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The problematic Duhamel pouch in Hirschsprung's disease: manifestations and treatment
K Chatoorgoon1, A Pena, T A Lawal
1Cincinnati Children's Hospital, Colorectal Center, Pediatric Surgery, Cincinnati 45229, USA.
Insights
Redo surgery for Hirschsprung
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Colorectal Surgery
Background:
- The Duhamel operation is a standard surgical treatment for Hirschsprung's disease (HD).
- Complications and persistent symptoms following the Duhamel procedure necessitate reevaluation and potential redo surgery.
- Our center has observed an increase in patients referred for management of post-Duhamel complications.
Purpose of the Study:
- To analyze the outcomes of redo pull-through surgery in patients experiencing persistent symptoms after an initial Duhamel procedure for Hirschsprung's disease.
- To identify the underlying causes of persistent symptoms and evaluate the effectiveness of reoperation.
Main Methods:
- Retrospective review of 17 patients with Hirschsprung's disease who underwent redo pull-through surgery after a prior Duhamel procedure.
- Surgical approaches included posterior sagittal (with or without laparotomy) and transanal Swenson-type resection with laparotomy.
- Histopathological analysis of biopsies and assessment of Duhamel pouch size were performed.
Main Results:
- All 17 patients presented with constipation, impaction, or enterocolitis; 9 experienced overflow incontinence.
- Pathological findings included persistent aganglionosis (6 patients) and transition zone bowel (2 patients). 9 patients had a mega Duhamel pouch without clear pathological indication.
- Post-redo surgery, 13 of 15 followed patients achieved voluntary bowel movements, with 2 remaining diverted.
Conclusions:
- The Duhamel pull-through, while often successful, can lead to significant long-term issues like impaction and incontinence.
- Mega Duhamel pouches are a key factor in persistent impaction and require identification.
- Reoperation, including resection of the Duhamel pouch, can substantially improve patient quality of life.
Purpose:
The Duhamel operation is commonly employed to treat Hirschsprung's disease (HD). We have seen a number of patients referred to our center with problems following a Duhamel procedure performed elsewhere, and have analyzed our experience with these children.
Methods:
We reviewed 17 patients with Hirschsprung's disease who underwent a Duhamel procedure elsewhere, in whom we performed a redo pull-through for persistent symptoms of constipation, impaction, and enterocolitis.
Results:
All patients (n=17) had constipation/impaction or enterocolitis, 9 of whom were soiling due to overflow incontinence. Biopsies of the pulled-through bowel found 6 patients with persistent aganglionic bowel and 2 patients with ganglion cells present but hypertrophic nerves, a finding we interpreted as "transition zone bowel". The remaining 9 patients without a pathological indication for reoperation had a mega Duhamel pouch. All patients underwent a redo operation: 8 via a posterior sagittal approach (7 with a laparotomy, 1 without) and 9 by a transanal, Swenson-type resection with a laparotomy. The posterior sagittal approach was used in cases with severe pelvic fibrosis considered unsuitable for a trans-anal operation. 15 patients were followed up postoperatively for longer than 2 months, 13 of whom now have voluntary bowel movements, including 8 who need a small dose of laxatives. 2 patients are still diverted.
Conclusion:
Although perhaps successful for many patients around the world, the Duhamel pull-through can leave patients with significant symptoms, including impaction and overflow incontinence. It is unclear why some patients with a Duhamel pouch do not empty well. Clearly, those patients with a mega Duhamel pouch suffer from impaction. These patients need to be detected, because reoperation with resection of the Duhamel pouch can dramatically improve their quality of life.
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