Modified Duhamel Procedure Research Articles

PD-001 ヒルシュスプルング病に対するGIAを用いたDuhamel変法(Z吻合法)の長期成績(ヒルシュスプルング病の手術方法と成績, 第44回日本小児外科学会学術集会)

PD-001 ヒルシュスプルング病に対するGIAを用いたDuhamel変法(Z吻合法)の長期成績(ヒルシュスプルング病の手術方法と成績, 第44回日本小児外科学会学術集会)

Efficacy and safety of combined use of subtotal colectomy and modified Duhamel procedure in the surgical treatment of severe functional constipation

To explore the satisfactory surgical procedure for severe functional constipation (SFC). The data of 50 SFC patients, undergone subtotal colectomy and modified Duhamel procedure from Sep. 2000 to Apr. 2005, were analyzed retrospectively. Gastrointestinal quality of life (GIQOL) of these patients were also evaluated. All the 50 patients failed to respond to conservative treatment and accepted subtotal colectomy and modified Duhamel procedure after finding pathological changes by the examination of colonoscopy, colon transit time (CTT) and dynamic proctography (DPG). Twenty-seven out of 50 cases (54%) showed colonic muscular atrophy and 29 out of 50 cases (58%) showed decreased ganglion cells in myenteric plexuses of colon. The mean follow-up time after surgical treatment was (2.4+/-1.2) years. GIQOL and constipation index improved dramatically after operations. Forty-four out of 50 patients (88%) were satisfied with their postoperative evacuation. Nine patients complained minor abdominal pain,3 patients diarrhea and 2 patients recurrence of constipation, who were healed by the use of bulk-forming laxatives and GI-mobility drugs. The combination of modified Duhamel procedure and subtotal colectomy is an effective surgical procedure for the treatment of SFC.

Short-Pouch and Low-Anastomosis Duhamel Procedure Results in Better Fecal Control and Normal Defecation Pattern

The purpose of this study was to analyze the long-term outcome of the short-pouch and low-anastomosis Duhamel procedure and to evaluate the quality of life after pull-through. We also tried to answer the questions: Does the modified Duhamel procedure produce fecal continence? Is the quality of life correlated to normal bowel function (1-3 per day) without the use of laxatives? Between January 1993 and January 2002, 53 patients, 44 (83 percent) males and 9 (17 percent) females, who underwent a Duhamel procedure were assessed retrospectively. Of the 53 children, 36 (67.9 percent) underwent a primary Duhamel procedure at our institute (Group A). Seventeen (32.1 percent) patients had a primary Duhamel pull-through and subsequently a stoma before a redo modified Duhamel procedure (Group B). The technical modification was creation of a short rectal pouch of 35 mm, achieving a low colorectal anastomosis 0.5 cm from or on the dentate line. All 53 patients were assessed prospectively by a disease-specific questionnaire. The total score provided a single index of the quality of life associated with fecal continence. For Group A (n = 36), the mean period of follow-up was 71.4 +/- 29 months. Constipation was seen in four (11.1 percent) patients. In two (5.6 percent) patients there was a mild degree of soiling. Sensation and urge to defecate was intact in 34 (94.4 percent) children who could wait to go to the toilet until it was socially convenient. For Group B (n = 17), the mean period of follow-up was 73.9 +/- 31.2 months. Constipation occurred in 17 (100 percent), encopresis in 14 (82.4 percent), and enterocolitis in 15 (88.2 percent) after the primary Duhamel procedure. In comparison, there was complete absence of constipation (100 percent), encopresis (100 percent), and complete resolution of enterocolitis (100 percent) after the redo modified Duhamel (P = 0.001). Continence to solid stools after primary Duhamel was seen in 5 (29.4 percent) vs. 17 (100 percent) after redo modified Duhamel. After the redo modified Duhamel all 17 (100 percent) patients have retained the sensation and urge to defecate and 15 (88.2 percent) can wait to get to the toilet until it is socially convenient. In all 53 patients, the quality of life was good in 86.8 percent (46/53) and correlated directly with fecal continence (r = 0.977). There was no correlation between age of patient and fecal continence (r = 0.597) and rate of fecal incontinence did not decrease with age. Direct correlation was seen with the presence of constipation and the incidence of late onset enterocolitis (r = 0.942). Short-pouch, low-anastomosis Duhamel pull-through procedure results in fecal continence and complete emptying. The above procedure has a positive impact on the quality of life in these children.

Hirschsprung’s Disease in Adults: the Duhamel Procedure

Hirschprung’s disease is a rare condition in the adult. We present three patients with Hirschsprung’s disease who successfully underwent the modified Duhamel procedure. The diagnosis was suspected on the basis of the typical medical history of lifelong constipation. The diagnosis was confirmed by anorectal manometric studies and/or full thickness rectal biopsy. The relief of the marked preoperative abdominal distention was complete and the bowel movements were active and smooth. Two out of three had perfect faecal control and continence. The Duhamel-Martin procedure seems a safe and reliable technique in the treatment of Hirschsprung’s disease.

Total colonic manometry as a guide for surgical management of functional colonic obstruction: Preliminary results

Background/Purpose: Functional colonic obstruction (pseudo-obstruction) encompasses a broad group of motility disorders. Medical management of colonic pseudo-obstruction is complex and often fails, leading to surgical referral. In most cases (excepting Hirschsprung's disease) the surgeon is unable to precisely localize the area of functional obstruction. Total colonic manometry can directly measure intraluminal pressures and contractile function along the entire length of the colon. The authors propose that total colonic manometry can be used by the pediatric surgeon to guide the timing and extent of surgical therapy in refractory functional colonic obstruction. Methods: Four patients were evaluated for functional colonic obstruction. All underwent barium enema and rectal biopsy with a diagnosis of Hirschsprung's disease in one patient. All patients underwent colonoscopy and total colonic manometry. Manometric tracings were obtained while fasting, after feeding, and after pharmacologic stimulation both preoperatively (n = 4) and postoperatively (n = 3). Results: Total colonic manometry identified an abrupt end of normal peristalsis in 2 of the non-Hirschsprung's patients (one in the proximal colon and one in the transverse colon). Medical therapy failed in both of these patients, and they underwent diverting ostomy proximal to the loss of normal peristalsis. The third non-Hirschsprung's patient essentially had normal manometry and was able to have her colon decompressed successfully on a laxative regimen. Repeat manometry after colonic decompression showed return of normal peristalsis in 2 of these patients and continued abnormal peristaltic activity in the third. Definitive surgical intervention based on the results of total colonic manometry was performed on the latter. All 3 patients achieved normal continence. A fourth patient had Hirschsprung's disease confirmed by rectal biopsy and underwent a 1-stage neonatal modified Duhamel procedure, which was complicated by postoperative functional obstruction. Manometry showed a lack of peristaltic function beginning in the right colon. An ileostomy was performed, and timing of ileostomy closure was guided by the return of normal colonic peristalsis seen on manometry. Conclusions: These initial cases show the utility of total colonic manometry in the management of colonic pseudo-obstruction syndromes. In addition to its diagnostic utility, direct measurement of colonic motor activity can be valuable in deciding the need for and timing of diversion, the extent of resection, and the suitability of the patient for restoring bowel continuity. In Hirschsprung's disease, total colonic manometry can potentially be used to determine suitability for primary neonatal pull-through versus a staged approach. J Pediatr Surg 36:1757-1763. Copyright © 2001 by W.B. Saunders Company.

All mechanical low rectal anastomosis in children

Purpose: The aim of this study is to demonstrate the feasibility and usefulness of mechanical suturing in children for low rectal anastomosis. Methods: The study group includes 31 children operated on from January 1993 to July 1996 by the same senior surgeon, performing the modified Duhamel procedure for Hirschsprung's disease in 17 children, intestinal neuronal dysplasia in seven, and the Knight-Griffen procedure in seven pediatric patients with chronic ulcerative colitis. Results: In all the cases the technique of “viscero-synthesis” was performed using the mechanical stapler. A circular stapler has been used for the end-to-end and the end-to-side anastomosis between the anal canal or the back wall of the rectum with the pulled viscus, while a linear endoscopic stapler (GIA) has been used for the consolidation of the rectocolic wall in the modified Duhamel technique. Conclusions: The results obtained demonstrate that the mechanical staplers in children are safe and effective in low rectal anastomosis, sparing operative time and reducing the risk of anastomotic dehiscence; however, the size of circular instruments limits its use in neonates and small infants.

Early definitive surgery for total colon aganglionosis: Duhamel procedure with right colon patch graft using GIA stapler

A report is presented of an infant with total colon aganglionosis (TCA) with ileal involvement in whom a modified Duhamel procedure was used accompanied by a right colon patch graft 12 cm in length using a GIA-90 stapler at 3 months of age. The patient with TCA is usually treated by an initial diverting ileostomy followed by a definitive operation performed several months later. However, the management during the ileostomy period is associated with a variety of problems. In to minimize the resulting complications, we developed a procedure to allow a much earlier definitive operation.

Hirschsprung's disease

From 1972 to 1985, 214 patients were treated for Hirschsprung's disease. One patient underwent a Swenson pull-through operation, 13 a Soave procedure, and 195 had modifications of the Duhamel procedure. Six children are newly diagnosed and awaiting definitive therapy. Of the patients in whom a modified Duhamel procedure was performed, 153 were males (78%) and 7 (4%) had Down's syndrome. There was no operative mortality for the procedure, and only 4 late deaths have been observed (3 with Down's syndrome). Fecaloma occurred in 12 of 14 patients who underwent the classic operation described by Duhamel, and postoperative enterocolitis was noted in 4 of 6 patients who had Martin's “long” Duhamel modification for total colonic aganglionosis. No urologic problems or anastomotic leaks were identified, and only 1 patient developed a rectal stricture postoperatively. Growth and development and fecal continence have been excellent in the vast majority of patients. The modified Duhamel pull-through operation is associated with excellent survival and highly acceptable long-term function.

Modified Duhamel procedure for treatment of Hirschsprung's disease in infancy and childhood: Review of 41 consecutive cases

The original Duhamel procedure has undergone several important modifications over the years by Martin, Ravitch, Soper, Talbert, and others. Combining the best features of these various modifications, a modified Duhamel procedure has been developed and utilized in 41 consecutive infants and children with all types of Hirschsprung's disease, including three with long segment involvement. The procedure includes the use of a formal upper and lower anastomosis and division of the spur by the GIA stapling device. There were no deaths and no early complications. At 2-7 yr all children are toilet-trained, continent, and growing well. With appropriate modifications, the Duhamel operation is a very satisfactory definitive procedure for Hirschsprung's disease in infancy and childhood.

Treatment of postradiation stricture of the rectum by the modified duhamel procedure

Benign rectosigmoid stenosis secondary to pelvic radiation presents a difficult problem in management and is usually treated by permanent colostomy with its attendant discomfort and inconvenience. Other approaches include low anterior resection or even transsacral resection of the affected area of rectosigmoid, but they involve risk to rectal, bladder, and sexual function. The Martin modification of the Duhamel procedure is specifically designed to avoid these problems and was used successfully in the present case for treatment of rectosigmoid stenosis. The patient has been followed up 8 years and reports normal sensation and function of bladder and rectum and no disturbance of sexual function.

A critical evaluation of the Duhamel operation for Hirschsprung's disease.

Eighty-nine patients with Hirschsprung's disease were treated from 1972 to 1977. Of the patients, 70 were boys, 85 were the result of full-term pregnancy, and four had Down's syndrome. There were 23 children, 32 infants, and 34 neonates including seven (20%) with enterocolitis. Early mortality was 8.8% in neonates and 3% in infants. After initial diversion (colostomy or enterostomy), 66 patients had "classic" (ten), modified (52), or "long" (four) Duhamel pull-through procedures at age 1 year. Operative mortality was zero. Three late deaths occurred; two of them were mongols. Fecaloma occurred in eight of ten classic cases that required revision. Postoperative enterocolitis occurred in three of four long procedures done for total colonic aganglionosis. The modified Duhamel procedure was associated with a low complication rate and good function. There were no instances of anastomotic leak, anal stricture, or genitourinary problems. These data indicate that the modified Duhamel operation is a highly acceptable procedure in the management of Hirsch sprung's disease.

Operative results of modified duhamel procedure for Hirschsprung's disease : S. Ohashi, E. Okamoto, K. Kuwata, et al. J. Jap. Soc. Pediat. Surg., 13:103–108 (February), 1977

Operative results of modified duhamel procedure for Hirschsprung's disease : S. Ohashi, E. Okamoto, K. Kuwata, et al. J. Jap. Soc. Pediat. Surg., 13:103–108 (February), 1977

Modified duhamel procedure for treatment of total aganglionic colon in childhood

Based on this series of six patients with aganglionosis of the entire colon we conclude: (1) Radiographic findings of a shortened colon of normal caliber or the presence of "jejunalization" of the colon suggest total colonic aganglionosis in patients with a suggestive history. (2) All infants with persistent obstipation, distention, and poor weight gain should have a punch biopsy of the rectum even if the barium enema is normal. (3) The Martin modification of Duhamel's operation gives functional results comparable to those achievable in children with short-segment Hirschsprung's disease. (4) The use of a stapling device to divide the septum between aganglionic colon and pulled-through ileum is less satisfactory than using crushing clamps.

Hirschsprung's disease: pitfalls in diagnosis and surgical management.

Forty-seven (41 male) patients with biopsy-proved Hirschsprung's disease were seen in the past decade. The condition of more than half the patients was diagnosed within the first three months of life. These patients harbored bewildering clinical and radiographic manifestations and suffered a high mortality (22%), mainly from sepsis and enterocolitis. Patients whose condition was diagnosed after the first three months of life developed a more characteristic constipation pattern and none died. Sixteen of the 38 patients who underwent corrective operation received the modified Duhamel procedure and 15 the modified Soave. A comparison of these two groups at follow-up showed them to be similar, the modified Soave procedure having a slightly better record, 14 of 15 excellent to good results as opposed to 12 of 16 for the modified Duhamel.

Surgical treatment of Hirschsprung's disease: Comparison of modifications of the duhamel and soave operations

Two operations used in the definitive surgical control of congenital aganglionosis coli were compared. Sixteen patients with biopsy-proven Hirschsprung's disease were treated by a modification of the Duhamel operation, and 13 patients were treated consecutively by a modification of the Soave endorectal procedure. The patients in the two treatment groups were found to be reasonably comparable. The anesthesia time and average length of postoperative stay in hospital were similar for the two operations. There was greater operative blood loss with the modified Soave operation in patients over 2 yr of age. Two patients in each group had anastomotic problems postoperatively, one patient requiring surgical revision of the anastomosis 1 yr following the modified Duhamel procedure. All of the late postoperative complications occurred after the modified Duhamel operation, the most common of which was recurrent enterocolitis. Since we altered this operation to include primary internal anal sphincterectomy, postoperative enterocolitis has not been a problem. Twenty-eight of the 29 patients in the two treatment groups were available for current evaluation. On the basis of ten criteria, 80% of patients were judged to have an excellent or good result following the modified Duhamel operation, compared with 92% following the modified Soave operation. In our experience, both of these operations are rather simple to perform technically and can be undertaken with little morbidity and no mortality, with a high expectation of control of the symptoms of Hirschsprung's disease.

Clinical Experience with a New Operation (Modified Duhamel Procedure) for Hirschsprungʼs Disease

Surgical Service of the Children's Hospital and the Department of Surgery of the College of Medicine, the University of Cincinnati