Duhamel Procedure Research Articles

Short-Term Complications Between Duhamel and Soave Procedures in Hirschsprung Patients: A Systematic Review

Hirschsprung's disease, or congenital megacolon, is a birth defect where ganglions are absent in the gut wall, leading to constipation and intestinal obstruction. It affects 1 in 500 births worldwide and, if untreated or treated late, significantly impacts children's growth and quality of life. Understanding the short-term complications of the Soave and Duhamel methods in Hirschsprung disease patients. A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In our initial PubMed search and hand-searching, we identified 36 articles. After screening titles and abstracts, four were relevant for discussion. We included three articles in our systematic review after reading the full texts. Enterocolitis was more frequent with the Duhamel procedure (28%) compared to the Soave procedure (10%). The risk of Hirschsprung-associated enterocolitis (HAEC) increased in patients with a history of enterocolitis in both treatment groups. Two studies indicate that short-term complications such as constipation and bloating occur more frequently after the Soave procedure than the Duhamel procedure. Based on the three studies we discussed, HAEC was more frequent in the Duhamel procedure than in the Soave procedure, with significant differences. Constipation was more common in the Soave procedure. Both procedures may cause complications such as voluntary bowel movement, soiling, and fecal incontinence, with no statistically significant differences. Minor complications in the Soave procedure include poor weight gain and strong-smelling flatulence. In the Duhamel procedure, minor complications include hardened stools and poor appetite.

Early Outcomes of Hirschsprung's Disease after Definitive Surgery: A Ten-Year Experience.

This study aimed to examine the characteristics of Hirschsprung's Disease (HD) in patients aged<18 who underwent surgical procedure at Dr. Zainoel Abidin (RSUDZA) General Hospital, Banda Aceh, Indonesia, between January 2010 and December 2020. This retrospective study collected and analyzed data from medical records of 18-yearold or younger children (n = 180) diagnosed with HD at RSUDZA. The surgical procedures included the Duhamel procedure, Soave procedure, the Soave Transanal Endorectal Pull-through (TEPT) procedure, and the Swenson TEPT procedure. Early outcomes of the surgery were then compared between males and females. The comparrative analysis was determined based on Chisquare analysis, where p&#60; 0.05 was considered significant. There were 111 (61.7%) male patients and 69 (38.3%) female patients, with a mean age of 15.2 months. The Soave TEPT is the most frequently performed procedure (91.7%). Emerging clinical manifestations include constipation (176; 97.8%) and soiling (171; 95%). Preoperative barium enema and postoperative pathological examination confirmed that almost all patients (99.4%) had an aganglionic segment confined to the rectosigmoid area. The average length of operation was 69.7 ± 65 minutes and average bleeding time was 5.4 ± 34 mL. The average discharge time was 3.3 ± 73.3 days. No significant difference was found in post-surgery complications between males and females (p&#60;0.5). The immediate complications were not associated with surgical methods (p = 0.83). Our descriptive study has suggested the Soave TEPT technique as appropriate to manage HD.

Comparison of Long-term Outcomes between Hirschsprung's Disease Patients after Soave Procedure and Duhamel Procedure Based on the Paediatric Incontinence and Constipation Scoring System: A Retrospective Cohort Study

Introduction: Hirschprung's disease is a congenital disease that causes intestinal motility disorders. Hirschprung's disease is still the most common condition that causes intestinal obstruction in children. The incidence of Hirschprung's disease is 1:5000 live births. The incidence ratio of this disease is around 4:1 between men and women, with a higher percentage of men 1,3,4. Approximately 75% of cases of Hirschprung's disease occur in the rectosigmoid colon area, 17% in the splenic flexure or transverse colon and 8% along the colon and terminal ileum. The Duhamel technique still remains a popular procedure most surgeons especially for long segment treatment and redo procedures.28, 30 The advantage of the Duhamel Procedure is that it is easy to perform, reduces the risk of damage to surrounding structures such as genitourinary innervation, but has the possibility of complications of anastomotic leakage which causes fistulas and abscesses.&#x0D; Materials and Methods: Total subjects of this study was 441 patients with Hirschprung's disease who were treated with the Soave procedure and the Duhamel procedure at Dr. Moewardi General Hospital in Surakarta, Central Java, Indonesia for the period January 2017 - January 2022. This type of research is descriptive analytics with a retrospective cohort.&#x0D; Results: The results of the study can be concluded that patients with HAEC increases the risk of constipation. Congenital abnormalities predispose to fecal incontinence. Differences in surgical techniques do not significantly influence or increase the risk of constipation and fecal incontinence based on statistical tests. However, the increased risk of constipation and fecal incontinence is higher in patients undergoing the Duhamel surgical procedure.&#x0D; Conclusion: Conclusions that can be drawn from research regarding the comparison of long-term outcomes of Hirschsprung disease patients after Soave and Duhamel operations based on the Pediatric Incontinence and Constipation Scoring System at Dr. Moewardi General Hospital in Surakarta, Indonesia for period January 2017 – January 2022, it can be concluded that there is no significant difference in the outcome of patients who underwent the Soave or Duhamel procedures. The Duhamel procedure has a higher prevalence of complications of constipation and fecal incontinence compared to the Soave procedure. The presence of HAEC before the surgical procedure increases the risk of constipation, significantly in the Soave and Duhamel procedures.

Comparative study between two-stage trans-abdominal Duhamel procedure and two-stage Soave pull-through in treatment of Hirschsprung’s disease: Clinical evaluation

Comparative study between two-stage trans-abdominal Duhamel procedure and two-stage Soave pull-through in treatment of Hirschsprung’s disease: Clinical evaluation

Assessment of Functional Outcome Following Duhamel Retro-Rectal Pull-Through Surgery for Hirschsprung's Disease - A Follow-up Study

Abstract Context Hirschsprung's disease (HD) is one of the commonest problems requiring surgery in children. More than 95% of children present during new-born period, when they are treated with leveling colostomy and are followed with pull-through surgery a few months later, once the child has gained adequate weight to withstand a major surgery. The commonest pull through surgery done is the Duhamel retro-rectal pull-through (DRPT) repair. Settings and Design This is a retrospective study of children who presented to one unit in our institute, a tertiary care referral hospital for children less than 12 years, with HD and underwent DRPT procedure during the period between July 2017 to June 2020. The children were evaluated after three years of follow-up for fecal incontinence and constipation. The study was conducted in children diagnosed with classical segment recto-sigmoid HD who underwent surgery. The children who were diagnosed with HD other than classical segment, who underwent primary pull through surgery and who underwent other repairs for HD were excluded from the study. Results Thirty-two children underwent DRPT procedure during the study period. Of them, five (15.6%) children were lost on follow-up and one (3.1%) child had expired in the immediate post-operative period. Twenty-six children were included in the study. The bowel function score was calculated. The mean age of definitive surgery was 4.2 years. The follow-up period was a minimum of three years. Only two children had a “good” score of eighteen and above. Nineteen children had a “fair” score of 13–17. Five children had a “poor” score of less than thirteen, and among them, two had a “very poor” score of less than nine. The mean BFS was 13.72. Conclusions Functional outcomes following Duhamel procedure are satisfactory, with 7.7% of children are in the fringe of requiring another surgery for constipation and pseudo-incontinence.

Comparison of the Duhamel Procedure and Transanal Endorectal Pull-through Procedure in the Treatment of Children with Hirschsprung's Disease: A Systematic Review.

Studies comparing the Duhamel and TERPT procedures were included until 22 July 2023. R software (version 4.3.0) was used to perform the meta-analysis. Ten studies with a sum of 496 patients were included. The length of postoperative hospital stay and incidence of postoperative constipation were longer and higher after the Duhamel procedure than the TERPT procedure (p < 0.0001 and p = 0.0041, respectively). The incidence of postoperative anastomotic stricture was higher after the TERPT procedure than the Duhamel procedure (p = 0.0015). No significant differences were found in the incidence of postoperative fecal continence, fecal incontinence/soiling, anastomotic leak, or ileus between these two procedures. The operation time seemed to be similar for both procedures, but it became longer for the Duhamel procedure than the TERPT procedure after sensitivity analysis. While the incidence of postoperative enterocolitis seemed to be higher after the TERPT procedure, it became similar for both procedures in the subgroup analysis. The Duhamel procedure seems to be associated with a longer length of postoperative hospital stay, a higher incidence of postoperative constipation, and a lower incidence of postoperative anastomotic stricture than the TERPT procedure. However, the effect of these two procedures on the operation time and the incidence of postoperative enterocolitis remains unclear.

Hirschsprung disease.

Hirschsprung disease (HSCR) is a rare congenital intestinal disease that occurs in 1 in 5,000 live births. HSCR is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses of the intestine. Most patients present during the neonatal period with the first meconium passage delayed beyond 24 h, abdominal distension and vomiting. Syndromes associated with HSCR include trisomy 21, Mowat-Wilson syndrome, congenital central hypoventilation syndrome, Shah-Waardenburg syndrome and cartilage-hair hypoplasia. Multiple putative genes are involved in familial and isolated HSCR, of which the most common are the RET proto-oncogene and EDNRB. Diagnosis consists of visualization of a transition zone on contrast enema and confirmation via rectal biopsy. HSCR is typically managed by surgical removal of the aganglionic bowel and reconstruction of the intestinal tract by connecting the normally innervated bowel down to the anus while preserving normal sphincter function. Several procedures, namely Swenson, Soave and Duhamel procedures, can be undertaken and may include a laparoscopically assisted approach. Short-term and long-term comorbidities include persistent obstructive symptoms, enterocolitis and soiling. Continued research and innovation to better understand disease mechanisms holds promise for developing novel techniques for diagnosis and therapy, and improving outcomes inpatients.

Management of children afflicted with hirschsprung’s disease: a narrative review

Introduction: Hirschsprung's disease is a genetic anomaly with an incidence of 1 in 5000 births, predominantly affecting females at a ratio of 1:4. It is characterized by the absence of ganglion cells in the enteric nervous system in the distal segment of the gastrointestinal tract. Approximately 90% of individuals with Hirschsprung's disease present with symptoms in the neonatal period. Classic symptoms include abdominal distension (&gt;90%), vomiting (&gt;85%), which can be bilious, and the absence of meconium passage in the first 24 hours of life (&gt;60%). Diagnosis is established through biopsies (gold standard), contrast enema, and anorectal manometry. While awaiting the results of rectal biopsy, saline rectal irrigations should be initiated one to three times daily to achieve functional bowel obstruction relief and enable enteral feeding until the pull-through operation. There are many surgical approaches for Hirschsprung's disease, including transabdominal approach (TAB) and transanal pull-through (TERPT). TAB mainly includes Swenson, Duhamel, Duhamel and Soave techniques. Swenson involves the removal of the affected area entirely with a termino-terminal anastomosis to the anal canal. In Duhamel, the normal colon is usually brought through the posterior rectal space and anastomosed with the contralateral rectum. In Soave, saline is injected into the rectum after circularly cutting the rectal muscular layer, leaving the mucosa intact at the level of the dentate line. Later, De La Torre-Mondragon proposed a new treatment called single-stage TERPT, a minimally invasive surgery with an anal approach that eliminates abdominal adhesions and pelvic nerve injury. The most commonly performed operation is the Duhamel procedure. The benefits of Duhamel include decreased stool frequency and increased consistency, but they must be balanced with the risk of pouch dilation and stool stasis. TERPT is superior to TAB in terms of hospital stay and constipation. However, there are still a large number of randomized studies to be verified, and more trials are expected to be conducted in the future to determine the best surgery. Among the postoperative complications are enterocolitis, dermatitis, fecal incontinence, and obstruction, with enterocolitis having the highest morbidity and mortality. Alternative treatments, although lacking evidence to prove their efficacy, include botulinum toxin, probiotics, and laser therapy. Objective: To synthesize the main and most up-to-date knowledge on the management of children with Hirschsprung's disease, from diagnosis to definitive treatment. Methods: This study is a narrative review. To carry out this work, systematic reviews, meta-analyses, and cohort studies published in the last five years (2018 to 2022) were searched in the PUBMED scientific database. The keywords used were "Hirschsprung disease" and "Surgical treatment." Sixteen articles were found in the database.

Case report: Anal tuberculosis presenting as an anal fistula

This is a case of a young gentleman, who presented with complaints of hematochezia, weight loss and fluctuating fever for the past five months. The patient was a known case of Hirschsprung disease and Ulcerative colitis (IUC) and underwent a rectal Duhamel procedure in the past. On examination there was a fistula with an external opening at the anal verge. The clinical suspicion at this point was enterocutaneous fistula, abscess, and incontinence secondary to Hirschsprung disease. Investigations including MRI and sigmoidoscopy were carried out. A tissue from the anorectal junction was taken for histopathology review. Histopathological analysis suggested granulomatous inflammation with collection of epithelioid histiocytes along with caseating necrosis. This was consistent with the diagnosis of anal tuberculosis. The patient was started on a quadruple regimen of anti-tuberculous drugs (ATT). The patient six months into treatment has shown significant clinical improvement.

Correlation between the number of Interstitial cells of Cajal (ICC) and defecation pattern in patients with Hirschsprung's disease after Duhamel's surgery at General Hospital Dr. Soetomo

Background: Hirschsprung is a congenital disorder of the distal bowel caused by the absence of a ganglion in the Aurbach and Meissner plexuses. Definitive treatment of the disorder is operative, namely by resection of the aganglionic segment of the intestine and performing a pull-through on the ganglionic segment. It cannot be denied that there are still disturbances in the pattern of defecation after definitive surgery, even though the pull-through segment has enough ganglion cells. Interstitial cells of Cajal (ICC) are the pacemaker in smooth muscle contraction in the intestine. In several studies, the number of these cells decreased in Hirschsprung's disease (HD), and it is not known with certainty the effect on the occurrence of defecation pattern disturbances. Methods: Data were collected retrospectively from all patients with Hirschsprung’s Disease (HD) who underwent Duhamel Procedure in Dr. Soetomo General Hospital, starting January 2016 – December 2021. Correlation analytic research with a cross sectional design was performed to analyze the correlation between the number of ICC and the defecation pattern of patients at Dr. Soetomo after Duhamel surgery. Results: From this study, it was found a decrease in the number of ICC in the ganglionic segments of the resected specimens from pull-through surgery. From the results of the correlation test, it was found that the p-value was 0.49 for the defecation pattern of postoperative Duhamel patients at Dr. Soetomo for the period January 2016 – December 2021. Conclusion: In this study, a significant correlation was found between the number of ICC and definitive pull-through postoperative defecation pattern.

Minimally invasive surgery inolder children with Hirschsprung's disease in a North African Country.

Hirschsprung's disease (HSD) is a bowel congenital anomaly affecting mainly the enteric nervous system of the rectosigmoid region. Surgical resection of the aganglionic segment and restoration of bowel continuity via coloanal anastomosis is the main stay of treatment. In 1999, Georgeson et al. introduced a new minimally invasive approach as a standard for the pull-through mechanism. This study aims to evaluate the safety and possibility of the use of a laparoscope in older children with HSD with various techniques for HSD surgery. This study was performed based on 20 patients diagnosed with HSD. The patients are older children, whose mean age is 3 years. The cases showing enterocolitis or obstruction were excluded from the study. We divided these cases into two groups: Group A, consisting of 10 cases where laparoscopic-aided transanal pull-through was done, and group B, in which the laparoscopic Duhamel procedure was done. We compared between two groups for the first year follow-up period. In Group A, there were two cases of stenosis that respond to regular dilation: one case of enterocolitis and one case of fecal incontinence. In Group B, we had two cases of constipation and three cases of enterocolitis. There was no anastomotic leak in both groups. Minimally invasive surgery is safe in management of HSD in older children in one stage, either by using the Duhamel or transanal Swenson procedure.

Exome sequencing identifies novel genes and variants in patients with Hirschsprung disease

BackgroundHirschsprung disease (HSCR) is a complex genetic disease characterized by the absence of ganglion cells in the intestines, leading to a functional obstruction in infants. At least 24 genes have been identified for the pathogenesis of HSCR. They contributed to approximately 72% of HSCR cases. We aimed to elucidate further the genetic basis of HSCR in Indonesia using the whole-exome sequencing (WES) approach. MethodsWES was performed in 39 sporadic non-syndromic HSCR patients and 16 non-HSCR subjects as controls. Variants presented in controls were excluded, followed by in silico prediction tools and population allele frequency databases to select rare variants. We determined the minor allele frequency (MAF) using gnomAD (MAF <0.1%). ResultsWe involved 24 (61.5%) males and 15 (38.5%) females. Most patients (62%) had short-segment aganglionosis and underwent the Duhamel procedure (41%). We identified several candidate novel variants in HSCR-related genes, including UBR4, GDNF, and ECE1. Moreover, we also identified some novel candidate genes, including a possible compound heterozygous variant in the MUTYH gene: the first variant, a known protein-truncating variant associated with colorectal cancer (CRC), p.Glu452Ter and the second variant is novel, p.Ala39Val. Moreover, the type of variants was not associated with the aganglionosis type. ConclusionsWe identified several novel genes and variants, including the variant associated with CRC, that might contribute to the pathogenesis of HSCR. No genotype–phenotype associations were noted. Our study further confirms the complex network involved in enteric nervous system development and HSCR pathogenesis. Level of evidenceLevel III.

Anal canal and sphincter function in children with Hirschsprung disease after definitive surgery

IntroductionAnorectal manometry may be useful to objectively evaluate anorectal function following definitive pullthrough for Hirschsprung Disease (HD) but there is little published data. Our study aims to investigate anorectal manometry findings and their association with bowel function. MethodologyThis was a prospective observational study. Convenience sampling method was used to recruit all HD patients who had definitive pullthrough from January 2019 to December2020 in our institution. High-resolution anorectal manometry (HRAM) was used to record anal resting pressure (ARP), length of high-pressure zone (HPZ), and presence/absence of recto-anal inhibitory reflex (RAIR). The Paediatric Incontinence/Constipation Scoring System (PICSS) was scored for all participants. PICSS is a validated questionnaire with scores mapped to an age-specific normogram to denote constipation, incontinence, and their combinations. Non-parametric and chi-square tests at significance p<0.05 were conducted to examine the relationship between PICSS categories and manometry findings. Ethical approval was obtained. ResultsThere were 32 participants (30 boys). Median age at participation was 26.5 months (range: 13.8–156). Twenty-four (75%) had transanal pullthrough, 8(25%) underwent Duhamel procedure. PICSS scored 10(31.3%) as normal, 8(25%) as constipation, 10(31.3%) as incontinent, and 4(12.5%) as mixed. RAIR was present in 12 patients (37.5%). HPZ, maximum ARP, mean ARP were comparable across all PICSS groups without statistically significant differences. Presence of RAIR was not significantly associated with any PICSS groups (p = 0.13). ConclusionBowel function does not appear to be significantly associated with HRAM findings after definitive pullthrough for HD, but our study is limited by small sample size. RAIR was present in 37.5% patients after pullthrough. Level of EvidenceLevel II

S3370 Chronic Intestinal Obstruction in Surgically Treated Hirschsprung’s Disease: A Rare Presentation

Introduction: Hirschsprung’s Disease (HD) is exceedingly rare and represents a failure of ganglion cell migration to the gut. Longitudinal studies examining long-term outcomes of surgically treated HD are extremely limited. We discuss a patient who underwent surgical treatment for HD as an infant and presented in adulthood with severe abdominal pain and weight loss. Case Description/Methods: A 34-year-old female presented with severe abdominal pain and 15-pound weight loss over 1 month. She had a history of HD that involved the entire colon diagnosed at 6 months which was treated with the Duhamel procedure at age 1. Her postoperative course was complicated by recurrent small bowel obstruction (SBO) requiring multiple surgeries for adhesiolysis. She continued to pass gas; bowel movements were at baseline. Physical exam revealed mild distention and tenderness in the periumbilical region. CT showed marked small bowel dilation proximal to the anastomosis, multiple areas of focal narrowing, and significant stool burden (Figure A). Endoscopy revealed nonobstructive ileal stenosis proximal to the anastomosis and ileal ulcerations with biopsies showing acute and chronic inflammation with cryptitis (Figure B). Empiric treatment for small intestinal bacterial overgrowth and Hirschsprung-associated enterocolitis were initiated without improvement. She was also trialed on mesalamine with no benefit. Manometry revealed impaired recto-anal inhibitory reflex possibly due to residual HD and Type 1 dyssynergic defecation. She was started on prucalopride with some improvement of her abdominal pain. Providing non-invasive venting options remains an ongoing challenge. Discussion: The curative treatment for HD is surgical resection and the limited studies on long-term outcomes of these patients have demonstrated that constipation or diarrhea are common, and obstructive symptoms or dyssynergia are rare. Potential reasons for the complications presented in this case include mechanical obstruction from strictures and possible residual aganglionosis from insufficient resection. Additionally, prolonged bowel dilation may lead to impaired motility, evacuation difficulties, chronic dilation, and ischemic changes. There is a need for longitudinal studies at dedicated colorectal centers to provide effective transition of care from childhood to adulthood as well as a formalized approach to the management of postoperative complications of HD in adulthood, especially as these issues closely relate to functional status and quality of life.Figure 1.: A: CT demonstrating areas of narrowing and marked dilation proximal to the anastomosis B: Endoscopic view of the ileum demonstrating ulceration and stenosis at the anastomosis site.

Impact of rectal dissection technique on primary-school-age outcomes for a British and Irish cohort of children with Hirschsprung disease

BackgroundThis prospective cohort study compared primary-school-aged outcomes between children with Hirschsprung disease (HD) following Soave, Duhamel or Swenson procedures. MethodsChildren with histologically proven HD were identified in British/Irish paediatric surgical centers (01/10/2010-30/09/2012). Parent/clinician outcomes were collected when children were 5–8 years old and combined with management/early outcomes data. Propensity score/covariate adjusted multiple-event-Cox and multivariable logistic regression analyses were used. Results277 (91%) of 305 children underwent a pull-through (53% Soave, 37% Duhamel, 9% Swenson). Based upon 259 children (94%) with complete operative data, unplanned reoperation rates (95% CI) per-person year of follow-up were 0.11 (0.08–0.13), 0.34 (0.29–0.40) and 1.06 (0.86–1.31) in the Soave/Duhamel/Swenson groups respectively. Adjusted Hazard Ratios for unplanned reoperation compared with the Soave were 1.50 (95% CI 0.66-3.44, p = 0.335) and 7.57 (95% CI 3.39-16.93, p < 0.001) for the Duhamel/Swenson respectively. Of 217 post-pull-through children with 5–8 year follow-up, 62%, 55%, and 62% in Soave/Duhamel/Swenson groups reported faecal incontinence. In comparison to Soave, Duhamel was associated with lower risk of faecal incontinence (aOR 0.34,95%CI 0.13-0.89,p = 0.028). Of 191 children without a stoma, 42%, 59% and 30% in Soave/Duhamel/Swenson groups required assistance to maintain bowel movements; compared to Soave, the Duhamel group were more likely to require assistance (aOR 2.61,95% CI 1.03–6.60,p = 0.043). ConclusionsCompared with Soave, Swenson was associated with increased risk of unplanned reoperation, whilst Duhamel was associated with reduced risk of faecal incontinence, but increased risk of constipation at 5–8 years of age. The risk profiles described can be used to inform consent discussions between surgeons and parents. Level of evidenceLevel II

Long-term functional outcomes of patients with Hirschsprung disease following pull-through

BackgroundHirschsprung disease (HSCR) is a common congenital disorder presenting with functional obstruction due to aganglionosis of the colon. There are numerous types of pull-through surgery for managing HSCR, such as transabdominal endorectal (Soave), Swenson, Duhamel, transanal endorectal pull-through (TEPT), and laparoscopic (Georgeson) approach. Here, we aimed to describe the long-term outcome of patients with HSCR who underwent transabdominal Soave, Duhamel, and TEPT in our institution.MethodsWe performed a cross-sectional analysis for patients who underwent Duhamel, Soave, and TEPT at our institution from January 2012 to December 2015. Long-term functional outcome was determined by bowel function score (BFS). The BFS was obtained by interviewing patients who had completed at least three years of follow-up.ResultsTwenty-five patients were included in this study who underwent transabdominal Soave (n = 8), Duhamel (n = 4), and TEPT (n = 13). There were 24 patients with short aganglionosis type. The median age of HSCR diagnosis was 10 (IQR = 1–39) months, while the median age of pull-through surgery was 17 (IQR = 7–47) months. The median follow-up of BFS level for HSCR patients after pull-through was 72 (IQR, 54–99) months. There were 11 patients with good BFS level and 10 patients with normal BFS level. Additionally, 50% of Duhamel patients had poor BFS level, while 50% of Soave patients had good BFS level, and 54% of TEPT patients had normal BFS level (p = 0.027). As many as 50% of Duhamel patients showed daily soiling and required protective aids, while 38.5% of TEPT had staining less than 1/week and no change of underwear required, and 50% of Soave patients revealed no soiling, respectively (p = 0.030). Furthermore, 75% of Duhamel patients had accidents, while 75% of Soave and 46.2% of TEPT patients had no accidents (p = 0.035).ConclusionOur study shows that the type of definitive surgery might affect the long-term bowel functional outcome; particularly, the TEPT approach might have some advantages over the transabdominal Soave and Duhamel procedures.

Comparison of Complication Regarding Modified Duhamel Procedure for Hirschsprung’s Disease in Male to Female Children

Aim: To compare the complications regarding modified Duhamel procedure in male to female children for Hirschsprung’s disease (HSCR).&#x0D; Methodology: This comparative retrospective study was done at pediatric surgery department PUMHSW Nawabshah during Jun 2019-Aug 2020. Sample size was selected as 70 patients and divided it into two groups. Group A contain 45 male children while group B also consists of 25 female children. The children between the age of 2-15 year, both sexes and confirm Hirschsprung’s disease was included in this study while the children below 2 years. The study was approved by ethical review board PUMHSW Nawabshah. Written informed consent was obtained from parents or guardians of the participants. &#x0D; Results: There were 64.28% (n=45) male and 35.72% (25) female patients (Fig 1). The mean weight of patients in male was 17.8 ± 7.6 kg while in female was 15.6±6.27 kg (Fig 2). In the distribution of patients by complications, anorectal stenosis was present in 13.33% (n=6) in male while 12% (n=3) in female children. Wound infection was present in 8.88% (n=4) in male and 8% (n=2) in female children. Intestinal obstruction was present in 11.11% (n=5) and 12% (n=3) in male and female children respectively.&#x0D; Conclusion: It was concluded that modified Duhamel Procedure for Hirschsprung’s disease has less postoperative complications in both male and females moreover there is no significant difference of postoperative complications in both sexes.

Laparoscopic-assisted duhamel for hirschsprung's children older than 3 years.

Context:Hirschsprung's disease (HD) is a congenital anomaly affecting the enteric nervous system commonly the rectosigmoid region. Treatment is surgical where the aganglionic segment is resected, and bowel continuity is achieved by a colo-anal anastomosis. In 1999, Georgeson et al. proposed a new technique of primary laparoscopic-assisted pull through for HD as a new gold standard.Aim of the Study:To evaluate the outcome of the laparoscopic Duhamel procedure for the management of HD in children older than 3 years.Methods:This study was performed on 8 patients who were more than 3-year-old, with confirmed diagnoses of HD. Patients who initially presented with enterocolitis or obstruction were excluded from this study. In all cases, laparoscopic-assisted Duhamel was done.Results:We reported our results for the 1st year follow-up period and divided our results into early outcome for the first 3 months postoperative during which we had 2 cases complaining of enterocolitis that responded to conservative treatment, we observed 2 cases of perianal excoriation that responded to medical treatment while the late outcome was reported after 3 months postoperative: We had two cases with attacks of enterocolitis at 6 months and 9 months postoperatively that needed conservative treatment in the hospital in the form of parenteral antibiotics, rectal irrigation, intravenous fluids and NP0. There was neither anastomotic leak nor stenosis.Conclusion:Laparoscopic Duhamel for the management of HD in children older than 3 years is safe and useful procedure.

Long-term outcomes in children with Hirschsprung's disease and transition zone bowel pull-through: impact of surgical techniques and role for conservative approach.

Presence of transition zone (TZ) in the pulled colon can impact the outcome of surgery in children with Hirschsprung's disease. There is a wide variation in terminology used to define TZ and its management. We present our series of managing 11 such children with considerations for conservative management. Eleven of 114 children operated for Hirschsprung's disease had features of TZ on the 4-quadrant doughnut assessment of proximal anastomosing margin. They were followed up for development of obstructive symptoms, failure of pull-through procedure or bowel-related complications. Intervention done were observation with laxatives, dilatation, Botox injection and redo pull-through. Of the 11 children, 6 underwent Duhamel's procedure and 5, transanal endorectal pull-through (TERP). Features identified on HPE were presence of hypertrophic nerve bundles involving 2 or 3 quadrants in the circumferential doughnut biopsy of proximal anastomosing margin. Observed symptoms included constipation, enterocolitis, increased bowel frequency and soiling. Intervention done were use of laxatives with bowel management program in six and Botox injections in four. Only one child with TZ in 3 quadrants required redo surgery. Mean follow-up was 5.2years with resolution of symptoms in most. This study highlights the role of conservative management with good outcomes in children with TZ bowel pull-through having hypertrophic nerve fibers and normal ganglion pattern. Children who underwent Duhamel's procedure had little impact with the presence of TZ at anastomotic margin and majority of those undergoing TERP benefitted from Botox injection. Conservative management can be attempted successfully to prevent redo surgical interventions as they can lead to poorer outcomes. Only those children not responding to conservative measures need to be planned for revision surgery.

Complication of Hirschsprung's disease immediately after pregnancy: A rare case report.

Hirschprung's disease (HD) is a rare congenital colonic disorder that may develop in adult age, often determining a poor life quality with complications needing an emergency surgical setting. The disease rarely presents as an acute intestinal obstruction like SV, which represents an abdominal emergency issue. A few days after discharge from gynecology unit because of her first childbirth, a young woman with HD developed colonic obstruction due to sigmoid volvulus, which was treated with Hartmann's procedure. Some months later, the patient underwent a two-stage Duhamel's procedure to restore the digestive tract's continuity. Both hospital periods were free of critical events. The woman regained a good quality of life: Duhamel's procedure revealed as a safe technique to use in HD adult.