title: Is complete resection of the aganglionic bowel in extensive total aganglionosis up to the middle ileum always necessary?
abstract: OBJECTIVE
  Total colonic aganglionosis is an unusual form of Hirschsprung disease, reflected by the small number of published case studies. The goal of this study was to analyze our cases of the last 22 years and report on our experience with 3 cases of extended total aganglionosis proximal to the middle ileum in which remaining aganglionic bowel was left in situ.
  
  
  METHODS
  In a period of 22 years (from January 1988 to April 2010), we operated on 15 children with total aganglionosis. These children were among 163 children with Hirschsprung disease. In 3 patients with extended aganglionosis proximal to the middle ileum, remaining aganglionic bowel was left in situ. Data were collected from the medical records, including each patient's demographics, medical history, primary treatment, complications, and follow-up.
  
  
  RESULTS
  Eleven of the 15 children received an ileostomy as first treatment, and 4 children underwent a primary Duhamel procedure. Early postoperative complications included an abscess after an open procedure in a patient with trisomy 21 syndrome and an incorrect leveling resection that required an ileostomy. There were 2 deaths at 6 and 16 months postoperatively. The mortality rate was 13.3%. Of the 15 patients, 7 (46%) presented with at least 1 episode of postoperative enterocolitis, and only 2 of these patients had more than 3 episodes. We treated 3 patients with extended aganglionosis up to midileum (20%) in which the proximal resection level was in the aganglionic segment of ileum at the level of the ileostomy. The ileostomies were shown to be functioning satisfactorily before the pull through, so going more proximal to the ileostomy might have meant that the patient would present short bowel problems. These 3 patients had good bowel function postoperatively.
  
  
  CONCLUSIONS
  In principle, resection of the aganglionic bowel is mandatory to relieve obstruction and subsequent complications. There are situations, however, where the complications of a short bowel begin to outweigh the benefits of resection. In these cases, leaving remaining aganglionic bowel in situ may be an advantageous option for the patients with total aganglionosis extending to the midileum whose ileostomy functions well.
authors.affiliation: Department Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Wilhelmina Children's Hospital, PO Box 85090, 3508 AB Utrecht, The Netherlands. d.vieira-travassos@umcutrecht.nl
authors.forename: Daisy Vieira
authors.initials: DV
authors.lastname: Travassos
authors.forename: David C
authors.initials: DC
authors.lastname: van der Zee
mesh_terms: D000015:Abnormalities, Multiple; D000714:Anastomosis, Surgical; D003872:Dermatitis / Q000453:epidemiology; D013505:Digestive System Surgical Procedures / Q000379:methods*; D004760:Enterocolitis / Q000453:epidemiology; D005260:Female; D006627:Hirschsprung Disease / Q000601:surgery*; D006801:Humans; D007081:Ileostomy; D007082:Ileum / Q000601:surgery*; D007231:Infant, Newborn; D010535:Laparoscopy; D007902:Length of Stay; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D016896:Treatment Outcome; D019564:Unnecessary Procedures