Results of total and subtotal colon resections in children.

ABSTRACT

AIM: The treatment of long-segment neuronal intestinal malformations confronts the paediatric surgeon with the problems of diagnosis, suitable surgical methods and postoperative care. The evidence based only on ganglion cells is inadequate to decide about the required extent of resection and does not exclude hypoganglionosis and disseminated dysganglionosis. For the surgical treatment, pouch procedures as well as the usual resection techniques according to Rehbein, Soave, and Duhamel are discussed. Since studies with greater numbers of patients are rare, we present here our own results. METHODS: 48 patients with long segment intestinal malformations were treated in our hospital between 1990 and 2000. A total of 35 patients were examined 1.5-6 years after definitive surgical therapy. Rehbein's anterior resection was performed in all cases. RESULTS: Our findings showed that the surgical treatment with Rehbein's technique offers good results, both with respect to complications as well as to the postoperative course, although a 4 cm long aganglionic segment remains in situ. We found that results were better after ascendorectostomy (n = 22) compared to ileorectostomy (n = 11). Earlier publications of this group (13) show that the histology of the proximal resection margin is decisive for the prognosis. Hypo- and aganglionic segments should be completely resected while short IND segments of the colon or terminal ileum may remain in situ. However, the additional effect of the aganglionic segment of the distal rectum and the decreased peristaltic flow of the pre-anastomotic bowel has to be taken into account. Further investigations are required to find out whether a combination of Soave's endorectal pull-through with a remaining neuronal dysplastic segment proximal to the resection margin may give better results or if the frequency of postoperative enterocolitis and incontinence increased in cases of long segment intestinal neuronal malformations. Accurate diagnosis of myenteric plexus is decisive for an optimal treatment and therefore, considering our results, it is essential that in case of newborns getting to hospital with colon obstruction and suspicion of neuronal intestinal malformation full thickness biopsies from the distal and proximal colon may be taken simultaneously with the enterostomy. Generally ileostomy is performed in patients suspected of long-segment neuronal intestinal malformations. Mucosa suction biopsies from the distal and proximal stoma side are less informative compared to full thickness biopsies.