Laparoscopic vs. Transabdominal Treatment for Overflow Fecal Incontinence Due to Residual Aganglionosis or Transition Zone Pathology in Hirschsprung's Disease Reoperation.

Feng Chen,Xiaoyu Wei,Xiaohua Chen,Lei Xiang,Jiexiong Feng

doi:10.3389/fped.2021.600316

Abstract

Objective: The aim of this study was to describe the details of laparoscopic-assisted reoperative surgery for Hirschsprung's disease (HSCR) with overflow fecal incontinence, and to retrospectively compare laparoscopic-assisted surgery with transabdominal pull-through surgery.Methods: We retrospectively analyzed patients with HSCR with overflow fecal incontinence after the initial surgery in our center between January 2002 and December 2018. Pre-operative, peri-operative, and post-operative data were recorded for statistical analysis.Results: Thirty patients with overflow fecal incontinence after initial megacolon surgery [17 who underwent transanal pull-through (TA-PT) and 13 who underwent laparoscopic-assisted pull-through (LA-PT)] required a secondary surgery [reoperation with LA-PT (LAR-PT) (n = 16) or reoperation with transabdominal pull-through (TR-PT) (n = 14)]. Indications for reoperation were residual aganglionosis (RA) (7/30, 23.3%) or transition zone pathology (TZP) (23/17, 76.7%). Blood loss was significantly decreased in the LAR-PT group (75 ± 29.2 ml) compared to the TR-PT group (190 ± 51.4 ml) (P = 0.001). The length of hospital stay was significantly shorter in the LAR-PT group (10 ± 1.5 days) than that in the TR-PT group (13 ± 2.4 days). No significant differences were found between two groups in surgical methods, defecation function score, or post-operative complications except for wound infection (LAR-PT vs. TR-PT 0 vs. 28.6%, P < 0.05).Conclusions: It is necessary to make a comprehensive analysis of the causes of fecal incontinence after HSCR surgery and make an accurate judgment using appropriate methods. If a reoperation was inevitable for patients with overflow fecal incontinence due to RA or TZP, a comprehensive evaluation prior to the operation is required to maximize the benefit from reoperation. Although laparoscopic reoperation with heart-shaped anastomosis was safe and feasible for patients with failed initial Soave technique, unnecessary reoperation should be avoided as much as possible.

Highlights

Since Swenson [1] first successfully performed surgical treatment for Hirschsprung’s disease (HSCR) in 1948, many modifications and advanced techniques have been used to improve this intervention
We classified the type of fecal incontinence in children with incontinence after HSCR surgery according to an algorithm (Figure 1). [1] The anal canal was intact: if a barium enema (BE) showed that the colon was dilated, and the patient had a history of constipation, the disorder was considered overflow fecal incontinence caused by intestinal hypomotility; if a BE showed an undiluted colon, it was considered as intestinal hypermotility, and loperamide, pectin, and dietary modifications were offered
Review of the surgical records and post-operative routine pathology showed that the rectum or rectosigmoid had been resected, and the normal intestine with normal ganglions was anastomosed at the distal end

Summary

Introduction

Since Swenson [1] first successfully performed surgical treatment for Hirschsprung’s disease (HSCR) in 1948, many modifications and advanced techniques have been used to improve this intervention. With the development of the less invasive surgical techniques, quality of life for patients with HSCR have been improved vastly. Many post-operative complications may occur, such as constipation, abdominal distention, soiling, and incontinence (defined as a patient with involuntary bowel movements) [2]. The physiologic elements needed to maintain continence include intact anal sensation, voluntary sphincter control, and appropriate colonic motility [3]. Once these constituent become damaged, partial or total fecal incontinence will occur.

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Discussion

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