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Guo
Wang, Xiao-Yi Sun, Ming-Fa Wei, Yi-Zhen Weng, Department of
Pediatric Surgery, Tongji Hospital Affiliated Tongji Medical
College, Huazhong University of Science and Technology, Wuhan
430030, Hubei Province, China
Supported by the National Natural Science Foundation of
China, No.39670746
Correspondence to: Guo Wang, Department of Pediatric Surgery,
Tongji Hospital, 1095 Jiefang Avenue, Wuhan 430030, Hubei Province,
China. gwang@tjh.tjmu.edu.cn
Telephone: +86-27-83662146
Received: 2004-04-22
Accepted: 2004-05-09
Abstract
AIM: To study the long-term therapeutic effect of
"heart-shaped" anastomosis for Hirschsprung's disease.
METHODS: From January 1986 to October 1997, we performed one-stage
"heart-shaped" anastomosis for 193 patients with
Hirschsprung's disease (HD). One hundred and fifty-two patients were
followed up patients (follow-up rate 79%).The operative outcome and
postoperative complications were retrospectively analyzed.
RESULTS: Early complications included urine retention in 2 patients,
enteritis in 10, anastomotic stricture in 1, and intestinal
obstruction in 2. No infection of abdominal cavity or wound and
anastomotic leakage or death occurred in any patients. Late
complications were present in 22 cases, including adhesive
intestinal obstruction in 2, longer anal in 5, incision hernia in 2,
enteritis in 6, occasional stool stains in 7 and 6 related with
improper diet. No constipation or incontinence occurred in any
patient.
CONCLUSION: The early and late postoperative complication rates were
7.8% and 11.4% respectively in our "heart-shaped anastomosis"
procedure. "Heart-shaped" anastomosis procedure for
Hirschsprung's disease provides a better therapeutic effect compared
to classic procedures.
ã
2005 The WJG Press and Elsevier Inc. All rights reserved.
Key words: Hirschsprung's disease; Heart-shaped anastomosis;
Follow-up studies
Wang G, Sun XY, Wei
MF, Weng YZ. Heart-shaped anastomosis for Hirschsprung's disease:
Operative technique and long-term follow-up. World J Gastroenterol
2005; 11(2): 296-298
http://www.wjgnet.com/1007-9327/11/296.asp
INTRODUCTION
During the period from 1955 to 1985, more than 400 children
received classic operations, including modified Duhamel, Soave, and
Ikeda operations, etc, for Hirschsprung's disease (HD) in our
hospital. Because of a high incidence of complications following
these methods[1], we have changed to use a
"heart-shaped anastomosis" designed by ourselves since
January 1986. During the ten years from 1986 to 1997, we performed
this procedure for 193 patients with HD. This procedure could not
only effectively prevent the occurrence of postoperative
complications, such as infection in wound or abdominal cavity,
anastomotic leakage and stricture, but also significantly decrease
the incidence of incontinence or soiling and recurrence of
constipation after surgery. This article reports the outcome of
"heart-shaped anastomosis" procedure in HD.
MATERIALS AND METHODS
Patients
All the 193 cases (155 boys and 38 girls) were diagnosed on
the basis of clinical history, radiological studies, rectoanal
manometry, and pathologic examination after surgery. The mean age of
the patients was 25 mo (range from 9 d to 10 years). Among these
patients, short-segment aganglionosis was found in 172 cases and
long-segment aganglionosis was found in 21 cases. The descending
colon was pulled down for anastomosis in 130 cases, the ascending
colon was pulled down for anastomosis in 63 cases, including 21 with
intestinal neuronal dysplasia (IND).
Operation methods
The operation was performed as previously described[1].
A low left transverse incision was made extending slightly to the
right of the midline. The peritoneal reflection from the rectum was
dissected on both the left and right sides down to just above the
level of the dentate line. To protect the pelvic autonomic nervous
system, the upper third of the lateral rectal ligaments was
dissected as close as possible to the rectal wall. Hemostasis was
achieved with a sponge pressed into the posterior cavity behind the
rectum. The proximal ganglionic bowel was identified with operative
biopsies and frozen section. Aganglionic bowel was then dissected
and mobilized up to the splenic flexure to allow a tension-free
anastomosis with an adequate blood supply.
Attention
was then paid to the perineum. The anus was dilated. An olive-shaped
dilator was inserted via the anus into the lumen of rectosigmoid and
aganglionic rectum was fastened to the dilator at the transition
level. The bowel was then prolapsed out of the rectum, and everted
(Figure 1). The rectum was transected and the ganglionic bowel was
pulled through the anal canal. The most dilated distal portion of
aganglionic bowel was resected at this point. The posterior wall of
aganglionic anorectum was split longitudinally to the level of the
dentate line (Figure 2). The tips of the two halves were trimmed so
that the remaining rectal wall, whose anterior aspect was longer
than the posterior one, had the shape of a heart. A point of
anastomosis in anterior wall was marked at 2 cm above the anal verge
and the proximal bowel opposite to this point was shortened about
2.5 cm for avoiding the formation of a valve. The point of
anastomosis in posterior wall was marked at 0.5 cm above the dentate
line (Figure 3). Interrupted sutures were placed circumferentially
at each quadrant through the seromuscular coats of the proximal
bowel and the full-thickness edge of the transected rectum. Each
suture was tied and grasped with clamps to prevent retraction.
Subsequent sutures were added to each quadrant as full-thickness
bites to complete the anastomosis. In order to prevent leakage, the
posterior wall was meticulously sutured. At completion of the
procedure, the anterior anastomosis was 4 cm above the anal verge
and the posterior anastomosis was 2 cm above the anodermal junction.
Among the 193 patients,
152 patients received complete follow-up (follow-up rate 79%). The
follow-up time ranged from 24 mo to 140 mo (mean 80 mo).
Figure 1(PDF)
Transrectal dilator tied around ganglionic bowel at
transition zone, and pulled through rectum. Bowel was everted until
mucocutaneous line was exposed posteriorly, but not anteriorly.
Figure 2(PDF)
Ganglionic bowel exposed by resection of most dilated bowel.
The posterior wall of the aganglionic anorectum was longitudinally
split in posterior wall of anorectal canal to dentate line.
Figure 3(PDF)
Suturing of seromuscular coats of rectum and colon. The bowel
was everted and exteriorized out of the anus.
RESULTS
Early postoperative complications occurred in 15 (7.8%)
patients, including urine retention in 2 who recovered following the
insertion of a urethral catheter 1wk after operation, enteritis in
1, anastomotic stricture in 1, and intestinal obstruction in 2 who
were cured with Chinese herbals. No infection in celiac/pelvic
cavity or wound, and anastomotic leakage or death occurred in any
patient.
Late complications occurred in 22 (11.4%)
patients, such as adhesive intestinal obstruction in 2 who were
treated with adhesive bowel resection, constipation due to longer
remaining anal canal in 5 who were treated with a strip of internal
sphincter cut, incision hernia in 2, enteritis in 6, occasional
soiling in 7 and 6 related with improper diet. No incontinence or
recurrence of constipation was found in any patient.
DISCUSSION
A number of operating procedures have been reported for treating
HD. Previous studies have shown that the incidence of early
postoperative complications in these procedures is over 25%, and the
late complication rate is approximately 40%[2-4].
However, these two complication rates in our "heart-shaped
anastomosis" procedure were 7.8 and 11.4%, respectively.
The incidence of infection in celiac/pelvic
cavity or wound was approximately 7 to 17% in our study. Unlike
other operations in which resection and anastomosis of the colon are
performed in abdominal cavity, they were performed outside the
abdominal cavity in our study and contamination or infection could
be avoided.
Anastomotic leakage is usually the most
severe complication in HD, and the incidence is 3 to 15.5%[2].
It often causes septic infection in the abdominal or pelvic cavity
and needs colostomy to save the patient's life. In some patients,
anastomotic leakage can result in multi-fistulae in pelvic cavity,
frozen pelvis or constipation, and even lifelong artificial anus. In
our procedure, the splenic flexure and left transverse colon are
mobilized sufficiently, so that the colon could be pulled-through
easily for a tension-free anastomosis outside the anus. On the other
hand, a clear field of vision and reliable manipulation also allow
us to avoid the occurrence of anastomotic leakage.
The occurrence of
anastomotic stricture is related to ring-stricture at anastomosis,
necrosis due to clamping of the bowel and its incidence is about 10%[2].
The "oblique anastomosis" procedure could prevent
ring-stricture at the anastomosis and avoid anal dilatation within
3-5 mo after operation[1]. In our patients, valvular
stricture in anterior wall was found in one patient due to
reservation of anterior coloanal wall and cured by dilating anus.
Because more than half of
the internal sphincter is resected in most operations, the incidence
of soiling or constipation is approximately 10 to 20%[2,5].
However, our procedure could retain almost all the internal
sphincter, so that it prevents recurrence of constipation and
decreases the incidence of soiling. On the other hand, this
procedure cut off the internal sphincter in the posterior wall, thus
preventing spasm of the internal sphincter after operation.
It has been reported that recurrence of
incontinence is related to insufficient resection of pathologic
colon or/and too much reservation of aganglionic rectum[4].
In our operation, the splenic flexure and transverse colon were
regularly mobilized and aganglionic colon was removed sufficiently,
therefore recurrence of incontinence was avoided. In our study, a
longer rectum was preserved in 5 patients, who were managed by
resection of internal sphincter.
This
procedure cannot prevent the occurrence of enterocolitis, which is
about 8 to 25%. Further studies are needed to elucidate the reason
for the occurrence of enterocolitis.
In summary,
"heart-shaped" anastomosis for HD provides a clear field
of vision, follwes simplified steps of operation, there is no need
for a colostomy, minimal mobilization of pelvic cavity, and
placement of urethral catheter is not needed. Colon can be resected
outside the anus, and oblique colorectal anastomosis is performed
end-to-end, thus minimizing the chance of contamination in
abdominal/pelvic cavity. Rectal blind pouch, septum, infection or
rupture of anastomosis are also avoided. There is no need to dilate
anus after operation. No special clamps or stapling devices are
required and complications resulting from them are avoided and
nursing work is simplified. Not only the internal sphincter is
persevered to a maximum degree but also the internal sphincter spasm
syndrome is avoided, thereby solving the problems of soiling,
incontinence and recurrence of constipation. Currently, this
procedure has been widely used in many hospitals in China[6-9].
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Edited
by
Wang XL and Kumar M
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PubMed