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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 39-41

Loop Colostomy Versus End Colostomy for Initial Stage Surgery in Children With Hirschsprung's Disease


1 Additional Professor, Dept. of Paediatric Surgery, IGIMS, India
2 Professor & HOD, Associate Professor, IGIMS, India
3 Associate Professor, Dept. of Paediatric Surgery, IGIMS, India
4 Assistant Professor, Dept. of Paediatric Surgery, IGIMS, India
5 Senior Resident, Dept. of Paediatric Surgery, IGIMS, India

Date of Web Publication20-Nov-2020

Correspondence Address:
Vijayendra Kumar
Professor & HOD, Paediatric Surgery, IGIMS, Patna
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Background: Staged surgery for Hirschsprung's disease involves an initial stoma formation with biopsies to determine the level of aganglionic segment, followed by a pullthrough procedure like Duhamel's pullthrough. Stoma type with the least complication rate and providing considerable ease during subsequent pullthrough procedure would be the preferred stoma technique as the initial step in Hirschsprung's disease.
Aims and Objectives: To compare loop colostomyand end colostomy as the initial stage in managing Hirschsprung's disease. Materials and methods: Data regarding 70 cases of Hirschsprung's disease operated for levelling biopsy and stoma formation (either loop or end colostomy) between 01.01.2017 to 31.12.2018 in the department of Pediatric surgery in a tertiary care hospital were collected prospectively and analyzed.
Results: Although loop colostomies with levelling biopsies took less time to be fashioned (mean 58 minutes) compared to End stoma with biopsies in Hartmann's fashion (mean 72 minutes), they were associated with more incidences of wound dehiscence, wound infection, stomal prolase, peri-stomal herniation and peri-stomal skin rashes. Subsequent pullthrough procedure was faster with less dissection and blood loss and overall complications including stump leak in patients who had been diverted via end stoma compared to those who had had loop colostomy at the time of initial surgery.
Conclusion: End colostomy in Hartmann's fashion is the preferred and safer mode of diversion in Hirschsprung's patients lessening the complication rate and making subsequent pullthrough easier and safe when compared to loop colostomies.

Keywords: End colostomy; Duhamel's Procedure; Loop colostomy; Hirschsprung's disease


How to cite this article:
Hasan Z, Kumar V, Yadav R, Thakur VK, Chaubey D, Rahul SK, Prasad R, Kumar D, Pallavi K. Loop Colostomy Versus End Colostomy for Initial Stage Surgery in Children With Hirschsprung's Disease. J Indira Gandhi Inst Med Sci 2019;5:39-41

How to cite this URL:
Hasan Z, Kumar V, Yadav R, Thakur VK, Chaubey D, Rahul SK, Prasad R, Kumar D, Pallavi K. Loop Colostomy Versus End Colostomy for Initial Stage Surgery in Children With Hirschsprung's Disease. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2021 Dec 4];5:39-41. Available from: http://www.jigims.co.in/text.asp?2019/5/1/39/301075




  Introduction: Top


Hirschsprung's disease (HD), a developmental disorder of the enteric nervous system resulting in variable lengths of aganglionic bowel, is a common cause of constipation in children.[1],[2],[3] Operative intervention is the only treatment available and it involves excision of the aganglionic segment followed by restoration of the intestinal continuity. We normally perform this as a two stage surgery, with the first stage devoted to creation of a stoma (loop or end) to relieve obstruction and optimise the patient with multiple biopsies to determine the level of aganglionic segment; this is followed by the formal Duhamel's Procedure (DP) wherein the gaglionated bowel is pulled down retrorectally and anastomosed to the rectum with the division of the spur. This second surgery is done when the child grows up and is optimised clinically to sustain this surgery. We have found that children with HD are often late presenters and have poor nutrition and need time to be stabilised on stoma. Creating a stoma without much complication is very important, therefore, to achieve good overall results. This study was conducted to compare the results of loop colostomy against end colostomy in Hartmann's fashion in Hirschsprung's disease.


  Materials and Methods: Top


Data regarding 70 cases of HD operated for levelling biopsy and stoma formation (either loop or end colostomy) between 01.01.2017 to 31.12.2018 in the department of Paediatric surgery in a tertiary care hospital were collected prospectively and analyzed. 37 of these patients had loop colostomy, while 33 patients had end colostomy. Data collected included the demographic details, routine blood investigations including serum albumin, radiological investigations including abdominal skiagrams and contrast enemas where available, intraoperative findings, postoperative details and finding and ease of operation of the results of subsequent DP in these patients. Student's t test was used to compare continuous variables against loop versus end colostomy. Discrete variables were compared against both groups using Chi-squared tests. P- Values less than 0.05 were uniformly considered to be statistically significant


  Results: Top


[Table 1] summarizes the demographic details including age at presentation and sex, type of HD depending on the level of aganglionosis and level of initial stoma formation. There was a great variation in the age at presentation of the patients. Many patients presented late with significant abdominal distension and poor nutritional status. Delayed presentation is common in developing countries like India and it increases the morbidity and complications of HD.
Table 1: Demographic details, Type of HD and level of stoma

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Classical Rectosigmoid HD (71.43%) outnumbered long segment HD (28.57%). Long segment HD was considered when the aganglionic segment extended beyond the descending colon.

[Table 2]: gives the details of the patients having loop stoma and end stoma separately and compares the intraoperative and post-operative details and complications seen in these patients.
Table 2: Initial stoma as diversion procedure with

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Although the creation of a loop stoma was faster compared to end stoma with less blood loss, the incidence of complications like wound infection, wound dehiscence including burst abdomen, peristomal excoriation, reoperation rates, complications observed after subsequent DP and time and blood loss during DP were more in cases of loop stoma. The ratio of span of stoma size to the wound size is very important. For loop stoma, this tends to be more (0.73) compared to (0.28) in the case of end stoma. It signifies that a greater portion of wound is left devoid of muscle apposition and only supported by the oedematous bowel loop. This increases the risks of wound dehiscence, burst abdomen and herniation in cases of loop stoma in an already malnutrited and weak child.

A patient who turned up late at age of around 3 years with severe malnutrition and anaemia had secondary haemorrhage and burst abdomen after one week of loop stoma diversion. He progressed rapidly into acute renal failure and couldnot be saved.


  Discussion: Top


Staged surgery for HD is still the recommended management option in sick children, late presenters, complicated patients, long segment disease and at centres where frozen section facilities are not available in the pathology lab. In all such cases, the creation of a safe stoma without complications is essential to optimise the patient for an elaborate pull through procedure later on.

In this study, many patients presented late making them vulnerable to related complications of HD. This is contrary to the observation in the developing world, where the mean age at diagnosis has gone down and increasing number of children are now diagnosed in the neonatal period.[4] This means early diagnosis will ensure timely surgical intervention leading to fewer HD- related complications and overall less morbidity and cost of treatment.

Male to female ratio in this study shows male predominance as reported by other investigators.[5],[6]

Classical Rectosigmoid HD (71.43%) outnumbered long segment HD (28.57%). Long segment HD was considered when the aganglionic segment extended beyond the descending colon and it signified that a longer portion of the bowel needed to be resected and extensive mobilisation of the right colon would be needed at the time of DP. This added to the intraoperative time and blood loss. One case of total colonic aganglionosis was managed using Martin's modification of DP. In such patients, we do not do upfront resection and only a diverting stoma is fashioned initially.

Our study highlights the importance the ratio of span of stoma size to the wound size. For loop stoma, this ratio is naturally larger than in case of end stoma and it signifies that a considerably longer portion of the wound is devoid of muscle apposition during closure and is simply supported by the bowel which has been taken out as stoma. This increases the risks of wound dehiscence, burst abdomen and herniation in cases of loop stoma in an already malnutrited and weak child. This explains the higher incidence of burst abdomen and peristomal herniation in loop stoma patients. Burst abdomen and large peri-stomal herniation necessitated redo surgery.

Other complications like wound infection and peristomal excoriation was also found to be increased in loop stoma patients. Per-stomal prolapse was also more in loop stoma group and the distal loop was found to prolapse more. Similar stoma related complications have been reported by other investigators in large series.[6],[7],[8],[9]

We observed during this study that the method of stoma created not only influenced the local complication and patient satisfaction but it also influenced the conduct and success of definitive pull-through procedure. Because the end stoma was fashioned in Hartmann's fashion and stump closed just above peritoneal reflection, this ensured adequate healing of the stump and prevented it from leakage and other stump related complications after definitive DP. Also, it lessened the time of resection and intra-operative blood loss. Occasionally, it was associated with shrinkage of the stump making its location not obvious but it could be identified by inserting a Hegar's dilator from the rectum and DP could then be done with ease. We now leave a stump that would remain of sufficient size even after such shrinkage.

This practice of doing end stoma in Hartmann's fashion is not used in cases of long segment disease anticipating their use in Martin's modification of DP, should a need arise for it. In such cases, the distal bowel is not resected and is simply closed in two layers, leaving adequate bowel length for use. In a study by Oda et.al. on colostomies done for anorectal malformation patients, there was a higher incidence of prolapse in loop stoma patients leading to an increase in other associated complications when compared to divided stoma.[10]

In a comparison between loop and end stoma in trauma patients, Bruns et. al. Concluded that local take down of loop stoma is easier with fewer complications.[11] We have found that although it is easier to construct loop stoma rapidly, it has more complications when done in HD patients and we do not close this stoma later and so second surgery is also easier after end stoma.


  Conclusion: Top


End stoma was found to have superior outcome with fewer complications compared to end stoma, for faecal diversion in HD patients; it helps in definitive DP as second stage surgery as well



 
  References Top

1.
Teeraratkul S. Transanal one-stage endorectal pull-through for Hirschsprung's disease in infants and children. J Pediatr Surg 2003;38:184-7.  Back to cited text no. 1
    
2.
Brown R, Cywes S. Disorders and congenital malformations associated with Hirschsprung's disease. In: Holschneider AM, Puri P, editors. Hirschsprung's Disease and Allied Disorders. Amsterdam: Harwood; 2000. p. 137-45.  Back to cited text no. 2
    
3.
Langer JC, Minkes RK, Mazziotti MV, Skinner MA, Winthrop AL. Transanal one-stage Soave procedure for infants with Hirschsprung's disease. J Pediatr Surg 1999;34:148-51.  Back to cited text no. 3
    
4.
Singh SJ, Croaker GD, Manglick P, Wong CL, Athanasakos H, Elliott E, et al. Hirschsprung's disease: The Australian Paediatric Surveillance Unit's experience. Pediatr Surg Int 2003;19:247-50.  Back to cited text no. 4
    
5.
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. 5
    
6.
Suita S, Taguchi T, Ieiri S, Nakatsuji T. Hirschsprung's disease in Japan: Analysis of 3852 patients based on a nationwide survey in 30 years. J Pediatr Surg 2005;40:197-201.  Back to cited text no. 6
    
7.
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. 7
    
8.
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. 8
    
9.
Sarioglu A, Tanyel FC, Senocak ME, Büyükpamukçu N, Hiçsönmez A. Complications of the two major operations of Hirschsprung's disease: A single center experience. Turk J Pediatr 2001;43:219-22.  Back to cited text no. 9
    
10.
Oda O, Davies D,Colapinto K, Ted Gerstle J. Loop versus divided colostomy for the management of anorectal malformations. J pediatr. Surg.2014;49:87-90.  Back to cited text no. 10
    
11.
Bruns BR, DuBose J, Pasley J, Kheirbek T, Chouliaras K, Riggle A, Frank MK, Phelan HA, Holena D, Inaba K, Diaz J, Scalea TM. Loop versus end colostomy reversal: has anything changed? Eur J Trauma Emerg Surg. 2015;41:539-43.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2]



 

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