Endorectal Pull-through Procedure Research Articles

Modified endorectal procedure for management of long-segment aganglionosis.

During the past five years, 65 patients with Hirschsprung's disease have been treated at our institution. Ten of these patients had long-segment aganglionosis, five with total colonic involvement, four with aganglionosis to the midtransverse colon, and one child with Hirschsprung's disease extending to the distal jejunum. There are six females and four males in the series, which is a reversal of the normal sex ratio for aganglionosis. An extensive literature review of long-segment Hirschsprung's disease has revealed a total of 489 reported cases. The mean frequency of long-segment aganglionosis in the literature is 12% of all cases of aganglionosis. Our series is comparable, with an incidence of 15%. The overall mortality rate in the literature of 54% indicates the poor therapeutic results obtained with this disease in the past. All ten of our patients have been definitively treated with a modified endorectal pull-through procedure. The mortality rate with this procedure has been zero. There has been one major complication (incorrect pathologic diagnosis of the level of aganglionosis) and four minor complications. The average follow-up period is 42.6 months. The functional results have been excellent with an average of three to four soft bowel movements per day. All of the children over 3 years of age are completely toilet trained. The remaining two patients are too young to be toilet trained, but are continent in the sense that they do not soil between bowel movements. Awareness of this entity of long-segment aganglionosis should lead to earlier diagnosis, appropriate operative therapy, and lower mortality rates.

Adult Hirschsprung's disease: results of surgical treatment at Mayo Clinic.

Fifty adult patients with Hirschsprung's disease were operated on at the Mayo Clinic between 1950 and 1978. Six different operations were used. Of the three patients treated by the Soave endorectal pull-through procedure, two suffered anastomotic leaks and required diverting colostomies; all three had excellent long-term results, however. All four patients who underwent the Duhamel procedure had excellent results, with only one minor complication. Of the 17 patients undergoing the Swenson procedure, 6 had major postoperative complications, including 2 with impotence; 3 (17.6 per cent) patients who underwent rectal myectomy, there was one minor complication, although 5 (38.5 per cent) had unsatisfactory results. Six patients had anterior resection, one of whom died of generalized peritonitis from an anastomotic leak, and one patient suffered recurrent megacolon that required resection of an additional segment of colon. Four of the five survivors had excellent results. Of the seven patients who underwent left hemicolectomy or total abdominal colectomy, two had serious postoperative complications, and two required resection of an additional segment of colon because of recurrent symptoms. All seven patients eventually had excellent results.

An evaluation of the modified endorectal procedure for Hirschsprung's disease

During the past 4 yr, 60 patients with Hirschsprung's disease have been treated at our institution. Twenty-eight patients within this group have undergone a modified endorectal pull-through procedure. There are 18 males and 10 females in the series. There are 5 children with total colonic involvement, 3 patients with aganglionosis to the mid-transverse colon, and one child with Hirschsprung's disease extending to the distal jejunum. The associated anomalies have consisted of four cases of Down's syndrome, one of whom also has transposition of the great vessels. There has been no operative-related mortality or late mortality in our series. Two major complications (anastomotic leak following a colostomy closure and incorrect pathological diagnosis of aganglionic level) and five minor complications have occurred. The average follow-up period is 31.3 mo. The functional results postoperatively have been excellent. The 18 patients over the age of 3 yr are completely toilet-trained. The remaining patients are too young to be toilet-trained, but are continent in the sense that they do not soil between bowel movements. Because of the satisfying functional results in this series, we have now expanded our indications for this procedure to patients requiring total colectomy for ulcerative colitis and familial polyposis. During the past 2 yr, 8 patients with ulcerative colitis have undergone the endorectal pull-through together with a total colectomy.

Anastomosis by invagination

The surgeon faced with cancer of the mid-third of the rectum who wishes to eradicate the tumor, yet avoid an abdominal colostomy, has three options. Goligher recommends the anal eversion pull-through technique of Cutait-Turnbull; however, an endorectal pull-through procedure similar to the Soave procedure where the mucosa is removed has also received favorable comment. Finally, there is the invagination technique utilized by Black.

Maneuver for easy dissection during the endorectal pull-through procedure in children: H. Blanchard, P.P. Collin, and P. Braun. Surg. Gynec. Obstet. 138, 607 (April), 1974

Maneuver for easy dissection during the endorectal pull-through procedure in children: H. Blanchard, P.P. Collin, and P. Braun. Surg. Gynec. Obstet. 138, 607 (April), 1974

Endorectal pull-through procedure in the surgical treatment of familial polyposis coli

Four patients with familial polyposis coli were treated by the Soave technique of endorectal mucosal stripping after total abdominal colectomy, with the bowel reconstituted by ileoanal anastomosis. After histologic confirmation of diagnosis, the patients were prepared for tis operation by 3 days of total parenteral nutrition while the bowel was completely emptied mechanically. Total parenteral nutrition was used for ten days postoperatively to assure healing of the suture lines, after which an elemental no-residue diet was begun which gradually progressed to an ordinary low-residue diet. Our patients were continent for gas and stool within a few days of operation and had no problems with bladder emptying. The patients now range from 9 to 18 mo since operation and have three to four soft-formed stools daily with good anal sphincter control. We feel that this operation is superior to either total proctocolectomy and permanent abdominal wall ileostomy or abdominal colectomy and ileoproctostomy with its continued threat of malignant degeneration of retained rectal polyps.

Endorectal pull-through procedure for Hirschsprung's disease with and without primary anastomosis

The advantages of the endorectal pull-through procedure with primary anastomosis are: (1.) The absence of any pelvic dissection; (2.) the presence of normal propulsive colon right down to the anus; (3.) the preservation of the rectal muscular cuff and its sensory receptors; (4.) few, if any, anastomotic problems; (5.) the preservation of all sphincters and (6.) simple postoperative care. Although more time and experience are required to evaluate the procedure, we believe that its relative ease of performance, inherent safety, and physiologic soundness may make it the operation of choice for Hirschsprung's disease.