure and function. This review aimed to consolidate and evaluate the literature pertaining to post-operative findings of anorectal manometry in children with Hirschsprung disease. PURPOSE (1) Synthesize the available data regarding anorectal motility patterns in children following repair of Hirschsprung disease. (2) Evaluate the reported anorectal manometry protocols. DATA SOURCES We performed a systematic review of four databases: Embase, MEDLINE, the Cochrane Library, and PubMed. STUDY SELECTION This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies reporting results of post-operative anorectal manometry in children with Hirschsprung disease were evaluated for inclusion. RESULTS Twenty-three studies satisfied inclusion criteria, with a combined cohort of 939 patients. Post-operative anorectal manometry results were reported for 682 children. The majority of included studies were assessed as "poor quality." Disparate manometry protocols, heterogeneous cohorts, and lack of standardized outcome assessments introduced a risk of outcome reporting bias, limited the comparability of results, and impeded clinical translation of findings. CONCLUSIONS This systematic review demonstrated the lack of high-quality evidence underlying the current understanding of post-operative anorectal motility in children with HD. There was little consistency in reported manometry outcomes between studies. In future work, emphasis must be placed on the application of standardized manometry protocols, cohort reporting, and patient outcome assessments.
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Affiliation(s)
- Hannah M E Evans-Barns
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Justina B Swannjo
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Misel Trajanovska
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Mark Safe
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - John M Hutson
- Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Urology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Phil G Dinning
- Department of Surgery, College of Medicine and Public Health, The Flinders University and Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Sebastian K King
- Department of Paediatric Surgery, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Surgical Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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10
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Arnaud AP, Cousin I, Schmitt F, Petit T, Parmentier B, Levard G, Podevin G, Guinot A, DeNapoli S, Hervieux E, Flaum V, De Vries P, Randuineau G, David-Le Gall S, Buffet-Bataillon S, Boudry G. Different Fecal Microbiota in Hirschsprung's Patients With and Without Associated Enterocolitis. Front Microbiol 2022; 13:904758. [PMID: 35847080 PMCID: PMC9279138 DOI: 10.3389/fmicb.2022.904758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives Patients with Hirschsprung's disease are at risk of developing Hirschsprung-associated enterocolitis, especially in the first 2 years of life. The pathophysiology of this inflammatory disease remains unclear, and intestinal dysbiosis has been proposed in the last decade. The primary objective of this study was to evaluate in a large cohort if Hirschsprung-associated enterocolitis was associated with alterations of fecal bacterial composition compared with HD without enterocolitis in different age groups. Methods We analyzed the fecal microbiota structure of 103 Hirschsprung patients from 3 months to 16 years of age, all of whom had completed definitive surgery for rectosigmoid Hirschsprung. 16S rRNA gene sequencing allowed us to compare the microbiota composition between Hirschsprung's disease patients with (HAEC group) or without enterocolitis (HD group) in different age groups (0-2, 2-6, 6-12, and 12-16 years). Results Richness and diversity increased with age group but did not differ between HD and HAEC patients, irrespective of the age group. Relative abundance of Actinobacteria was lower in HAEC than in HD patients under 2 years of age (-66%, P = 0.045). Multivariate analysis by linear models (MaAsLin) considering sex, medications, birth mode, breast-feeding, and the Bristol stool scale, as well as surgery parameters, highlighted Flavonifractor plautii and Eggerthella lenta, as well as Ruminococcus gnavus group, as positively associated with Hirschsprung-associated enterocolitis in the 0-2 years age group. Conclusion Hirschsprung-associated enterocolitis was associated with features of intestinal dysbiosis in infants (0-2 years) but not in older patients. This could explain the highest rate of enterocolitis in this age group. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT02857205, MICROPRUNG, NCT02857205, 02/08/2016.
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Affiliation(s)
- Alexis P Arnaud
- Institut NuMeCan, INRAE, INSERM, Univ Rennes, Rennes-Saint-Gilles, France.,Department of Pediatric Surgery, CHU Rennes, Univ Rennes, Rennes, France
| | - Ianis Cousin
- Department of Pediatric Surgery, CHU Brest, Brest, France
| | | | - Thierry Petit
- Department of Pediatric Surgery, CHU Caen, Caen, France
| | | | | | | | - Audrey Guinot
- Department of Pediatric Surgery, CHU Nantes, Nantes, France
| | | | - Erik Hervieux
- Department of Pediatric Surgery, CHU Trousseau, APHP, Paris, France
| | - Valérie Flaum
- Department of Pediatric Surgery, CHU Trousseau, APHP, Paris, France
| | | | | | | | - Sylvie Buffet-Bataillon
- Institut NuMeCan, INRAE, INSERM, Univ Rennes, Rennes-Saint-Gilles, France.,Department of Infection Control and Prevention, CHU Rennes, Univ Rennes, Rennes, France
| | - Gaëlle Boudry
- Institut NuMeCan, INRAE, INSERM, Univ Rennes, Rennes-Saint-Gilles, France
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11
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Metzger U, Michel AJ, Ardelean MA, Metzger RP. Transanal Endoscopic-Assisted Pull-Through Colectomy for Children with High Intestinal Aganglionosis. CHILDREN 2022; 9:children9050588. [PMID: 35626766 PMCID: PMC9139831 DOI: 10.3390/children9050588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/28/2022] [Accepted: 03/31/2022] [Indexed: 11/23/2022]
Abstract
Intestinal aganglionosis in children is a common cause of neonatal and infantile obstruction or ileus. Diagnosis is based on a histologically proven absence of enteric ganglion cells in deep biopsies of the gut wall. Therapeutic goal is a one-stage repair with a resection of the affected segment. The endorectal pull-through (ERP) can be performed entirely transanally in a lot of the cases. In patients with difficult preparation or a high aganglionosis ERP often needs to be assisted by laparoscopy or laparotomy. We present two cases with a technical modification performing a totally transanal pull-through colectomy without any trocars other than an umbilical camera trocar. The procedure starts with a classical endorectal technique. Usually, the transanal preparation is limited by reaching the colon descendens. A camera trocar is inserted and under laparoscopic vision the preparation is completed placing the instruments directly via the opened anus. After reaching the healthy colon segment, the pull-through is completed transanally. One of the main advantages of ERP is the sparing dissection. Our modification combines advantages of laparoscopy and ERP. The umbilical camera allows an excellent view while the instruments for dissection are used like with ERP without any further trocar or traction of the anal sphincter. The dispensation of any transanal trocar allows a higher grade of freedom in preparation and possibly a smaller trauma on the distal anal channel.
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12
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Kim SH, Cho YH, Kim HY. Assessment of defecation function beyond infantile period for transanal single-stage endorectal pull-through in Hirschsprung disease. Ann Surg Treat Res 2021; 101:231-239. [PMID: 34692595 PMCID: PMC8506020 DOI: 10.4174/astr.2021.101.4.231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/20/2021] [Accepted: 08/19/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose Transanal single-stage endorectal pull-through (TERPT) procedure for patients with Hirschsprung disease (HD) has favorable outcomes, with a lower complication rate. Nevertheless, various degrees of bowel dysfunction and fecal incontinence can persist for a long time in some patients. The aim of this study was to assess the mid- and long-term outcomes of TERPT performed during the infantile period after the completion of toilet training. Methods We retrospectively reviewed 82 patients aged ≥4 years who underwent TERPT during the infantile period after the pathological diagnosis of HD between 2001 and 2013. Functional outcomes were investigated according to the answers of the Bowel Function Score (BFS) questionnaire, a previously validated 7-item questionnaire about bowel habits. Normal values were obtained in a previous study on BFS for children in Western countries, and a one-sample t-test was used for statistical analysis. Results Overall, BFS was similar in all investigated age groups. On comparing fecal soiling and social problems between the HD and normal populations, a lower score at an early age in patients with HD was noted; however, the scores became similar when the patients were 7 years of age. Stool frequency decreased continuously but was not significantly different between the 2 groups. Conclusion The functional outcomes of TERPT performed during the infantile period, after completing toilet training, were similar to that of the normal population. In most cases, uncomfortable symptoms were diminished and functions improved with age.
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Affiliation(s)
- Soo-Hong Kim
- Division of Pediatric Surgery, Department of Surgery, Pusan National University Yangsan Hospital and Pusan National University Children's Hospital, Yangsan, Korea
| | - Yong-Hoon Cho
- Division of Pediatric Surgery, Department of Surgery, Pusan National University Yangsan Hospital and Pusan National University Children's Hospital, Yangsan, Korea
| | - Hae-Young Kim
- Division of Pediatric Surgery, Department of Surgery, Pusan National University Hospital, Busan, Korea
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13
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Saad SA, Elseed MMG, AbouZeid AA, Ibrahim EA, Radwan AB, Hay SA, El-Behery MM. Histopathological perspective of the pulled-through colon in Hirschsprung disease: Impact on clinical outcome. J Pediatr Surg 2020; 55:1829-1833. [PMID: 32037218 DOI: 10.1016/j.jpedsurg.2020.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 12/16/2019] [Accepted: 01/09/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The outcome in HD has not been always satisfactory even after a technically sound operation. PURPOSE To define the characteristic histopathological features of the pulled-through colon in patients with HD, and it is impact on clinical outcome. PATIENTS AND METHODS The study included patients with HD who underwent surgical repair between 2010 through 2016. The proximal margin of resected bowel segments (which corresponds to the pulled through colon) was subjected to detailed histopathological examination by two experienced pathologists. Based on the frequency of postoperative attacks of HAEC (fever, vomiting, abdominal distention, fluid offensive stools), cases included in the study were divided into two groups: Group A, those with less frequent attacks of HAEC; and Group B, those with recurrent attacks of HAEC (more than 3). RESULTS The study included 35 patients (25 in group A; and 10 in group B). Their age ranged from 0.2 to 144 months (median 6 months). Comparing the histopathological findings in the two clinical groups, we have found that Group B (recurrent attacks of HAEC) had significantly more frequent focal disarray of nerve bundles and thicker nerve bundle diameter. Also, histopathological features of acute inflammation were more prevalent in examined specimens from group B. CONCLUSION Several histopathological features of the examined bowel specimens in HD, other than presence or absence of ganglion cells, are indicative of postoperative functional outcome. These include the thickness and maturity of nerve bundles, in addition to the presence of histopathological features of acute inflammation. LEVEL OF EVIDENCE This is a case control study (level III evidence).
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Affiliation(s)
- Somaia Ahmed Saad
- Department of Pathology, Faculty of medicine, Ain Shams University, Egypt
| | | | | | | | | | - Sameh Abdel Hay
- Pediatric Surgery department, Faculty of medicine, Ain Shams University, Egypt
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14
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Kyrklund K, Sloots CEJ, de Blaauw I, Bjørnland K, Rolle U, Cavalieri D, Francalanci P, Fusaro F, Lemli A, Schwarzer N, Fascetti-Leon F, Thapar N, Johansen LS, Berrebi D, Hugot JP, Crétolle C, Brooks AS, Hofstra RM, Wester T, Pakarinen MP. ERNICA guidelines for the management of rectosigmoid Hirschsprung's disease. Orphanet J Rare Dis 2020; 15:164. [PMID: 32586397 PMCID: PMC7318734 DOI: 10.1186/s13023-020-01362-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/18/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hirschsprung's disease (HSCR) is a serious congenital bowel disorder with a prevalence of 1/5000. Currently, there is a lack of systematically developed guidelines to assist clinical decision-making regarding diagnostics and management. AIMS This guideline aims to cover the diagnostics and management of rectosigmoid HSCR up to adulthood. It aims to describe the preferred approach of ERNICA, the European Reference Network for rare inherited and congenital digestive disorders. METHODS Recommendations within key topics covering the care pathway for rectosigmoid HSCR were developed by an international workgroup of experts from 8 European countries within ERNICA European Reference Network from the disciplines of surgery, medicine, histopathology, microbiology, genetics, and patient organization representatives. Recommendation statements were based on a comprehensive review of the available literature and expert consensus. AGREE II and GRADE approaches were used during development. Evidence levels and levels of agreement are noted. RESULTS Thirty-three statements within 9 key areas were generated. Most recommendations were based on expert opinion. CONCLUSION In rare or low-prevalence diseases such as HSCR, there remains limited availability of high-quality clinical evidence. Consensus-based guidelines for care are presented.
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Affiliation(s)
- Kristiina Kyrklund
- Department of Pediatric Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ivo de Blaauw
- Department of Surgery, Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Kristin Bjørnland
- Department of Pediatric Surgery, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Udo Rolle
- Department of Pediatric Surgery and Pediatric Urology, University Hospital Frankfurt, Frankfurt/M, Germany
| | - Duccio Cavalieri
- Department of Biology, University of Florence, A.Mor.Hi, The Italian Association for Hirschsprung's disease, Florence, Italy
| | - Paola Francalanci
- Pathology Unit, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Fabio Fusaro
- Neonatal Surgery Unit - Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Annette Lemli
- SoMA, The German patient support organization for anorectal malformations and Hirschsprung Disease, Munich, Germany
| | - Nicole Schwarzer
- SoMA, The German patient support organization for anorectal malformations and Hirschsprung Disease, Munich, Germany
| | - Francesco Fascetti-Leon
- Pediatric Surgery, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health; Department of Pediatric Gastroenterology, Great Ormond Street Hospital for Children, London, UK
| | | | - Dominique Berrebi
- Department of Pediatric Pathology, Hôpital Universitaire Robert Debré, Paris Diderot University, Paris, France
| | - Jean-Pierre Hugot
- Department of Pediatric Gastroenterology, Hôpital Universitaire Robert Debré, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Célia Crétolle
- Department of Pediatric Surgery, University Hospital Necker-Enfants Malades, APHP centre, Paris University, Paris, France
| | - Alice S Brooks
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert M Hofstra
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Tomas Wester
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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15
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Meng X, Wang J, Zhu T, Zhuansun D, Feng J. Long-term outcomes of single-incision laparoscopic technique in Soave procedure compared with heart-shaped anastomosis for Hirschsprung disease. Int J Colorectal Dis 2020; 35:1049-1054. [PMID: 32172319 DOI: 10.1007/s00384-020-03565-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE This retrospective study compared the long-term outcomes of single-incision laparoscopy-assisted Soave procedure (SILSP) with single-incision laparoscopy-assisted heart-shaped anastomosis (SILHSA) in patients with Hirschsprung disease (HSCR). METHODS Patients diagnosed with HSCR that underwent SILSP or SILHSA between January 2009 and January 2015 at our institute were enrolled in this retrospective study. Data on the clinical characteristics, perioperative complications, and postoperative quality of life were retrospectively collected and analyzed. RESULTS There were 109 patients in the SILSP group and 95 patients in the SILHSA group. No differences in clinical characteristics, including age, weight, hospitalization length, blood loss volume, and operation time, were noted between the two groups. The incidence rates of constipation and soiling were lower in the SILHSA group than those in the SILSP group. The SILHSA group showed lower scores in constipation and soiling compared with the SILSP group, indicating a better surgical outcome for patients receiving SILHSA procedure. CONCLUSION SILHSA is a feasible and reliable minimally invasive surgical procedure for patients with HSCR. Patients who underwent SILHSA had lower incidence rates of constipation and soiling than patients who underwent SILSP, suggesting that SILHSA could be a better choice for patients with HSCR.
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Affiliation(s)
- Xinyao Meng
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Jing Wang
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Tianqi Zhu
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Didi Zhuansun
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China.
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16
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Iacusso C, Leonelli L, Valfrè L, Conforti A, Fusaro F, Iacobelli BD, Bozza P, Morini F, Mattioli G, Bagolan P. Minimally Invasive Techniques for Hirschsprung Disease. J Laparoendosc Adv Surg Tech A 2019; 29:1605-1608. [DOI: 10.1089/lap.2019.0165] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Chiara Iacusso
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lorenzo Leonelli
- Unit of Pediatric Surgery, Department of Surgery, G. Gaslini Institute, Genoa, Italy
| | - Laura Valfrè
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Conforti
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabio Fusaro
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Barbara Daniela Iacobelli
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Patrizia Bozza
- Unit of Anesthesiology, Department of Anesthesiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Morini
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Girolamo Mattioli
- Unit of Pediatric Surgery, Department of Surgery, G. Gaslini Institute, Genoa, Italy
| | - Pietro Bagolan
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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17
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Analysis of Outcomes After Surgical Correction for Hirschsprung’s Disease: Are the Long-Term Results of the Transanal and Transabdominal Pull-Through Operations Equally Satisfying for Children and Their Parents? Indian J Surg 2018. [DOI: 10.1007/s12262-017-1671-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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18
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Zheng Z, Zhang F, Jin Z, Gao M, Mao Y, Qu Y, Liu Y. Transanal endorectal stepwise gradient muscular cuff cutting pull-through method: Technique refinements and comparison with laparoscopy-assisted procedures. Exp Ther Med 2018; 16:2144-2151. [PMID: 30186452 DOI: 10.3892/etm.2018.6414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 06/08/2018] [Indexed: 12/26/2022] Open
Abstract
In all existing radical resection procedures available for Hirschprung's disease (HD), the muscular cuff has been retained. In recent years, our study group has modified the procedure using a stepwise gradient muscular cuff cutting pull-through method for the treatment of HD. The objective of the present study was to assess patient prognosis following the use of the transanal endorectal pull-through (TEPT) method or the laparoscopy-assisted pull-through (LPT) method and to provide evidence to assist in clinical decisions. The medical records of 172 patients (age, ≥3 years) who underwent TEPT or LPT for HD between September 2003 and August 2014 at the Pediatric Surgery Department of The Affiliated Hospital of Zunyi Medical College (Zunyi, China) were reviewed (TEPT, n=94; LPT, n=78). Preoperative, intraoperative and post-operative data for the subjects involved were recorded. Each patient's family was interviewed using a uniform 12-item post-pull-through long-term outcome questionnaire, which was scored in order to compare the short and long-term treatment outcomes of patients in each group. Patients in the LPT group had significantly prolonged operating times, reduced intraoperative blood loss and perioperative transfusion rates and shorter anal dissection times. Furthermore, the oral feeding time and length of hospital stay were similar between groups. There were no significant differences in early complications between the groups. No significant differences in late complications, including anastomotic stricture and enterocolitis were observed; however, the soiling and constipation rates were significantly higher in the TEPT group compared with the LPT group. The stool pattern score was not significantly different between groups, while the frequency of bowel movements in the LPT group was significantly higher compared with the TEPT group from 9-24 months post-surgery. The stepwise gradient muscular cuff cutting pull-through method demonstrated a good safety profile and efficacy with regard to the long-term outcomes of patients with HD. These results support the clinical application of LPT as a promising surgical approach for children with HD.
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Affiliation(s)
- Zebing Zheng
- Department of Pediatric General Thoracic and Urinary Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563000, P.R. China
| | - Fan Zhang
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563000, P.R. China
| | - Zhu Jin
- Department of Pediatric General Thoracic and Urinary Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563000, P.R. China
| | - Mingjuan Gao
- Department of Pediatric General Thoracic and Urinary Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563000, P.R. China
| | - Yuchen Mao
- Department of Pediatric General Thoracic and Urinary Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563000, P.R. China
| | - Yan Qu
- Department of Pediatric General Thoracic and Urinary Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563000, P.R. China
| | - Yuanmei Liu
- Department of Pediatric General Thoracic and Urinary Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou 563000, P.R. China
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19
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Huang WK, Li XL, Zhang J, Zhang SC. Prevalence, Risk Factors, and Prognosis of Postoperative Complications after Surgery for Hirschsprung Disease. J Gastrointest Surg 2018; 22:335-343. [PMID: 28956279 DOI: 10.1007/s11605-017-3596-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/18/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although most of patients do well after surgery for Hirschsprung disease (HSCR), there are complications in some instances that impact social aspects and quality of life. The aim of this study was to explore the prevalence, risk factors, and prognosis of these complications, providing guidance for surgeons and healthcare personnel. METHODS A cohort of patients (N = 229) was retrospectively reviewed in the aftermath of surgery for HSCR. All medical data and operative notes were assessed. Early and late postoperative complications were solicited by questionnaire, using logistic regression and the Cox proportional hazards regression model for analysis. RESULTS A total of 181 patients qualified for the study. Enterocolitis and soiling/incontinence constituted the most frequent complications, whether early or late in the postoperative period. Risk factors for developing enterocolitis included low weight, low-level IgA, preoperative enterocolitis, and lengthy aganglionic segment in the early term; whereas preoperative enterocolitis and diet control impacted complications emerging later. Risk factors in early soiling/incontinence were low weight, operative age of < 2 months, low IgA level, and lengthy aganglionic segment. Lengthy aganglionic segment, operative age of < 2 months, and toilet training were factors long-term. Prognostic factors included diet control and toilet training. CONCLUSION Enterocolitis and soiling/incontinence remain the most frequent complications after surgery for HSCR. Risk factors in early and late postoperative periods differed, with diet control and toilet training contributing favorably to enterocolitis and soiling/incontinence, respectively.
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Affiliation(s)
- Wen-Kai Huang
- Department of Pediatric Surgery, Major Laboratory of Chinese Health Ministry for Congenital Malformations, The Shengjing Hospital, China Medical University, 36 Sanhao Street Heping District, 110004, Shenyang, People's Republic of China
| | - Xue-Li Li
- Department of Pediatric Surgery, Major Laboratory of Chinese Health Ministry for Congenital Malformations, The Shengjing Hospital, China Medical University, 36 Sanhao Street Heping District, 110004, Shenyang, People's Republic of China
| | - Jin Zhang
- Department of Pediatric Surgery, Major Laboratory of Chinese Health Ministry for Congenital Malformations, The Shengjing Hospital, China Medical University, 36 Sanhao Street Heping District, 110004, Shenyang, People's Republic of China
| | - Shu-Cheng Zhang
- Department of Pediatric Surgery, Major Laboratory of Chinese Health Ministry for Congenital Malformations, The Shengjing Hospital, China Medical University, 36 Sanhao Street Heping District, 110004, Shenyang, People's Republic of China.
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20
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Bjørnland K, Pakarinen MP, Stenstrøm P, Stensrud KJ, Neuvonen M, Granström AL, Graneli C, Pripp AH, Arnbjörnsson E, Emblem R, Wester T, Rintala RJ. A Nordic multicenter survey of long-term bowel function after transanal endorectal pull-through in 200 patients with rectosigmoid Hirschsprung disease. J Pediatr Surg 2017; 52:1458-1464. [PMID: 28094015 DOI: 10.1016/j.jpedsurg.2017.01.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/07/2016] [Accepted: 01/03/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Transanal endorectal pull-through (ERPT) is the most popular technique to treat Hirschsprung disease (HD). Still, there is limited knowledge on long-term bowel function. This cross-sectional, multicenter study assessed long-term bowel function in a large HD population and examined predictors of poor outcome. METHODS Patients older than four years or their parents filled out a validated questionnaire on bowel function. Clinical details were recorded retrospectively from medical records. RESULTS 73/200 (37%) patients reported absolutely no impaired bowel function, meaning no constipation, fecal accidents, stoma, appendicostomy or need for enemas. Seven (4%) had a stoma, and 33 (17%) used antegrade or rectal colonic enemas. Most disarrangements of fecal control and constipation were significantly less common in older age group, but abnormal defecation frequency and social problems remained unchanged. Syndromic patients (n=31) experienced frequent fecal accidents (46%) more often than nonsyndromic (14%, P<0.001). Having a syndrome (adjusted OR 5.6, 95% CI 2.1-15, P=0.001) or a complete transanal ERPT (adjusted OR 2.4, 95% CI 1.1-5.7, P=0.038) was significantly associated with poor outcome defined as having a stoma, an appendicostomy, daily fecal accidents or need of regular rectal wash outs. CONCLUSION A significant number of HD patients experience bowel problems many years after definite surgery. Fecal control was significantly better in older than younger HD patients, but some continued to have considerable bowel problems also as adults. A total transanal ERPT was associated with poorer outcome. Long-term follow-up of HD patients is warranted. Prognosis Study: Level II.
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Affiliation(s)
- Kristin Bjørnland
- Department of Paediatric Surgery, Oslo University Hospital-Rikshospitalet and University of Oslo, Oslo, Norway.
| | - Mikko P Pakarinen
- Department of Paediatric Surgery, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pernilla Stenstrøm
- Department of Paediatric Surgery, Skåne University Hospital, Lund, Sweden
| | - Kjetil J Stensrud
- Department of Paediatric Surgery, Oslo University Hospital-Rikshospitalet and University of Oslo, Oslo, Norway
| | - Malla Neuvonen
- Department of Paediatric Surgery, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anna L Granström
- Department of Paediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Christina Graneli
- Department of Paediatric Surgery, Skåne University Hospital, Lund, Sweden
| | - Are H Pripp
- Department of Paediatric Surgery, Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Einar Arnbjörnsson
- Department of Paediatric Surgery, Skåne University Hospital, Lund, Sweden
| | - Ragnhild Emblem
- Department of Paediatric Surgery, Oslo University Hospital-Rikshospitalet and University of Oslo, Oslo, Norway
| | - Tomas Wester
- Department of Paediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Risto J Rintala
- Department of Paediatric Surgery, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Neuvonen MI, Kyrklund K, Rintala RJ, Pakarinen MP. Bowel Function and Quality of Life After Transanal Endorectal Pull-through for Hirschsprung Disease: Controlled Outcomes up to Adulthood. Ann Surg 2017; 265:622-629. [PMID: 28169931 DOI: 10.1097/sla.0000000000001695] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to define controlled outcomes up to adulthood for bowel function and quality of life (QoL) after transanal endorectal pull-through (TEPT) for Hirschsprung disease (HD). SUMMARY OF BACKGROUND DATA Although TEPT is the surgical standard for HD, controlled long-term follow-up studies evaluating bowel function and QoL are lacking. METHODS Patients aged ≥4 years operated for HD with TEPT between 1987 and 2011 answered detailed questionnaires on bowel function and QoL [Pediatric Quality of Life Inventory (PedsQL, age <18 yrs) or Gastrointestinal Quality of Life Index (GIQLI) and SF-36]. Patients were compared with 3 age- and gender-matched controls each randomly selected from the general population. RESULTS Seventy-nine patients (64%) responded (median age 15, range 4-32 years; 86% rectosigmoid aganglionosis). Compared with controls, patients reported impairment of all aspects of fecal control (P < 0.05), except constipation. In cross-section, 75% of patients were socially continent (vs 98% of controls; P < 0.001). Soiling, fecal accidents, rectal sensation, and ability to withhold defecation improved with age to levels comparable to controls by adulthood (P = NS), but stooling frequency remained higher in 44% of patients (P < 0.05 vs controls). PedsQL domains in childhood were equal to controls (P = NS), except for proxy-reports of sadness/depression. Adults exhibited lower emotional scores, limitation of personal, and sexual relationships (P < 0.05). CONCLUSION Compared with matched peers, significant impairment of fecal control prevails after TEPT in HD patients during childhood, but symptoms diminish with age. Although overall QoL appeared comparable to controls, impairment of emotional and sexual domains may prevail in adulthood.
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Affiliation(s)
- Malla I Neuvonen
- Department of Pediatric Surgery, Children's Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
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Church JT, Simha S, Wild LC, Teitelbaum DH, Ehrlich PF. Antegrade continence enemas improve quality of life in patients with medically-refractory encopresis. J Pediatr Surg 2017; 52:778-782. [PMID: 28190558 DOI: 10.1016/j.jpedsurg.2017.01.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 01/23/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Fecal incontinence is a socially debilitating problem for many children. We hypothesized that in selected patients with medically-refractory encopresis, placement of an appendicostomy or cecostomy tube for administration of antegrade continence enemas (ACE) would improve quality of life (QOL). METHODS We reviewed all patients with encopresis who underwent appendicostomy or cecostomy placement from 2003 to 2014 at our institution. We contacted subjects' parents by phone and administered 3 surveys: a survey reflecting current stooling habits, a disease-specific QOL survey, and the PedsQL™ QOL survey. QOL surveys were completed twice by parents, once reflecting pre-operative QOL, then again reflecting current QOL. Pre-procedure and post-procedure scores were compared by paired t-test. RESULTS Ten patients underwent appendicostomy/cecostomy for encopresis. Eight completed phone surveys. All procedures were performed laparoscopically. All patients experienced fecal soiling pre-operatively, whereas 5/8 surveyed patients (63%) noted complete resolution of soiling post-procedure (p<0.01). General and disease-specific QOL improved from pre-procedure to post-procedure in the following domains: social habits, physical activity, ability to spend the night elsewhere, feeling, and overall QOL (p<0.05). PedsQL™ scores improved significantly in physical functioning, social functioning, and overall functioning (p<0.05). CONCLUSIONS Antegrade continence enemas significantly improve quality of life in patients with medically-refractory encopresis, likely related to resolution of soiling. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Joseph T Church
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Sidd Simha
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Laurie C Wild
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Daniel H Teitelbaum
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Peter F Ehrlich
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
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Treatment and Patient Reported Outcome in Children with Hirschsprung Disease and Concomitant Congenital Heart Disease. BIOMED RESEARCH INTERNATIONAL 2017; 2017:1703483. [PMID: 28373976 PMCID: PMC5360935 DOI: 10.1155/2017/1703483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 02/12/2017] [Accepted: 02/21/2017] [Indexed: 12/29/2022]
Abstract
Purpose. Congenital heart disease (CHD) is reported to be associated with Hirschsprung disease (HD). The aim was to evaluate any differences between children with HD with and without CHD, respectively, with regard to patient characteristics, medical care, and patient reported bowel function. Method. This is a retrospective chart study and a cross-sectional long-term follow-up of patients older than 4 years old, including all children with HD operated on with transanal endorectal pull-through (TERPT) at a tertiary center of pediatric surgery. Information about patient characteristics, diagnostics, surgery, and medical care was compiled. At long-term follow-up, bowel function was assessed by Bowel Function Score. Results. Included were 53 HD-patients, 13 with CHD and 40 without CHD. Children with CHD more commonly presented with failure to thrive; 4 (23%) compared to those without CHD (0%) (p < 0.01). In the long-term follow-up, including 32 patients (6 with CHD), constipation was more commonly reported by children with CHD 5 (83%) than by children without CHD 4 (27%) (p = 0.01). No differences were shown in the other parameters such as fecal control and incontinence. Conclusion. HD-patients with CHD more commonly presented with failure to thrive and more frequently reported constipation than HD-patients without CHD. The findings indicate that HD-patients with CHD might need special consideration in their initial care and long-term follow-up.
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Tannuri ACA, Ferreira MAE, Mathias AL, Tannuri U. Long-term results of the Duhamel technique are superior to those of the transanal pullthrough: A study of fecal continence and quality of life. J Pediatr Surg 2017; 52:449-453. [PMID: 27836370 DOI: 10.1016/j.jpedsurg.2016.10.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/26/2016] [Accepted: 10/11/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND/PURPOSE The Duhamel and transanal pull-through (TAPT) techniques have been commonly used for the treatment of children with Hirschsprung disease (HD). However, despite adequate treatment, some patients present with fecal incontinence that severely affects the quality of life (QoL) and lead to psychiatric disorders. The objectives of the present study were to evaluate, through previously adapted questionnaires, the incidence of fecal incontinence and the quality of life (QoL) of children with HD who underwent Duhamel or TAPT techniques. In addition, we compared the incidence of fecal incontinence and QoL indices in these patients with those in healthy children. MATERIALS/METHODS The Fecal Continence Index (FCI) questionnaire and the questionnaire for the Assessment of Quality of Life in Children and Adolescents with Fecal Incontinence (AQLCAFI) were used in this study. A series of 41 patients with HD were divided into 2 groups according to the utilized surgical technique: the Duhamel group (20 patients) and the TAPT group (21 patients). The patients were compared with a control group of 59 healthy children. RESULTS In the control group, 25 (42.4%) children had good continence and 34 (57.6%) had normal continence. In contrast, among patients with HD, 4 (9.8%) had poor fecal continence, 11 (26.8%) had fair continence, 18 (43.9%) had good continence, and 8 (19.5%) had normal continence. The QoL of children with HD was globally impaired in all domains of the AQLCAFI as well as in the FCI, when compared with the QoL of healthy children (P=0.001). The comparison between children who underwent surgery with the Duhamel technique and those who underwent surgery with TAPT technique showed similar outcomes according to the FCI. However, the results were inferior in patients who underwent TAPT technique according to the AQLCAFI questionnaire (P=0.003), lifestyle (P=0.006), behavior (P=0.01), depression (P=0.01), and embarrassment (P=0.003). CONCLUSION The QoL and the FCI were impaired in patients who underwent surgery for correction of HD compared with healthy children; however, the impairment in QoL was greater in patients who underwent TAPT technique. LEVEL OF EVIDENCE 2B.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Arthur Loguetti Mathias
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Division of Pediatric Surgery and Liver Transplantation Unit, University of Sao Paulo Medical School, Sao Paulo, Brazil.
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Bandi AS, Bradshaw CJ, Giuliani S. Advances in minimally invasive neonatal colorectal surgery. World J Gastrointest Surg 2016; 8:670-678. [PMID: 27830038 PMCID: PMC5081548 DOI: 10.4240/wjgs.v8.i10.670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/27/2016] [Accepted: 08/18/2016] [Indexed: 02/06/2023] Open
Abstract
Over the last two decades, advances in laparoscopic surgery and minimally invasive techniques have transformed the operative management of neonatal colorectal surgery for conditions such as anorectal malformations (ARMs) and Hirschsprung’s disease. Evolution of surgical care has mainly occurred due to the use of laparoscopy, as opposed to a laparotomy, for intra-abdominal procedures and the development of trans-anal techniques. This review describes these advances and outlines the main minimally invasive techniques currently used for management of ARMs and Hirschsprung’s disease. There does still remain significant variation in the procedures used and this review aims to report the current literature comparing techniques with an emphasis on the short- and long-term clinical outcomes.
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Guerra J, Wayne C, Musambe T, Nasr A. Laparoscopic-assisted transanal pull-through (LATP) versus complete transanal pull-through (CTP) in the surgical management of Hirschsprung's disease. J Pediatr Surg 2016; 51:770-4. [PMID: 26949144 DOI: 10.1016/j.jpedsurg.2016.02.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 02/07/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND It is unclear whether laparoscopic-assisted transanal pull-through (LATP) or complete transanal pull-through (CTP) is superior for the surgical management of Hirschsprung's disease. We compared outcomes between approaches. METHODS We retrospectively reviewed patients with Hirschsprung's disease who underwent LATP or CTP at our centre between 1995 and 2014. Patients were matched based on age, birth weight, and level of aganglionosis. A systematic literature review and meta-analysis were also performed. RESULTS From our data, LATP (n=24) took significantly longer than CTP (n=12; 3.9±1.1 vs. 2.6±0.6h, p=0.001). There was no difference in length of stay or incidence of postoperative complications. A literature search identified 17 published studies, of which 2 were comparative. Our pooled analysis of comparative studies including our results showed that operative time was significantly longer for the LATP group (OR 1.59, 95% CI 1.21-1.96, p<0.001). There was no significant difference in major complications (OR 1.75, 95% CI 0.76-4.04, p=0.19) or length of stay (OR 0.33, 95% CI -0.41 to 1.08, p=0.38). CONCLUSION Clinical outcomes are comparable between LATP and CTP. CTP offers shorter operative time without the need for laparoscopic instruments.
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Affiliation(s)
- Julia Guerra
- Department of Pediatric Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Carolyn Wayne
- Department of Pediatric Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Tatenda Musambe
- Department of Pediatric Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Ahmed Nasr
- Department of Pediatric Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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Xia X, Li N, Wei J, Zhang W, Yu D, Zhu T, Feng J. Laparoscopy-assisted versus transabdominal reoperation in Hirschprung's disease for residual aganglionosis and transition zone pathology after transanal pull-through. J Pediatr Surg 2016; 51:577-581. [PMID: 26651281 DOI: 10.1016/j.jpedsurg.2015.10.085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 09/26/2015] [Accepted: 10/29/2015] [Indexed: 12/11/2022]
Abstract
INTRODUCTION This study aims to describe laparoscopic reoperation (LSR) and compare its outcomes with transabdominal reoperation (TAR) for treating Hirschsprung's disease (HD). PATIENTS AND METHODS Eighteen patients with HD underwent reoperation for recurring constipation due to residual aganglionosis and transition zone pathology after an initial transanal procedure (LSR, n=10; TAR, n=8). Preoperative, operative and postoperative data were collected through patient follow-ups ranging from 13 to 75months to compare operative characteristics and postoperative outcomes between the two groups. RESULTS Ten patients underwent laparoscopic reoperation in our institution without major complications. On average, blood loss was significantly lower in the LSR group (mean±standard deviation, 83±32.7mL) than in the TAR group (185±69mL) (P=0.001). The LSR group had a shorter hospitalization time (12±2days) than the TAR group (15±2.1days) (P=0.02). There was no statistically significant difference in incidence of postoperative complications between the two groups. CONCLUSIONS LSR is safe and technically feasible in HD for recurring constipation due to residual aganglionosis and transition zone pathology, when initial transanal procedure fails. Although RA and TZP can be cured by reoperation, great efforts should be made to diminish the necessity of reoperation.
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Affiliation(s)
- Xue Xia
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China.
| | - Ning Li
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Jia Wei
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Wen Zhang
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Donghai Yu
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Tianqi Zhu
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China.
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Banasiuk M, Banaszkiewicz A, Piotrowski D, Albrecht P, Kamiński A, Radzikowski A. 3D high-definition manometry in evaluation of children after surgery for Hirschsprung's disease: A pilot study. Adv Med Sci 2016; 61:18-22. [PMID: 26344909 DOI: 10.1016/j.advms.2015.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 07/03/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Anorectal 3-dimensional high definition manometry (3D HRM) could be the best tool for postoperative assessment of restorative surgical procedures for Hirschsprung's disease. The aim of our study was to evaluate patients after surgery for Hirschsprung's disease using 3D HRM. MATERIALS AND METHODS Anorectal function was evaluated using solid state 3D HRM. We measured the length of the anal canal, mean resting squeeze pressures, the presence of rectoanal inhibitory reflex, cough reflex, ano-anal reflex and the bear down manoeuvre. RESULTS We studied 14 children operated on for Hirschsprung's disease. The mean values of pressure asymmetry were higher in patients after the Duhamel procedure than after the TEPT procedure (29.58% vs. 22.26% during resting and 26.1% vs. 14.01% during squeeze, respectively). No difference between the groups was observed in the measurement of all the manometric parameters except the presence of rectoanal inhibitory reflex (87.5% after TEPT vs. 33% after Duhamel). CONCLUSIONS Anorectal 3D HRM evaluation of patients with Hirschsprung's disease demonstrated that the asymmetry of the anal canal occurred in a similar percentage after both procedures.
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Xia X, Li N, Wei J, Zhang W, Yu D, Zhu T, Feng J. Single-incision laparoscopic versus conventional laparoscopic surgery for Hirschsprung's disease: A comparison of medium-term outcomes. J Pediatr Surg 2016; 51:440-443. [PMID: 26611332 DOI: 10.1016/j.jpedsurg.2015.10.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 10/13/2015] [Accepted: 10/13/2015] [Indexed: 12/11/2022]
Abstract
INTRODUCTION This study aims to report medium-term outcomes of single-incision laparoscopic surgery (SILS) and compare its results with conventional laparoscopic surgery (CLS). PATIENTS AND METHODS Seventy-five patients with Hirschsprung's disease (HD) underwent operations from January 2009 to December 2012 in our institution (SILS, n=40; CLS, n=35). SILS procedure is similar to CLS, but uses a single, 1.5-cm horizontal skin incision in the umbilicus for laparoscopic access. Operative characteristics and medium-term outcomes were assessed. RESULTS On average, patients in the SILS group had shorter operative times (mean±standard deviation, 226±69.4min) than those in the CLS group (268.9±83.6min) (P=0.01). Fourteen cases (35%) in the SILS group and ten cases (28.6%) in the CLS group had extended HD. Medium-term outcomes did not significantly differ between the groups, and the SILS group had better cosmetic results. CONCLUSIONS SILS could be safely performed in HD patients with good medium-term outcomes. Although SILS and CLS procedures had similar medium-term outcomes, SILS has advantages such as better cosmetic results and shorter operative times.
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Affiliation(s)
- Xue Xia
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China.
| | - Ning Li
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Jia Wei
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Wen Zhang
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Donghai Yu
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Tianqi Zhu
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China
| | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, China.
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A population-based, complete follow-up of 146 consecutive patients after transanal mucosectomy for Hirschsprung disease. J Pediatr Surg 2015; 50:1653-8. [PMID: 25783387 DOI: 10.1016/j.jpedsurg.2015.02.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/15/2015] [Accepted: 02/03/2015] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The objective of the study is to define the population-based bowel functional outcomes and enterocolitis following transanal endorectal pull-through (TEPT) in patients with Hirschsprung disease (HD) treated at our institution between 1986 and 2011. METHODS 146 consecutive patients who had undergone primary surgical treatment for HD were included. The median follow-up time was 15 (3-33) years. The clinical details and prevalence of enterocolitis were evaluated in all patients, and bowel function in patients >3 years of age with functional intestino-anal continuity. RESULTS No patients were lost to follow-up. Overall survival was 98%. The level of disease was rectosigmoid in 83%, long segment in 7%, total colonic in 4%, and extending up to the small bowel in 6%. 29% had an associated syndrome. 22% had a preoperative stoma. Operations included TEPT (89%), proctocolectomy with ileoanal anastomosis in 9%, and 3% had a permanent endostomy owing to small intestinal aganglionosis. One patient underwent intestinal transplantation. At the latest follow-up, 42% had occasional soiling, 12% had frequent soiling and 46% had no soiling. Constipation occurred in 9%. An associated syndrome was the only predictor for soiling or constipation (OR 4.3, 95% CI 1.5-12). 44% developed recurrent postoperative enterocolitis, which was predicted by extended aganglionosis (OR 6.9, 95% CI 2.4-20) and syndromatic disease (OR 2.4, 95% CI 1.2-5.0). CONCLUSION The major functional sequelae following TEPT were recurrent enterocolitis and fecal soiling, which was mostly occasional. An associated syndrome was a predictor of a reduced bowel functional outcome, and alongside extended aganglionosis were significant risk factors for recurrent postoperative enterocolitis.
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Stensrud KJ, Emblem R, Bjørnland K. Anal endosonography and bowel function in patients undergoing different types of endorectal pull-through procedures for Hirschsprung disease. J Pediatr Surg 2015; 50:1341-6. [PMID: 25783406 DOI: 10.1016/j.jpedsurg.2014.12.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 12/10/2014] [Accepted: 12/27/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The reasons for fecal incontinence after surgery for Hirschsprung disease (HD) remain unclear. The aim of this study was to examine the anal sphincters by anal endosonography and manometry after transanal endorectal pull-through, with or without laparotomy or laparoscopy, in HD patients. Furthermore, we aimed to correlate these findings to bowel function. PATIENTS AND METHODS Fifty-two HD patients were followed after endorectal pull-through. Anal endosonography and manometry were performed without sedation at the age of 3 to 16 years. RESULTS Endosonographic internal anal sphincter (IAS) defects were found in 24/50 patients, more frequently after transanal than transabdominal procedures (69 vs. 19%, p=0.001). In a multiple variable logistic regression model, operative approach was the only significant predictor for IAS defects. Anal resting pressure (median 40mm Hg, range 15-120) was not correlated to presence of IAS defects. Daily fecal incontinence occurred more often in patients with IAS defects (54 vs. 25%, p=0.03). CONCLUSIONS Postoperative IAS defects were frequently detected and were associated with daily fecal incontinence. IAS defects occurred more often after solely transanal procedures. We propose that these surgical approaches are compared in a randomized controlled trial before solely transanal endorectal pull-through is performed as a routine procedure.
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Affiliation(s)
- Kjetil J Stensrud
- Oslo University Hospital, Department of Pediatric surgery, P.O. Box 4950 Nydalen, 0424 Oslo, Norway.
| | - Ragnhild Emblem
- Oslo University Hospital, Department of Pediatric surgery, P.O. Box 4950 Nydalen, 0424 Oslo, Norway; University of Oslo, Faculty of Medicine, P.O. Box 1078 Blidern, 0316 Oslo, Norway
| | - Kristin Bjørnland
- Oslo University Hospital, Department of Pediatric surgery, P.O. Box 4950 Nydalen, 0424 Oslo, Norway; University of Oslo, Faculty of Medicine, P.O. Box 1078 Blidern, 0316 Oslo, Norway
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Thomson D, Allin B, Long AM, Bradnock T, Walker G, Knight M. Laparoscopic assistance for primary transanal pull-through in Hirschsprung's disease: a systematic review and meta-analysis. BMJ Open 2015; 5:e006063. [PMID: 25805527 PMCID: PMC4386272 DOI: 10.1136/bmjopen-2014-006063] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To compare outcomes following totally transanal endorectal pull-through (TTERPT) versus pull-through with any form of laparoscopic assistance (LAPT) for infants with uncomplicated Hirschsprung's disease. DESIGN Systematic review and meta-analysis. SETTING Five hospitals with a paediatric surgical service. PARTICIPANTS 405 infants with uncomplicated Hirschsprung's disease. INTERVENTIONS TTERPT versus LAPT. PRIMARY OUTCOMES mortality, postoperative enterocolitis, faecal incontinence, constipation, unplanned laparotomy or stoma formation, and injury to abdominal viscera. SECONDARY OUTCOMES Haemorrhage requiring transfusion of blood products, abscess formation, intestinal obstruction, intestinal ischaemia, enteric fistula formation, urinary incontinence or retention, impotency and duration of procedure. RESULTS Five eligible studies comprising 405 patients were identified from 2107 studies. All studies were retrospective case series, with variability in outcome assessment quality and length of follow-up. Operative duration was 50.29 min shorter with TTERPT (95% CI 39.83 to 60.74, p<0.00001). There were no significant differences identified between TTERPT and LAPT for incidence of postoperative enterocolitis (OR=0.78, 95% CI 0.44 to 1.38, p=0.39), faecal incontinence (OR=0.44, 95% CI 0.09 to 2.20, p=0.32) or constipation (OR=0.84, 95% CI 0.32 to 2.17, p=0.71). CONCLUSIONS This meta-analysis did not find any evidence to suggest a higher rate of enterocolitis, incontinence or constipation following TTERPT compared with LAPT. Further long-term comparative studies and multicentre data pooling are needed to determine whether a purely transanal approach offers any advantages over a laparoscopically assisted approach to rectosigmoid Hirschsprung's disease. TRIAL REGISTRATION NUMBER PROSPERO registry- CRD42013005698.
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Affiliation(s)
- David Thomson
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Benjamin Allin
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Anna-May Long
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Tim Bradnock
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow, UK
| | - Gregor Walker
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
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Redo pullthrough for Hirschsprung disease: a single surgical group's experience. J Pediatr Surg 2014; 49:1394-9. [PMID: 25148745 DOI: 10.1016/j.jpedsurg.2014.04.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 03/24/2014] [Accepted: 04/18/2014] [Indexed: 11/23/2022]
Abstract
INTRODUCTION This study presents our surgical experience for redo-pullthrough (RedoPT) for Hirschsprung disease (HD). It reviews the patient's clinical outcomes and assesses stooling patterns after RedoPT. METHODS A retrospective review of our institution's RedoPTs as well as one author's overseas cases was performed. Stooling scores were tabulated using an established survey tool and compared to primary PT matched patients. RESULTS Between 1974 and 2012, 46 individuals (52% males) underwent RedoPT, representing 3 percent of all HD pullthroughs. Median age at primary PT and RedoPT was 1year (range 1week-18years) and 3.5years (range 8weeks-41years), respectively. Indications for RedoPT were predominately for aganglionosis/transition zone pathology (71%); followed by stricture or an obstructing Duhamel pouch (19%), tight cuff (8%) and a twisted PT (4%). None were performed for an isolated clinical diagnosis of repeated bouts of enterocolitis. RedoPT surgical approach depended upon the initial pullthrough technique and any previous complications. Stooling scores were significantly (P<0.05) worse in the RedoPT patients compared to the historically-matched group of children undergoing a primary PT for HD (5.5±1.2 vs. 12.2±1.4, primary PT versus RedoPT, respectively). When breaking down this total score into individual parameters, stooling pattern scores (1.0±0.2 vs. 4.1±0.4, P=0.001) and enterocolitis scores (2.0±0.4 vs. 4.2±0.4, P=0.001) were statistically worse in the RedoPT group. Patients in both groups had similar overall continence rates. CONCLUSION Appropriately selected children undergoing a RedoPT can achieve good results, with comparable continence rates to those undergoing a primary PT.
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Freeman JJ, Simha S, Jarboe MD, Ehrlich PF, Teitelbaum DH. Antegrade continent enema procedures performed prior to starting school may improve functional stooling and quality of life. Pediatr Surg Int 2014; 30:715-22. [PMID: 24874343 DOI: 10.1007/s00383-014-3520-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE A major research gap is determining the best age to perform an appendicostomy or cecostomy. This study hypothesizes that performance of appendicostomy/cecostomy prior to starting school (<6 years) would improve functional stooling and quality of life (QOL). METHODS Patients who underwent appendicostomy/cecostomy for bowel management between 2003 and 2013 were retrospectively identified. Families were prospectively surveyed regarding current stooling habits (17 items) and a (7 item) pediatric QOL survey. Lower stooling survey scores represent better bowel control. Higher QOL scores indicated better quality. The primary outcome was to correlate age of appendicostomy/cecostomy to QOL score. Statistics were performed using paired, unpaired t tests, and Chi-square. p Values ≤0.05 were considered significant. RESULTS 35 patients underwent placement of appendicostomy/cecostomy. Fourteen (40%) patients/families were prospectively contacted (<6, n = 6; >6, n = 8). Stooling scores (15.17 ± 1.35 vs. 22.25 ± 1.70; for <6 vs. >6 years old, p = 0.009) and continence scores (6.33 ± 1.45 vs. 11.13 ± 1.64; p = 0.06), at time of contacting families, were significantly better in those undergoing appendicostomy/cecostomy in the <6 group. Pre-procedure QOL scores for the two groups were similar (p = 0.89). Post-procedure QOL significantly increased to the good subcategory for both age groups; however improvement was significantly better in the <6 age group vs. ≥6 group: 6.33 ± 0.92 vs. 3.13 ± 0.91 points (p = 0.03). A secondary parent survey showed significantly more families wished an appendicostomy/cecostomy were done earlier in the >6 vs. <6 group (87.5 vs. 33%; p = 0.04). CONCLUSION Early placement of cecostomy or appendicostomy as part of a bowel management program may contribute to improved QOL and functional stooling.
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Affiliation(s)
- Jennifer J Freeman
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Mott Children's Hospital, 1540 E. Hospital Dr., SPC 4211, Ann Arbor, MI, 48109-4211, USA,
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Mathur MK, Aggarwal SK, Ratan SK, Sinha SK. Laparoscopic-assisted transanal pull-through for Hirschsprung's disease: Comparison between partial and near total laparoscopic mobilization of rectum. J Indian Assoc Pediatr Surg 2014; 19:70-5. [PMID: 24741208 PMCID: PMC3983770 DOI: 10.4103/0971-9261.129596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Transanal pull-through with laparoscopic assistance is gaining popularity. How much rectal dissection to do laparoscopically and how much transanally is not clear. Laparoscopic rectal mobilization is akin to open pelvic dissection of Swenson's operation — the most physiological procedure. Through this comparative study, we aim to evolve a technique that maximizes the benefits of Swenson's technique and minimizes the problems of a transanal procedure. Materials and Methods: Twenty patients (19 boys and one girl, newborn to 6 years) with Hirschsprung's disease (HD) were randomized for laparoscopic-assisted transanal pull-through (LATAPT) either by near complete (Group A) or partial (Group B) laparoscopic mobilization of rectum. Patients were followed up for at least 3 months. Demographic profile; operative details (time taken, blood loss, operative difficulty, and complications); postoperative course (duration of urinary catheter, oral feeding, and hospital stay); and follow-up stooling pattern, consistency, and continence were compared in the two groups. Results: The time taken for laparoscopic mobilization was marginally higher in group A, but the time taken for transanal dissection in this group was significantly less than in group B. All other comparisons showed no significant difference in the two groups. Stool frequency and continence improved with time in both groups. Conclusion: Extent of laparoscopic mobilization of rectum does not appear to be a factor deciding the outcomes. No recommendations could be made in view of the small number of cases. However, it shows that laparoscopic assistance can be used to maximize the benefits of Swenson type of operation and a transanal pull-through.
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Affiliation(s)
- Mohit Kumar Mathur
- Senior Resident of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India ; Senior Resident at Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Satish Kumar Aggarwal
- Senior Resident of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Simmi K Ratan
- Senior Resident of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India
| | - Shandip Kumar Sinha
- Senior Resident of Paediatric Surgery, Maulana Azad Medical College, New Delhi, India
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Sun NF, Zhong WY, Lu SA, Tian YL, Chen JB, Hu SY, Tian AL. Coexpression of recombinant adenovirus carrying GDNF and EDNRB genes in neural stem cells in vitro. Cell Biol Int 2013; 37:458-63. [PMID: 23504906 DOI: 10.1002/cbin.10060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Accepted: 01/20/2013] [Indexed: 12/13/2022]
Abstract
Gene therapy and nerve stem cells isolated from the developing human enteric nervous system (ENS) are significant. They may open the route for the cell therapy of Hirschsprung's disease (HD). We have constructed the recombinant adenovirus-carrying glial cell line-derived neurotrophic factor (GDNF) and endothelin receptor B (EDNRB) gene, and investigated the exosomatic coexpression in neural stem cells. The recombinant adenovirus Ad-GE coexpressing GDNF and EDNRB gene was constructed by the AdEasy system and confirmed by the reverse transcription polymerase chain reaction (RT-PCR) method. Expression of exogenous genes in neural stem cells after transfection was confirmed by the flow cytometry and real-time fluorescence quantitative PCR. Fragments of pAd Track-CMV-GE were consistent with GDNF and EDNRB. The green fluorescence of the positive cells was followed by fluorescence microscopy at 24 h after NSCs had been transfected, reaching a peak at 72 h after transfection. Flow cytometry showed that the efficiency of transfection was 15.0, 23.6, and 25.4% at 24, 48 and 72 h respectively. Real-time fluorescence quantitative PCR showed the expression levels of mRNA of GDNF and EDNRB in 48 and 72 h groups were obviously higher than that in 24 and 96 h groups. Recombinant adenovirus carrying GDNF and EDNRB genes are coexpressed in neural stem cells, which may offer the possibility of a novel approach to local combination gene therapy for Hirschsprung's disease.
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Affiliation(s)
- Nian-Feng Sun
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan 250012, China
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Transanal endorectal pull-through versus transabdominal approach for Hirschsprung's disease: a systematic review and meta-analysis. J Pediatr Surg 2013; 48:642-51. [PMID: 23480925 DOI: 10.1016/j.jpedsurg.2012.12.036] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 11/11/2012] [Accepted: 12/08/2012] [Indexed: 12/16/2022]
Abstract
AIM Transanal endorectal pull-through (TERPT) has become popular for single-stage treatment of Hirschsprung's disease. The benefits of TERPT over the conventional transabdominal approach (TAB) are still unclear. We performed a comprehensive meta-analysis comparing the clinical outcomes of TERPT and TAB. METHODS Original articles published from 1998 to 2012 were searched from Medline, Embase, and Cochrane databases. Randomized controlled trials (RCT) and observational clinical studies (OCS) comparing TERPT and TAB were included. Outcomes evaluated included operative time, hospital stay and incidence of postoperative incontinence/soiling, constipation and enterocolitis. Pooled odds ratios (OR) were calculated for dichotomous variables; pooled mean differences (MD) were measured for continuous variables. RESULTS Of 93 studies, 1 RCT and 11 OCS were included, comprising 444 cases of TERPT and 348 cases of TAB (215 Soave, 94 Duhamel, 24 Swenson, 15 Rehbein procedures). TERPT had shorter operative time (MD=-57.85 min; 95% confidence interval [CI], -83.11 to -32.60; P<0.00001) and hospital stay (MD=-7.06 days; 95% CI, -10.95 to -3.16; P=0.0004). TERPT had less postoperative incontinence/soiling (OR=0.58; 95% CI 0.37-0.90; P=0.01) and constipation (OR=0.49; 95% CI 0.30-0.81; P=0.005). There was no difference in incidence of postoperative enterocolitis. CONCLUSION TERPT is superior to TAB in operative time, hospital stay, postoperative incontinence and constipation. However, more randomized controlled trials are necessary to verify the benefit of TERPT for Hirschsprung's disease.
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Aworanti OM, Mcdowell DT, Martin IM, Hung J, Quinn F. Comparative review of functional outcomes post surgery for Hirschsprung's disease utilizing the paediatric incontinence and constipation scoring system. Pediatr Surg Int 2012; 28:1071-8. [PMID: 23001072 DOI: 10.1007/s00383-012-3170-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE We aim to analyze differences in functional outcomes in children operated on for Hirschsprung's disease (HD) using the Paediatric incontinence/constipation scoring system (PICSS) validated in a normative group. METHODS A retrospective review of the records of all children operated on for HD between 1997 and 2010 was performed. Patients had either a Soave or transanal endorectal pull-through. Children with total colonic aganglionosis and Down's syndrome were excluded. Utilizing the PICSS children who scored below their age-specific lower limit 95 % confidence interval PICSS scores were considered to have incomplete continence or constipation. The rates of incomplete continence and constipation were compared between groups. Significance was set at p < 0.05. RESULTS PICSS analysis could be completed in 51 (Soave 35, transanal 16). The median age at interview was 71 months (range 6-191 months). The rate of incomplete continence was 75 % (n = 21) and 71 % (n = 10) for the Soave and transanal groups, respectively (p = 1.00). The constipation rate was 34 % (n = 12) and 25 % (n = 4) for the Soave and transanal groups, respectively (p = 0.74). The overall rates of incomplete continence and constipation rates were 74 and 31 %, respectively, compared with 14 and 10 %, respectively, when rates were calculated by review of records. CONCLUSION The PICSS is a sensitive tool for assessing functional outcome post HD surgery. The Soave and transanal procedures have similar functional outcomes.
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Quality of life and parents’ satisfaction with Duhamel’s versus transanal endorectal pull-through for the treatment of Hirschsprung’s disease in children. ANNALS OF PEDIATRIC SURGERY 2012. [DOI: 10.1097/01.xps.0000418468.33021.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Affiliation(s)
- A Gunnarsdóttir
- Section of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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Yang L, Tang ST, Cao GQ, Yang Y, Li S, Li SW, Wang Y, Mao YZ, Ruan QL, Wang GB. Transanal endorectal pull-through for Hirschsprung's disease using long cuff dissection and short V-shaped partially resected cuff anastomosis: early and late outcomes. Pediatr Surg Int 2012; 28:515-21. [PMID: 22426598 DOI: 10.1007/s00383-012-3071-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2012] [Indexed: 01/14/2023]
Abstract
BACKGROUND Transanal endorectal pull-through was described by De la Torre-Mondragon's technique. In the original transanal pull-through procedure, a long rectal muscular cuff was dissected and left for anocolic anastomosis, which would sometimes lead to postoperative obstructive symptoms and enterocolitis. While a modified short mucosal dissection may increase the risk of injury to pelvic and perirectal nerves and other structures when dissected on the outside of the rectum deep in the pelvis. We report early and late results of the modified transanal procedure for Hirschsprung's disease (HD) over 8 years. METHODS The clinical course of all children with aganglionic rectum or sigmoid colon receiving the modified transanal pull-through between May 2003 and April 2011 were reviewed. The main modifications were rectal mucosa dissection with a long cuff, coloanal anastomosis with a short cuff and a V-shaped partial resection in the posterior wall of the muscular cuff. Children with preliminary stoma or total colonic disease were excluded. RESULTS Short- and long-term follow-up was obtained in 137 patients with HD operated upon by the same surgeon. The aganglionic segment was located in the rectum or sigmoid colon in all patients. The mean age at surgery was 165 ± 74 days. The mean operating time was 108 ± 38 min. Mean intra-operative blood loss was estimated to be 15 ± 10 ml. No patient required a blood transfusion. Mean postoperative hospital stay was 7 ± 2 days. Early postoperative complications included perianal excoriation in 38 patients (27.7 %), enterocolitis in two patients (1.4 %), and anastomotic leak in two patients (1.4 %). Late postoperative complications included perianal excoriation in 16 patients (11.7 %), anal stricture in two patients (1.4 %), constipation in four patients (2.8 %), enterocolitis in 10 patients (7.3 %), and soiling problems in six patients (4.4 %). Mean follow-up was 56 months (6 months-9 years). In patients older than 4 years, 85.4 % of them had excellent/good bowel function, 9.4 % had fair bowel function, and 5.2 % of patients had bad bowel function. CONCLUSION Transanal endorectal pull-through with a long cuff dissection and a short V-shaped resected cuff anastomosis is a safe and effective procedure for HD. It reduced incidence of anastomotic stricture and constipation without an increased soiling incidence.
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Affiliation(s)
- Li Yang
- Department of Pediatric Surgery, Union Hospital of Huazhong University of Science and Technology, Wuhan, 430022, China
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Bowel function and fecal continence after Soave’s trans-anal endorectal pull-through for Hirschsprung’s disease: a local experience. Updates Surg 2012; 64:113-8. [DOI: 10.1007/s13304-012-0140-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 02/21/2012] [Indexed: 10/28/2022]
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Giuliani S, Betalli P, Narciso A, Grandi F, Midrio P, Mognato G, Gamba P. Outcome comparison among laparoscopic Duhamel, laparotomic Duhamel, and transanal endorectal pull-through: a single-center, 18-year experience. J Laparoendosc Adv Surg Tech A 2011; 21:859-63. [PMID: 21854203 DOI: 10.1089/lap.2011.0107] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Transanal endorectal pull-through has changed the treatment of Hirschsprung's disease (HD) in the past decade. The aim of the study was to compare outcomes, obtained in a single center, with laparotomic Duhamel (LTD), laparoscopic Duhamel (LSD), and laparoscopic-assisted transanal endorectal pull-through (LTEPT). MATERIALS AND METHODS We retrospectively reviewed the charts of all patients operated on for HD since 1992. Preoperative, operative, and postoperative data were collected to compare short- and long-term outcomes among the three groups. RESULTS From 1992 to 2010, 70 children were treated for HD. Patients were divided into three groups based on the surgical technique used: 14 LTEPT, 32 LSD, and 24 LTD. Mean ages at surgery were 4.67, 14.61, and 13.28 months, respectively. Patients in the LTEPT group had significant shorter operating times (195 versus 257 versus 291 minutes, P=.03), earlier start of feeding (1.2 versus 3.1 versus 4.7 days, P<.01), and shorter length of hospital stay (4.4 versus 6.8 versus 9.7 days, P<.011). Overall complications rate was lower in the LTEPT (14%) than in the LSD (31.2%) and LTD (29.7%) groups. Postoperative enterocolitis incidence was 3%-4% in the Duhamel groups and none in LTEPT. Long-term outcome showed less constipation and better continence for age in the LTEPT group at the 1-year follow-up (P=.033). CONCLUSIONS This study further supports technical advantages, lighter impact of the surgical procedure on infants, lower incidence of complications, and better long-term outcome of the transanal pull-through compared to the Duhamel approaches.
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Affiliation(s)
- Stefano Giuliani
- Division of Pediatric Surgery, Department of Pediatrics Salus-Pueri, University of Padova, Padova, Italy.
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Romero P, Kroiss M, Chmelnik M, Königs I, Wessel LM, Holland-Cunz S. Outcome of transanal endorectal vs. transabdominal pull-through in patients with Hirschsprung's disease. Langenbecks Arch Surg 2011; 396:1027-33. [PMID: 21695592 DOI: 10.1007/s00423-011-0804-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Accepted: 05/02/2011] [Indexed: 10/18/2022]
Abstract
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. METHODS Records were reviewed for 53 patients over 3 years of age in whom a pull-through procedure was performed for HD (TERPT, n = 24; ABD, n = 29) between 1992 and 2007 at the Departments of Pediatric Surgery, University of Heidelberg and University Hospital of Mannheim, and their families were interviewed and scored via a thorough 15-item, post-pull-through, long-term outcome questionnaire. Total scores ranged from 0 to 40: 0 to 10, excellent; 11 to 20, good; 21 to 30, fair; and 31 to 40, poor. Two-sided Fisher's exact test and analysis of variance were used to compare different variables in patients in the two groups with significance set at p < 0.05. Results are expressed as mean and standard deviation (SD). RESULTS Overall scores were similar (TERPT, n = 16, 7.3 +/- 6.6 vs. ABD, n = 23, 4.6 +/- 3.5, p = 0.11) and showed mainly excellent or good long-term outcome for TERPT (93.8%) and ABD (99.7%) pull-through procedures. The incidence of incontinence in children older than 3 years was insignificantly lower in ABD group (TERPT 18.7% vs. ABD 4.3 %, p = 0.15). Regarding the soiling score, however, the soiling tended to be significantly more severe after TERPT than ABD. For the TERPT procedure, the appearance of postoperative constipation, enterocolitis, anastomotic dehiscence, and symptomatic anastomotic stricture was lower but this was not statistically significant. After TERPT, patients started to feed sooner (TERPT 2.8 days vs. ABD 4.4 days, p = 0.005) and operating time (TERPT 133.2 min vs. ABD 204 min, p < 0.001) and hospital stay (TERPT 9.8 days vs. ABD 17.7 days, p < 0.001) were significantly shorter. CONCLUSION We employ the TERPT procedure as the first choice in children with rectosigmoid HD.
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Affiliation(s)
- Philipp Romero
- Department of Surgery, Division of Pediatric Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
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Abstract
PURPOSE After 25 years of practice and positive results of the Rehbein-procedure (RB) for children with Hirschsprung Disease (HD), we changed to the less invasive transanal endorectal pull through (TERPT). The aim of this study was to compare short- and mid-term complications of these two procedures in our patients with HD. METHODS Retrospective data of 50 HD patients were analyzed. Of these patients, 25 underwent RB (2000-2006) and in 25 the TERPT was performed (2005-2009). Medical records were reviewed to score complications and outcomes. Differences were analyzed using Chi-Square and Mann-Whitney U tests. RESULTS All RB patients (100%) were given a colostomy compared with four patients (16%) in the TERPT group (p < 0.001). The average age at surgery in the RB group was 191 days whereas this was 72 days in the TERPT group (p < 0.01). The mean length of time of surgery in the RB group (158 min) was not significantly different from that in the TERPT group (183 min). Ganglion cells were located in all specimens at the proximal end of the specimens. The median time to first feeding significantly decreased from 2 days (range 1-11) in the RB group to 1 day (range 1-3) in the TERPT group (p < 0.01). The median length of hospital stay decreased in the TERPT group (8 days) compared with the RB group (10 days) (p < 0.001). There was a significant reduction in postoperative obstructive symptoms during the first 6 months in the TERPT group (48%) compared with the RB group (84%) (p = 0.016). Postoperative enterocolitis decreased from 40% in the RB group to 24% in the TERPT group although this was not statistically significant. CONCLUSIONS The introduction of TERPT reduced the need for colostomies; it shortened days to first feeding after surgery and reduced hospital stay. It also improved short-term outcome with less obstructive symptoms. We recommend TERPT surgery as a first choice in children with HD. we consider the RB now to be obsolete.
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Functional outcome after operation for Hirschsprung disease--transanal vs transabdominal approach. J Pediatr Surg 2010; 45:1640-4. [PMID: 20713213 DOI: 10.1016/j.jpedsurg.2010.02.065] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 02/15/2010] [Accepted: 02/17/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND It has been hypothesized that the extensive transanal dissection in transanal endorectal pull-through (TEPT) for Hirschsprung disease (HD) can impair the anal sphincters in neonates and thereby cause incontinence. Theoretically, transabdominal endorectal pull-through might have less impact on the sphincters. The aim of this study was to compare functional outcome in HD patients operated with either TEPT or laparotomy-assisted endorectal pull-through (LEPT) with particular focus on soiling and fecal incontinence. PATIENTS AND METHODS Anorectal function in 52 children older than 3 years is reported. The patients were operated for HD with either TEPT (n = 28) or LEPT (n = 24) and followed prospectively. Functional outcome was recorded by standardized interviews. The Krickenbeck criteria were used to classify voluntary bowel movements, soiling, and constipation. RESULTS The median age at follow-up was 5.7 years (3.1-13.2) for TEPT and 10.1 years (7.7-16.2) for LEPT. Twenty-nine patients reported soiling at final follow-up. There was no difference in the rate of soiling between children operated with TEPT (54%) or LEPT (58%). Constipation was reported in 11 children (TEPT, 25%; LEPT, 17%). CONCLUSIONS The functional outcome and in particular the rate of soiling did not differ between patients operated with LEPT or TEPT.
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Endorectal pull-through for Hirschsprung's disease-a multicenter, long-term comparison of results: transanal vs transabdominal approach. J Pediatr Surg 2010; 45:1213-20. [PMID: 20620323 DOI: 10.1016/j.jpedsurg.2010.02.087] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Accepted: 02/22/2010] [Indexed: 01/27/2023]
Abstract
PURPOSE Previous studies have reported decreased continence in patients undergoing transanal endorectal pull-through (TERP) for Hirschsprung's disease compared to the older transabdominal approach (TAA). To address this, we examined long-term stooling outcomes in a large, multicenter cohort of patients undergoing either TERP or TAA. METHODS Data were collected from 5 large pediatric institutions. Patient families were surveyed using a stooling score system (0-40, best to worst total score). Inclusion criteria included patients older than 3 years and those who had more than 6 months of recovery after pull-through. Those with total colonic aganglionosis were excluded. Statistical analysis included univariate and multivariate linear regression (significance, P < .05). RESULTS Two hundred eighty-one patients underwent TERP (192) or TAA (89). Interviews were completed in 149 (104 [52%] TERP vs 45 [52%] TAA). The TAA group had a significantly greater number of daily bowel movements for each respective postoperative year and experienced more early complications (3% vs 1% with >1 complication; P = .061) and late complications (19% vs 4% with >1 complication; P < .001). Although the TAA group had a higher mean enterocolitis score (3.3 +/- 0.4 vs 1.8 +/- 0.2; P < .001), this was not borne out by multivariate regression analysis (P = .276). Parental survey showed that there were no significant differences between procedures in mean total, continence, or stooling pattern scores. CONCLUSION Transanal endorectal pull-through was associated with fewer complications and fewer episodes of enterocolitis. In contrast to prior studies, TERP patients did not have a higher rate of incontinence. These results support use of TERP as an excellent surgical approach for children with Hirschsprung's disease.
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Abstract
The operative management of pediatric colorectal diseases has improved significantly in recent years through the development of innovative approaches for operative exposure and a better understanding of colorectal anatomy. Advances in transanal and minimal access techniques have formed the cornerstone of this innovation, leading to improved functional outcomes, earlier recovery, and superior cosmetic results for a number of colorectal diseases. In this regard, we have witnessed a significant evolution in the way that many of these conditions are managed, particularly in the areas of anorectal malformations and Hirschsprung disease. Furthermore, a more thorough understanding of the pathophysiology underlying encopresis and true fecal continence has led to novel and less invasive approaches to the operative management of these conditions. The goal of this review is to describe the evolution of operative management pertaining to these diseases, with an emphasis on technical aspects and relevant clinical pitfalls.
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Affiliation(s)
- Shawn J Rangel
- Department of Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02210, USA.
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