Combined Radial Incision and Steroid Injection for Refractory Colorectal Stenosis After Pull-Through Surgery in Hirschsprung Disease: An Innovative Conservative Treatment.

Abstract

BACKGROUND Anastomotic stenosis after pull-through surgery remains a challenge in the management of Hirschsprung disease. Based on the management of esophageal stenosis, we evaluated the efficacy of combined radial incision and steroid injection for the treatment of refractory colorectal anastomotic stenosis after pull-through. IMPACT OF INNOVATION Combined radial incision and steroid injection is an alternative conservative treatment of refractory anastomotic stenosis after pull-though for Hirschsprung disease, avoiding a potential complicated redo pull-though surgery. TECHNOLOGY MATERIALS AND METHODS We included patients with recto-sigmoid Hirschsprung disease that developed a refractory anastomotic stenosis after a laparoscopic-assisted Swenson pull-through at Robert-Debré Children University Hospital, Paris, France. Refractory stenosis was defined as obstructive symptoms associated with an anastomotic stenosis upon rectal exam without improvement after serial anal dilatations. Under general anesthesia, an injection of 10mg delayed-action steroid per quadrant was combined with a radial incision of the stenosis using monopolar cautery. PRELIMINARY RESULTS Combined radial incision and steroid injection was performed in 4 children, for either early or late refractory stenosis. This resulted in improvement of refractory anastomotic stenosis, avoiding a redo pull-through in 75% of patients. One child presented with transient improvement after combined radial incision and steroid injection but developed recurrent stenosis despite additional combined radial incision and steroid injection and redo pull-through. The median follow-up was 29 months. CONCLUSION AND FUTURE DIRECTIONS We observed a clinical improvement in all the patients after combined radial incision and steroid injection. Steroids injection should be considered as a potential alternative therapy for anastomotic stenosis.