A 19 year old who was operated for Heirshprung's disease (Ileoanl anstamosis) 2years ago elsewhere presented with subacute small bowel obstruction. Abdomen is distended and small bowel loops are seen. It is not tender. Digital rectal examination is normal. CT scan showed distended small bowel loops up to the anus and Anus is collapsed.
The Duhamel procedure using a surgical stapler to connect the good and bad bowel. may be attempted but recurrent surgery is difficult.why ileoanal was done was the entire colon aganglionic
Thanks Dr Mohsin,pt had multiple surgeries outside India,I am still not able to get details.Can any proceedure on the anal canal like sphincterotomy of any use ?
Is it possible that the patient has an adhesion ileus/subileus? What is the result of flexible endoscopy? How is the anastomosis? If the anus is collapsed , than the problem is obviously higher, so a sphincterotomy would not be of any use IMHO
an option may be injection with botox toxines in the internal sphincter to relieve the spasm of the anal canal. If that is the cause of the obstruction it is relieved. If botox is not working the problem is not the tension in the anal canal but has to be found intra-abdominally and then a ileostomy is more sensible.
If the anastomosis or inlet of the pouch are not strictured one might question the Heirshprung's diagnosis. There are a few possibilities with enteric neurogenic disorders and it might be worthwile to have a truely interested pathologist to look into the primary specimen (if possible). I would be very reluctant to do anytthing with the sphincter. If obstruction doesn´t settle I would go for a diverting dubbel barrel ileostomy and at the same time excise a part of the affected small bowel to get a possible diagnosis of neurogenic disorder or not.
Thankyou,Duhammel's seems to have gone in to problems,hence finally ileoanl without pouch was done.Digital examination of anal canal is normal,colonoscopic assessment of anastamosis is normal,scope went past the anastamosis and dilated bowel no other abnormality,HP reported as ganglionic small bowel.Pt is reluctant to have ileostomy.So daily enemas were suggested till the anal canal opens up in due course.
I remember a similar case ( a female ), in a centre I have worked, who presented each time in shock due to the stasis, vomiting and sepsis. A pop off intubated ileostomy was done . (something like Mitrofanoff principle) to aid immediate decompression. Voted against IAS sphincterotomy since that may render her incontinent. Hope, this is of help.
As you describe, seems to have no mechanical ileus, but we do not know if the patient has not eliminated gas and the passing stool, and if so then I think that colonoscopic assessment of anastamosis and the part above its .
We see this type of bowel dysfunction in children who have had their definitive operation for Hirschsprung disease, with or without a colon. The dysfunction is poorly understood, and we would treat with tube decompression, after which most resolve spontaneously.
I quite agree with Dr. Prasanna's circumstance of moment, to maintain a conservative treatment to ensure daily evacuation of stool and occasional enema, "Primum Non Nocere".
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