Duhamel Surgery - Procedure and Complications

Introduction

Certain conditions occur where the functioning of organs is decreased or lost right from birth. One such condition is Hirschsprung disease which occurs due to the loss of cells helping in the motility of the intestine. When the functioning of the intestine is hindered, the wastes get accumulate in the abdomen, which leads to distension, and surgery has to be carried out. Duhamel surgery comes into action to treat such conditions. The procedure, along with the complications and management of the same, is explained in this article.

What is Duhamel surgery?

Duhamel surgery is a technically easy, minimally invasive procedure that is done to preserve the sphincter function and to bring down the innervated bowel to the anus. These are the changes seen due to the absence of certain cells in the intestine. Duhamel surgery aims at removing that portion and replacing with without a toma (pouch). The success of the surgery depends on various factors, and hence the treatment outcome and the quality of life after the surgery are important both for children and adults. Duhamel surgery can be a single-stage surgery or a modified two-staged surgery. Single-staged procedures are mostly preferred to avoid major complications.

What Are the Indications for Duhamel Surgery?

Duhamel surgery is indicated in the following situations-

• Failed Swenson operation.

• Long intestinal segment Hirschsprung disease.

• Difficult mucosectomy cases.

• Repeated attacks of enterocolitis.

• Dilated hypertrophic rectum.

What Is Hirschsprung Disease?

It is a congenital defect in which the newborn is born with some missing cells in the large intestine. The missing cells are the nerve cells that help in the mobility of the stool in the child's intestine. Due to the absence of nerve cells, the intestine gets blocked without mobility. One in 15000 infants are born with Hirschsprung disease.

What Are the Causes of Hirschcprung Disease?

Due to the inefficient formation of nerve cells, the function of the intestines is hampered, leading to the accumulation of excretory wastes and obstruction of the intestines.

What Are the Symptoms of Hirschsprung Disease?

The following are the symptoms of Hirschsprung disease:

• Swelling and pain in the abdomen.

• Constipation.

• Intestinal obstruction.

• Refusal to eat.

• Abdominal distention.

• Vomiting's.

• Severe diarrhea alternating with constipation.

What Are the Diagnostic Procedures for Hirschsprung Disease?

• Proper medical history.

• Physical examination.

• Imaging tests.

• X-ray of the abdomen.

• Anorectal manometry (tests to evaluate the function of anal and rectal muscles).

• Rectal biopsies.

• Barium enema (it is an x-ray of the intestine that detects the changes in the colon).

What Is the Procedure for Duhamel Surgery?

The retro rectal approach is followed where the internal anal sphincter is disrupted posteriorly.

The anterior wall of the rectum is preserved along with its nerve supply.

The septum between the colon and rectum (colo-rectal septum) is eliminated and anastomosed.

The procedure can be divided into two parts.

1. Laparoscopic part.

2. Trans-anal part.

The laparoscopic part of the procedure includes the following:

• Devascularization of the distal part.

• Mobilization of the proximal part.

• Dissection of the transverse colon from the gastrocolic ligament, preserving the colic vessels.

• The aganglionic rectal segment is left to remain in the new pouch after it is joined to the healthy colon.

• The entire aganglionic rectum is mobilized.

• The gastrointestinal stapler is used to divide the aganglionic rectum.

Trans-anal part:

• Rectal dissection is further made along with the laparoscopically dissected portion.

• As it is done closer to the rectal wall, the dissected rectum is pulled and anastomosed.

To conclude the treatment process, four main steps in the procedure are included:

1. Retro rectal approach.

2. Upper colon mobilization and rectum closure.

3. Retro-rectal space preparation.

4. Endoanal incision.

What are the Advantages of Duhamel surgery?

• Less post-operative time.

• Better results as per cosmetics are concerned.

• Avoidance of conventional twisting of certain structures.

• Easier technical advantages.

What Are the Alternatives to Duhamel Surgery?

• Soave Procedure - The process is carried out by injecting saline into the rectum in a circular manner, keeping the mucosa intact.

• Trans-anal Swenson Procedure - In this procedure, the anal sphincter and sigmoid colon are overstretched. Unlike the Duhamel procedure, where the normal colon is pulled out of the rectal space and contralaterally anastomosed to the non-angular rectum, the Swenson procedure includes the removal of the entire affected segment of the colon.

What Are the Outcomes After the Duhamel Surgery?

Treatment outcomes speak for themselves as well as represent the whole procedure followed. There are two types of outcomes.

• Short-term outcomes.

• Long-term outcomes.

Short-term outcomes are those results that are noted within a period of the first six months after the surgery. They include

• Pelvic collection.

• Wound infection.

• Anastomotic leak.

• Perineal excoriation.

Long-term outcomes are those that can be noted after six months of surgery.

• Obstruction of the intestine.

• Constipation (one or less than one bowel movement in two days).

What Are the Complications Associated With Duhamel Surgery?

• Occurrence of stenosis.

• Colo rectal septum incompletely divided.

• Recurrent enterocolitis

• Persistent constipation

• Stool incontinence.

• Strictures.

• Longspur.

How Are the Complications Managed?

• Strictures that occur as a complication of the Duhamel procedure are managed by dilation. Strictures can be short or long. Long strictures cannot be managed by dilation. After the procedure, the development of anastomotic stricture can appear. In cases where the condition does not resolve, the redo pull-through is carried out. After which laparoscopy is done, a simple division is made. This procedure is called laparoscopic division of the obstructing cuff.

• The most common complication after the Duhamel procedure is the long spur. A long spur leads to the formation of enterocolitis. Division of the spur can help in managing the condition with the help of a gastrointestinal anastomosis stapler.

• Retained aganglionosis is a condition that needs redo to pull through. The redo pull trough procedure can be performing a Duhamel surgery again or performing a surgery alternative to Duhamel surgery.

• Constipation was managed with the help of Pyridostigmine which is a cholinesterase inhibitor. It acts by increasing intestinal motility.

• The spasm of the anal sphincter is relieved by a botulinum toxin injection or sphincterotomy, or nitroglycerine paste. The sphincter is relaxed by using the botulinum toxin. Not every case is relieved by the toxin alone. Few cases need sphincterotomy to be done.

Conclusion

Minimally invasive procedures that include Duhamel procedures are safe in most cases in managing certain clinical conditions like Hirschspring disease in older children. Persistent complications should be managed as per the cause, either medically, by redo pull-through, or by simple surgical procedure. An experienced surgeon also plays an important role in achieving better treatment outcomes.