Redo pull through combined procedures in Hirschprung disease

Abstract

Introduction. One of the actual problems of reconstructive colorectal surgery in childhood is a high frequency of complications after the initial reconstructive procedures for Hirschprung disease. Currently, in the clinical practice there is a wide range of surgical techniques, the combination of which allows to avoid serious outcomes leading to child’s disability. The choice of the volume of repeated surgeries is strictly individual, depending on the nature of complications, types of previously performed surgeries as well as on patient’s initial status. The key for developing a curative tactics is findings after instrumental and morphological examination which were obtained for previous interventions and which often require additional further clarification.Material and methods. In 2010–2021, in the Center of Pediatric Colorectal Anomalies (Irkutsk, Russia) redo endorectal pullthrough surgeries were performed in 18 patients with Hirschprung disease after previous correcting interventions. Surgeons made transanal resection in combination with posterior sagittal perineotomy. Indications for repeated surgical procedures, in most cases, were residual aganglionic segments and the constipation relapses – 11 (61,2%) patients; scar deformation and anus channel stenosis – 5 (27,8%) patients; stricture of coloanal anastomosis – 1 (5,5%) patient; scar stenosis of the neorectum with a rectobulbar fistula – 1 (5,5%) patient.Results. 13 (72,2%) patients had good clinical outcomes: no parents’ complaints, stable rhythms of defecation (from 1 to 4 times per day), feces contents (type 3–6 by Bristol scale of feces). In 4 (22,2%) cases, there was chronic constipation where defecation was 2–3 times a week with preserved defecation urgencies and rare episodes of anal overflow incontinence requiring conservative treatment under the bowel emptying program. One patient had a stricture of coloanal anastomosis which was corrected with its dissection and further dilatation.Conclusion. To confirm indications for redo surgeries, a comprehensive assessment of the colon and perineum with clinical, functional and morphological examination is required. Transanal pull-down is a relatively safe procedure which, in most cases, has good and satisfactory clinical postoperative results and which may be performed even after previous endorectal resections. The rehabilitation program after the discussed surgery is strictly personified and developed under close interaction of a surgeon and a gastroenterologist after assessing the state of the formed coloanal anastomosis and the distal part of the pulled-down intestine.