Abstract：
BACKGROUND: Children with Hirschsprung disease (HSCR) proximal to the splenic flexure or those needing a redo pull-through (PT) are at risk for tension and ischemia of the PT which could result in leak, stricture, or loss of ganglionated bowel. Colonic derotation is a technique used to minimize tension and avoid duodenal obstruction. The aim of this study was to describe this technique and outcomes in a series of patients requiring this intervention.
METHODS: All patients underwent initial diversion and colonic mapping. The derotation procedure involves mobilization of the remaining colon, counterclockwise rotation via the stoma closure site, placement of the pull through (the right colon) lying on the right of the pelvis, and ligation of the middle colic artery with preservation of the marginal branch running from the ileocolic artery. This maneuver prevents compression of the duodenum by the mesenteric vessels and allows for an isoperistaltic, tension-free anastomosis. Intraoperative indocyanine green fluorescence angiography (ICG-FA) was utilized in many of the cases to map the blood supply of the pull-through colon. We reviewed outcomes for all children with HSCR who underwent colonic derotation from 2014 to 2023. Descriptive statistics were performed.
RESULTS: There were 37 children included. Most were male (67.5%) with the original transition zone proximal to the rectosigmoid (81.1%). The median age at PT was 9.3 months [6.1-39.7]. Median operative time was 6.6 h [4.9-7.4] and 19 cases (51.4%) used ICG-FA. Most children had no 30-day postoperative complications (67.6%); in those who did develop complications, readmissions for electrolyte imbalance was most common (50.0%). There were zero cases of anastomotic leak at PT anastomosis. At long-term follow up, median 4.4 years [2.3-7.0], three children (8.1%) developed an anastomotic stricture, all were amenable to anal dilation, and five experienced episodes of enterocolitis (14.7%). Most children had between 1 and 4 stools per day (58.8%).
CONCLUSIONS: Colonic derotation is a useful strategy to ensure well-perfused colonic length, protect the marginal artery blood supply, avoid duodenal compression, and ensure a tension-free anastomosis with minimal complications.
METHODS: Original research, retrospective cohort.
METHODS: III.
METHODS: All patients underwent initial diversion and colonic mapping. The derotation procedure involves mobilization of the remaining colon, counterclockwise rotation via the stoma closure site, placement of the pull through (the right colon) lying on the right of the pelvis, and ligation of the middle colic artery with preservation of the marginal branch running from the ileocolic artery. This maneuver prevents compression of the duodenum by the mesenteric vessels and allows for an isoperistaltic, tension-free anastomosis. Intraoperative indocyanine green fluorescence angiography (ICG-FA) was utilized in many of the cases to map the blood supply of the pull-through colon. We reviewed outcomes for all children with HSCR who underwent colonic derotation from 2014 to 2023. Descriptive statistics were performed.
RESULTS: There were 37 children included. Most were male (67.5%) with the original transition zone proximal to the rectosigmoid (81.1%). The median age at PT was 9.3 months [6.1-39.7]. Median operative time was 6.6 h [4.9-7.4] and 19 cases (51.4%) used ICG-FA. Most children had no 30-day postoperative complications (67.6%); in those who did develop complications, readmissions for electrolyte imbalance was most common (50.0%). There were zero cases of anastomotic leak at PT anastomosis. At long-term follow up, median 4.4 years [2.3-7.0], three children (8.1%) developed an anastomotic stricture, all were amenable to anal dilation, and five experienced episodes of enterocolitis (14.7%). Most children had between 1 and 4 stools per day (58.8%).
CONCLUSIONS: Colonic derotation is a useful strategy to ensure well-perfused colonic length, protect the marginal artery blood supply, avoid duodenal compression, and ensure a tension-free anastomosis with minimal complications.
METHODS: Original research, retrospective cohort.
METHODS: III.
摘要：
背景：脾曲近端Hirschsprung病（HSCR）或需要重做牵拉（PT）的儿童有PT紧张和缺血的风险，这可能导致泄漏，狭窄,或神经节化的肠丢失。结肠旋转是一种用于最小化张力和避免十二指肠阻塞的技术。这项研究的目的是描述这种技术和一系列需要这种干预的患者的结果。
方法：所有患者均接受初始改道和结肠标测。去旋转过程涉及剩余结肠的动员，通过造口闭合部位逆时针旋转，通过（右结肠）放置在骨盆右侧，结扎结肠中动脉，保留从回结肠动脉延伸的边缘分支。这种操作可以防止肠系膜血管对十二指肠的压迫，并允许等位肌，无张力吻合.在许多情况下，术中吲哚菁绿荧光血管造影术（ICG-FA）被用来绘制牵拉结肠的血液供应图。我们回顾了2014年至2023年所有接受结肠移位的HSCR儿童的结局。进行描述性统计。
结果：包括37名儿童。大多数为男性（67.5％），原始过渡区靠近直肠乙状结肠（81.1％）。PT时的中位年龄为9.3个月[6.1-39.7]。中位手术时间为6.6h[4.9-7.4]，19例（51.4%）使用ICG-FA。大多数儿童没有术后30天并发症（67.6%）；在那些出现并发症的儿童中，电解质失衡的再入院最为常见(50.0%).PT吻合术中吻合口漏0例。在长期随访中，中位数4.4年[2.3-7.0]，三名儿童(8.1%)出现吻合口狭窄，所有人都适合肛门扩张，和5次经历小肠结肠炎发作(14.7%)。大多数儿童每天大便1至4次（58.8%）。
结论：结肠旋转是确保结肠长度良好灌注的有用策略，保护边缘动脉供血,避免十二指肠压迫,并确保无张力吻合，并发症最少。
方法：原始研究，回顾性队列。
方法：III.
方法：所有患者均接受初始改道和结肠标测。去旋转过程涉及剩余结肠的动员，通过造口闭合部位逆时针旋转，通过（右结肠）放置在骨盆右侧，结扎结肠中动脉，保留从回结肠动脉延伸的边缘分支。这种操作可以防止肠系膜血管对十二指肠的压迫，并允许等位肌，无张力吻合.在许多情况下，术中吲哚菁绿荧光血管造影术（ICG-FA）被用来绘制牵拉结肠的血液供应图。我们回顾了2014年至2023年所有接受结肠移位的HSCR儿童的结局。进行描述性统计。
结果：包括37名儿童。大多数为男性（67.5％），原始过渡区靠近直肠乙状结肠（81.1％）。PT时的中位年龄为9.3个月[6.1-39.7]。中位手术时间为6.6h[4.9-7.4]，19例（51.4%）使用ICG-FA。大多数儿童没有术后30天并发症（67.6%）；在那些出现并发症的儿童中，电解质失衡的再入院最为常见(50.0%).PT吻合术中吻合口漏0例。在长期随访中，中位数4.4年[2.3-7.0]，三名儿童(8.1%)出现吻合口狭窄，所有人都适合肛门扩张，和5次经历小肠结肠炎发作(14.7%)。大多数儿童每天大便1至4次（58.8%）。
结论：结肠旋转是确保结肠长度良好灌注的有用策略，保护边缘动脉供血,避免十二指肠压迫,并确保无张力吻合，并发症最少。
方法：原始研究，回顾性队列。
方法：III.
