Stooling patterns and colonic motility after transanal one-stage pull-through operation for Hirschsprung's disease in children

Abstract

Background The transanal one-stage endorectal pull-through operation for Hirschsprung's disease is relatively new and makes assessment of the functional outcome and colonic motility difficult. The aim of this study was to evaluate the stooling patterns and colonic motility after a one-stage transanal pull-through operation for Hirschsprung's disease in children. Methods Twenty-two children who underwent a one-stage transanal pull-through operation for Hirschsprung's disease were followed up for at least 6 months. The children (17 boys and 5 girls) were from 12 months to 13 years of age (mean age, 4 years). All patients had an aganglionic segment confined to the rectosigmoid area (confirmed by preoperative barium enema and postoperative histology). Clinical outcome was assessed by interviews and questionnaires, and children were divided into symptomatic and nonsymptomatic groups. Contrast barium enema and defecography and determination of total and segmental colonic transit time (using radio-opaque markers) were performed on all 22 children. Results The stooling patterns were considered satisfactory in 17 children. Of all the children, the mean stool times were 1 to 2 per day and only 2 were 8 to 10 per day; postoperative soiling was found in 4, constipation was observed in 2, and Hirschsprung-associated enterocolitis in 1. There was no incontinence, cuff infection, anastomotic leak, or mortality noted. Barium enema showed that the dilated and spastic colonic segment disappeared in all 22 children. The dilated sigmoid loops decreased in 17 (2 symptomatic, 15 nonsymptomatic) and disappeared in 5 (4 symptomatic, 1 nonsymptomatic). There was a significant difference between the decreasing and disappearing loop group in regard to stooling disorders ( P < .05). Postoperative defecography showed that the anorectal angle of all children was open, fixed, and significantly larger than that of the preoperative and control groups (123.3° ± 15.1° vs 84.7° ± 8.3° vs 79.0° ± 11.6°, P < .01) and larger in the symptomatic group when compared with the nonsymptomatic group (135.6° ± 15.9° vs 111.0° ± 14.3°, P < .05). Postoperatively, the total gastrointestinal transit time, left colonic transit time, and rectosigmoid colonic transit time of all the children were shorter than preoperatively (26.8 ± 8.2 vs >188 hours, P < .01; 6.3 ± 4.1 vs >60 hours, P < .01; 11.8 ± 4.4 vs >120 hours, P < .01) and similar to controls. The total gastrointestinal transit time and rectosigmoid colonic transit time of the symptomatic group were significantly shorter than the nonsymptomatic group (25.2 ± 5.6 vs 28.1 ± 10.1 hours, P < .05; 12.2 ± 6.7 vs 9.8 ± 4.0 hours, P < .05). Conclusions The stooling pattern and colonic motility are satisfactory in most children after the one-stage transanal pull-through operation for Hirschsprung's disease. Normalization of colon appearance and total and segmental colonic transit time are signs of recovery of colonic motility. Stooling disorders were noted in a few cases and may be related to decrease or disappearance of the sigmoid loop, dysfunction of the “neorectosigmoid”, an open and fixed anorectal angle, and ischemia of the pull-through segment.