Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article

Degree

Master of Science

Program

Surgery

Supervisor

Vogt, Kelly N.

2nd Supervisor

Bütter, Andreana

Co-Supervisor

Abstract

Hirschsprung Disease (HD) and Anorectal Malformations (ARM) are congenital colorectal conditions that necessitate surgical correction via bowel resection with the creation of an anastomosis. Surgical complications, thought to be in part due to malperfusion of the bowel anastomosis, are frequent, as revealed by the retrospective review enclosed. Indocyanine Green Angiography (ICGA) is a process in which water-soluble dye (ICG) is used to assess perfusion of tissue, and it has been employed with success in adult populations to reduce rates of anastomotic leak during colorectal surgery. The systematic review conducted within confirms that this tool has not been extensively studied in pediatric patients undergoing bowel resection. To understand the feasibility of conducting an adequately powered multi-centered trial to determine if ICGA reduces the rates of malperfusion-related complications such as anastomotic stricture, leak, or dehiscence during pull-through for HD or ARM, a feasibility randomized controlled trial was conducted. We found that the designed protocol achieved a recruitment rate of 80%, which met our prespecified criteria to proceed with a larger study. Further research into the utility of ICGA in pediatric colorectal surgery is required.

Summary for Lay Audience

Hirschsprung Disease (HD) and Anorectal Malformations (ARM) are conditions that affect the large bowel or colon in around one in 5,000 babies born around the world. HD is caused by nerves in the colon not developing, specifically ganglion cells. This results in the colon not being able to move stool through it properly. Due to this, babies born with HD have symptoms of a bowel blockage. ARM is a term used to describe a spectrum of abnormalities in the development of the rectum and anus. It can range from absence of an anus to an abnormal connection between the rectum and a surrounding structure such as the vagina or bladder.

Both HD and ARM need a surgery to fix them. In HD, the part of the bowel that doesn’t have ganglion cells and bringing healthy colon down to the anus. Similarly in ARM, healthy colon is brought through to the skin to form an anus, making sure to fix any abnormal connection, and preserving the muscles in the pelvis that allow children to control their bowel movements. Unfortunately, all surgeries come with risks of complications. It is thought that these complications may be due to the connection (anastomosis) between the colon and anus not having enough blood flow. Some of the complications that occur after repair of HD and ARM include anastomotic strictures (narrowing of the connection), anastomotic leaks (a disruption in the connection, resulting in spillage of stool), and anastomotic dehiscence (the connection between the skin and colon coming apart).

One way to assess the anastomosis for good blood supply is using indocyanine green angiography (ICGA). This is a contrast dye that binds to blood proteins and glows green when a special light is used and there is good blood flow to the area of interest. This technology has been studied in adults with some success but has not been studied in children. We looked at the existing literature and conducted a study to see if a trial designed to find out if ICGA reduces the risks of complications.

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