Total Colectomy and Straight Ileo-Anal Soave Endorectal Pull-Through: Personal Experience with 42 Cases

Abstract

During the period from 1974 to June 2000 we used the straight ileo-anal Soave pull-through to treat 42 patients (24 affected by total colonic aganglionosis [TCA], 10 with ulcerative colitis and 8 with familial polyposis). The aim of this paper is to show that this operation, associated with total colectomy, is highly recommended, causing a lower number of complications when compared to the various "reservoir" techniques. The mean age of the 24 patients with TCA at the time of the pull-through was 2.8 years; in the ulcerative colitis group, it was 14.3 years and in the familial polyposis group 27.2 years. We always used an ileo-anal deferred anastomosis and never performed temporary loop-diverting ileostomy at the time of the pull-through. In the TCA patients we had no immediate or long-term serious post-operative complications: ileal adaptation, after a frequency of 10 - 12 liquid stools a day, showed a gradual, constant and in some cases amazing improvement in all children. Two years after surgery, the mean stool frequency was 3.6 per 24 hours with no significant differences between the 3 main groups; only 4 children still presented with occasional soiling. After pull-through, all children showed normal growth curves in the long term. There was no malabsorption, no serious electrolyte imbalance, no perianal excoriation, no strictures or intestinal obstruction; their quality of life was considered more than satisfactory by the children's families. We have no direct experience with the various ileal "reservoir" techniques for ulcerative colitis and ileal polyposis nor with colon-sparing operations for TCA; as reported in the literature, all these surgical procedures seem to have a higher number of complications such as pelvic sepsis, pouchitis, enterocolitis, etc. compared with our series; we therefore confirm that total colectomy with the straight ileo-anal Soave pull-through is our treatment of choice, as it is simpler to perform and has fewer short- and long-term complications.

Long-Term Results of the Treatment of Total Colonic Aganglionosis with Two Different Techniques

“…No case of stenosis or persistent constipation was seen and the proportion of patients with postoperative enterocolitis was not higher than in other series [14,32]. As regards to the straight ileo-anal pull-through, we share the opinion of other authors regarding its relative simplicity, its feasibility at a young age and the surprising adaptation of patients to the increased fecal volume along the years [8]. A comparison between both techniques was not possible because they were not performed during the same period and patients operated upon with straight pull-through are obviously younger than those operated on with the modified Martin.…”

“…Total colonic aganglionosis (TCA) accounts for 5 to 10 % of all cases of Hirschsprung's disease (HD) [15] and deserves separate consideration, because the nature of the operations aimed at reestablishing fecal flow through a healthy intestine may compromise nutrition, continence and quality of life (QOL). A long-term assessment of large cohorts of patients with TCA has seldom been made and reported results have been quite uneven, due in part to the inclusion in some series of patients with extensive small bowel or total intestinal aganglionosis [8,10,12,19,21,31,32]. Only a few specifically address QOL.…”

“…Duhamel-based pull-through with side-to-side ileocolonic anastomosis proposed by Martin [20] was for years the predominant treatment [5,10,13,18,21,29,30]. Preservation of the absortive function of the aganglionic colon was attempted with several types of colonic patches [1,2,4,9,10,13,16,22,23,29,30] although straight ileo-anal pull-through with either Duhamel, Soave or Swenson techniques can serve the same purpose [7,8,11,32]. The first of the surgical techniques used at our institution to treat this condition deserves particular comment.…”

Results of Total and Subtotal Colon Resections in Children

“…In addition, an accumulation time of 1 year has proved to be good for the small bowel, and the time should be used for the patients treatment by means of suitable diet and medication in order to form mushy or solid stools from the ileostoma which provides much better conditions for postoperative management. Whether Soaves pullthrough with a safer anastomosis may have a better outcome still remains open, since separating rectal mucosa from the thinned out colon wall brings other problems in its train (2,4). Dodero et al (3) reported on very good results in 42 patients (24 affected by total colonic aganglionosis) after ileonal anastomosis according to Soaves technique but the evaluation protocol should be prospective and standardised.…”

Hirschsprung Disease beyond Infancy

“…We prefer to delay the definitive reconstructive procedure until the child is 1 year of age after a leveling ileostomy during the neonatal period. Some prefer to delay the reconstruction until later in life, 33 whereas others perform a pull-through without a diversion procedure in the neonatal period. [34][35][36] Another option is to perform the definitive reconstruction at diagnosis but leave a protective ileostomy until the child is toilet-trained for urine and is willing to tolerate rectal irrigations.…”