Short-pouch and low-anastomosis Duhamel procedure results in better fecal control and normal defecation pattern.
OBJECTIVE
The purpose of this study was to analyze the long-term outcome of the short-pouch and low-anastomosis Duhamel procedure and to evaluate the quality of life after pull-through. We also tried to answer the questions: Does the modified Duhamel procedure produce fecal continence? Is the quality of life correlated to normal bowel function (1-3 per day) without the use of laxatives?


METHODS
Between January 1993 and January 2002, 53 patients, 44 (83 percent) males and 9 (17 percent) females, who underwent a Duhamel procedure were assessed retrospectively. Of the 53 children, 36 (67.9 percent) underwent a primary Duhamel procedure at our institute (Group A). Seventeen (32.1 percent) patients had a primary Duhamel pull-through and subsequently a stoma before a redo modified Duhamel procedure (Group B). The technical modification was creation of a short rectal pouch of 35 mm, achieving a low colorectal anastomosis 0.5 cm from or on the dentate line. All 53 patients were assessed prospectively by a disease-specific questionnaire. The total score provided a single index of the quality of life associated with fecal continence.


RESULTS
For Group A (n = 36), the mean period of follow-up was 71.4 +/- 29 months. Constipation was seen in four (11.1 percent) patients. In two (5.6 percent) patients there was a mild degree of soiling. Sensation and urge to defecate was intact in 34 (94.4 percent) children who could wait to go to the toilet until it was socially convenient. For Group B (n = 17), the mean period of follow-up was 73.9 +/- 31.2 months. Constipation occurred in 17 (100 percent), encopresis in 14 (82.4 percent), and enterocolitis in 15 (88.2 percent) after the primary Duhamel procedure. In comparison, there was complete absence of constipation (100 percent), encopresis (100 percent), and complete resolution of enterocolitis (100 percent) after the redo modified Duhamel (P = 0.001). Continence to solid stools after primary Duhamel was seen in 5 (29.4 percent) vs. 17 (100 percent) after redo modified Duhamel. After the redo modified Duhamel all 17 (100 percent) patients have retained the sensation and urge to defecate and 15 (88.2 percent) can wait to get to the toilet until it is socially convenient. In all 53 patients, the quality of life was good in 86.8 percent (46/53) and correlated directly with fecal continence (r = 0.977). There was no correlation between age of patient and fecal continence (r = 0.597) and rate of fecal incontinence did not decrease with age. Direct correlation was seen with the presence of constipation and the incidence of late onset enterocolitis (r = 0.942).


CONCLUSIONS
Short-pouch, low-anastomosis Duhamel pull-through procedure results in fecal continence and complete emptying. The above procedure has a positive impact on the quality of life in these children.
Department of Paediatric Surgery, Great Ormond Street Hospital for Children NHS Trust, London, UK. madan.samuel@ addenbrookes.nhs.uk
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D000714:Anastomosis, Surgical / Q000379:methods*; D039021:Colonic Pouches; D003248:Constipation / Q000453:epidemiology / Q000503:physiopathology; D003672:Defecation / Q000502:physiology*; D005242:Fecal Incontinence / Q000453:epidemiology / Q000503:physiopathology; D005260:Female; D006627:Hirschsprung Disease / Q000601:surgery*; D006801:Humans; D007223:Infant; D008297:Male; D011446:Prospective Studies; D011788:Quality of Life; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D016896:Treatment Outcome