title: The problematic Duhamel pouch in Hirschsprung's disease: manifestations and treatment.
abstract: OBJECTIVE
  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 enterocolitis.
  
  
  RESULTS
  All patients (n=17) had constipation/impaction or enterocolitis, 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 trans-anal 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.
  
  
  CONCLUSIONS
  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.
authors: Cincinnati Children's Hospital, Colorectal Center, Pediatric Surgery, Cincinnati 45229, USA.
authors: K
authors: K
authors: Chatoorgoon
authors: A
authors: A
authors: Pena
authors: T A
authors: TA
authors: Lawal
authors: M
authors: M
authors: Levitt
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D039021:Colonic Pouches / Q000009:adverse effects*; D003672:Defecation; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006627:Hirschsprung Disease / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D012086:Reoperation / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome