Operative failure and secondary repair in Hirschsprung's disease

Abstract

The particular advantages of a variety of operations used in the treatment of Hirschsprung's disease have been widely described. Similar endeavors, guiding the surgeon should any one of these procedures fail, are decidedly less common. The referral of five children with operative failures led us to review our experience with secondary repairs in children with Hirschsprung's disease. The failed operations included the following pull-through procedures: Primary and secondary endorectal (4). Swenson (1), Duhamel (3), State-Rehbein (1) and an ileoproctostomy (1). Our review indicates that identical complications, such as anastomotic leaks, require different approaches depending on the primary procedure. Most patients with major complications did not respond adequately to diverting colostomies or direct operative repair alone, but required either a repetition of the primary procedure or a conversion into another type of abdominoperineal pull-through procedure. In three patients with a failed endorectal pull-through procedure, the anastomosis was taken down and the endorectal pull-through successfully repeated. Of three patients with a failed Duhamel procedure, one required a conversion into an endorectal procedure and another into a Swenson procedure. A failed ileoproctostomy and a failed State-Rehbein procedure were successfully converted into Duhamel pull-through procedures. Our experience with failed operative procedures for Hirschsprung's disease indicated that major complications after abdominoperineal pull-through procedures appear to be more common than reported, that secondary repair varies considerably and may require either a direct repair, a repetition of the original procedure or a conversion into another type of abdomino-perineal pullthrough, and that even major failures can be corrected successfully with the appropriate selection of the secondary procedure. The particular advantages of a variety of operations used in the treatment of Hirschsprung's disease have been widely described. Similar endeavors, guiding the surgeon should any one of these procedures fail, are decidedly less common. The referral of five children with operative failures led us to review our experience with secondary repairs in children with Hirschsprung's disease. The failed operations included the following pull-through procedures: Primary and secondary endorectal (4). Swenson (1), Duhamel (3), State-Rehbein (1) and an ileoproctostomy (1). Our review indicates that identical complications, such as anastomotic leaks, require different approaches depending on the primary procedure. Most patients with major complications did not respond adequately to diverting colostomies or direct operative repair alone, but required either a repetition of the primary procedure or a conversion into another type of abdominoperineal pull-through procedure. In three patients with a failed endorectal pull-through procedure, the anastomosis was taken down and the endorectal pull-through successfully repeated. Of three patients with a failed Duhamel procedure, one required a conversion into an endorectal procedure and another into a Swenson procedure. A failed ileoproctostomy and a failed State-Rehbein procedure were successfully converted into Duhamel pull-through procedures. Our experience with failed operative procedures for Hirschsprung's disease indicated that major complications after abdominoperineal pull-through procedures appear to be more common than reported, that secondary repair varies considerably and may require either a direct repair, a repetition of the original procedure or a conversion into another type of abdomino-perineal pullthrough, and that even major failures can be corrected successfully with the appropriate selection of the secondary procedure.