Endorectal Pull-through Operation Research Articles

Transanal Endorectal Pull-Through Procedure for patients with Hirschsprung`s Disease: A prospective study

Back ground: Hirschsprung`s disease is a common problem among pediatric population, many procedures had been implemented in the treatment with different results. In the last decades one stage transanal endorectal pullthrough (TEPT) had come into the stage as a minimal invasive choice for such condition with good results.Objectives: To evaluate the feasibility and safety of TEPT procedure among pediatrics in a tertiary pediatric surgery center in Iraq.Patients and Methods: A prospective study was conducted on 11 patients with Hirschsprung’s disease, attending Central Teaching Hospital of Pediatrics for the period from March 2007 till August 2014. Their ages were ranging from 1 month - 12 years. All cases had diverting colostomy and leveling biopsy. The aganglionic segment was confined to the rectum and rectosigmoid junction. TEPT was done to all cases with closure of colostomy 6-8 weeks after pullthrough. The patients were followed up for a period of 6 months-4 years.Results: The study was conducted on 11 patients with a mean age of (33.7 ± 43.4 months); the male to female ratio was 9:2. Regarding the level of aganglionosis, it was confined to the rectum in 4 cases, while it reached the rectosigmoid junction in 7 cases. The mean operating time was (115.4 ± 23.5 minutes), and the mean volume of blood loss was (37.3 ± 17.6 ml). The average length of resected aganglionic segment was (13.9 cm). There is no conversion to laparotomy in any case. Complications developed in two cases one with perianal excoriation and the other develop postoperative enterocolitis.Conclusion: Transanal Endorectal Pull-Through operation for Hirschsprung’s disease is feasible and safe, and it can be performed successfully in all ages of children with good results avoiding transabdominal exploration.

Beginning experience with the transanal endorectal pull-through operation for the surgical treatment of Hirschsprung’s Disease

Beginning experience with the transanal endorectal pull-through operation for the surgical treatment of Hirschsprung’s Disease

Single Stage Transanal Endorectal Pull-through Operation for Hirschsprung’s Disease in Neonate: A Single Center Experience

Single Stage Transanal Endorectal Pull-through Operation for Hirschsprung’s Disease in Neonate: A Single Center Experience

Clinical and manometric evaluations of anorectal function in patients after transanal endorectal pull-through operation for Hirschsprung's disease: A multicentre study

Aim Transanal endorectal pull-through (TEPT) operation is one the most popular operations for Hirschsprung's disease. This aim of the present study was to evaluate its outcome by clinical and manometric assessments. Patients and Methods This study was a multicentred study involving all three paediatric surgical centres under the Hospital Authority in Hong Kong. All patients, over the age of 3 years, who had undergone primary TEPT operation for more than 1 year, were included in the present study. Clinical evaluation with bowel function score (BFS) and anorectomanometry were carried out. A BFS > 18 and sphincter resting pressure between 30 mmHg and 60 mmHg were considered normal. Those with concomitant anorectal/neurological anomaly or who could not cooperate were excluded. Results A total of 37 patients were enrolled in this study. The median age was 60 months (range: 36–144 months), and the median age at the time of operation was 3 months (range: 0.5–60 months). With respect to functional outcomes, six patients (16.2 per cent) suffered from constipation, but more than two-thirds of patients had satisfactory stool consistency, as well as frequency. Sixteen patients (43.2 per cent) had no report of any soiling. For the BFS, 26 patients had a BFS above 18, with the median value being 16 (range: 7–20). Manometric assessment revealed that 27 patients (72.9 per cent) had sphincteric resting pressure within the normal value, and the median value was 45 mmHg (range: 14–79 mmHg). Rectoanal inhibitory reflex was present in six patients (16.2 per cent), and the median value for the volume of air to elicit the first anal sensation was 41 mL (range: 18–126 mL). Using univariate analysis, long segment disease was identified as a risk factor for developing soiling of more than two times per week [relative risk (RR): 1.87, 95 per cent confidence interval (CI):1.03–2.22, P = 0.05], whereas the creation of stoma (RR: 1.69, 95 per cent CI: 1.41–2.14, P = 0.04) and occurrence of postoperative enterocolitis (RR: 1.58, 95 per cent CI: 1.36–1.0, P = 0.04) were risk factors for abnormal bowel function score. There was no significant risk factor identified for abnormal manometric results. Lastly, patients with abnormal sphincter resting pressure detected in the anorectomanometry study were also more likely to have an abnormal BFS. Conclusion Most patients have satisfactory clinical and manometric outcomes after primary TEPT operation. Anorectomanometry findings can predict clinical outcomes. Patients with long segment disease, development of enterocolitis and stoma creation before operation will need more attention, as they are prone to develop abnormal bowel function. Early interventions, such as manometric assessment and proper bowel management, are recommended in order to correct bowel dysfunction, as well enabling patients to have a better quality of life.

Long-term health-related quality of life for patients with Hirschsprung's disease at 5 years after transanal endorectal pull-through operation.

This study aims to evaluate the health-related quality of life (HRQoL) for children as well as parents' satisfaction 5-7 years after transanal pull-through operation of Hirschsprung's disease. The PedsQL™ 4.0-Core Measurement Model-and the PedsQL™ 3.0 Healthcare Satisfaction Generic Module were used to evaluate the quality of life and parents' satisfaction, respectively. Parents of 53 children who were operated by transanal pull-through operation 5-7 years earlier were included in the study. The HRQoL of children was generally good. The mean scores were 87.3, 95.5, 92.3 and 93.2 % for physical, emotional, social and school functioning, respectively. Overflow incontinence was significantly affecting physical (ß = -.261), emotional (ß = -.299), social (ß = -.42) and school functioning (ß = -.534). Constipation significantly affected emotional (ß = -.742), social (ß = -.108) and school (ß = -.282) functioning. Failure to thrive was significantly affecting social (ß = -.215) and school functioning (ß = -.176). Age at time of surgery was affecting physical, emotional, social and school functioning (ß = -.686, -.627, -.865 and -.907, respectively). Parents were generally satisfied from the healthcare service with an overall satisfaction of 90.7 with the least satisfaction (79.8) in family inclusion category. Transanal pull-through operation disease showed a good postoperative long-term HRQoL. Overflow incontinence and age at time of surgery had a significant negative effect on all the aspects of children's HRQoL. Parental satisfaction was good and could be improved by more family inclusion.

Pneumaturia signaling a fistula between the rectum anastomosis and seminal vesicle as a complication after transanal endorectal pull-through operation for Hirschsprung's disease. A method of repair

A 2-year-old boy underwent an uneventful transanal endorectal pull-through for Hirschsprung's disease. Postoperatively he suffered from pneumaturia which prompted surgical evaluation. He was found to have a rectum to seminal vesicle fistula. He was re-operated closing the fistula through an anterior transperineal approach with a successful operative outcome. • A minimal invasive technique was used for closing a rectum to seminal vesicle fistula. • A perineal approach was used to avoid further damage to the already operated area. • The method was adopted from adult colorectal and urological surgeons to be used by pediatric surgeons.

Transcolostomy-site endorectal pullthrough for Hirschsprung’s disease

Purpose To present our results for an endorectal pullthrough operation as the second stage for the treatment of Hirschsprung’s disease through the colostomy site. Materials and methods This study included 13 patients, four girls and nine boys. Their ages ranged from 9 months to 7 years. They presented with a leveling colostomy with a diagnosis of Hirschsprung’s disease. The colostomy was carried out in the neonatal period because of neonatal intestinal obstruction in three patients (one female and two males), in two patients because of recurrent attacks of enterocolitis, and three patients because of the inability of the patient to withstand major surgery. Four patients presented without a clear history of the cause for the colostomy. One patient aged 7 years presented with sigmoid volvulus. All the patients were subjected to a transcolostomy endorectal pullthrough. Results The operation was completed as described in all patients. The time from colostomy to pullthrough ranged from 3 to 7 months (median 4.7 months). The operation time ranged from 95 to 140 min (median 113 min). All the patients passed stool within 24–48 h. Stool output ranged from two to six stools per day. Optimal wound healing occurred in all patients without wound complications. Postoperative perineal excoriation occurred in four patients. A urinary tract infection developed in one patient. A patient with a history of recurrent attacks of preoperative enterocolitis developed mild enterocolitis 2 weeks after the operation. Adhesive intestinal obstruction occurred in one patient. Recurrence of symptoms occurred in two patients because of stricture at the anastomotic site, one responded to repeated dilatation and the other required internal sphincterotomy. Conclusion Transcolostomy endorectal pullthrough has the following advantages: it is associated with less pain and a shorter hospitalization than the classic endorectal pullthrough. Wound complications are rare. The cosmetic result is better than the classic Soave operation. It has no specific technique-related complications. Long-term outcome and functional results are good. To our knowledge, this approach has not been described before. Keywords : Hirschsprung’s disease, leveling colostomy, pullthrough

Long term outcome of transanal endorectal pull-through for Hirschsprung's disease:A single institute experience

Background: The transanal endorectal pull-through operation (TEPT) for Hirschsprung's disease (HD) is relatively new and this makes assessment of the functional outcome difficult. The aim of this study was to assess the long-term.functional outcome ofTEPT for short segment HD (at Faculty ofMedicine-Zagazig University) and to evaluate its effect on the patients' quality of life. Patients and methods: Fifty-eight patients out of 176 patients who underwent TEPT technique for HD between August 2002 to August 2009 were followed up for at least one year.All patients had aganglionic segment that is confined to the rectosigmoid area. Long term outcome and quality of life were assessed by interviews with the parents and/or patients using pre-structured questionnaires filled by the attending doctor. Results: Forty-four patients had satisfactory results without complications. Reported postoperative complications included soiling in 11 patients, constipation in 3 patients, incontinence in 3 patients and enterocolitis in 7 patients. According to quality of life scoring criteria, 75.9% of patients had good quality of life and 18.9% had fair quality of life. Conclusion: TEPT for short segment HD is associated with gradual recovery of stooling pattern and long term normal bowel function and good quality of life for patients.

One-Stage Transanal Endorectal Pull-through for Treatment of Hirschsprung’s Disease in Adolescents and Adults

BackgroundOne-stage pull-through operation has become increasingly popular for treatment of Hirschsprung’s disease. The one-stage transanal pull-through was introduced in the late 1990s and has rapidly replaced traditional procedures in infants and young children in many surgical centers. ObjectiveThe aim of this study is to determine feasibility and safety of transanal primary repair in adolescent and adults. MethodsFifteen patients who underwent transanal endorectal pull-through were prospectively studied. All patients presented by chronic refractory constipation with the age ranged from 11 to 22 years. The patients were followed up for a mean of 18 months. Anal continence and postoperative complication were evaluated. ResultsIncomplete continence in the form of soiling occurred in four patients (26.6%) and improved gradually with conservative management. No patients suffered from complete incontinence. Anastomotic strictures occurred in two patients and were successfully treated with regular dilatations. One patient had continued outlet obstruction and revision was considered for him. One patient complicated with low perianal fistula which needed fistulectomy. There was no impotence in adults. ConclusionThese findings indicate that one-stage transanal endorectal pull-through operation in adolescent and adults is feasible and safe.

Stabilization period after 1-stage transanal endorectal pull-through operation for Hirschsprung disease

Purpose The aim of this study was to evaluate postoperative outcomes and to find the period required for normal stooling pattern after the 1-stage transanal endorectal pull-through operation (TERPT). Method The authors retrospectively reviewed the clinical data and postoperative courses of 61 patients who had the aganglionic bowel confined to rectosigmoid and underwent TERPT between 2001 and 2007. Results Thirty-three patients (54.1%) were neonates, and 56 patients (91.8%) were less than 6 months old at operation. The mean age at TERPT was 90 ± 216 days, and the mean body weight at TERPT was 4.5 ± 2.8 kg. The average operating time was 189 ± 49 minutes, and mean length of bowel resection was 11.1 ± 3.2 cm. The mean postoperative hospital stay was 8.0 ± 3.6 days. Postoperatively, 5 (8.2%) patients were considered as failure of TERPT because of persistent problems in defecation. Fifty-six (91.8%) patients finally had normal stooling patterns and normal findings in abdominal radiography after 9.4 ± 6.2 weeks of the mean postoperative stabilization period. Neonatal cases had significantly longer postoperative stabilization periods than nonneonatal cases (11.3 ± 6.9 weeks vs 7.3 ± 4.6 weeks, P = .016). The postoperative stabilization period significantly decreased by age at operation as the patient's age increased ( P = .018). Conclusion Clinical outcomes after TERPT are satisfactory, but a postoperative stabilization period is required for a normal stooling pattern to develop. The outcome of TERPT should consider a postoperative stabilization period.

Our Experience with Transanal Endorectal Pull-Through in Hirschsprung's Disease

The aim of the study was to evaluate the functional results, complications, the problems caused, and the outcomes of the transanal endorectal pull-through (TEPT) operation in Hirschsprung's disease. The 22 patients who were operated for Hirschsprung's disease with TEPT between November 2003 and September 2006 were reviewed retrospectively. The patients were evaluated for age, gender, operational findings, duration of hospitalization and functional outcomes after the operation. A total of 22 patients, sixteen males (72.7 %) and 6 females (27.3 %) aged 23 days to 11 years (mean 19.3 +/- 6.9 months), were operated using TEPT over a 34-month period. The mean length of the resected aganglionic segment was 23 +/- 2.4 cm; the shortest segment was 7 cm and the longest 40 cm. The postoperative hospital stay was 3 - 10 days, oral feeding was started at 1 - 4 days, the first bowel movement was at 1 - 7 days and the number of daily movements for patients in whom the colostomy was closed was 2 - 5. The mean postoperative follow-up period was 18 +/- 2.4 months (1 - 33 months). Two patients (9 %) were hospitalized once for enterocolitis. One patient had a constipation problem that resolved with medical treatment. One patient needed colostomy for anastomosis leakage on the 5th postoperative day, followed by a redo pull-through using a posterior sagittal approach. None of the patients had a continence problem. No urethral damage was observed and there were no abscesses at the muscular cuff. We observed that mucosal dissection was more difficult in the rectal biopsy area. Although only recently accepted, TEPT has quickly found a place in clinical practice as it is based on an operational technique whose results are well identified and accepted and with which there is extensive experience. It seems that TEPT has the advantages of having no additional problems compared to the classical techniques with respect to complications and functional outcomes while providing better patient comfort and cosmetic outcomes. We conclude that TEPT may be preferred in appropriate cases and will evolve to become a more practical and effective technique.

Is acetylcholinesterase activity in neorectum after laparoscopic endorectal pull-through method for Hirschsprung’s disease a primary or a secondary condition?

Between 1996 and 2002, 22 cases of Hirschsprung's disease were treated laparoscopically by endorectal pull-through operation. The proximal margin of the resected bowel materials from these 22 patients were examined histologically by frozen sections at surgery and also after surgery using H&E staining, and complete resection of the aganglionic segment was confirmed. Eleven patients, in whom an informed consent was obtained at randomly, underwent suction biopsy from the pulled-though neorectum after surgery. Of these 11 patients, 2 revealed many AchE-positive nerve fibers in the lamina propria, the muscularis mucosa and around the ganglion cells in the submucosal plexuses. These structural changes were similar to intestinal neuronal dysplasia that was characterized by hyperganglionosis and other neuronal abnormalities. The remaining 9 revealed no AchE activity. Unexpectedly, the two patients showing AchE activity in their neorectum continued to have persistent constipation and were treated with laxatives or glycerin enema. It was suggested that their persistent constipation was caused by intestinal neuronal dysplasia showing an abnormal increase of AchE activity in spite of presence of ganglion cells of the neorectum after surgery, but it was uncertain that they were primary condition as a HaIND or secondary reactions after surgery.

Stooling patterns and colonic motility after transanal one-stage pull-through operation for Hirschsprung's disease in children

Background The transanal one-stage endorectal pull-through operation for Hirschsprung's disease is relatively new and makes assessment of the functional outcome and colonic motility difficult. The aim of this study was to evaluate the stooling patterns and colonic motility after a one-stage transanal pull-through operation for Hirschsprung's disease in children. Methods Twenty-two children who underwent a one-stage transanal pull-through operation for Hirschsprung's disease were followed up for at least 6 months. The children (17 boys and 5 girls) were from 12 months to 13 years of age (mean age, 4 years). All patients had an aganglionic segment confined to the rectosigmoid area (confirmed by preoperative barium enema and postoperative histology). Clinical outcome was assessed by interviews and questionnaires, and children were divided into symptomatic and nonsymptomatic groups. Contrast barium enema and defecography and determination of total and segmental colonic transit time (using radio-opaque markers) were performed on all 22 children. Results The stooling patterns were considered satisfactory in 17 children. Of all the children, the mean stool times were 1 to 2 per day and only 2 were 8 to 10 per day; postoperative soiling was found in 4, constipation was observed in 2, and Hirschsprung-associated enterocolitis in 1. There was no incontinence, cuff infection, anastomotic leak, or mortality noted. Barium enema showed that the dilated and spastic colonic segment disappeared in all 22 children. The dilated sigmoid loops decreased in 17 (2 symptomatic, 15 nonsymptomatic) and disappeared in 5 (4 symptomatic, 1 nonsymptomatic). There was a significant difference between the decreasing and disappearing loop group in regard to stooling disorders ( P < .05). Postoperative defecography showed that the anorectal angle of all children was open, fixed, and significantly larger than that of the preoperative and control groups (123.3° ± 15.1° vs 84.7° ± 8.3° vs 79.0° ± 11.6°, P < .01) and larger in the symptomatic group when compared with the nonsymptomatic group (135.6° ± 15.9° vs 111.0° ± 14.3°, P < .05). Postoperatively, the total gastrointestinal transit time, left colonic transit time, and rectosigmoid colonic transit time of all the children were shorter than preoperatively (26.8 ± 8.2 vs >188 hours, P < .01; 6.3 ± 4.1 vs >60 hours, P < .01; 11.8 ± 4.4 vs >120 hours, P < .01) and similar to controls. The total gastrointestinal transit time and rectosigmoid colonic transit time of the symptomatic group were significantly shorter than the nonsymptomatic group (25.2 ± 5.6 vs 28.1 ± 10.1 hours, P < .05; 12.2 ± 6.7 vs 9.8 ± 4.0 hours, P < .05). Conclusions The stooling pattern and colonic motility are satisfactory in most children after the one-stage transanal pull-through operation for Hirschsprung's disease. Normalization of colon appearance and total and segmental colonic transit time are signs of recovery of colonic motility. Stooling disorders were noted in a few cases and may be related to decrease or disappearance of the sigmoid loop, dysfunction of the “neorectosigmoid”, an open and fixed anorectal angle, and ischemia of the pull-through segment.

Clinical outcome in children after transanal 1-stage endorectal pull-through operation for Hirschsprung disease

Background/Purpose Recently, the transanal 1-stage pull-through operation has been widely used in Hirschsprung disease (HD), and it is obviously superior to traditional approach in early term for its noninversion. However, the procedure is relatively so new that it makes assessment of the functional outcome and stooling patterns difficult. The aim of this study was to evaluate the clinical outcomes of the transanal 1-stage endorectal pull-through operation in the management of rectosigmoid HD. Methods Fifty-eight children (39 boys and 19 girls) aged 12 months to 13 years (mean, 2 years) who underwent transanal 1-stage endorectal pull-through operation for HD were followed up from 6 to 24 months. Clinical outcome was assessed by interviews and questionnaires. All patients had an aganglionic segment confined to the rectosigmoid area which was confirmed by the preoperative barium enema and postoperative pathological examination. Results Forty-six patients had satisfactory results without complications. In all the children, the mean stool times were 1 to 2 per day; only 4 had mean stool times of 8 to 10 per day. Postoperative soiling was present in 9, constipation in 5, and HD-associated enterocolitis in 3. There were no incontinence, cuff infection, anastomotic leak, and mortality in any of the patients. In the 12 symptomatic patients, there were 4 children with length of aganglionic segment less than 30 cm, and 8 had 30 cm or more. In the 46 asymptomatic patients, 42 had length of aganglionic segment less than 30 cm, and 4 had 30 cm or more. There was a significant difference between the group with less than 30 cm and the group with 30 cm or more of aganglionic segment. For statistical analysis, the Fisher exact test showed P < .05. Conclusions The transanal 1-stage endorectal pull-through is a feasible and safe procedure in children with rectosigmoid HD. The clinical outcome is satisfactory. A gradual recovery could be noted in the stooling patterns along with the time after surgery. The younger the patient operated on and the shorter the aganglionic segment, the lower do the stooling disorders occur and the faster does the stooling function recover.

Does high-pressure carbon dioxide insufflation facilitate mucosal dissection in transanal endorectal pull-through? A rabbit model.

The aim of the present study was to investigate whether high-pressure carbon dioxide insufflation facilitates mucosal dissection in the transanal endorectal pull-through (TEPT) operation performed in Hirschsprung's disease in a rabbit model. In the study, ten New Zealand rabbits were used. In six of the rabbits, CO(2) under 50 mmHg pressure was insufflated into the submucosal area through a 25-gauge scalp needle inserted 0.3 cm over the dentate line. Two of the rabbits were taken for histopathological examination. In four rabbits, the TEPT operation was performed and in another four the operation was performed without CO(2) insufflation. Histopathological examination in the CO(2)-insufflated group of rabbits showed that at transversal incisions mucosa was seen to be separated circumferentially from submucosa by high pressure CO(2) and at longitudinal incision the separation was seen to be complete along the anal canal. It was noted that mucosal dissection was rapid, non-bloody and without induced mucosal tears or perforation; however, in the non-insufflated group the operation was time-consuming, bloody and more difficult to perform and needed meticulous care. In the present study, it was seen that submucosal high pressure CO(2) insufflation in rabbits facilitates mucosal dissection in the TEPT operation and is easy to perform, time-saving and highly economical.

Clinical Quiz

A 9-year-old boy, known to have Crohn disease, presented to the emergency room with a one-week history of increasing, colicky abdominal pain. He was diagnosed at four years of age with severe perianal and rectal disease. His disease was refractory to extensive medical management, and he required a diversion sigmoid colostomy and the establishment of a Hartmann pouch at seven years of age because of persistent anal stenosis and severe dyschezia. In addition to his abdominal pain, he reported the passage of flatus, but no stool, into his colostomy bag. His vital signs were stable; he was apyrexial and had a normal urine analysis. On examination, his abdomen was protuberant with a 15 by 12 cm mass in the hypogastric region extending down into the pelvis. The colostomy site in the left flank appeared healthy. Anal inspection revealed extensive scarring, and no anal orifice was readily identified. Imaging included an abdominal radiograph (Fig. 1), abdominal and pelvic sonography (Fig. 2), and retrograde colon study via his colostomy.FIG. 1. No Caption AvailableFIG. 2. No Caption AvailableWhat is the most likely diagnosis? A. Colostomy stenosis and obstruction B. Pelvic abscess C. Rectal mucocele D. Distended bladder due to outlet obstruction Answer: C. Rectal Mucocele The mucosal lining of a Hartmann's pouch secretes mucus, which must drain or it will accumulate over time. Inflammation, scarring and epithelialization of the anal canal obstructed the drainage in this case, causing a mucocele, which progressively enlarged. The abdominal radiograph indicated a soft-tissue mass arising from the pelvis, displacing bowel superiorly and to the right. Sonography demonstrated a markedly dilated hollow viscus arising from the deep pelvis and extending up to the left hypochondrium. There was no obvious connection to the stoma site. The mass was causing mild, left-sided hydronephrosis. Retrograde enema via the colostomy filled a normal caliber colon. The anus was probed open under general anesthesia and 1100 ml of mucus was evacuated. A Penrose drain was left across the anus to maintain patency. Comment: Mucoceles are commonly associated with the appendix and cranial sinuses. Rectal mucoceles are rare. The first reported pediatric case was an extraluminal pelvic mucocele in a patient with an imperforate anus following an endorectal pull-through operation with incomplete mucosal excision (1). There are case reports of rectal mucoceles following Hartmann's procedure for ulcerative colitis, and secondary to high anal sphincter tone following spinal trauma (2,3). Mucoceles have developed in defunctioned colon after pull-through surgery due to stenosis and retraction of the colonic stump (4,5). Scarring of the mucus fistula, or failure to creat a mucus fistula are other described contributing factors. In our patient, obstruction of the isolated distal colon was caused by severe, long-standing anorectal Crohn disease which caused scarring, stricture and epithelialization of the anal orifice. Treatment requires effective drainage or removal of the mucus-producing epithelium. This case illustrates a rare but interesting complication of Crohn disease.

Endorectal pull-through operation for massive rectal trauma in children

Endorectal pull-through operation for massive rectal trauma in children

Endorectal pull-through operation for diffuse cavernous hemangiomatosis of the sigmoid colon, rectum and anus : H. Takamatsu, H. Akiyama, H. Noguchi, et al. Eur J Pediatr Surg 2:245–247, (August), 1992

Endorectal pull-through operation for diffuse cavernous hemangiomatosis of the sigmoid colon, rectum and anus : H. Takamatsu, H. Akiyama, H. Noguchi, et al. Eur J Pediatr Surg 2:245–247, (August), 1992

Early effects of colectomy and endorectal pullthrough operation on biliary lipid composition

In order to determine the effects of total colectomy and endorectal pullthrough with ileal reservoir (ERP) on biliary lipid composition in the early postoperative period, gallbladder bile of dogs was examined after biliary cannulation alone (control); biliary cannulation and colectomy with ileorectal anastomosis (IRA); and biliary cannulation, colectomy with mucosal proctectomy, and ERP. Bile collected from 3 to 6 weeks postoperation was analyzed for total bile acids, cholesterol, phospholipids, bilirubin, and calcium concentrations. Cholesterol saturation was calculated. Serum collected over the same period was analyzed for electrolytes and liver function tests. There was no evidence of sludge or gallstones postoperatively in any animal. Significant decreases in total bile acids, phospholipids, and calcium concentrations were noted in the bile of the IRA group when compared to the bile of the controls ( P < 0.05) and in total bile acids, cholesterol, phospholipids, and calcium in ERP vs controls ( P < 0.05). Moreover, all three biliary lipids and calcium were significantly decreased in ERP animals compared to those in the IRA group ( P < 0.05). No change in cholesterol saturation was noted between any of the three groups. Other than an increase in alkaline phosphatase concentrations compared to preoperative levels ( P < 0.05) which was noted in all groups, no significant changes were noted in serum parameters. We conclude that during the early postoperative period, ERP causes a significant decrease in gallbladder bile concentrations of total bile acids, cholesterol, phospholipids, and calcium which cannot be explained by colectomy alone. The longterm effects on biliary composition remain to be defined.

The radiographic appearance of the endorectal pull-through.

Children and young adults with ulcerative colitis and polyposis syndromes requiring colectomy are increasingly undergoing the endorectal pull-through procedure. We reviewed the contrast studies of the neorectum of 27 patients and the abdominal radiographs in 26 patients after the endorectal pull-through operation. Normal features included smooth mucosa with loss of the small bowel features, dilatation of the neo-rectum on consecutive examinations, and an enlarged presacral space. The normal appearance before closure of the ileostomy varied depending upon the amount of distension of the pull-through segment; redundant ileum within the rectal muscle sleeve was seen in the two patients. Abnormalities included rectovaginal fistulas, sinus tracts, focal strictures requiring dilatation, complete obstruction, mucosal irregularities, and generalized narrowing with lack of distensibility. These abnormalities are attributable to inflammation and were associated with a poor clinical outcome. A contrast examination of the pull-through segment is useful to exclude the presence of serious inflammatory change before ileostomy closure or in the patient with excessive diarrhea or obstruction.