Page 12 - WJOLS - Journal of Laparoscopic Surgery

WJOLS

Laparoscopic Management of Hirschsprung’s Disease
pulled-through colon that was reduced without further risk for long segment disease. Transanal approach was
sequels; one (group III) had infection of the stoma closure also supported by Dela Torri with shorter hospital stays
wound. Perianal skin rash was more often in neonatal and fewer complications.
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patients (group I, 10 of 15; group II: 4 of 11; group III: 8 Schofield and Ram compared between open
of 14). Anastomotic dilatation regimen was required more Duhamel’s (OD) and laparoscopy-assisted Duhamel’s
often in neonatal cases (group I, 6 of 15; group II, 1 of 11; (LD) procedure.
group III, 2 of 14). Enterocolitis requiring hospital care From 11 articles, 456 patients were included (253 OD,
occurred in two patients (group I), and five further patients 203 LD), with no significant difference in age at surgery
(group II, 1; group III, 4) were treated as outpatients for and length of follow-up (p > 0 .05). The open group had
symptoms, suggesting mild enterocolitis or bacterial over- a significantly greater incidence of soiling/incontinence
growth. They concluded that transanal ERPT in neonatal (11 vs 4%; p = 0.02) and further surgery (25 vs 14%;
patients was as feasible and safe as in older children. Tem- p =0 .005), longer hospital stay (9.79 vs 7.3 days; p < 0.00001),
porary postoperative skin rash occurred more frequently and time to oral feed (4.05 vs 3.27 days; p < 0.00001).
in neonatal patients, and postoperative dilatations were Operative time was significantly longer in the laparo-
required more often than in older children. scopic group (3.83 vs 4.09 hours; p= 0.004). There was no
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In another article, Minford et al compared the significant difference in incidence of enterocolitis (15 vs
outcome of Duhamel’s operation and transanal ERPT. 10%; p =0 .14) and constipation (23 vs 30%; p =0 .12). They
In their study, 70% were neonates (Duhamel, 24 of 34; have compared the quality of life and Fecal Continence
transanal endorectal coloanal anastomosis, 26 of 37). They Index in children with Duhamel’s operation and trans-
assessed the functional outcome. Functional outcome anal pull-through and normal children. They have found
was similar in the two groups. They found that ERPT that both quality of life and Fecal Continence Index were
and Duhamel procedures had similar medium-term lower than normal children in both groups and transanal
functional outcomes. The ERPT had a high incidence of pull-through had still a lower score.
postoperative enterocolitis and transient stricture forma-
tion but was suitable for single-stage neonatal treatment DISCUSSION
of Hirschsprung’s disease. Open laparotomy and transanal pull-through procedures
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Lu et al also found a high rate of postoperative
enterocolitis in neonates undergoing transanal pull- whether Duhamel’s or Swenson’s or Soave are associated
through. with immediate and delayed complications and morbid-
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Teeraratkul in an article described the limitation of ity. This includes wound infections, intra-abdominal and
the procedure of transanal pull-through. Retroperitoneal pelvic abscesses, wound dehiscence, anastomotic leak,
fixation of the descending colon could not be dissected by stricture at the anastomotic line, intestinal adhesions and
the transanal route, especially if it needed mobilization intestinal obstructions, constipation, incontinence prob-
of the splenic flexure. The length of bowel that could be lems, and perineal excoriations in addition to the enteroco-
dissected varied from 9 to 25 cm. litis. Colostomy in addition has its own complications like
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Langer et al compared transanal Soave with the prolapse, herniation, stenosis, abdominal wall excoriation
open approach to see whether it offers any advantage and in addition to the stoma management problems.
whether routine laparoscopic visualization is necessary. He But the transanal pull-through procedures were
studied 37 children. They had children with open Soave 13, associated with fewer complications even though various
transanal Soave with laparotomy 9, and transanal Soave authors have reported increased episodes of enterocoli-
with selective laparotomy or minilaparotomy 15. tis. So the endorectal dissection became the dominant
In two patients with transanal Soave, they had to do minimal access procedure, which could be done easily
laparoscopy for a long segment in one and small umbilical in the neonates without entering the peritoneal cavity.
incision for mobilization of the splenic flexure in another. The peritoneal dissection is avoided and hence, its early
There were no differences in operating time, and intra- and late complications.
operative complications, such as enterocolitis, stricture, Number of days of hospital stay was reduced, but the
or cuff narrowing, but hospital stay was longer in open level of resection was an arbitrary choice of visualized
Soave and there were four reoperations in open Soave, transitional zone. The resected ends could be sent for
adhesion obstruction, twisted pull-through, and recur- biopsy, but necessitated opening up of the abdomen if
rent aganglionosis being the causes. They concluded that the level was higher up. Also if the transition zone was
transanal pull-through had shorter hospital stay and low above the usual rectosigmoid junction, peritoneal dissec-
incidence of intra-abdominal adhesions. Laparoscopic tion especially at the splenic flexure needed laparotomy
visualization was needed for children who are at high or a minilaparotomy at the umbilicus. Some studies
World Journal of Laparoscopic Surgery, September-December 2017;10(3):91-94 93