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Long-term outcomes in children with Hirschsprung’s disease and transition zone bowel pull-through: impact of surgical techniques and role for conservative approach

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Abstract

Purpose

Presence of transition zone (TZ) in the pulled colon can impact the outcome of surgery in children with Hirschsprung’s disease. There is a wide variation in terminology used to define TZ and its management. We present our series of managing 11 such children with considerations for conservative management.

Methods

Eleven of 114 children operated for Hirschsprung’s disease had features of TZ on the 4-quadrant doughnut assessment of proximal anastomosing margin. They were followed up for development of obstructive symptoms, failure of pull-through procedure or bowel-related complications. Intervention done were observation with laxatives, dilatation, Botox injection and redo pull-through.

Results

Of the 11 children, 6 underwent Duhamel’s procedure and 5, transanal endorectal pull-through (TERP). Features identified on HPE were presence of hypertrophic nerve bundles involving 2 or 3 quadrants in the circumferential doughnut biopsy of proximal anastomosing margin. Observed symptoms included constipation, enterocolitis, increased bowel frequency and soiling. Intervention done were use of laxatives with bowel management program in six and Botox injections in four. Only one child with TZ in 3 quadrants required redo surgery. Mean follow-up was 5.2 years with resolution of symptoms in most.

Conclusion

This study highlights the role of conservative management with good outcomes in children with TZ bowel pull-through having hypertrophic nerve fibers and normal ganglion pattern. Children who underwent Duhamel’s procedure had little impact with the presence of TZ at anastomotic margin and majority of those undergoing TERP benefitted from Botox injection. Conservative management can be attempted successfully to prevent redo surgical interventions as they can lead to poorer outcomes. Only those children not responding to conservative measures need to be planned for revision surgery.

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Authors and Affiliations

  1. Department of Paediatric Surgery, Indira Gandhi Institute of Child Health Hospital, South Hospital Complex, Near NIMHANS, Hombegowda Nagar, Bangalore, 560029, India

    Gowri Shankar, J. G. Deepak, Vinay Jadhav, K. Venkatesh & S. Ramesh

  2. Translational Research Laboratory for Gut Motility Disorders, St. John’s Medical College, Bangalore, India

    Usha Kini

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  1. Gowri Shankar
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  2. J. G. Deepak
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  3. Vinay Jadhav
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  4. K. Venkatesh
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  5. Usha Kini
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  6. S. Ramesh
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Correspondence to Gowri Shankar.

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Presentation at a meeting: PCC 2020.

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Shankar, G., Deepak, J.G., Jadhav, V. et al. Long-term outcomes in children with Hirschsprung’s disease and transition zone bowel pull-through: impact of surgical techniques and role for conservative approach. Pediatr Surg Int 37, 1555–1561 (2021). https://doi.org/10.1007/s00383-021-04974-3

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