Obstructive complications after pull-through for Hirschsprung\u2019s disease: different causes and tailored management

Mohammed Elsherbeny,Sameh Abdelhay

doi:10.1186/s43159-019-0003-y

Abstract

BackgroundMost children have a successful outcome after a pull-through for Hirschsprung’s disease. Some may have persisting symptoms after the pull-through. They could be managed conservatively, need minor surgical procedures, or a redo pull-through will be required. In this study, we presented our results in the management of the obstructive complications after pull-through for Hirschsprung’s disease.ResultsDuring the specified time period from January 2011 to December 2015, 21 patients presented to our department with persistent constipation or recurrent enterocolitis after a pull-through for Hirschsprung’s disease. Their age ranged between 4 months and 5 years (mean 2 years, median 2.5 years). They were 13 males and 8 females. Eleven patients underwent initial trans-anal endorectal pull-through, 4 underwent Duhamel procedure, and 6 underwent abdominal Soave technique. Three of the 11 patients with initial trans-anal endorectal pull-through had a tight anastomotic stricture which responded well to dilatation, 2 had a long muscular cuff which was incised laparoscopically, 4 had spasm of the internal anal sphincter which was relieved by sphincterotomy, and 2 had residual aganglionosis which required a redo pull-through. Two of the 4 patients who underwent initial Duhamel procedure had a long spur which was divided using a stapler, and the other 2 patients had residual aganglionosis which required a redo pull-through. One of the 6 patients who underwent abdominal Soave technique developed a long tight stricture and required a redo pull-through; in 1 patient, biopsy confirmed hypoganglionosis of the whole colon and was managed medically, and 4 patients had spasm of the internal anal sphincter which was relieved in 1 of them by sphincterotomy and in 2 by botulinum toxin injection while the remaining patient did not improve by either sphincterotomy or botulinum toxin injection.ConclusionPersistent constipation or recurrent enterocolitis after pull-through for Hirschsprung’s disease should be managed according to the cause; they could be managed medically by simple surgical procedures, or a redo pull-through may be required.

Highlights

Most children have a successful outcome after a pull-through for Hirschsprung’s disease
* Correspondence: mohamedsaid@med.asu.edu.eg Department of Pediatric Surgery, Faculty of Medicine, Ain Shams University, Lotfy Elsayed St., Abbassyyah, Cairo, Egypt. The cause of these complications may be a functional problem in the whole colon, anastomotic stricture, long obstructing seromuscular cuff, long spur after a Duhamel procedure, twisted pull-through, spasm of the internal anal sphincter, or residual aganglionosis [3]
We presented our results in the management of the obstructive complications after pull-through for Hirschsprung’s disease

Summary

Introduction

Most children have a successful outcome after a pull-through for Hirschsprung’s disease. About 32% of children have complications after a pull-through for Hirschsprung’s disease [1] These complications may be persistent constipation, recurrent enterocolitis, or stool incontinence [2]. The cause of these complications may be a functional problem in the whole colon, anastomotic stricture, long obstructing seromuscular cuff, long spur after a Duhamel procedure, twisted pull-through, spasm of the internal anal sphincter, or residual aganglionosis [3]. These complications can be managed medically using drugs which improve the intestinal motility, by simple surgical procedures like dilatation of a stricture, splitting of a long obstructing seromuscular cuff, division of a spur, sphincterotomy, botulinum toxin injection, or a Elsherbeny and Abdelhay Annals of Pediatric Surgery (2019) 15:2 redo pull-through procedure may be the only option to relieve the child complaint [4, 5].

Methods

Results

Discussion

Conclusion