Sir,
This letter to you is a critical appraisal of the Original Article published in JIAPS volume 25, issue 5, September–October 2020, entitled “Modified Duhamel's Two-Stage Procedure for Hirschsprung's Disease (HD): Further Modifications for Improved Outcome” from one of India's Premier Institutes.
I have gone through the article avidly but failed to understand how their “further modification of sacrificing sigmoid colon irrespective of the extent of aganglionosis and doing a Hartman's procedure as a first step” is achieving better result and they had not explained it either. They had done this operation in a select group of short segment HD and reported on their results. However, this was an “Overkill” for majority with rectosigmoid HD[1] and could not be justified. This may however be a choice in adolescents and adults with rectosigmoid HD, who may present with a sigmoid volvulus with an unmanageable tire-like colon loaded with stool.[2]
During definitive surgery, this aganglionic rectal segment, kept as Hartman pouch, poses great difficulty in identification and retro-rectal dissection, even with a Hagar's Dilator in place due to extensive fibrosis (personal experience of two cases). Consequently, chances of pelvic nerve damage are more and so its sequalae in adult life.[3]
Their method of colorectal anastomosis was at the “pecten zone” of the anal canal, which essentially damages a significant area of sensitive anal mucosa and internal sphincter. Good continence with this type of surgery is difficult to achieve.[4] They had not assessed the nocturnal continence/soiling in these children, which could affect Quality of Life to a great extent. The response at follow-up was only 45% (69/152) and these patients might be a select happier group; the good result was thus skewed by inherent selection bias.
From 1948 to 2020, over 72 years of our journey with HD, we now know that a significant number of them carries their difficulty into adulthood, irrespective of whatever procedure is done.[5] Hence, a maximum follow-up period of 11 years is very small compared to the lifespan of any individual. We will eagerly wait for follow-up of these select groups of children to adulthood, from the same institute in future and hope it will clarify the situation further.
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Conflicts of interest
There are no conflicts of interest.
REFERENCES
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