Transanal Endorectal Pull-through Research Articles

Duhamel and transanal endorectal pull-throughs for Hirschsprung disease: a Bayesian network meta-analysis

BackgroundTo comprehensively compare the effects of open Duhamel (OD), laparoscopic-assisted Duhamel (LD), transanal endorectal pull-through (TEPT), and laparoscopic-assisted endorectal pull-through (LEPT) in Hirschsprung disease.MethodsPubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, and VIP were comprehensively searched up to August 4, 2022. The outcomes were operation-related indicators and complication-related indicators. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence. Network plots, forest plots, league tables and rank probabilities were drawn for all outcomes. For measurement data, weighted mean differences (WMDs) and 95% credibility intervals (CrIs) were reported; for enumeration data, relative risks (RRs) and 95%CrIs were calculated.ResultsSixty-two studies of 4781 patients were included, with 2039 TEPT patients, 1669 LEPT patients, 951 OD patients and 122 LD patients. Intraoperative blood loss in the OD group was more than that in the LEPT group (pooled WMD = 44.00, 95%CrI: 27.33, 60.94). Patients lost more blood during TEPT versus LEPT (pooled WMD = 13.08, 95%CrI: 1.80, 24.30). In terms of intraoperative blood loss, LEPT was most likely to be the optimal procedure (79.76%). Patients undergoing OD had significantly longer gastrointestinal function recovery time, as compared with those undergoing LEPT (pooled WMD = 30.39, 95%CrI: 16.08, 44.94). The TEPT group had significantly longer gastrointestinal function recovery time than the LEPT group (pooled WMD = 11.49, 95%CrI: 0.96, 22.05). LEPT was most likely to be the best operation regarding gastrointestinal function recovery time (98.28%). Longer hospital stay was observed in patients with OD versus LEPT (pooled WMD = 5.24, 95%CrI: 2.98, 7.47). Hospital stay in the TEPT group was significantly longer than that in the LEPT group (pooled WMD = 1.99, 95%CrI: 0.37, 3.58). LEPT had the highest possibility to be the most effective operation with respect to hospital stay. The significantly reduced incidence of complications was found in the LEPT group versus the LD group (pooled RR = 0.24, 95%CrI: 0.12, 0.48). Compared with LEPT, OD was associated with a significantly increased incidence of complications (pooled RR = 5.10, 95%CrI: 3.48, 7.45). Patients undergoing TEPT had a significantly greater incidence of complications than those undergoing LEPT (pooled RR = 1.98, 95%CrI: 1.63, 2.42). For complications, LEPT is most likely to have the best effect (99.99%). Compared with the LEPT group, the OD group had a significantly increased incidence of anastomotic leakage (pooled RR = 5.35, 95%CrI: 1.45, 27.68). LEPT had the highest likelihood to be the best operation regarding anastomotic leakage (63.57%). The incidence of infection in the OD group was significantly higher than that in the LEPT group (pooled RR = 4.52, 95%CrI: 2.45, 8.84). The TEPT group had a significantly increased incidence of infection than the LEPT group (pooled RR = 1.87, 95%CrI: 1.13, 3.18). LEPT is most likely to be the best operation concerning infection (66.32%). Compared with LEPT, OD was associated with a significantly higher incidence of soiling (pooled RR = 1.91, 95%CrI: 1.16, 3.17). Patients with LEPT had the greatest likelihood not to develop soiling (86.16%). In contrast to LD, LEPT was significantly more effective in reducing the incidence of constipation (pooled RR = 0.39, 95%CrI: 0.15, 0.97). LEPT was most likely not to result in constipation (97.81%). LEPT was associated with a significantly lower incidence of Hirschprung-associated enterocolitis (HAEC) than LD (pooled RR = 0.34, 95%CrI: 0.13, 0.85). The OD group had a significantly higher incidence of HAEC than the LEPT group (pooled RR = 2.29, 95%CrI: 1.31, 4.0). The incidence of HAEC was significantly greater in the TEPT group versus the LEPT group (pooled RR = 1.74, 95%CrI: 1.24, 2.45). LEPT was most likely to be the optimal operation in terms of HAEC (98.76%).ConclusionLEPT may be a superior operation to OD, LD and TEPT in improving operation condition and complications, which might serve as a reference for Hirschsprung disease treatment.

Comparison between Anal Dilatation Protocols Following an Endorectal Pull-through for Hirschsprung Disease

Objective: The purpose of this study was to compare the mechanical obstruction rate following a transanal endorectal pull-through (TERPT) in patients with Hirschsprung disease, between regular anal dilatation (AD) and selective anal dilatation (NAD) which meant that dilatation was only performed when an obstructive symptom occurred. Materials and Methods: A retrospective chart review of patients with Hirschsprung disease who underwent TERPT/abdominal assisted TERPT at Siriraj Hospital between January 2009 and December 2021 was carried out. It was the surgeon’s preference that the dilatation protocols between the 2 groups (AD or NAD) were assigned. Mechanical obstructions included evidence of stricture, a clinical symptom of constipation, presence of Hirschsprung-associated enterocolitis (HAEC), and/or requirement of re-operation. Results: In total, 132 patients were included in this study, including 55 cases in the AD group (41.7%) and 77 cases in the NAD group (58.3%). Postoperative mechanical obstructions occurred in 84 patients (63.6%). Among the mechanical obstructions, there were 35 strictures (26.5%), 26 constipation (19.7%), 40 HAECs (30.3%), and 6 reoperation (4.5%). The mechanical obstruction rates in the AD [33/55 (60.0%)] and NAD [51/77 (66.2%)] groups were not significantly different (p = 0.582). The AD group was of a significantly younger age (p = 0.022) and lower body weight (p = 0.048) than the NAD group; however, a younger age and lower body weight were not significantly related with any of the obstructive complications. AD had a rate of anastomosis/cuff stricture [13/55 (23.6%)] similar to NAD [22/77 (28.6%)] (p = 0.665). 

Concurrence of Hirschsprung disease and annular pancreas: a rare case report

Hirschsprung’s disease (HD) and annular pancreas are both uncommon congenital gastrointestinal malformations. Although additional abnormalities are associated with 18% of HD cases, there is limited evidence of concomitant HD and annular pancreas. We present a full-term, two-day-old male with abdominal distended, and failure to pass first stool after 3 days of observation and rectal washout the abdominal X-rays showed a double bubble appearance. Intraoperative finding, the patient had pancreas annulare (PA). Colonic aganglionosis was discovered using full-thickness rectal biopsies (FTRB). At the age of seven months, a transanal endorectal pull-through was performed without complications. Although the diagnosis of these conditions might be difficult due to their clinical similarities, appropriate diagnosis, and surgical management are possible and can dramatically minimize morbidity and death in the newborn.

Comparison of the quality of life of children with congenital megacolon (Hirschsprung’s disease) post transanal endorectal pull-through with other children's surgical cases in the 5-7-years age group at Moewardi Hospital Surakarta

Background: Congenital megacolon (Hirschsprung's disease) is caused by intestinal innervation abnormalities, due to failure of neuroblast migration from the proximal to the distal intestine so there is no nerve innervation in the distal intestine and causes functional ileus and hypertrophy and excessive intestinal distension. The classic triad of clinical features in neonates is late meconium expulsion, namely more than the first 24 hours, green vomiting, and an enlarged stomach. Management of congenital megacolon is divided into two, namely non-surgical treatment to overcome complications that may occur and to improve the general condition until definitive surgery and surgical treatment namely transabdominal approach (TAB), consisting of Swenson, Duhamel, Rehbein, and Soave, and transanal endorectal pull-through (TEPT). The advantages of TEPT include better cosmetic effects and shorter hospital stays. Quality of life (QoL) is a subjective perception of a person's well-being regarding levels in his life, which includes physical, social, and psychological conditions. Methods: This research is observational analytical research with a cross-sectional approach conducted at RSUD Dr. Moewardi Surakarta during August - September 2022. Results: Patients with congenital megacolon (Hirschsprung disease) after TEPT have a worse QoL than patients without congenital megacolon (p value <0.05). All components of the pediatrics quality of life questionnaire (PedsQLTM) are influenced by the patient's condition (p value <0.05). Conclusions: The poor quality of life should increase awareness of the importance of immediate treatment. Difficulty defecating, diarrhea, and abdominal pain can reduce the patient's QoL after TEPT. Family dynamics and support must be prioritized to improve the QoL.

Incidence of Infection-related Complications and Optimal Saline Irrigation Volume for Preoperative Bowel Preparation to Reduce Postoperative Infections in Hirschsprung’s Disease

Objective: The purpose of this study was to find incidence of infection-related complications and the optimal volume and duration (days) of rectal NSS irrigation that would result in the low post-operative complications following transanal endorectal pull-through (TERPT) in patients with Hirschprung’s disease. Materials and Methods: We conducted a retrospective chart reviews of 131 patients diagnosed with Hirschsprung’s disease who underwent TERPT at Siriraj Hospital between January 2006 and December 2020. Results:  Infection-related complications were observed in 23(17.6%) patients, comprising 22(16.8%) cases of anastomotic strictures, 3(2.3%) cases of anastomotic leakages, and 2(1.5%) cases of intraabdominal collections. The median (Q1, Q3) volume of NSS irrigation (ml/kg/day) for those without complications (38.1 (33.9,50)) and those with complications (39.5 (35,45)) was statistically identical (p = 0.945). Similary, the median duration of for both groups was the same (p = 0.854). The mean (SD) volume of irrigated NSS in those with leakage (55.6 (32.7)) and those without leakage (44.3 (17.9)) showed no statistically significant difference (p = 0.291). Patients with post-operative stricture received the same amount of irrigated NSS (40.7 (11.9)) as those without stricture (45.4 (19.2)) (p = 0.138). Similarly, those with hyponatremia received the same amount of irrigated NSS as those without hyponatrema (p = 0.475). Conclusion: The volume of rectally irrigated NSS did not correlate with infection-related complications such as anastomotic leakage, stricture and intraabdominal collection. However, this study observed a low complication rate, thus, future research should cover a larger population.

Peri-anal infiltration versus caudal block for multimodal analgesia in paediatric patients with Hirschsprung's disease undergoing transanal endorectal pull-through procedure: A randomised trial.

Transanal endorectal pull-through (TERPT) is a standard procedure for managing paediatric patients with Hirschsprung's disease (HD). This study aimed to evaluate peri-anal infiltration versus caudal block as a part of multimodal analgesia for paediatric patients with HD undergoing the TERPT procedure. This randomised trial included 60 patients of both genders, aged 6 to 18 months who underwent the TERPT procedure under general anaesthesia. The patients were randomly assigned into two groups to receive either peri-anal infiltration or caudal block with 1 ml/kg bupivacaine 0.25% and dexmedetomidine 1 µg/kg in 0.5 ml normal saline. The primary outcome was the time to the first rescue analgesia. The secondary outcomes were the total consumption, the frequency of nalbuphine administration as rescue analgesia within 24 hours and the level of postoperative sedation. The time to first rescue analgesia was significantly shorter in the peri-anal infiltration group versus the caudal block group (median [interquartile range] 10 [7.5-12.5] h versus 16 [13.5-18.5] h, respectively, P = 0.008). The frequency of administration and the total dose of nalbuphine was significantly higher in the peri-anal infiltration group (P = 0.003 and 0.013, respectively). The sedation score was significantly higher in the caudal block group postoperatively. For paediatric patients undergoing the TERPT procedure, peri-anal infiltration was less effective than caudal block in terms of the duration of postoperative analgesia. However, both techniques were comparable during the first 6 hours postoperatively.

Clinical outcomes evaluation of congenital megacolon (Hirschsprung disease) short segment type after transanal endorectal pull through at Moewardi Hospital Surakarta

Background: Congenital megacolon occurs in 1 in 5000 live births, with an estimated 1200 cases annually in Indonesia, predominantly affecting males. Mortality and morbidity in these patients can be reduced through improved diagnosis, neonatal care, surgical techniques, and enterocolitis management. The transanal endorectal pull through (TEPT) procedure, a minimally invasive surgery, is the common definitive treatment for congenital megacolon, performed even in neonates. However, TEPT can lead to post-operative anorectal dysfunction, necessitating assessment through fecal continence evaluation. The aims of this study is to understand of the clinical outcome congenital megacolon short segment type after TEPT procedure at Moewardi Hospital, Surakarta. Methods: The study is a cross sectional descriptive analysis in patients with congenital megacolon short segment type who have received TEPT treatment at Moewardi Hospital Surakarta from 2010 until 2022. Results: Among the patients, 18.9% exhibited normal anorectal function, 54.1% had good continence, 24.3% had moderate continence, and 2.7% experienced incontinence. Surgery age was mostly between 1 and 12 months (64.9%), with 62.2% achieving good continence. At the 1-5-year follow-up, 48.6% had good continence. Among primarily male patients (86.1%), 43.2% had good continence. Strong correlation (Pearson Chi-square score: 0.001) confirmed the relationship between age at the time of surgery and anorectal function outcomes. Conclusions: TEPT yielded favorable anorectal function outcomes in short-segment congenital megacolon patients, with surgery age significantly impacting these outcomes. This study supports the hypothesis that surgery age influences anorectal function outcomes after TEPT at Moewardi Hospital, Surakarta.  

Comparison of the Duhamel Procedure and Transanal Endorectal Pull-through Procedure in the Treatment of Children with Hirschsprung's Disease: A Systematic Review.

Studies comparing the Duhamel and TERPT procedures were included until 22 July 2023. R software (version 4.3.0) was used to perform the meta-analysis. Ten studies with a sum of 496 patients were included. The length of postoperative hospital stay and incidence of postoperative constipation were longer and higher after the Duhamel procedure than the TERPT procedure (p < 0.0001 and p = 0.0041, respectively). The incidence of postoperative anastomotic stricture was higher after the TERPT procedure than the Duhamel procedure (p = 0.0015). No significant differences were found in the incidence of postoperative fecal continence, fecal incontinence/soiling, anastomotic leak, or ileus between these two procedures. The operation time seemed to be similar for both procedures, but it became longer for the Duhamel procedure than the TERPT procedure after sensitivity analysis. While the incidence of postoperative enterocolitis seemed to be higher after the TERPT procedure, it became similar for both procedures in the subgroup analysis. The Duhamel procedure seems to be associated with a longer length of postoperative hospital stay, a higher incidence of postoperative constipation, and a lower incidence of postoperative anastomotic stricture than the TERPT procedure. However, the effect of these two procedures on the operation time and the incidence of postoperative enterocolitis remains unclear.

Post-surgical Outcomes of Different Surgical Techniques in Hirschsprung's Disease: A Literature Review.

Hirschsprung's disease (HD) is a rare condition that affects newborns and is characterized by the lack of ganglion cells in the colon. Typical symptoms include difficulty passing stool, vomiting, and trouble feeding. Various surgical methods are available to manage the condition. The aim of the study is to investigate and compare the post-surgical outcomes of different surgical techniques used in the treatment of HD. A thorough literature search was conducted using various electronic databases to identify relevant studies to be referred to.Double-blinded screening of the identified articles led to the final selection of 40 out of 440 HD, including transanal endorectal pull-through (TERPT), laparoscopic approaches, and modified techniques.Several studies have investigated surgical procedures for HD, including TERPT, laparoscopic methods, and modified techniques. These have shown positive outcomes, with fewer complications, improved bowel function, and favorable cosmetic results. Individual patient characteristics and surgeon expertise should guide procedure selection.Surgery for HD aims to restore normal bowel function, but post-surgical outcomes can include constipation or fecal incontinence. Complications like enterocolitis, anastomotic stricture, and sphincter damage may occur. Laparoscopic approaches have shorter hospital stays. However long-term follow-up is essential to assess quality of life, psychological well-being, and potential side effects.

Long-term bowel function after single-stage transanal endorectal pull-through in neonatal patients with Hirschsprung disease.

The aim of this study was to assess long-term outcomes of neonatal patients with Hirschsprung disease (HD) after single-stage transanal endorectal pull-through (TEPT) and to explore the predictive factors contributing to subnormal bowel function. Patients aged > 3years operated for HD with TEPT during neonatal period between 2007 and 2019 answered the bowel function score (BFS) questionnaire. The patients were retrospectively divided into two groups according to whether they had normal bowel function. The clinical variables were compared between the subnormal and normal BFS groups. Univariate and multivariable logistic regression analysis were performed to identify the predictive factors contributing to subnormal bowel function. A total of 160 children (71.7%) were included in this study, with mean follow-up time of 7.3years (range 3.0-15.1years). The level of aganglionosis were determined to be the short-segment (124/160, 77.5%), long-segment (33/160, 20.6%), and TCA (3/160, 1.9%). One hundred and thirty-four patients (83.8%) had a BFS ≥ 17, and 26 patients (16.2%) with subnormal bowel function (BFS < 17). Univariate and multivariate logistic regression analysis showed that level of aganglionosis with long-segment or TCA and postoperative hospital stay > 8.5days were independent risk factors with OR of 3.213 (1.252, 8.246) and 3.813 (1.371, 10.606) for subnormal BFS, respectively. Most HD patients who underwent one-stage TEPT in the neonatal period have favorable long-term results, and the level of aganglionosis with long-segment or TCA and long postoperative hospital stay may be closely related to subnormal bowel function.

Comparison of clinical results of Transanal Endorectal Pull-Through of the colon with and without laparoscopic assistance in children with Hirschsprung’s disease

Introduction. Techniques of Transanal Endorectal Pull-Through (TEPT) with and without laparoscopic assistance have been widely used in pediatric surgery for correction of Hirschsprung’s disease (HD) in children with. Many clinics in their studies have noted the positive features of this approach compared to classical methods, but the long-term results after such operations in children are still debated. Purpose - to study and compare the clinical results of TEPT with and without laparoscopic assistance in children with HD. Materials and methods. We analyzed the experience of TEPT approach with laparoscopy (n=65 (29.41%)) and without laparoscopic assistance (n=144 (70.59%)) in childreb for correction of HD. For confirmation diagnosis we used the results of general clinical and special procedures (barium enema, anomanometry, histological, determination of acetylcholesterase activity). Results. Overall, among 55 (26.32%) of 209 patients who underwent TEPT, postoperative in long term follow up we found intestinal problems like - moderate stenosis of the colo-anal anastomosis without incontinence 4 (1.91%), constipation 9 (4.31%), partial faecal incontinence 20 (9.57%) and enterocolitis (EC) 22 (10.53%). There was no significant difference in the clinical results of TEPT with laparoscopy and without laparoscopic assistance in our patients. After TEPT without laparoscopic assistance, 6 (4.17%) of 144 patients had constipation, 11 (7.64%) had partial fecal incontinence, and 16 (11.11%) had enterocolitis (EC). And among 65 children after TEPT with laparoscopy, 3 (4.62%) patients were diagnosed with constipation, 9 (13.85%) with partial fecal incontinence and 6 (9.23%) with EC. All children with postoperative intestinal problems were treated conservatively. There was no need for redo surgical interventions in these patients. Conclusions. The technique of TEPT with laparoscopy and without laparoscopic assistance is a modern method of surgical correction of HD, which has significant technical advantages compared to other existing methods. In 26.32% of children with HD who were operated by the TEPT method, persistent intestinal problems continue in the long term follow-up period. The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of all institutions mentioned in the work. Informed consent of the children’s parents was obtained for the research. No conflict of interests was declared by the authors.

Early Surgical Complications Following Transanal Endorectal Pull-through for Hirschsprung’s Disease

Objective: The purpose of this study was to examine factors affecting early complications following transanal endorectal pull-through (TERPT) in  patients with Hirschprung’s disease. Materials and Methods: Retrospective chart reviews of  patients with Hirschsprung’s disease who underwent TERPT/ abdominal assisted TERPT at Siriraj Hospital between January 2009 and  December 2019 was carried out. . Results: The overall complication rate was 26% (43/163). The complications were as follows:  14 cases of anastomotic strictures (32.6%), five cases of abscess at anastomosis (11.6%), and three cases of anastomotic leakages (7.0%). In regards to preoperative bowel preparation,  when comparing  those with and those without post-operative complications, the amount of NSS for rectal irrigation (ml/Kg), duration required (days), and duration of changed diet (days) were the same. Colostomy prior to a  pull-through operation could not prevent post-operative complications following endorectal pull-through (p = 1.000). The incidences of early complications following TERPT and  abdominal assisted TERPT was  the same (p = 0.344). Abdominal assisted TERPT had a higher incidence (4%) of anastomotic leakages whereas TERPT had a higher rate of anastomosis strictures (12%) compared to o abdominal assisted TERPT (5%). The higher the transitional zone, the higher the complication rate. Anastomotic leakages, the most serious complication, rarely occurred following TERPT in the  low transitional zone. Conclusion: There was no significant risk factor associated with early surgical complications following TERPT. Abdominal assisted TERPT should be selected properly according to the  level of transitional zone. The complications correlate with whether a perfect pull-through operation could be performed or not.

Comparison between two minimally invasive techniques for Hirschsprung disease: transanal endorectal pull-through (TERPT) versus laparoscopic-TERPT.

Surgical treatment for Hirschsprung disease (HD) has recently evolved into different minimally invasive techniques. The aim of the present study is to compare results from two different minimal invasive approaches, transanal endorectal pull-through (TERPT) and laparoscopic-assisted endorectal pull-through (LA-TERPT). Patients have been divided into two groups according to surgical technique. Data of HD patients treated by TERPT and those treated by LA-TERPT, respectively, performed at two different centers from January 2007 to December 2017, were retrospectively collected. Patients with aganglionosis confined to the recto-sigmoid colon with a minimum follow-up period of 4years have been included. Demographic, clinical, surgical and functional outcome data were reviewed for each group using Chi-square and Fisher tests (statistical differences were considered for p < 0.05). Among patients treated for HD in the two centers during the study period, 65 met the inclusion criteria (37 TERPT group and 28 LA-TERPT group). No differences regarding demographic and clinical data were observed between the two groups. Operative time was longer in the LA-TERPT group (p < 0.001). Time to start oral feeding was faster in the TERPT group while hospital stay was similar between the two groups. Three patients of the TERPT group required an additional abdominal approach. The rate of early complications was higher in the TERPT group. Long-term bowel function was assessed in 31 patients for the TERPT group and 24 patients for the LA-TERPT group. Outcomes showed that the bowel functional outcome was good (BFS ≥ 17) in 55% (n = 17) of TERPT group and 54% of LA-TERPT group (p = 0.97), moderate (BFS 12 to 16) in 16% (n = 5) and 33% (n = 8), respectively (p = 0.24), and poor in 29% (n = 9) and 13% (n = 3), respectively (p = 0.23). Both TERPT and LA-TERPT techniques should be considered safe and feasible for the treatment of HD patients. TERPT patients present faster time to return to normal bowel function while LA-TERPT patients have slightly lower incidence of postoperative complications. Long-term functional outcomes are similar between the two groups. III.

Outcome of Transanal Endorectal Pull-Through in Patients with Hirschsprung's Disease.

Transanal endorectal pull-through (TERPT) has become one of the preferred treatments for Hirschsprung's disease (HD) in our setting. This report aims to evaluate the current outcome of TERPT in the setting. A retrospective review of 71 children who had TERPT for histologically-confirmed HD in 11 years (2006-2017) in Nigeria. There were 48 boys and 23 girls; aged 3 days-12 years at initial presentation (median = 10 months). Three (4.2%) patients had associated anomalies (duodenal atresia; anorectal malformation and sensorineural deafness with hypopigmented skin patches each). Age at TERPT was 2 months to 15 years (median = 3 years), with surgery waiting time of 1 month-14.9 years (median = 18 months). Sixty-six (93.0%) patients had rectosigmoid, four (5.6%) patients had long segment and one (1.4%) had total colonic disease. Five (7.0%) patients with large megacolon and one (1.4%) with the total colonic disease had assisted abdominal resection of the colon at TERPT. Seventeen (23.9%) patients had post-operative complications, including post-operative enterocolitis 8 (11.3%); anastomotic dehiscence 3 (4.2%); retained aganglionic segment 2 (2.8%); anastomotic stenosis 2 (2.8%), resulting in prolonged hospital stay (P = 0.0001; range = 1-30 days; median = 5 days). The mortality rate was 4.2% (3) from malignant hyperthermia in one patient and in 2 patients, the cause of mortality was unclear. Patients were followed up for 3-6 years (median = 3.5 years). Bowel movement stabilised to 2-4 times daily by 6 weeks after surgery. TERPT is a safe treatment for HD in this setting with good short-term outcomes. Longer follow-up is necessary to further evaluate the long-term bowel movement outcomes.!

Transanal endorectal or transabdominal pull-through for Hirschsprung's disease; which is better? A systematic review and meta-analysis.

Hesitations concerning the long-term results of transanal endorectal pull-through (TEPT) due to prolonged anal stretching and resultant stricture and continence problems has been started to be questioned. This meta-analysis intended to compare long-term results between TEPT and transabdominal (TAB) pull-through techniques in the surgical management of Hirschsprung's disease. All publications between the years 1998-2021 in the PubMed, Medline, Google Scholar, Cochrane databases were reviewed. Retrospective and prospective comparative studies for TEPT, TAB as well as Laparoscopic-assisted TEPT (LTEPT) were included. Data included age at operation, postoperative constipation, enterocolitis, incontinence, stricture, and soiling rates. Eighteen publications met the inclusion criteria for TAB and TEPT, and six for TEPT and LTEPT. Patients who underwent TEPT had significantly younger operation age than patients with TAB (SMD -1.02, 95%Cl -1.85 to -0.18, p: 0.0168). Postoperative constipation (OR 0.39, 95% Cl 0.25-0.61 p < 0.0001) and enterocolitis (OR 0.65, 95% Cl 0.46-0.90, p: 0.0108) rates were significantly lower in TEPT groups. Postoperative incontinence (OR 1.06, 95% Cl 0.56-2.01, p: 0.8468), stricture (OR 1.97, 95% Cl 0.81-4.80, p: 0.1352) and soiling rates were similar between the two groups. Furthermore, when TEPT and LTEPT results were compared, incidence of incontinence (OR 7.01, 95% Cl 0.75-65.33, p: 0.0871), constipation (OR 1.95, 95% Cl 0.70-5.37, p: 0.199), enterocolitis (OR 3.16, 95% Cl 0.34-29.55 p: 0.3137), stricture (OR 1.33, 95% Cl 0.29-6.15, p: 0.7188) and soiling (OR 1.57, 95% Cl 0.57-4.31, p: 0.3778) were similar for both techniques. TEPT is superior to TAB in terms of constipation and enterocolitis. Contrary to concerns, postoperative incontinence rates are not statistically different. However, further publications about long-term LTEPT results are necessary for more reliable conclusions.

Comparison of clinical features and prognosis between ultrashort-segment and short-segment hirschsprung disease.

To compare the differences in clinical features, postoperative complications, and long-term bowel function outcomes of ultrashort-segment Hirschsprung disease (USHD) and short-segment Hirschsprung disease (SHD). A retrospective study was conducted to compare patients with USHD or SHD who underwent transanal endorectal pull-through (TEPT) at Beijing Children's Hospital between January 2014 and June 2021. Clinical details were collected from medical records. A long-term bowel function questionnaire (age > 4 years old) was completed by the patients' parents. A total of 84 patients (USHD = 15, SHD = 69) were included. Age at diagnosis and radical surgery in the USHD group were significantly older than the SHD group (46 [38, 66] vs. 34 [6, 55] months, p = 0.002; 51 [39, 68] vs. 37 [10, 68] months, p = 0.001, respectively). Compared with the SHD group, patients with USHD are more likely to suffer anastomosis leakage and postoperative enterocolitis after TEPT ([3/15, 33.3%] vs. [1/69, 1.4%], p = 0.017; [5/15, 33.3%] vs. [6/69, 8.7%], p = 0.023). In addition, patients in the USHD group are inclined to suffer lower bowel function scores (12.0 [7.5, 18.3] vs. 17 [15, 19], p = 0.018).Patients in the USHD group were more likely to suffer poorer ability to hold back defecation (p = 0.023), soiling (p = 0.011), fecal accidents (p = 0.004), and social problems (p = 0.004). Compared with patients with SHD, patients with USHD are diagnosed and performed TEPT at an older age. and they are inclined to suffer postoperative enterocolitis, anastomosis leakage, and poorer long-term bowel function following TEPT.

Single-stage Transanal Endorectal Pull-Through for Hirschsprung’s Disease: A Retrospective Study of Surgico-pathological Correlations and Technical Considerations

Abstract Background: Transanal endorectal pull-through (TEPT) is a well-established operation for the management of rectosigmoid and short-segment Hirschsprung’s disease (HD). A well-performed contrast enema (CE) is an essential road map for the surgeon when attempting the TEPT. We looked at the surgicopathological–radiological correlations and technical considerations of this procedure and discussed our experience over a decade. TEPT essentially relies on radiological mapping of the disease correlating with intraoperative and pathological findings. Some investigators opine that the radiological correlation of the transition zone (rTZ) with the pathological transition zone (pTZ) is accurate whereas others disagree. We review our experience in managing HD patients with TEPT, in terms of pre-operative workup and operative and pathological considerations. Materials and Methods: A retrospective study was done in a single unit, from January 2010 to January 2020. Forty-seven patients who met the inclusion criteria such as short-segment HD and uncomplicated HD underwent CE before surgery. The patients included in the review underwent a primary TEPT. For each patient, we identified the radiological transition zone (rTZ) on the contrast enema, the gross transition zone (gTZ) on intraoperatively visual examination, the frozen section transition zone (fTZ) on intraoperative analysis of the frozen section specimens (fTZ), and the pathological transition zone (pTZ) on permanent paraffin blocks of the specimens. We determined the strength of correlation of the rTZ, the gTZ and the fTZ with reference to the pTZ. Results: Forty-seven patients underwent single-stage transanal pull-through. There were 40 males. There were 8 neonates, 20 infants and 19 children (&gt;12 months of age). The mean age at diagnosis was 8.7 days (3–20 days) for the neonates, 5.11 months (2–12 months) for the infants and 4.3 years (1.5–9 years) for children. In our study, 85% correlation was noted between the rTZ and the pTZ (tb = 0.362, P = 0.006). There was an excellent correlation between the intraoperative gTZ, fTZ and the pTZ in all patients except one (97.8%, tb = 0.942, P &lt; 0.001). Conclusions: The TEPT is a feasible option to manage carefully selected patients with rectosigmoid HD. The presence of robust support from pathology and a properly carried out CE are essential parameters to be considered before successfully undertaking these operations. The functional outcomes of TEPT are comparable with other procedures for HD with the added advantage of it being a scar-less and a stoma-less approach.

Redo pull-through for postoperative complications following pull-through in Hirschsprung disease: a single center experience.

Although surgical management of Hirschsprung disease (HD) is effective in most patients, some patients experience long-term postoperative complications, and require redo pull-through (PT). The present study evaluated clinical outcomes of redo PT in HD patients at a single center. Patients with HD who underwent redo PT procedures between 2003 and 2019 were retrospectively reviewed. Thirteen patients were included. Five (38.5%) had undergone initial PT surgery at our center and 8 (61.5%) at other centers. Redo PT procedures were transanal endorectal PT in 12 patients (92.3%) and the posterior sagittal approach in 1 patient (7.7%). Indications for redo PT included pathologic misdiagnosis in 8 patients (61.5%); stricture in 2 (15.4%); and rectal stenosis, obstructing Duhamel pouch and remnant septum in 1 each (7.7%). At a median follow-up of 68 months (range, 3-227 months) after redo PT, 8 patients (61.5%) had normal bowel function, 2 (15.4%) had incontinence, and 1 (7.7%) had constipation. Redo PT procedures could be an effective approach for improving obstructive symptoms in HD patients with anatomic or pathologic reasons following primary PT. Careful selection of patients and discreet indications for redo PT are crucial.

Primary Trans-anal Endorectal Pull Through for The Management of Hirschsprung Disease: Our Experience of 20 Cases

Hirschsprung’s disease can be defined in terms of the aganglionic part of the colon and the definitive treatment is a one-stage trans-anal endorectal pull-through surgery.  Objectives: To find out the efficacy and safety of this one-stage pull-through. Mostly the surgery is done in early childhood or the neonatal period, as the case is less frequently reported in older children and adolescents. Methods: A retrospective study was conducted including 16 males and 4 females. 20 cases including children of 6 months to 14 years, all were diagnosed with Hirschsprung’s disease in the study duration of two years. The diagnostic criteria of these patients included; Clinical history of delayed passage of meconium, contrast enema, and rectal biopsy. Definitive variables were; Age, sex, and length of the aganglionic part of the colon. Results: All the patients included in the study had distended abdomens and persistent constipation. All of them have an aganglionic colon, a diagnosing feature of Hirschsprung’s disease. All patients underwent the trans-anal endorectal one-stage pull-through. The average operative time recorded was 150 minutes. Post-operative complications were also recorded including anastomosis leakage (only in one case; for that a diversion colostomy was done), anastomotic stenosis or stricture (not reported in any case), enterocolitis and perineum irritation (In four cases), Transient fecal incontinence is a major complication (11 cases had transient fecal incontinence which resolved spontaneously with 1 to 2 weeks). No death had been recorded. Conclusion: For the treatment of Hirschsprung’s disease, primary trans-anal endorectal pull-through is a safe and efficient technique.  

One-stage transanal endorectal pull-through for Hirschsprung disease: experience with 229 neonates.

To evaluate the safety and efficacy of transanal endorectal pull-through (TEPT) and the long-term outcomes in newborns with Hirschsprung disease (HD). A total of 229 newborns with HD underwent one-stage TEPT between 2007 and 2020, and the diagnoses were confirmed by rectal biopsy. The perioperative clinical course for all patients was reviewed, and the postoperative short- and long-term outcomes were assessed. A total of 229 neonates (187 male and 42 female) had a median age at TEPT of 17days (range 6-28days). Sixty-eight patients (29.7%) underwent TEPT combined with an abdominal approach or laparoscopy. Early postoperative complications (using the Clavien-Dindo grading system) were documented in 36 patients (15.7%), and late postoperative complications were noted in 9 patients (3.9%). The follow-up period in the remaining 165 children ranged from 1.2 to 14.0years (median 5.0years). A total of 106 of the patients older than four years old took part in an interview about bowel function, and 85 patients (80.2%) had bowel function scores (BFS) ≥ 18. TEPT is effective and safe for HD in the neonatal period and presents with a low rate of complications and an acceptable outcome.