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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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LETTERS TO THE EDITOR
Year : 2020  |  Volume : 25  |  Issue : 4  |  Page : 257-258
 

Distal loop colonoscopy-assisted transanal excision of retained spur after duhamel's procedure


1 Department of Medical Gastroenterology, JIPMER, Puducherry, India
2 Department of Pediatric Surgery, JIPMER, Puducherry, India
3 Department of Pediatrics, JIPMER, Puducherry, India

Date of Submission26-Jul-2019
Date of Decision18-Oct-2019
Date of Acceptance07-Nov-2019
Date of Web Publication24-Jun-2020

Correspondence Address:
Dr. K Senthamizhselvan
Department of Medical Gastroenterology, JIPMER, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_122_19

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How to cite this article:
Senthamizhselvan K, Mohan P, Naredi BK, Jagadisan B. Distal loop colonoscopy-assisted transanal excision of retained spur after duhamel's procedure. J Indian Assoc Pediatr Surg 2020;25:257-8

How to cite this URL:
Senthamizhselvan K, Mohan P, Naredi BK, Jagadisan B. Distal loop colonoscopy-assisted transanal excision of retained spur after duhamel's procedure. J Indian Assoc Pediatr Surg [serial online] 2020 [cited 2020 Jul 4];25:257-8. Available from: http://www.jiaps.com/text.asp?2020/25/4/257/287649




Sir,

Hirschsprung's disease (HD) is characterized by congenital absence of ganglion cells in the submucosal and myenteric plexus of distal intestine, resulting in functional obstruction.[1] Surgery is the only treatment modality available for HD, and the different surgical techniques have evolved from multistage procedures to single-stage procedures and laparoscopy-assisted techniques. These single-stage procedures, however, need a convincing histopathological diagnosis of HD from frozen sections during surgery. In our country, most HD presents with complications such as enterocolitis, colonic perforation, and intestinal obstruction. Hence, a staged procedure to first address the complications followed later by a definitive surgery would be appropriate.

A staged Duhamel's procedure (DP) is a commonly performed surgery for the entire spectrum of HD where aganglionic segment is resected followed by rectorectal pull-through and anastomosis with ganglionated segment of the bowel. However, various complications may occur after DP, namely wound infection, rectal stump leak, perianal excoriation, stricture formation, retained spur, and enterocolitis.[2],[3] Retained spur and spur-related complications have been reported in 4.17% of cases after DP.[4] It may present as fecal impaction and fecal soiling and may warrant a repeat surgery. We report a novel technique of distal loop colonoscopy-assisted transanal excision of the retained spur in a 1-year-old child.

He presented with abdominal distension and failure to pass meconium on the 5th day after birth. He was diagnosed to have a sealed sigmoid colon perforation, for which emergency loop transverse colostomy was done. Rectal biopsies taken were suggestive of HD. He underwent Martin's modification of Duhamel's pull-through procedure at the age of 1 year. Post-Duhamel's operation, the distal loopogram done showed a retained spur [Figure 1]a which was confirmed by sigmoidoscopy. The transanal division of the spur was planned under colonoscopic guidance. The child was placed in lithotomy position. Under general anesthesia, pediatric colonoscope (PENTAX-EPK100) was passed through the transverse loop stoma into the distal loop and the spur was visualized [Figure 1]b. Endoscopic linear stapler was passed up through the anal canal, and 35-mm staplers were fixed and the spur was divided [Figure 1]c and [Figure 1]d. The postprocedure colonoscopy revealed complete division of the spur following which colostomy closure was done. The child was symptom-free and doing well on follow-up.
Figure 1: (a) Post-Duhamel's operation distal loopogram showing a retained spur, (b) colonoscope passed through the transverse loop stoma into the distal loop showing retained spur, (c) endoscopic linear stapler was passed up through the anal canal and 35 mm staplers were fixed and the spur was divided, (d) postprocedure colonoscopy revealed complete division of the spur

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In conclusion, distal loop colonoscopy-assisted management of retained spur ensures real-time assessment of the completeness of spur division and avoids repeat surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
de LorijnF, Boeckxstaens GE, Benninga MA. Symptomatology, pathophysiology, diagnostic work-up, and treatment of Hirschsprung disease in infancy and childhood. Curr Gastroenterol Rep 2007;9:245-53.  Back to cited text no. 1
    
2.
Bourdelat D, Vrsansky P, Pagès R, Duhamel B. Duhamel operation 40 years after: A multicentric study. Eur J Pediatr Surg 1997;7:70-6.  Back to cited text no. 2
    
3.
Mattioli G, Castagnetti M, Martucciello G, Jasonni V. Results of a mechanical Duhamel pull-through for the treatment of Hirschsprung's disease and intestinal neuronal dysplasia. J Pediatr Surg 2004;39:1349-55.  Back to cited text no. 3
    
4.
Thakur VK, Rahul SK. Outcome of Duhamel's Pull-through in Hirschsprung's disease: A tertiary center experience. Int J Sci Stud 2017;5:48-53.  Back to cited text no. 4
    


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