Background/Purpose: Primary pull-through via a perineal approach (PA) has recently been reported for Hirschsprung's disease. One criticism of this approach is that it requires a large amount of retraction on the anal sphincters. Additionally, because the procedure is new, most patients undergoing a PA are too young to assess long-term continence rates. This study examined early stooling patterns, anal sphincteric pressures, and number of enterocolitic episodes in infants who underwent a PA. Results were compared with a conventional combined transabdominal and perineal approach (TA). Methods: Over 2 years, 26 pull-through procedures were performed. Nine of those were PA, and 17 were TA. Twelve of the 26 patients had formal manometric studies postoperatively. Results are expressed as mean ± SD; unpaired t test and X2 were used for statistical analysis. Results: Mean follow-up post–pull-through was 23 ± 2.3 months for the TA and 14 ± 1.9 months for the PA. Manometric resting sphincter pressure in the TA group averaged 79 ± 17 mm Hg compared with 76 ± 21 mm Hg in the PA group (P =.78). Number of stools per day was 3.3 ± 0.6 in the TA group compared with 2.2 ± 0.3 in the PA group (P =.17). Post–pull-through enterocolitis was experienced by 53% of the TA group (mean, 1.5 ± 0.6 episodes) and 56% of the PA group (mean 0.9 ± 0.4 episodes) for a P =.08 by X2 analysis. Conclusions: Manometric sphincter pressure and enterocolitic episodes after a PA for Hirschsprung's disease appear to be similar to results obtained with a conventional TA. Evaluation of early stooling frequency shows a comparable frequency after a PA. This suggests that both methods are safe, and the PA does not appear to compromise sphincter integrity. J Pediatr Surg 37:1321-1325. Copyright 2002, Elsevier Science (USA). All rights reserved.