Comparison of Complication Regarding Modified Duhamel Procedure for Hirschsprung’s Disease in Male to Female Children

Aim: To compare the complications regarding modified Duhamel procedure in male to female children for Hirschsprung’s disease (HSCR). Methodology: This comparative retrospective study was done at pediatric surgery department PUMHSW Nawabshah during Jun 2019-Aug 2020. Sample size was selected as 70 patients and divided it into two groups. Group A contain 45 male children while group B also consists of 25 female children. The children between the age of 2-15 year, both sexes and confirm Hirschsprung’s disease was included in this study


INTRODUCTION
Constipation is one of the most common gastrointestinal problems in children. Constipation occurs when the colon absorbs too much of water or if the contraction of colonic muscle are slow or sluggish, causing the stool to move through the colonic too slowly, as a result stool become hard and dry [1,2]. Hirschsprung's Disease (HD) is a congenital condition, which is characterized by the absence of Ganglion cells in submucosal (Meissner's) plexus and the intermuscular (Auerbach's) plexus3,4. Hirschsprung's Disease is actually caused by the failure of vagal neural crest cells to migrate distally from upper and of alimentary tract or due to failure of maturation or degeneration of neural cells inaltered micro environment [5]. Hirschsprung's Disease the incidence is 1: 5000 births. It is 4 times more common in boys than in girls [6]. Older children typically present with chronic constipation, abdominal distention, emesis and failure to thrive. Some of them patient present with enterocolitis [7]. Initial diagnosis for workup of HD is constract enema, the classic finding is transition zone [8]. After diagnosis surgery is normally the treatment option in the form of different pull through procedures, most of them being two stage procedures. The complication rate generally range from 4-16% [9]. In 1956 Bernard Duhamel first described retrorectal dissection with pull through of ganglionic colon and anastomosis of both ganglionic and agalionic parts [10]. This procedure is further modified using gastrointestinal stapler (GIA) to create anastomosis. The long term outcome of this procedure depends on level of retroectal incision and length of blind rectal pouch [11]. The aim of this study is to know the early post operative complications of this procedure.in male and female child.

MATERIALS AND METHODS
This study was done at pediatric surgery department PUMHSW Nawabshah during Jun 2019-Aug 2020. Sample size was selected as 70 patients and divided it into two group. Group A contain 45 male children while group B consists of 25 female children. The children between the age of 2-15 year, both sexes and confirm Hirschsprung's disease was included in this study while the children below 2 years and with comorbidity were excluded from the study. Anastomosis was done with the help of 75mm GIA linear cutting stapler. A drain was placed through the anastomosis in the pulled through segment. Follow up was done till ninety days postoperatively.

RESULTS
The mean age of the patients was 6.2±3.1 years and 5.9±2.6 years in male and female children respectively. There were 64.28% (n=45) male and 35.72% (25) female patients (Fig 1). The mean weight of patients in male was 17.8 ± 7.6 kg while in female was 15.6±6.27 kg (Fig 2). In the distribution of patients by complications, anorectal stenosis was present in 13.33% (n=6) in male while 12% (n=3) in female children. Wound infection was present in 8.88% (n=4) in male and 8% (n=2) in female children. Intestinal obstruction was present in 11.11% (n=5) and 12% (n=3) in male and female children respectively. Constipation was present in 15.55% in male while 16% (n=4) in female children. Enterocolitis was found in 51.11% (n=23) in male and 52% (n=13) in female children (Table 1).

DISCUSSION
The Duhamel Procedure is widely used for definitive treatment of Hirschsprungs disease. Hirschsprungs disease is a congenital disorder characterized by the absence of ganglion cells in the distal bowel, which results in functional obstruction, most commonly in the newborn period. Although many types of pull through procedures have been described, the most commonly performed operations in North America have been the Swenson, Duhamel, and soave (or endorectal) pullthrough) procedures. Clinical presentation is variable, newborns present with failure to pass meconium with distended abdomen and bilious vomiting. About 98% of full term newborn pass meconium within 48 hours but these children has history of delayed passage. The features like fecal incontinence, fecal urgency and stool withholding behavior are usually not present in HD while it is common in functional constipation [12,13].   16.6% of their patients developed enterocollitis while in our study it was observed 51.5% and 52% in male and female children respectively, which is in contrast with the above study [14]. In our study wound infection was found in 8.88 and 8% in male and female children respectively. As compared with another study wound infection was found in 17.60% patients [15]. In our study intestinal obstruction was found in 11.11% in male while 12% in female children. As compared with another study Intestinal obstruction was found in 5.8% patients [16]. In our study enterocolitis was found in 50.7% Patients. As compared with other study enterocolitis was found in 11.6% patients [8].

CONCLUSION
It was concluded that modified Duhamel Procedure for Hirschsprung's disease has less postoperative complications in both male and females moreover there is no significant difference of postoperative complications in both sexes.

CONSENT AND ETHICAL APPROVAL
The study was approved by ethical review board PUMHSW Nawabshah. Written informed consent was obtained from parents or guardians of the participants.