Usefulness of laparoscopy for determining the location of transitional zone in patients with inconclusive barium enema for Hirschsprung’s disease: a prospective clinical trial

Abstract

Objective: The present study aims to evaluate the efficacy of laparoscopy to localize the transitional zone in cases of Hirschsprung’s disease (HD) with nondiagnostic contrast enema.

Summary background data: In the treatment of HD, preoperative ascertainment of the extent of aganglionosis by contrast enema is crucial, as this affects the planning for transanal endorectal pull-through. Patients with aganglionic rectal biopsy with inconclusive barium enema present difficulty in determining the extent for transanal resection as
the colon is not directly visualized as compared with transabdominal approach.

Patients and methods: A study was conducted in our institution on 30 patients fulfilling such criteria with a median age at the time of surgery of 50 months. The location of the transitional zone by intraoperative laparoscopy view was used to plan further management.

Results: The junction between normal dilated bowel with peristalsis and aganglionic collapsed bowel without peristalsis was marked by diathermy followed by transanal endorectal pull-through in the same setting in 14 (46.7%) cases. Subsequent histopathological examination of the excised specimens showed adequately ganglionated surgical margin in all 14 cases. In three (10%) patients, the transitional zone was seen in the most distal part of the rectum and the patients were diagnosed as suffering from very shortsegment HD; therefore, anorectal myectomy was performed. In the remaining 13 patients no definite funnel was seen and leveling biopsy was done to exclude total colonic HD. Since frozen section biopsy was not available in our facility at the time of this study, all biopsies were sent for fixed paraffin sections. Further management for biopsied patients at later stage was in the form of either anorectal myectomy in five (16.7%) patients or Botox injection in eight (26.7%) patients.

Conclusion: Laparoscopy was found to be a useful diagnostic and therapeutic tool for such patients.

Keywords: Hirschsprung’s disease, laparoscopic biopsy, transanal endorectal pull-through, transition zone, ultra-short segment