Modified Duhamel Procedure Research Articles

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).
 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. 
 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.
 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.

The Surgical Correction of Hirschsprung’s Disease in Adults Using the Modified Duhamel Procedure

Background: Hirschsprung’s disease (HD) is rare in adults, since a majority of cases are corrected in childhood. Objectives: The authors describe the profile of patients with HD who reached adulthood without having undergone corrective surgery. Also, they describe the outcomes of a modified Duhamel procedure in these patients, in terms of morbidity and mortality. Methods: This retrospective study, included patients 18 years old and above, diagnosed with HD who reached adulthood without having undergone definitive repair and managed surgically by the Division of Colorectal Surgery, UP-PGH from January 1, 2004 to December 31, 2014. A review from the Department Surgical Database was used and patients’ hospital records were used to fill out a Data Collection Form. Descriptive statistics were used to summarize the data. Results: The 13 patients included in the study were diagnosed at an average age of 16.6 (± 13.16) years. The mean age at the time of definitive surgery was 23.46 (± 6.96) years. The M:F ratio was 5.5:1. The most common presenting symptom was constipation (69.23%). All had a prior proximal bowel diversion, with a transverse loop colostomy (61.54%) being the most common. The transition zone was located in the sigmoid in a third of patients. The mean time from diagnosis to definitive surgery was 6.69 years. Eight (61.54%) have since undergone stoma reversal. There was only one (7.69%) morbidity, a superficial surgical site infection. No mortalities were reported. Conclusion: The modified Duhamel procedure is a safe definitive surgical procedure for the adult patient with HD. Key words: adult Hirschsprung’s disease, colostomy, Modified Duhamel procedure

Duhamel operation for Hirschsprung’s disease; laparoscopic modified Duhamel procedure with Z-shaped anastomosis

We assessed outcome of surgery for total colon aganglionosis (TCA) and classical type recto-sigmoid Hirschsprung disease (RS-HD) comparing laparoscopic Duhamel-Z (Lap-DZ) with other techniques. For Lap-DZ, four 5mm ports were used to dissect the colon from the peritoneal reflection to the ileostomy, which was then taken down, a retrorectal route for the ganglionic pull-through ileum was created, and the rectal stump resected 2 cm above the peritoneal reflection. Following pull-through, a transverse incision was made on the anterior wall of the ganglionic ileum at the level of the proximal end of the rectal stump, and the posterior wall of the rectal stump and the lower edge of the ileal anterior wall incision were anastomosed. A surgical stapler, inserted through the anus, was used to divide the posterior rectal wall and the anterior ileal wall. Finally, the anterior wall of the rectal stump and the upper edge of the ileal anterior wall incision were anastomosed to complete a Z-shaped colorectal side-to-side anastomosis without a blind pouch. Surgery and recovery were unremarkable; mean annual continence evaluation scores improved gradually over time with no constipation. Based on outcome, we recommend Lap-DZ for TCA, but not for RS-HD.

Duhamel operation for Hirschsprung’s disease; laparoscopic modified Duhamel procedure with Z-shaped anastomosis

Duhamel operation for Hirschsprung’s disease; laparoscopic modified Duhamel procedure with Z-shaped anastomosis

OUR EXPERIENCE FOR EARLY COMPLICATION AT THE CHILDREN HOSPITAL & THE INSTITUTE OF CHILD HEALTH, FAISALABAD.

Objectives: To evaluate the early complications of Martin’s Modified DuhamelProcedure. Design: Retrospective study. Period: January 2017–December 2017. Setting: TheChildren Hospital & Institute of Child Health, Faisalabad. Material and Methods: This studyincluded Eighty Six children who underwent Martin’s modification of Duhamel’s procedure fortreatment of Hirschsprung’s disease. Results: Early postoperative complications (with in 1st 30days of operation) were observed in 86 patients. The complications noted were bleeding (n=3),wound infection (n=20), burst abdomen (n=5), anastomotic leak (n=8), intestinal obstruction(n=4), early post-operative constipation (n=6), enterocolitis (n=6), soiling (n=5) and mortality(n=2). Conclusion: Early post-operative complications in the series included bleeding, woundinfection, burst abdomen, anastomotic leak, intestinal obstruction, constipation, enterocolitis,soiling and death. The complications rate in this study is comparable to the previous studies.

MODIFIED DUHAMEL PROCEDURE;

Objectives: To evaluate the early complications of Martin’s Modified DuhamelProcedure. Design: Retrospective study. Period: January 2017–December 2017. Setting: TheChildren Hospital & Institute of Child Health, Faisalabad. Material and Methods: This studyincluded Eighty Six children who underwent Martin’s modification of Duhamel’s procedure fortreatment of Hirschsprung’s disease. Results: Early postoperative complications (with in 1st 30days of operation) were observed in 86 patients. The complications noted were bleeding (n=3),wound infection (n=20), burst abdomen (n=5), anastomotic leak (n=8), intestinal obstruction(n=4), early post-operative constipation (n=6), enterocolitis (n=6), soiling (n=5) and mortality(n=2). Conclusion: Early post-operative complications in the series included bleeding, woundinfection, burst abdomen, anastomotic leak, intestinal obstruction, constipation, enterocolitis,soiling and death. The complications rate in this study is comparable to the previous studies.

MODIFIED DUHAMEL PROCEDURE AS A METHOD OF RECONSTRUCTIVE COLON SURGERY AFTER HARTMANN PROCEDURE

Objective: to evaluate the efficacy and safety of a new method for restoration of intestinal continuity after Hartmann procedure in patients with rectal cancer. Materials and methods . We analyzed the results of reconstructive surgeries in patients that underwent obstructive resection of the rectum for rectal cancer between 1991 and 2011. We included patients with a rectal stump located under the pelvic peritoneum (its mean length was 8 (4–11) cm). All study participants underwent modified Duhamel procedure. We evaluated demographic characteristics of patients, as well as early and late postoperative complications. Results. A total of 9 patients were treated with this method. Median time between the resection and reconstructive surgery was 13.2 months; median surgery duration was 255 min; median blood loss was 800 mL. One patient had an intraoperative complication (spleen injury). Early postoperative complications were observed in 2 (22.2 %) participants; of them, 1 (50 %) patient had necrosis of the brought-out bowel. One patient (11.1 %) developed anastomosis stricture 6 months post surgery. Conclusion. We developed a new method to restore intestinal continuity after Hartmann procedure. None of the patients had complications associated with rectal stump isolation. The efficiency of this method should be confirmed by larger studies.

Laparoscopic-assisted subtotal colectomy combined with modified Duhamel procedure for mixed constipation.

Background and Objectives:To evaluate the effects of subtotal colectomy combined with the modified Duhamel procedure on mixed constipation.Methods:A total of 16 female patients with mixed constipation were enrolled and underwent subtotal colectomy combined with the modified Duhamel procedure under laparoscopy from April 2010 to April 2012. Before surgery, physical examinations such as the gastrointestinal transit test, barium enema, and defecography were performed for all the patients. After surgical treatment, 2-year follow-up was performed using questionnaires to assess the effect of treatment.Results:All 16 cases were treated successfully, with a mean operation time of 230 minutes (range, 180–290 minutes). No intraoperative or postoperative complications were found, and no deaths occurred. Constipation and relevant symptoms were relieved, and all patients were satisfied with their quality of life. The gastrointestinal quality-of-life score was significantly increased 6 months postoperatively (mean, 102) compared with preoperatively (mean, 75).Conclusion:Subtotal colectomy combined with the modified Duhamel procedure under laparoscopy is effective and safe for the treatment of mixed constipation.

Laparoscopy assisted with transanal endoscopic microsurgery in the treatment of severe functional constipation

To investigate the feasibility and efficacy of laparoscopic subtotal colectomy and modified Duhamel procedure combined with transanal endoscopic microsurgery (TEM) in the treatment of severe functional constipation(SFC). The clinical data of 10 patients with SFC treated by laparoscopic surgery combined with TEM between May 2010 and October 2012 in Ruijin Hospital of Shanghai Jiaotong University School of Medicine were retrospectively analyzed. The gastrointestinal quality of life index(GIQLI), Wexner constipation scale and daily frequency of defecation postoperatively during follow-up were collected. All the 10 operations were successfully accomplished laparoscopic subtotal colectomy combined with TEM without abdominal incision. There was no conversion to open procedure. One case had preventive terminal ileum stoma. The mean operative time was (256 ± 58) min. The mean blood loss was (178 ± 67) ml. The mean time to first flatus was (40 ± 11) h. There were no ureteric injury, anastomotic leak, pelvic sepsis and other complications postoperatively. There was one case of insufficient small bowel obstruction which was released by conservative treatments. The patients were discharged from the hospital in (9.0 ± 1.5) d postoperatively. The GIQLI in one year postoperatively was (112 ± 10) points, which indicated good results compared to (75 ± 12) points preoperatively (P=0.000). The Wexner constipation scale was 20.8 ± 2.2 preoperatively and decreased to 5.2 ± 1.8 at one year follow-up(P=0.000). Laparoscopic subtotal colectomy and modified Duhamel procedure combined with TEM provides SFC patients a safe and feasible minimally invasive surgery.

Novel surgery for refractory mixed constipation: Jinling procedure - technical notes and early outcome.

IntroductionThe treatment of slow-transit constipation combined with outlet obstruction is controversial. This study introduced a new surgical strategy, subtotal colectomy combined with a modified Duhamel procedure (Jinling procedure), of which the safety and satisfactory rate were examined.Material and methodsNinety patients with refractory slow-transit constipation associated with outlet obstruction were consecutively included between Jan 2010 and Dec 2010. All underwent the laparoscopic-assisted Jinling procedure, which added a new side-to-side anastomosis to the colorectal posterior anastomosis after subtotal colectomy. The pre- and post-operative data were collected.ResultsThere was no surgery-related death. A total of 39 complications and adverse events were reported in 22 patients (morbidity rate of 24.4%). Most complications were managed conservatively without significant events. The satisfactory rate was 93.1% at 6-month follow-up.ConclusionsThe Jinling procedure is safe for refractory slow-transit constipation associated with outlet obstruction, with minimal major complications and a high satisfaction rate. However, this procedure requires rigorous preoperative examination, exquisite surgical and laparoscopic techniques and excellent perioperative management. The pelvic floor, especially the presacral space, is damaged, and therefore it may be unsalvageable if severe complications, such as anastomosis leakage or ischemia, occur.

Long-term outcomes and quality of life after subtotal colectomy combined with modified Duhamel procedure for adult Hirschsprung’s disease

Subtotal colectomy combined with modified Duhamel procedure (Jinling procedure) was used in patients with adult Hirschsprung's disease (AHD) at Jinling Hospital in the last decade. The aim of this study is to evaluate the safety, effectiveness and quality of life of Jinling procedure for AHD. All the data are from the database of the Jinling Hospital Constipation Registry System. Primary outcomes, including safety (morbidity and adverse events), effectiveness (satisfaction rate, Wexner constipation scale (WCS) and bowel function score (BFS)) and gastrointestinal quality of life index (GIQLI), were all evaluated. Fifty-nine patients were available for this study and the mean postoperative period was 44 months. Seventeen major complications were found in 11 patients and most of the complications could be managed conservatively. A significant improvement in WCS, BFS and GIQLI at 6 months postoperatively was obtained. Jinling procedure is safe and effective for AHD.

Importance of anorectal manometry after definitive surgery for Hirschsprung′s disease in children

The purpose of this investigation is to evaluate anorectal function after definitive surgery for Hirschsprung's disease (HD) by anorectal manometry. We evaluated the anorectal manometric assessment of 18 children who were operated for HD. Functional outcomes were determined by a questionnaire. Rectoanal inhibitory reflex (RAIR) and maximum anal resting pressure (MARP) were monitored. The results were compared between obstructive patients and asymptomatic patients. The median age at definitive operation was 19 months (range 12-72 months). Anorectal manometry was performed in 14 male and 4 female patients. All the cases underwent three staged procedure for HD and modified Duhamel procedure was performed as definitive procedure for all the patients. Mean age was 4.3 months (range 25 days to 5 years) at time of diagnosis. Post-operative enterocolitis or severe constipation was observed in seven patients (38.8%). There were no patients with incontinence. Eighteen patients underwent anorectal manometry meanly 2 years after definitive operation. RAIR was absent in 14 (77.7%) patients and abnormal in 4 (22.2%). There were no significant differences in the MARP values between symptomatic and asymptomatic patients. The results of our study showed that the majority of the patients have impaired anorectal motility. There were no significant differences in the results of the functional studies for the seven patients with symptoms of obstruction or constipation when compared with asymptomatic patients after surgery for HD.

Novel surgery for refractory mixed constipation: analysis of the technical notes and outcome to Jinling procedure

To discuss a new surgical strategy: Jinling procedure (subtotal colectomy combined with modified Duhamel procedure), of which the indications, technical notes and outcomes were analyzed. The 590 patients with refractory slow-transit constipation associated with outlet obstruction was strictly included between February 2000 and December 2011. The patients included 103 males and 487 females. Their age were 14-75 years (average 42 ± 13). The 412 patients received laparoscopic-assistant Jinling procedure, and 178 patients with open Jinling procedure. The pre- and post-operation data were collected. The follow up rate were 100%, 98.1%, 95.8% and 92.7% at 3, 6, 12 and 24 months. There was no surgery-related death. Mean hospital day was (12 ± 9) days. Most complications were managed conservatively without significant events. The common complications after surgery were adhesive intestinal obstruction (9.2%), anastomosis bleeding (8.1%) and anastomosis leakage (2.9%). The gastrointestinal quality of life index score was 72 ± 9 preoperatively and increased to 68 ± 11, 99 ± 6, 105 ± 9, 106 ± 9 at 3, 6, 12 and 24 month follow-up, respectively (t = 62.1, -25.1, -126.5, -143.2, P < 0.01). The Wexner constipation scale was 21.9 ± 4.5 preoperatively and decreased to 9.6 ± 2.4, 5.9 ± 2.1, 4.6 ± 1.9, 4.5 ± 1.8 at 3, 6, 12 and 24 month follow-up, respectively (t = 48.6, 61.8, 58.2, 45.9, P < 0.01). The satisfactory rate was 77.5%, 92.1%, 93.0% and 94.1% at 3, 6, 12, and 24 month follow-up. Jinling procedure provides a good surgical option for refractory slow-transit constipation associated with outlet obstruction.

Single-stage Modified Duhamel procedure for Hirschsprung′s disease : Our experience

Primary single-stage pull-through for Hirschsprung's disease (HD) has been reported to give comparable surgical outcomes to staged operations with less morbidity. Herein, we present our experience with single-stage Modified Duhamel procedure for management of HD. This was a review of 48 cases of HD who underwent single-stage Modified Duhamel procedure without a protective colostomy. The age at surgery ranged from 6 months to 10 years (median - 9 months, mean - 2.3 years). The average weight of the child was 7.2 kg (range, 4.9-22 kg). 38 (79.2%) patients had classical rectosigmoid HD, the rest being long segment HD (the proximal most level being the splenic flexure). The average duration of surgery was 175 minutes (range, 130-245 minutes). The average blood loss was 45 ml. The average hospital stay was 7.2 days (range: 6-10 days). The major postoperative complications (n=3) included postoperative adhesive intestinal obstruction, anastomotic leak and persistent constipation due to residual aganglionosis. Each required a re-exploration. Minor complications included surgical site infection (n=3) and post-operative enterocolitis (n=3), which were managed conservatively. Six patients had constipation for a limited period post-operatively. All patients have a satisfactory functional outcome and normal development and growth. For HD, we recommend that single-stage Modified Duhamel procedure should be the preferred approach in view of its low morbidity, satisfactory functional outcome and avoidance of stoma, multiple surgeries and economic benefit in view of decreased hospital stay.

Outcome of laparoscopic modified Duhamel procedure with Z-shaped anastomosis for Hirschsprung’s disease

Several laparoscopic Duhamel-type procedures for Hirschsprung's disease (HD) have been reported, but laparoscopic, Z-shaped, colorectal, side-to-side anastomosis has not been described. Z-shaped anastomosis has been used as the treatment of choice for HD at our clinic for a long time. A laparoscopic approach was adopted to perform this Z-shaped anastomosis in 2001. We describe herein our experiences with laparoscopic Z-shaped anastomosis and evaluate the clinical outcomes. Between 2001 and 2010, 26 children with rectosigmoid HD underwent a laparoscopic modified Duhamel procedure comprising Z-shaped anastomosis. Mean age at operation was 17.2 months. Mean weight was 8.7 kg. No children had a colostomy. Seven children had trisomy 21 and one had Klinefelter syndrome. Laparoscopic modified Duhamel procedure was performed using three 5-mm trocars. Intra- and postoperative complications and functional outcomes were evaluated. Patients with trisomy 21 were excluded from the functional evaluation. The operation was completed laparoscopically for 25 of the 26 patients, with only one patient requiring conversion to an open procedure because of injury to the ureter. Mean operating time was 296 min. In one case, a minor leak was observed. No infections or related complications were observed. Mean follow-up period was 50.4 months. Sudden death secondary to rotaviral enterocolitis occurred 8 months postoperatively in one case. Twenty-one of the 25 patients (84%) showed episodes of constipation during the early follow-up period, and one child required late myectomy due to sphincter achalasia. As the child grew older, the need for medication was diminished. Of the 14 patients over 4 years old, excluding those patients with trisomy 21, all achieved normal defecation without incontinence. Our series revealed that all patients over 4 years old who underwent laparoscopic Z-shaped colorectal anastomosis achieved normal defecation without fecal incontinence. Laparoscopic Z-shaped colorectal anastomosis for HD appears feasible and safe to perform with good results.

Clinical features’ diagnostics and treatment of Hirschsprung’s disease in adults

Hirschsprung's disease first diagnosed in adulthood is symptomatic from early childhood in most cases. However, the condition is frequently masked when constipation is managed effectively by enemas and aperients. One third of the patients will experience progressive symptoms or complications, requiring urgent surgical intervention. Ninety patients with adult Hirschsprung's disease were observed by a combination of investigations: barium enema, anorectal physiology, estimation of acetylcholinesterase activity and a 60mm full-thickness strip biopsy. The latter two modalities were performed in selected patients where there was diagnostic uncertainty. Single-staged resections, mostly modified Duhamel procedures, were performed in patients who were stable and fit, and with only a limited degree of megacolon present, and no other complications. Otherwise patients were temporarily defunctioned prior to staged resection. All patients underwent surgical treatment. Long-term functional outcomes were expressed as good, satisfactory or poor. Median age was 24.5 years, range 14-47 years, and 72.2% were men. Almost three quarters (73.3%) of the patients had symptoms dating from early childhood. Barium enema was diagnostic in 84.3%, and 36.2% had a positive, but weak rectoanal inhibitory reflex. Acetylcholinesterase staining was positive in 85.7%, but full-thickness strip biopsy was positive in 100% of equivocal cases. A separate cadaveric study of unaffected individuals determined the true length of the normal physiological hypoganglionic zone, mean 24.4 mm and range 7.5-50 mm. Supra-anal short segment Hirschprung's disease was found in 5.6% patients, rectal involvement in 54.4%, rectosigmoid in 38.9% and total aganglionosis of the colon in 1.1%. Resection of the aganglionic zone and proximally dilated colon was performed as a single-staged procedure in 67.8%. Staged surgery was carried out in 32.2%. A modified Duhamel procedure was performed in 91.2% of cases. A good or satisfactory functional outcome was achieved in 96.7%. Long-term functional outcome after resection depends on the degree of preoperative megacolon present. Megacolon limited to the sigmoid colon was associated with a good outcome in 89.7%, but in only 66.7% with more proximal dilatation (P < 0.05). Occasionally, Hirschsprung's disease presents in adulthood, with ongoing symptoms from early childhood or with the development of functional obstruction, faecal impaction and megacolon in later life. Diagnosis often requires multimodal investigation. A 60 mm full-thickness strip biopsy confirms aganglionosis in 100%. A modified Duhamel procedure is the operation of choice.

HIRSCHSPRUNG’S DISEASE

Introduction: Hirschsprung’s Disease is one of the most common congenital anomalies that Pediatric Surgeons manage. In spite of the various modifications of pull through procedures available, the long term functional results are less than ideal. However, Modified Duhamel Procedure is one which has relatively good functional results and that is the reason we have selected this procedure for Hirschsprung’s disease in Sheikh Zayed Hospital, Rahim Yar Khan. Objectives: To evaluate the outcome of patients after Modified Duhamel Procedure for Hirschsprung’s Disease. Design: This is case series study. Settings: Department of Pediatric Surgery Sheikh Zayed Medical College/ Hospital Rahim Yar Khan. Period: Seventeen cases were studied over a period of two year i.e. from November 2006 to December, 2008. Material and Method: Seventeen (17) cases from both sexes were operated for Hirschsprung’s Disease over a period of one year and Modified Duhamel Procedure was adopted for all these cases. All patients were diagnosed cases of rectosigmoidal aganglionosis and follow up was done over a period of one year according to a comprehensive Proforma. Four parameters like normal stool evacuation, abdominal distension, soiling and stool incontinence were followed and then the results were compared with other national and international studies. Results: Fever 19.4% (n=04), wound infection 19.4% (n=04), vomiting 9.52% (n=02), abdominal distension 4.76% (n=01), and bleeding per rectum 4.76% (n=01), were the immediate post operative complications. Fourteen patients (82.35%), used to pass stool once daily. Abdominal distension was observed occasionally in six patients (28.57%). Soiling was seen in five patients (29.41%). Out of Seventeen, stool incontinence was seen in only three patients (17.64%). Conclusion: Modified Duhamel Procedure with the help of linear cutter stapler device is quite safe, easy and less time consuming. Infact Modified Duhamel is a procedure of choice for Hirschsprung’s Disease.

Laparoscopy-assisted total/subtotal colectomy: a report of 150 cases

To summarize the clinical experience and to evaluate the safety and technical characters of laparoscopy-assisted total/subtotal colectomy(LAC). From June 2005 to May 2008, a total of 150 cases underwent LAC in Jinling Hospital. There were 126 cases of severe functional constipation (SFC) treated by LAC combined with modified Duhamel procedure. There were 11 cases of familial adenomatous polyposis, 8 cases of ulcer colitis and 5 cases of multiple colorectal tumors treated with LAC combined with ileum-rectum anastomosis. Of the 150 cases, LAC was successfully performed in 147 cases. The mean operation time of LAC was (76.0+/-23.5) min. The estimated operative blood loss was (35.4+/-10.9) ml. The length of assisted incision was (5.2+/-1.1) cm. The time to resume intestinal function was (42.5+/-12.6) h. There was no postoperative wound infection, anastomotic stoma and other complications. Within 1 week after operation, severe diarrhea occurred in 2 cases and incomplete small bowl obstruction in 2 cases, who were relieved by conservative treatment. The mean postoperative hospital stay in patients without complication was(7.2+/-1.5) d. One year later, the score of gastrointestinal index quality of life in 116 patients was (110.3+/-20.7), which was significantly elevated as compared with the pre-operation score (90.1+/-23.8) and was not significantly different with the healthy score. The constipation symptoms were released in all the 105 SFC patients with different degree diarrhea in 7 cases and recurrence of mild constipation in 4 cases. There was no sign of recurrence and metastasis in 3 cases of multiple colorectal tumors. LAC embodies the advantages of less invasiveness of laparoscopy. It is a reasonable choice of operation method in treating various diseases related to total colon.

Comparison of Transanal One-stage Soave Procedure to Modified Duhamel Procedure in Hirschsprung's Disease

Purpose: Transanal one-stage Soave (TOS) procedure is the most recently reported procedure for Hirschsprung’s disease. This study was performed to compare the surgical outcomes of TOS with those of modified Duhamel procedure. Methods: The study populations were 17 consecutive patients who underwent TOS procedure between March, 2003 and February, 2008 (TOS group) and 19 consecutive patients who underwent modified Duhamel procedure between March, 1996 and February, 2001 (Duhamel group) by one pediatric surgeon. Age, gender, length of aganglionic segment, operating time, complications, duration of postoperative hospital stay, and functional results were retrospectively analyzed and compared between the two groups. Results: There was no difference in age, gender, and length of the aganglionic segment between the two groups. The operating time (195 versus 255 minutes, P<0.05) and the duration of postoperative hospital stay (7 versus 9 days, P<0.05) were significantly shorter in the TOS group. Postoperative complications occurred in 10 of 17 in the TOS group (4 perianal excoriation, 3 anastomotic stenosis, and 3 postoperative enterocolitis) and 10 of 19 in Duhamel group (2 wound infection, 1 perianal excoriation, 1 anastomotic leakage, 1 rectal bleeding, 2 intestinal obstruction, and 3 postoperative enterocolitis). Two cases in the Duhamel group required operation to treat postoperative complication, one for anastomotic leakage and one for intestinal obstruction. There was no significant difference in the functional results between both groups. Conclusion: TOS shows similar functional results and postoperative complications but has the advantage of a significantly shorter operating time and postoperative hospital stay compared with modified Duhamel procedure. (J Korean Surg Soc 2009;77:202-206)

Ureterorectostomy as a continent urinary diversion for complicated bladder exstrophy in children by using a modified Duhamel procedure: A case series

Introduction Whatever the method and timing of surgery, a high proportion of children with bladder exstrophy will continue to suffer from urinary incontinence. They face the options of urinary diversion to an external stoma or construction of a neobladder from bowel. This study describes a modified Duhamel's rectal pouch with a ureterorectostomy was carried out on 11 children who had a failed repair of bladder exstrophy. Materials and methods Ten boys and one girl, aged from 4 to 7 years (mean 5.5), had several unsuccessful operations for bladder exstrophy. All selected to have good renal function and no other anomalies, but were incontinent of urine and had a small contracted or prolapsed bladder. They underwent urinary diversion to the rectum using the Duhamel pullthrough technique, where the sigmoid colon was opened into the back of the anal canal above the dentate line, creating a rectal bladder and making use of the anal sphincter to control urine and stool. All were followed up for 24 months (18–27 months). Results In this selected group of patients there were no major operative or postoperative complications. Follow-up for 2 years revealed no deterioration in renal function, or electrolytes disturbance. They can hold up to 300 ml of urine and all patients are continent during the daytime with an emptying frequency of 3–5 times. Nocturnal wetting occur some 4–8 times per month with significant decrease with time. Two cases developed pyelonephritis but this was controlled with medical treatment. Conclusion Eleven children achieved effective urinary continence by ureteric diversion to the rectum using a modified Duhamel pullthrough technique. Two years follow up showed no complications, except bed wetting, but long term assessment is warranted.