Functional outcome after Swenson′s operation for Hirshsprung′s disease

Abstract

Background/Aim:Hirschsprung's disease (HD) is one of the most common causes resulting in lower intestinal obstruction in children with atypical clinical symptoms and inconspicuous morphological findings by barium enema X-ray. Recently, this situation has been largely ameliorated by improvement of instrument for measurement of anorectal pressure. By now, anorectal manometry has been regarded as a routine means for functional assessment and diagnosis of HD. It is accurate in nearly all cases of HD with characteristic absence of rectoanal inhibitory reflex. Different surgical modalities of treatment are available and Swenson's operation is one of the surgical procedures done for HD. Anorectal manometric findings may change after Swenson's operation with improvement of rectoanal inhibitory reflex in some cases. We aimed to evaluate functional results after Swenson's operation for HD using anorectal manometry.Patients and Methods:Between 1996 and 2005, 52 patients were diagnosed with HD and operated upon by Swenson's operation in Gastroenterology Center, Mansoura University. There were 33 males (63.46%) and 19 females (36.54%) with a mean age of 3.29 ± 1.6, (range 2-17 years). Anorectal manometry and rectal muscle biopsy were done preoperatively for diagnosis but after operation anorectal manometry was done after every six months and then yearly.Results:All of the 52 patients showed absent rectoanal inhibitory reflex on manometric study with relatively higher resting anal canal pressure and within normal squeeze pressure. Postoperatively, there were 35 continent patients (67.31%) with 11 patients (21.15%) showing minor incontinence and six (11.54%) with major incontinence. On the other side, there were five patients (9.62%) with persistent constipation after operation (three due to anal stricture and two due to residual aganglionosis). Postoperative manometric study showed some improvement in anal sensation with the rectoanal inhibitory reflex becoming intact in six patients (11.54%) four years after operation.Conclusion:Anorectal manometry is a more reliable method for diagnosis of HD than barium enema X-ray but for final diagnosis, it is reasonable to combine anorectal manometry with tissue biopsy. Functional outcome after Swenson's operation for HD may improve in some patients complaining of incontinence or constipation. Anorectal manometry may show improvement of the parameters after Swenson's operation.

Interest of Anorectal Manometry During Long-term Follow-up of Patients Operated on for Hirschsprung's Disease

“…In the literature, several authors stated that patients with true incontinence present a significantly lower resting pressure than normal subjects. 24,27 As also reported by Gad ElHak et al, 25 in a study of 52 patients after pull-through operation, the mean pressure was 58.1 ± 15.1 mmHg among continent cases, 49.1 ± 15.1 mmHg among minor incontinent cases, and 37.1 ± 12.1 mmHg among major incontinent cases with a highly significant difference between continent and major incontinent groups. On the other hand, Meinds et al 10 reported a wide range of anal resting pressure 70 (25-110) mmHg.…”

“…30 So, it raised an hypothesis that the normally innervated bowel anastomosed to the anal canal acquires a "quite normal" rectal function as an adaptation of the neo-rectum years after a pull-through operation. 25 However, re-establishment of RAIR was not clinically correlated with any positive long-term outcome in our series as well as in the other studies. 9 Of course, a RAIR re-establishment due to technical issues should be always considered.…”

“…On the other hand, Meinds et al 10 reported a wide range of anal resting pressure 70 (25-110) mmHg. Of note, the HRAM system with solid catheters was used in the study of Meinds et al, 10 whereas the conventional polygraph anorectal manometry was used in the study of Gad El-Hak et al 25 In our study, anal resting pressure in incontinent patients was 47 ± 12 mmHg which was significantly lower than in continent patients with 63 ± 11 mmHg ( Table 2). Regarding surgical treatment, there is an ongoing debate in the literature on whether the risk of fecal incontinence is associated with the operative technique.…”

“…10 In contrast, Mishalany et al 9 and Moore et al 11 reported RAIR reappearance in 10.0% and 13.6% of the operated patients for HD, respectively. Recently, Gad El-Hak et al 25 reported RAIR becoming intact in 11.5% of the HD patients 4 years after operation as well as their improvement in rectoanal sensation. Interestingly, in our series, 8 out of 19 patients got their RAIR back.…”

Classic Swenson abdomino perineal pull through in the treatment of Hirschsprung’s Disease – 3 years experience in a tertiary care Paediatric Hospital in Bangladesh

“…The incidence may vary from 1% to as high as 37.7%. [19][20] In this study only 3 patients complained of soiling The mean operation time from incision to dressing was 115.16±16.17minutes the mean hospital stay was 7.15 ± 1.85days. (Table-IV Postoperative complications were evaluated immediately and on 2nd, 4th, 8th and 12th weeks following operations to seeshort term outcome of children who have undergone the Classic swensonabdominoperineal pull through operation in the treatment of Hirschsprung's disease.Five patients needed perioperative blood transfusion.…”