LETTERS TO THE EDITOR
|Year : 2021 | Volume
| Issue : 1 | Page : 69-70
Division of Long Residual Spur after Duhamel's Pull through with Endo-GIA Stapler under Colonoscopic Guidance
Ankur Mandelia1, Moinak Sen Sharma2, Yousuf Siddiqui1, Ashwani Mishra1
1 Department of Pediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||14-Aug-2020|
|Date of Acceptance||02-Sep-2020|
|Date of Web Publication||11-Jan-2021|
Dr. Ankur Mandelia
Department of Pediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mandelia A, Sharma MS, Siddiqui Y, Mishra A. Division of Long Residual Spur after Duhamel's Pull through with Endo-GIA Stapler under Colonoscopic Guidance. J Indian Assoc Pediatr Surg 2021;26:69-70
|How to cite this URL:|
Mandelia A, Sharma MS, Siddiqui Y, Mishra A. Division of Long Residual Spur after Duhamel's Pull through with Endo-GIA Stapler under Colonoscopic Guidance. J Indian Assoc Pediatr Surg [serial online] 2021 [cited 2022 Sep 29];26:69-70. Available from: https://www.jiaps.com/text.asp?2021/26/1/69/306704
We read with keen interest the recent article published in JIAPS by Senthamizhselvan et al., in which the authors describe a novel technique of distal loop colonoscopy-assisted transanal excision of the retained spur in a 1-year-old child. We applaud the authors for their successful management of this difficult problem. We had recently presented a similar technique at PESICON, 2020 held at Pune. We wish to describe our case and technique in detail to add to the aforementioned article.
A 6-year-old girl was referred to us with a history of severe constipation and intermittent enterocolitis for 1 year of age. She had undergone a levelling colostomy in the new-born period followed by a Duhamel's pull through at 1 year of age for Hirschsprung's disease at another center. Previous biopsies were reported as adequate ganglion cells in the pull through the bowel. Abdominal examination revealed a soft and distended abdomen. Per rectal examination revealed a residual spur starting at about 8 cm from the anal verge. Contrast enema revealed a long aganglionic rectum anteriorly with long residual spur with grossly dilated proximal colon loaded with fecal matter [Figure 1]a. Colonoscopy confirmed the findings of a residual spur starting at 8 cm from the anal verge and extending proximally for 6 cm [Figure 1]b.
|Figure 1: (a) Contrast enema showing a long residual spur (arrows) (b) Colonoscopy image showing the extent of the residual spur|
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The child was initially managed with rectal wash outs and enemas to decompress the proximal colon and residual rectum. Bowel preparation was done for 48 h before surgery. Under general anesthesia, anal dilatation with the application of retracting sutures was done to accommodate two 12-mm ports per anally [Figure 2]a. One port was used for a 12 mm colonoscope and the other for a 12-mm endo-GIA stapling instrument (Covidien, Medtronic Inc., USA). Under colonoscopic guidance, the residual spur was defined in its entire length and divided completely by two firings of endo-GIA 45 mm × 3.5 mm (blue) load [Figure 2]b and [Figure 2]c. Check scopy was done to ensure complete division and hemostasis [Figure 2]d. On follow-up, child regained a near normal bowel habit with occasional requirement of rectal wash.
|Figure 2: (a) Two 12-mm ports inserted per anally (b) After the first application of endo-GIA stapler showing partially divided and stapled spur (arrows) and residual pillar (star) (c) Second application of endo-GIA stapler to divide spur completely (d) Check colonoscopy showing complete division of spur with single lumen|
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The upper limit of the retained spur in our case was 14 cm from the anal verge. In the absence of colonoscopy and an endo-GIA instrument, it is not possible to divide the spur per anally with a linear stapler as the maximum length of the cartridge is only 10 cm. Second, applying the stapler blindly per anally is fraught with danger. In such cases, the conventional surgical approach would have been to perform a laparotomy with the application of a linear stapler through a colotomy in an antegrade fashion to divide the spur completely and closure of colostomy. However, division of spur with an endo-GIA stapler under colonoscopic guidance avoids the morbidity of a relaparotomy. Our technique is similar to that reported by Senthamizhselvan et al. with few modifications. As there was no colostomy in our case, both the colonoscope and the endo-GIA instrument had to be inserted per anally. We used anal dilatation with retraction sutures for the insertion of two 12-mm ports. This technique has not been reported in the literature previously. The publication of similar techniques from two different Indian centers in a short span of time highlights the quality of pediatric surgical research and innovation in the country today.
We conclude that the division of residual spur after Duhamel's procedure with endo-GIA stapling device under colonoscopic guidance if feasible and safe. It avoids the need for a re-do laparotomy for dividing the spur, especially in cases where the spur is high and long and not accessible per anally for division. Furthermore, real-time assessment of the completeness of spur division is ensured.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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. [Full text]
Mandelia A, Sharma MS, Siddiqui Y, Mishra A. Division of long residual spur after Duhamel's pull through with endo-GIA stapler under colonoscopic guidance. PESICON 2020, Pune, India; 28 February, 2020.
Elsherbeny M, Abdelhay S. Obstructive complications after pull-through for Hirschsprung's disease: Different causes and tailored management. Ann Pediatr Surg 2019;15,2.
Gupta DK, Khanna K, Sharma S. Experience with the redo pull-through for Hirschsprung's Disease. J Indian Assoc Pediatr Surg 2019;24:45-51.
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[Figure 1], [Figure 2]