Redo pull-through surgery in Hirschsprung disease: Short-term clinical outcome.

INTRODUCTION: Although surgery is effective in most patients with Hirschsprung disease (HD), some have persistent obstructive symptoms. Additional medical treatment is generally sufficient, but a small fraction of these patients needs secondary surgery. Series on redo surgery are scarce. Aim of this study is to evaluate complications and clinical outcome of patients in need of redo surgery for HD. MATERIALS AND METHODS: Sixteen patients underwent redo endorectal pull-through surgery in our center between 2007 and 2015. Medical records were reviewed and demographics, indication for redo surgery, surgical procedures, complications, and clinical outcome were scored. RESULTS: The median age at the time of redo was 4.6years (range: 2months-21years). Median follow-up after redo was 3years (range: 9months-7years). Before redo surgery, all patients (100%) had obstructive symptoms, one patient had recurrent enterocolitis, and four patients were fecally incontinent despite adequate attempts of bowel management. Surgical procedure consisted of a transanal endorectal pull-through (TERPT) in all patients, with additional laparotomy in 7 (44%) and protective stoma in 8 patients (50%). Complications within 30days after redo surgery were anastomotic dehiscence (3; 19%), wound abscess (2; 13%), rectovaginal fistula (1; 7%) or enterocutaneous fistula (1; 7%). During follow-up, nine patients needed additional surgery, mainly to close the stoma. At final follow-up there were no patients with stenosis, obstructive symptoms, remaining rectovaginal fistula, or small bowel obstruction. Only one patient experienced enterocolitis. Six patients (43%) reported soiling or fecal incontinence. CONCLUSION: TERPT for redo surgery for HD is effective in resolving sustained severe obstructive symptoms after primary surgery, but the outcome is complicated by a relatively high rate of soiling and fecal incontinence.

Long-term neurodevelopmental impairment in neonates surgically treated for necrotizing enterocolitis: enterostomy associated with a worse outcome.

BACKGROUND: Necrotizing enterocolitis (NEC) patients often have neurodevelopmental impairment, but the long-term follow-up data is limited. We determined whether surgical factors were of prognostic value for long-term neurodevelopment in children surviving surgery for NEC (SNEC). PATIENTS AND METHODS: SNEC patients born between 1996 and 2002 were tested for verbal (VIQ), performance (PIQ) and total (TIQ) intelligence using Wechsler's Intelligence Scale for Children, Third Edition, Dutch Version, and motor skills using the Movement Assessment Battery for Children (M-ABC). Neonatal and surgical data were obtained retrospectively to assess prognostic factors. RESULTS: 19 patients (12 boys), median age 9.9 years (range 6.2-13.1), gestational age 31.0 weeks (range 25.2-40), birth weight 1 250 g (range 780-3 175) were evaluated. Infants with an enterostomy (n=14) scored lower on intelligence than children with a primary anastomosis (n=5): VIQ 85 ± 12 vs. 101 ± 15, p=0.04; PIQ 79 ± 13 vs. 92 ± 11, p=0.06; TIQ 82 ± 11 vs. 97 ± 13, p=0.04. Motor skills were either suspect or clinically impaired in 74%. Clinical classification of results suggest more children in the enterostomy group had a performance rated as clinically impaired compared to the primary anastomosis group, although no statistical difference in M-ABC score was found. There were no differences between primary anastomosis and enterostomy patients with regard to gestational age, birth weight, comorbidities, preoperative Bell stage, residual small and large bowel lengths, inotropic medication, duration of ventilatory support, NICU and hospital stay, and physical exam data on follow-up. However, a selection bias could not be ruled out. CONCLUSIONS: The results suggest that an enterostomy in SNEC patients could be associated with worse neurodevelopmental outcomes by the age of 6-13 years compared to a primary anastomosis, although the severity of illness was comparable between both groups. Further studies are needed to prevent selection bias and to elucidate the impact of abdominal surgical factors on neurodevelopmental outcome and the underlying pathophysiology.