Sa. Banani et al., INTESTINAL NEURONAL DYSPLASIA AS A CAUSE OF SURGICAL FAILURE IN HIRSCHSPRUNGS-DISEASE - A NEW MODALITY FOR SURGICAL-MANAGEMENT, Journal of pediatric surgery, 31(4), 1996, pp. 572-574
Two hundred fifteen cases of Hirschsprung's disease (HD) had follow-up
after definitive surgical treatment, which had been performed between
September 1983 and August 1994. Of these, 20 (9.3%) had recurrence of
obstructive symptoms that was unresponsive to conservative treatment,
Nine cases were improved by posterior anorectal myectomy (FARM), The
other 11 patients, who did not have improvement after FARM, had a re-p
ull-through. Reoperation consisted of excision of the descending and l
eft transverse colon with pull-through of the right colon, regardless
of the histology of the colon. The blood supply was based on the ileoc
olic vessels, with or without division of the right colic artery. To p
rovide a smooth course for these blood vessels, without kinking, and t
o obtain adequate length of the right colon with less dissection, the
entire bowel was derotated clockwise, Re-pull-through was then perform
ed from the left side of the abdomen. The excised bowel from both oper
ations was examined, using H&E staining, for possible evidence of inte
stinal neuronal dysplasia (IND) or acquired aganglionosis. All had gan
glion cells in the remaining colon and at the distal limit of the pull
-through. Histological signs of IND were present in all patients in th
e previously pulled-through colon. Apart from one mentally retarded ch
ild, all had satisfactory bowel movements in a 10 to 54-month follow-u
p period. IND should be considered a cause of surgical failure in HD.
Subtotal colectomy and pull-through of the right colon after clockwise
derotation of the entire bowel appears to be effective when symptoms
persist after conservative therapy or PARM. (C) 1996 by W.B. Saunders
Company