CAPS original paper
Postoperative Hirschsprung's enterocolitis after minimally invasive Swenson's procedure

https://doi.org/10.1016/j.jpedsurg.2006.12.055Get rights and content

Abstract

Background/Purpose

Our preferred minimally invasive technique of Swenson's procedure has evolved from laparoscopic (LapSwen) to Swenson's transanal pullthrough (SWAP). We studied the incidence of postoperative Hirschsprung's enterocolitis (HEC) over the past decade.

Methods and Materials

We retrospectively reviewed the charts of 52 children who had a primary Swenson's pullthrough procedure between 1995 and 2006. Two cohorts (25 LapSwen [1995-2000] and 27 SWAP [1998-2006]) were compared.

Results

Median ages of diagnosis were 13 days for LapSwen and 4 days for SWAP. Median age at surgery was 4.1 months for LapSwen and 3.3 months for SWAP. Postoperative HEC occurred in 12% (16% LapSwen, 7.4% SWAP). The incidence of Down's syndrome and preoperative HEC did not differ between the 2 cohorts. Three children with HEC were Clostridium difficile–positive. Long-term function in the 36 children older than 4 years was excellent in 22%, good in 50%, fair in 11% and poor in 17%.

Conclusion

Our incidence of postoperative HEC is low, and we have seen a trend toward fewer cases after the SWAP procedure. Early diagnosis, preoperative rectal irrigations, and routine postoperative anal dilatation may be contributing to the elimination of HEC as a significant risk after surgery for Hirschsprung's disease.

Section snippets

Materials and methods

A retrospective chart review of all children having surgery for HD by 4 pediatric surgeons at McMaster Children's Hospital from 1995 to 2006 was approved by the research ethics board. We excluded patients who were older than 18 years, had an open pullthrough, had total colonic aganglionosis, or had a previous pullthrough at another institution. For the purposes of this study, an episode of HEC was recorded if it had been diagnosed by the attending surgeon (face sheet, discharge diagnosis,

Results

Fifty-two patients with HD were found to fit our inclusion criteria, 25 with a LapSwen and 27 with the SWAP. The preoperative data are shown in Table 1. There was no significant difference in age at diagnosis or age at surgery between the 2 groups. The incidence of Down's syndrome, long-segment aganglionosis, and preoperative HEC did not differ. There were significantly more males in the LapSwen group. Eight patients required a preoperative stoma because of inadequate decompression with rectal

Discussion

There have been tremendous improvements in understanding HD, but HEC still remains a major source of morbidity. The proposed causes include obstruction, infection, alterations in intestinal mucous, diminished enterocyte adherence, alterations in intestinal immunocytes, and intestinal neuronal dysplasia [8]. The clinical diagnosis of HEC is based on signs and symptoms, with a spectrum of presentation from mild episodes of abdominal distension and explosive diarrhea to fulminant shock [1], [8].

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