Abstract
Purpose:
The Duhamel operation is commonly employed to treat Hirschsprung’s disease (HD). We
have seen a number of patients referred to our center with problems following a Duhamel
procedure performed elsewhere, and have analyzed our experience with these children.
Methods:
We reviewed 17 patients with Hirschsprung’s disease who underwent a Duhamel procedure
elsewhere, in whom we performed a redo pull-through for persistent symptoms of constipation,
impaction, and enterocolits.
Results:
All patients (n=17) had constipation/impaction or enterocolits, 9 of whom were soiling
due to overflow incontinence. Biopsies of the pulled-through bowel found 6 patients
with persistent aganglionic bowel and 2 patients with ganglion cells present but hypertrophic
nerves, a finding we interpreted as “transition zone bowel”. The remaining 9 patients
without a pathological indication for reoperation had a mega Duhamel pouch. All patients
underwent a redo operation: 8 via a posterior sagittal approach (7 with a laparotomy,
1 without) and 9 by a transanal, Swenson-type resection with a laparotomy. The posterior
sagittal approach was used in cases with severe pelvic fibrosis considered unsuitable
for a transanal operation. 15 patients were followed up postoperatively for longer
than 2 months, 13 of whom now have voluntary bowel movements, including 8 who need
a small dose of laxatives. 2 patients are still diverted.
Conclusion:
Although perhaps successful for many patients around the world, the Duhamel pull-through
can leave patients with significant symptoms, including impaction and overflow incontinence.
It is unclear why some patients with a Duhamel pouch do not empty well. Clearly, those
patients with a mega Duhamel pouch suffer from impaction. These patients need to be
detected, because reoperation with resection of the Duhamel pouch can dramatically
improve their quality of life.
Key words
Hirschsprung’s disease - Duhamel procedure - reoperation - constipation - megarectum
