Gülnur GÖLLÜ, Aydın YAĞMURLU, Tanju AKTUĞ, Hüseyin DİNDAR, Haluk GÖKÇORA, Bingöl Meltem KOLOĞLU, Rahşan VARGÜN

Transanal endorektal pull-through ameliyatı sonrası geç dönem bulgularının ve anal manometri sonuçlarının değerlendirilmesi

Amaç: Hirschsprung hastalığı tanısıyla transanal endorektal pull-through (TEP) amelıyatı yapılmış olan hastalarımızın sonuçlarını değerlendirmek. Hastalar ve Yöntem: Kliniğimizde 2001-2005 yılları arasında Hirschsprung hastalığı tanısı alan ve TEP uygulanan 17 hastanın kayıtlı bilgileri geriye dönük olarak incelendi. Hastalar kontrole çağrılarak klinik muayene, eksternal anal sfinkter muayenesi ve anal manometri ile değerlendirildi. Bulgular: Hastalarin ortalama tanı yaşı› 15±7.4 ay ve erkek/kız oranı 2 idi. Dokuz hasta yenidoğan döneminde intestinal obstrüksiyon, beş hasta çocukluk döneminde kronik konstipasyon ve üç hasta da süt çocukluğu döneminde enterokolit atağı ile başvurdu. Kolon grafilerinde 12 hastada rektum ve sigmoid, üç hastada inen kolon lokalizasyonlu geçiş bölgesi görüldü. İki hastada geçiş bölgesi gösterilemedi. Ameliyat öncesi anal manometri uygulanan beş hastada rektoanal inhibitör refleks (RAIR) negatif ve rektal dinlenim basınçları yüksek olarak bulundu. Hastaların tümüne kesin tanı işlem öncesi uygulanan rektal biyopsi ile konuldu. Ortalama ameliyat süresi 2±0.8 saat ve ortalama yatış süresi 5.8±0.6 gün olarak saptandı. Postoperatif erken dönemde komplikasyona rastlanmadı. Hastaların ortalama izlem süresi 2.2±0.3 yıl idi. Geç dönemde üç hastada kısa sürede tedavi edilen perianal dermatit, iki hastada zaman zaman olan bulaşı tarzında dışkı kaçırma ve bir hastada beş dilatasyonla giderilen anal darliı gelişti. Ortalama günlük dışkılama sayısı 4.8±0.6 olarak saptandı. Ameliyat sonrası anal manometri incelemelerinde ortalama rektal dinlenim basıncı 28±14 mmHg, ortalama anal dinlenim basıncı 50±17 mmHg olarak saptandı. Ortalama rektal/anal basınç oranı 0.8±1.1 olarak bulundu. Hastaların %80'inde ameliyat sonrası RAIR pozitif olarak bulundu. Tartışma: Hirschsprung hastalığının definitif tedavisinde TEP ameliyatını kolay uygulanabilen, hastanede yatış süresini kısaltan, kozmetik üstünlükleri olan ve komplikasyonları sınırlı olan bir yöntem olarak benimsiyoruz. Henüz erken dönem sonuçları olmakla birlikte TEP ameliyatı sonrası anal manometrik bulguların normal çocuklarda elde edilenlere benzer gözlenmesini yöntemin ek üstünlüğü olarak değerlendiriyoruz.

Evaluation of anal manometric findings and late results after transanal endorectal pull-through

Aim: To evaluate late outcome and postoperative anal manometry findings of the patients who underwent transanal endorectal pull-through (TEP) for Hirschsprung's disease (HD). Patients and Methods: Records of 17 patients who underwent TEP procedure for HD, from 2001 to 2005, were reviewed retrospectively. Information recorded for each patient included demographic findings, diagnostic procedures, preoperative preparation, operative findings, postoperative early and late complications, anal manometric findings and outcome. Results: Mean age of patients was 15±7.4 months with a male/female ratio of two. Neonatal intestinal obstruction (n=9), chronic constipation (n=5) and abdominal distention and enterocolitis (n=3) were the presenting symptoms. Aganglionic segment was limited to rectum and sigmoid region in 12 patients and descending colon in three patients. Location of the aganglionic segment could not be determined preoperatively in two patients. Rectoanal inhibitory reflex was absent in all five patients in whom anal manometry was performed preoperatively. All the patients underwent full-thickness rectal biopsy for definitive diagnosis preoperatively. The mean operation time was 2±0.8 hours and mean hospitalization time was 5.8±0.6 days. There wasn't any postoperative early complication. The mean follow up period was 2.2±0.3 years. Perianal excoriation resolving in a short period (n=3), intermittent soiling (n=2) and anastomotic stricture (n=1) requiring five dilatations were the late complications. The average bowel movements were 4.8±0.6 times per day. The mean resting anal pressure of the patients was 50±17 mmHg and the mean rectal pressure was 28±14 mmHg. The mean ratio of rectal/anal pressure was 0.8±1.1. Rectoanal inhibitory reflex was present in 80% of the patients, postoperatively. Conclusion: Depending on our limited experience, we advocate TEP procedure as a good technique for treatment of HD with highly satisfactory cosmetic, functional outcome with minimal complication. Additionally, postoperative anal manometry findings after TEP procedure are comparable with normal children.

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