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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 274-277

Late postoperative complications after single-stage transanal endorectal pull-through for Hirschsprung's disease


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Abu-El Reesh Insurance Hospital, Cairo, Egypt

Date of Submission25-Apr-2013
Date of Acceptance04-Aug-2013
Date of Web Publication26-Sep-2014

Correspondence Address:
Mahmoud F Zalat
MBBCh, El-Gharbya Governature, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.141675

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  Abstract 

Objective
The aim of the study was to assess the late postoperative complications after single-stage transanal endorectal pull-through for Hirschsprung's disease.
Background
Hirschsprung's disease is a common cause of bowel obstruction during the newborn period. One-stage surgery for Hirschsprung's disease is well established, and the results are comparable or better than multistage surgery.
Patients and methods
This was a retrospective study conducted at the Pediatric Surgery Unit of Department of General Surgery, Menoufia University Hospital and Abu-El Reesh Insurance Hospital between October 2007 and November 2011. This study included 20 patients with Hirschsprung's disease; there were 15 boys and five girls, their ages ranging from 6 months to 5 years. All these patients were subjected to transanal pull-through, and their data were retrieved by checking their files.
Results
The mean age of these patients was 32.1 ± 17.47 months. Rectal biopsy was diagnostic in all patients, whereas barium enema was diagnostic only in 16 patients. The mean operative time was 91.3 ± 11.89 min. The commonest postoperative complication was enterocolitis (30%); two patients (10%) were in need for frequent dilatation, three patients (15%) complained of rectal prolapse, two other patients (10%) complained of increased stool frequency, and finally four patients (20%) complained of recurring constipation.
Conclusion
Transanal pull-through is both feasible and safe for the management of patients with Hirschsprung's disease, and it is associated with acceptable morbidity.

Keywords: Constipation, Hirschsprung′s disease, rectal biopsy, transanal pull-through


How to cite this article:
Lolah MA, Sultan TA, Zalat MF. Late postoperative complications after single-stage transanal endorectal pull-through for Hirschsprung's disease. Menoufia Med J 2014;27:274-7

How to cite this URL:
Lolah MA, Sultan TA, Zalat MF. Late postoperative complications after single-stage transanal endorectal pull-through for Hirschsprung's disease. Menoufia Med J [serial online] 2014 [cited 2019 Nov 21];27:274-7. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/274/141675


  Introduction Top


Hirschsprung's disease, 'congenital aganglionic megacolon', is one of the commonest causes of neonatal intestinal obstruction. The incidence of Hirschsprung's disease is estimated to be approximately one in 5000 live births [1]. The boy-to-girl ratio is 4 : 1 [2].

Hirschsprung's disease is characterized by absence of ganglion cells in the nerve plexus of rectum and colon, associated with dilatation of the normal proximal colon due to neurogenic obstruction [3].

In 1984, Whitehouse and Kernohan [4] definitely documented the absence of ganglion cells of the myenteric plexus in patients with Hirschsprung's disease. Aganglionosis typically extends to the rectosigmoid region in ~80% of patients [5]. In about 10% of patients, the proximal colon is involved, and in the remaining 10% of patients entire colon with variable extension into small bowel may occur. Because of absence of the ganglion cells, cholinergic activity is increased and nonadrenergic inhibitory system is decreased, which leads to contracted spastic state of the aganglionic bowel [6].

The evolution of the surgical treatment for Hirschsprung's disease over the past 50 years has been a wide variety of techniques ranging from the Swenson procedure in 1984 [7] to one-stage transanal pull-through described by Langer et al. [8].

Recently, the most popular procedure is the single-stage total transanal endorectal pull-through, which is first described by De la Torre-Mondragσn and Ortega in 1998 [9]. In transanal endorectal pull-through, the procedure is completed without diverting colostomy. Transanal endorectal pull-through can be assisted by laparoscopy as in LATP or without any additional procedure as in transanal endorectal pull-through. This technique has various advantages over other traditional ones, such as the Swenson, Duhamel, and Soave procedure, and avoids the complications of laparotomy. Other benefits include better cosmesis, sphincter preservation, short operative time, short hospital stay, and cost effectiveness. The short-term outcomes of the procedure are promising [10].


  Patients and methods Top


This was a retrospective study conducted at the Pediatric Surgery Unit of Department of General Surgery, Menoufia University Hospital and Abu-El Reesh Insurance Hospital between October 2007 and November 2011.

This study included 20 patients with Hirschsprung's disease; there were 15 boys and five girls, their ages ranging from 6 months to 5 years. All these patients were subjected to transanal pull-through, and their data were retrieved by checking their files and focusing on the findings in the following points: history taking, clinical examination, radiological examination, rectal biopsy, routine laboratory investigations, preoperative preparation, surgical treatment, postoperative care, and postoperative follow-up.

Data chart was designed to collect the following information from operative sheets and outpatient clinic. Operative details included the level of initiating the submucosal dissection, length of excised segment (according to level of transitional zone in barium enema and determining the level of funneling intraoperative), estimated blood loss and blood transfusion, and conversion to laparotomy and its cause.

Postoperative complications were reported, and clinical outcome was assessed by interviews.


  Results Top


In our study, the mean age of patients was 32.1 ± 17.47 months, and boys-to-girls ratio was 3 : 1. The most common clinical manifestations of the studied group are presented in [Table 1]. The rectal biopsy was diagnostic in all patients, and barium enema was only diagnostic in 16 patients. Colonic biopsies, which were sent later, confirmed the presence of ganglion cells in the proximal end of the resected colon in 18 patients, with absent ganglionic cells in two patients. Intraoperative blood loss was negligible and no blood transfusion was needed. The mean operative time was 91.3 ± 11.89 min. The first per rectal examination was performed 2 weeks after operation with the little finger, and only two patients required repeated dilatations due to anastomotic stricture [Table 2]. Three infants had prolapse of the pulled-through colon on the fourth, 11th, and 15th postoperative day; two of them reduced uneventfully and one needed resection of the prolapsed segment. Six patients required readmission for treatment of enterocolitis (admitted after operation, 2 weeks, 3 months, 9 months, 10 months, 11 months, and 15 months). They were treated with saline rectal irrigation, no oral feeding, and third-generation cephalosporin. Nine patients showed increased stool frequency ranging from 4 to 10 times/day, which then improved with time ranging from 2 to 3 times/day, and only two patients developed fecal incontinence. Constipation developed in four patients [Table 3].
Table 1: The most common manifestations of the studied group

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Table 2: Diagnostic methods

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Table 3: Shows the late postoperative complications

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Statistics in this study were performed by computer using Epi Info Software version 6.04, a word processing, database, and statistics program (WHO, 2004).


  Discussion Top


Ninety-five percent of full-term infants pass meconium in the first 24 h of life, but less than 10% of children with Hirschsprung's disease pass meconium during that time [11]; in our series, 75% of patients experienced delayed passage of meconium. In addition, our study demonstrated a transition zone on barium enema; however, absence of transitional zone does not rule out the diagnosis.

The initial descriptions of transanal endorectal pull-through involved a long rectal cuff that reaches the peritoneal reflection, but this cuff may constrict the pulled-through bowel; in addition, the cuff may be rolled down into a ring during the pull-through. Hence, some authors now prefer shorter distance for mucosectomy that come through the full-thickness of the rectum 2-3 cm above the dentate line. This prevents cuff stenosis and at the same time protects nerve, prostate, and vagina from injury [12]. Moreover, many authors avoided mucosectomy and adopted transanal Soave's technique with successful preliminary results [13].

The mean operative time in our series was 91.3 ± 11.89 min, which is significantly shorter when compared with the Egyptian multicenter study by Elhalaby et al. [14] (120.2 ± 27.8 min) and with that by Teeraratkul [15] (140 min). This difference may attribute to gaining experience and increasing learning curve.

Postoperative enterocolitis was noted in 30% of our series. This in controversy to the series conducted by Hadidi [16] in which the incidence of enterocolitis was 4.4% only and to the series by Gao et al. [17] in which the incidence was 6%.

Several authors reported that preoperative enterocolitis significantly increases the incidence of postoperative enterocolitis. This has been attributed to predisposing immunologic factors shared by patients of Hirschsprung's disease, who seem to be prone to develop enterocolitis both preoperatively and postoperatively [18].

Stricture formation after definitive pull-through procedure is another important complication [19]. Four patients (20%) experienced constipation during follow-up periods; two of them showed stenosis at the suture line and responded to frequent dilatations. The risk factors for these strictures include anastomotic ischemia or dehiscence and circular anastomosis. Most strictures can be managed conservatively by adhering to a strict dilation regimen, and only a few persistent strictures require a more aggressive operative correction [20].

Two required redo-transanal pull-through to excise more length of the colon as their colonic biopsies showed absence of ganglion cells in the proximal colonic segment.

Nine patients showed increased stool frequency ranging from 4 to 10 times/day, which then improved with time ranging from 2 to 3 times/day. This improved with time, and, by 6 months to 1 year after surgery, it declined to 1-4 times/day [19].

In our study, only two patients developed fecal incontinence. Fecal incontinence in postoperative Hirschsprung's disease may be a consequence of functional constipation or high-amplitude propagating contractions through the rectum. In a healthy colon, several times each day high-amplitude propagating contractions begin in the cecum and dump the colon contents into the rectum. After Hirschsprung's surgery, high-amplitude propagating contractions move colon contents to the anal verge with neorectal pressures that often exceed the anal sphincter pressure. The child has two choices: relax the sphincter and experience incontinence or hold it tight. When the colon is transected, instead of several high-amplitude propagating contractions each day, there may be several each hour, and this can explain this incontinence [21].

Three infants had prolapse of the pulled-through colon on the fourth, 11th, and 15th postoperative day; two of them reduced uneventfully and one needed resection of the prolapsed segment.


  Conclusion Top


The current study was conducted at the Department of General Surgery, Menoufia University Hospital and Abu-El Reesh Insurance Hospital, Health Insurance Organization during a time period of 6 months to 2 years postoperative, from October 2007 to November 2011. This study included 20 patients with Hirschsprung's disease; there were 15 boys and five girls, their ages ranging from 6 months to 5 years.

Our results confirmed that transanal pull-through has become a widely popular procedure for the treatment of Hirschsprung's disease (especially those patients with short-segment disease); the procedure does not damage the pelvic structures, it is not expensive, and it has best cosmetic results.

Transanal pull-through is both feasible and safe for the management of patients with Hirschsprung's disease. It is associated with acceptable morbidity and mortality. Preoperative enterocolitis increases the incidence of postoperative enterocolitis and perianal excoriation. Both the transitional zone and a part of the dilated colon proximal to it should be excised to decrease the incidence of postoperative constipation.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.Spouge D, Baird PA. Hirschsprung′s disease in a large birth cohort. Teratology 1985; 32 :171-177.  Back to cited text no. 1
    
2. Ryan ET, Ecker JL, Christakis NA, et al. Hirschsprung′s disease: associated abnormalities and demography. J Pediatr Surg 1992; 27 :76-81.  Back to cited text no. 2
    
3. Iqbal MZ, Jahangir M, Anwar M, et al. Hirschsprung′s disease; modified Duhamel (Martin Mokification),a procedure of choice (a study at Sheikh Zayed Hospital Rahim Yar Khan). Professional Med J 2010; 17 :223-231.  Back to cited text no. 3
    
4. Whitehouse ER, Kernohan JW. Myenteric plexus in congenital megacolon. Arch Intern Med 1984; 82 :75.  Back to cited text no. 4
    
5. Polley TJr, Coran AG, Wesley JR. A ten years experience with ninety-two cases of Hirschsprung′s disease. Including sixty-seven consecutive endorectal pull-through procedures. Ann Surg 1985; 202 :349.  Back to cited text no. 5
    
6. Trigo GM, Del Tacca M, Lechinis, et al. Some observations on the intrinsic nervous mechanism in Hirschsprung′s disease. Gut 1973; 14 :15-40.  Back to cited text no. 6
    
7. Swenson O, Bill AH. Resection of rectum and rectosigmoid with preservation of the sphincter for benign spastic lesions producing megacolon. An experimental study. Surgery 1984; 24 :212-220.  Back to cited text no. 7
    
8. Langer JC, Minkes RK, Mazzioti MY, et al. Transanal one stage Soave procedure for infants with Hirschsprung′s disease. J Pediatr Surg 1999; 34 :148-151.  Back to cited text no. 8
    
9. Georgeson KE, Fuenfer MM, Hardin WD. Primary laparoscopic pull-through for Hirschsprung′s disease in infants and children. J Pediatr Surg 1995; 30 :1017-1022.  Back to cited text no. 9
    
10.Pratap A, Shakya VC, Biswas BK, et al. Single-stage transanal endorectal pull-through for Hirschsprung′s disease: perspective from a developing country. J Pediatr Surg 2001; 42 :532-535.  Back to cited text no. 10
    
11.Roshni D, Jacob CL. Transanal pull-through for Hirschsprung disease. Semin Pediatr Surg 2005; 14 :64-71.  Back to cited text no. 11
    
12.Rintala RJ, Wester T. Transanal endorectal pull-through with short muscular cuff in the treatment of Hirschsprung′sdisease. Preliminary study with 37 patients. Cir Pediatr 2003; 16 :161-165.  Back to cited text no. 12
    
13.Russeic MB, Russeic CA, Niebuhr E. An epidemiological study of Hirschsprung′s disease and additional anomalies. Acta Paediatr 1994; 83 :68.  Back to cited text no. 13
    
14.Elhalaby E, Hashish A, Elbarbary MM, et al. Transanal one stage endorectal pull-through for Hirschsprung′s disease: a multicenter study. J Pediatr Surg 2004; 39 :345-351.  Back to cited text no. 14
    
15.Teeraratkul S. Transanal one-stage endorectal pull-through for Hirschsprung′s disease in infants and children. J Pediatr Surg 2003; 38 :184-187.  Back to cited text no. 15
    
16.Hadidi A. Transanal endorectal pull-through for Hirschsprung′s disease: a comparison with the open technique. Eur J Pediatr Surg 2003; 13 :176-180.  Back to cited text no. 16
    
17.Gao Y, Li G, Zhang X, et al. Primary transanalrectosigmodectomy for Hirschsprung′s disease: preliminary results in the initial 33 cases. J Pediatr Surg 2001; 36 :1816-1819.  Back to cited text no. 17
    
18.Fouquet V, De Lagausie P, Faure C, et al. Do prognostic factors exist for total colonic aganglionosis with ileal involvement. J Pediatr Surg 2002; 37 :71-75.  Back to cited text no. 18
    
19.Teitelbaum DH, Coran AG. Long-term results and quality of life after treatment of Hirschsprung′s disease and allied disorders. In: Holschneider AM, Puri P, editors. Hirschsprung′s disease and allied disorders. 3rd ed.. New York, NY: Springer; 2008. 389-397.  Back to cited text no. 19
    
20.Engum SA, Grosfeld JL. Long-term results of treatment of Hirschsprung′s disease. Semin Pediatr Surg 2004; 13 :273-285.  Back to cited text no. 20
    
21.Kaul A, Connor F, Cocjin J, et al. Characterization of abnormalcolonic motor activity in children after surgery for Hirschsprung′sdisease: results of a multicenter study. J Pediatr Gastroenterol Nutr 2004; 39 :110.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Introduction
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