COMPARISON BETWEEN SWENSON AND SOAVE-BOLEY PROCEDURE IN THE MANAGEMENT OF HIRSCHSPRUNG ’ S DISEASE ASM

Objective: The purpose of study was to compare Swenson & Soave-Boley procedure in the staged operative treatment of Hirschsprung’s Disease (HD). Methods : During 16 months of study period, 25 patients of histopathologically confirmed HD were selected for staged operative treatment, following certain inclusion & exclusion criteria & were admitted & operated at DSH; after completion of all stages operation they were followed up & studied under two groups : staged Swenson procedure (Group-A; na=13) & staged Soave-Boley procedure (Group-B, nb=12). They were similar for age, sex, body weight, reselected length of aganglionic segment & postoperative follow up. The level of ganglionosis was assessed from marking biopsy. Preoperative & postoperative observations of Swenson procedure were analyzed & compared with those of Soave-Boley procedure in the staged operative treatment of HD statistically (unpaired ‘t’ test & χ2 test) Results : For group A (Swenson procedure) the operative time was significantly lesser (unpaired ‘t’ test : <P0.01) than for the group B (Soave-Boley procedure). First bowel movement after colostomy closure was also significantly lesser in duration in Swenson procedure (χ2 test :P<0.05). 1. Assistant Professor, Department of Pediatric Surgery, Dhaka Medical College, Dhaka, Bangladesh. 2. Professor, Department of Pediatric Surgery & Pediatric Urology, Bangladesh Institute of Child Health, Dhaka Shishu Hospital, Dhaka, Bangladesh. 3. Assistant Professor, Department of Physiology, Dhaka Medical College, Dhaka. 4. Professor & Head of the Department of Paediatric Surgery, Dhaka Medical College Hospital, Bangladesh. 5. Associate Professor, Department of Paediatric Surgery, Dhaka Medical College & Hospital, Bangladesh. 6. Assistant Professor, Department of Paediatric Surgery, Holy Family Red Crescent Medical College Hospital, Dhaka Bangladesh. continue to be used as the standard operations for the definitive treatment of this disease.4 Swenson first introduced the abdomino-perineal resection with pull through for HD in 1948. The risk of damage to the sacral nerves responsible for fecal & urinary continence as well as sexual function with the Swenson operation stimulated the development of the other pull through procedure.4 Soave introduced the endorectal pull through for HD in 1963 as an ERPT procedure without a distal anastomosis. The operation was modified by Boley in 1964 to include a primary anastomosis at the anus. The main advantages of the ERPT are relatively easy to perform & minimal chance of damage to the sacral nerves which control fecal & continence as the dissection is done entirely within the rectal cuff.4 J MEDICINE 2008; 9 : 16-19


Introduction :
Hirschsprung's Disease (HD) is a development disorder of the enteric nervous system (ENS) characterized by absence of ganglion cells in the myenteric & submucosal plexuses along a variable portion of the distal intestine. 1The rectum is always involved & in 90% patients the disease extends upto rectosigmoid region. 2 The most widely accepted etiopathogenic hypothesis is based on a defect of craniocaudal migratiion of Neuroblasts originating from the neural crest. 1 Three most common operations for the definitive treatment of HD are the Swenson, Duhamel & the Soave procedure. 3Although each has been modified following its original description, three procedure

Abstract :
Objective: The purpose of study was to compare Swenson & Soave-Boley procedure in the staged operative treatment of Hirschsprung's Disease (HD).continue to be used as the standard operations for the definitive treatment of this disease. 4enson first introduced the abdomino-perineal resection with pull through for HD in 1948.The risk of damage to the sacral nerves responsible for fecal & urinary continence as well as sexual function with the Swenson operation stimulated the development of the other pull through procedure. 4ave introduced the endorectal pull through for HD in 1963 as an ERPT procedure without a distal anastomosis.The operation was modified by Boley in 1964 to include a primary anastomosis at the anus.

Methods
The main advantages of the ERPT are relatively easy to perform & minimal chance of damage to the sacral nerves which control fecal & continence as the dissection is done entirely within the rectal cuff.A gentle rectal examination was performed at 15 th postoperative day if the colorectal anastomosis was adequate.We advised anastomotic dilation by metallic anal dilator twice daily by the mother / father at home till colostomy closure after adequate demonstration to the parents as per Pena scheduled.
After the first post pull through follow up visit the patients were advised to attend the follow up 2 weeks interval till the colostomy closure.
Data for colostomy closure was scheduled within 6 to 8 weeks for the definitive operation, if the anastomotic lumen was adequate.After closing the colostomy the patients were advised to attend the follow up at 2 weeks internal for 3 months.

Observations & Results:
Among the total number of patients 9 (69.23%) were male & 4(30.77%)were female in group A, 11(91.67%)male & 1(8.34%) female in group B. Age of the patients ranges from 9 month to 72 months in Group A, 8 months to 36 months in Group B. Out of 25 patients of our series 3(12%) patients came from a contagious parents.
In Group A the length of resected aganglionic segment was ranging from 10 cm to 25 cm with a mean of 15.31 cm (SD±3.82cm).
In Group B the length of resected ananglionic segment was ranging from 12 cm to 30 cm with a mean of 18.67 cm (SD±6.93cm) (Table-I).Thus both the groups were age matched for comparative study.Both the groups were sex matched with a uniform male : female ratio of 4:1 P >0.10, which is not significant.Similar male preponderance was found in a previous study at DSH, with a male female ratio of 4:01. 5Comparable American & Japanese studies reported male : female ratio to be 4:1 & 3:1 respectively. 6 our series, consanguinity present in two patients (15.38%) in grpup-A & 1 patient (7.69%) in group-B P<0.50 which is not significant.None of the siblings was affected.The average length of resected anganglionic segment was15.31cm (range from 10 to 25 cm) in group A & 18.67 cm (range from 12 to 30 cm) in group B. A study 7   None of the patients in our series developed disturbances of micturation.

Table-I
In Group-A first bowel movement occurred ranging from 2 to 5 days with a mean of 3.54 days (SD±0.775days).
In group B first bowel movement occurred ranging from 2 to 4 days, with a mean of 3.8 days (SD±0.839days) Fig. -2).A Mexican study showed that the operative time was ranging from 90 min to 300 min with an average of 186 min variation in the operation time for the procedure in our series was portable due to meticulous dissection in the cuff separation.
In In a study in DSH 12.5% of the patients developed enterocolitis after Swenson procedure.
An American study showed that 11.5% of the patients developed enter colitis after Swenson procedure.
In 1628 Japanese patients, enter colitis had been noted to occurred in 34% after Swenson procedure.
In a western study 5 out of 31 patients developed enter colitis after Swenson procedure. 6cording to the western published reports the incidence of enterocolitis after repair of HD has not changed during recent years (Holschneider & Ure 2000)10 thus both East & West there is increased incidence of postoperative enterocolit is after Swenson procedure.
The Comparative study in the staged operative treatment of HD suggest that Swenson procedure was a better procedure ensuring economic by consuming significantly lesser operative time.Both the procedure produced significant lesser incidence of operative complications but better functional results & patients parenteral satisfaction without requring any additional operative procedure for the treatment of complications.
Statistically, the difference between the two procedures are not significant except operative time.Both the procedures were safer, more comfortable & one procedure was effective alternative to others in staged operative treatment of HD.

Conclusion:
The study shows the results are good & equally comparable in both the procedures as far as outcome in concerned.Soave-Boley procedure requires little extra-time with the available expertise in anaesthesia & postoperative care, this extra time should not be taken as a deterrent to practice Soave-Boley procedure.
The researcher feels that the choice between the two procedures for pull through operation of HD should be left to individual paediatric surgeons.

:
During 16 months of study period, 25 patients of histopathologically confirmed HD were selected for staged operative treatment, following certain inclusion & exclusion criteria & were admitted & operated at DSH; after completion of all stages operation they were followed up & studied under two groups : staged Swenson procedure (Group-A; n a =13) & staged Soave-Boley procedure (Group-B, n b =12).They were similar for age, sex, body weight, reselected length of aganglionic segment & postoperative follow up.The level of ganglionosis was assessed from marking biopsy.Preoperative & postoperative observations of Swenson procedure were analyzed & compared with those of Soave-Boley procedure in the staged operative treatment of HD statistically (unpaired 't' test & χ 2 test) First bowel movement after colostomy closure was also significantly lesser in duration in Swenson procedure (χ 2 test :P<0.05).
Results :For group A (Swenson procedure) the operative time was significantly lesser (unpaired 't' test : <P0.01) than for the group B (Soave-Boley procedure).
This is a prospective study conducted on the children admitted & subsequently operated for Hirschsprung's disease in the department of Surgery of Dhaka Shishu (Children) Hospital (DSH).During the study period of 16 months, (December/2002 to June/2004), total 25 operated patients with HD with transverse colostomy were selected for evaluation.Total operated patients of HD were grouped under 2 categories.Group A (n a =13) patients underwent Swenson pull through operation as a part of staged procedure.Group B (n b =12) patients underwent Soave-Boley procedure of pull through operation as part of staged procedure.