The role of transanal endorectal pull-through in the treatment of Hirschsprung’s disease—a multicenter experience

Abstract

During the last decade, pediatric surgeons have tried to reduce the surgical trauma for correction of Hirschsprung’s disease, eg, by laparoscopic approaches. In 1998, the first description of an entirely transanal pull-through (TAPT) was published. The authors collected their experience with TAPT technique in 18 patients within 2 years including 15 infants and 3 older children. All but one showed rectosigmoid aganglionosis, 3 had a preliminary enterostomy for neonatal obstruction. The rectal mucosa was incised above the dentate line, a mucosal cylinder formed, and the muscle layer penetrated cranial to the peritoneal reflection. The colon was mobilized by dividing the vessels up to the level of normal ganglion cells. After posterior myotomy of the distal muscle cuff, the colon was pulled through and anastomosed to the mucosal incision line. Fourteen children were treated with TAPT alone. In 3 patients, laparoscopy was necessary to (1) confirm proper penetration into the peritoneal cavity in 2 older children and (2) to mobilize the long aganglionic segment in an infant. Once laparotomy was necessary because of severe adhesions. The postoperative course was uneventful in 17 patients; one developed a retrorectal abscess. TAPT is a quick and easy technical adaptation of Soave’s method with excellent results especially in babies. Critical issues mentioned by the authors are (1) that the best level of mucosal dissection to preserve delicate nerve endings for sensation and continence is unclear, (2) that the pull-through of very large megacolon in older children causes marked anorectal distension probably followed by temporary soiling, and (3) that the technique is useful for rectosigmoid aganglionosis only and should not be used in unclear extension without reliable evaluation by biopsies.—Peter Schmittenbecher During the last decade, pediatric surgeons have tried to reduce the surgical trauma for correction of Hirschsprung’s disease, eg, by laparoscopic approaches. In 1998, the first description of an entirely transanal pull-through (TAPT) was published. The authors collected their experience with TAPT technique in 18 patients within 2 years including 15 infants and 3 older children. All but one showed rectosigmoid aganglionosis, 3 had a preliminary enterostomy for neonatal obstruction. The rectal mucosa was incised above the dentate line, a mucosal cylinder formed, and the muscle layer penetrated cranial to the peritoneal reflection. The colon was mobilized by dividing the vessels up to the level of normal ganglion cells. After posterior myotomy of the distal muscle cuff, the colon was pulled through and anastomosed to the mucosal incision line. Fourteen children were treated with TAPT alone. In 3 patients, laparoscopy was necessary to (1) confirm proper penetration into the peritoneal cavity in 2 older children and (2) to mobilize the long aganglionic segment in an infant. Once laparotomy was necessary because of severe adhesions. The postoperative course was uneventful in 17 patients; one developed a retrorectal abscess. TAPT is a quick and easy technical adaptation of Soave’s method with excellent results especially in babies. Critical issues mentioned by the authors are (1) that the best level of mucosal dissection to preserve delicate nerve endings for sensation and continence is unclear, (2) that the pull-through of very large megacolon in older children causes marked anorectal distension probably followed by temporary soiling, and (3) that the technique is useful for rectosigmoid aganglionosis only and should not be used in unclear extension without reliable evaluation by biopsies.—Peter Schmittenbecher