Transanal Endorectal Pull-through Research Articles

Transanal endorectal pull-through for classic segment Hirschsprung's disease: With or without laparoscopic mobilization of the rectosigmoid?

BackgroundIt has been suggested that the outcome of transanal endorectal pull-through for classic Hirschprung's disease can be improved by laparoscopically mobilizing the colon before the pullthrough. MethodsCharts of 43 patients (2005–2009) with proven recto-sigmoid aganglionosis were retrospectively analyzed with respect to postoperative outcomes. Twenty-one had been treated with the transanal endorectal pull through (TERPT) and 22 with the laparoscopically assisted TERPT (LTERPT). ResultsGender ratio, congenital anomalies, preoperative enterostomy, and follow up did not differ between the groups. More colon was resected in the TERPT group: median 25cm vs. 15cm in the L-TERPT group (p<0.001). The TERPT-procedure took less time: median 153min. vs. L-TERPT 263min (p<0.001). Postoperatively, three patients showed colonic torsions after TERPT (p=0.07). The long-term clinical outcomes did not differ significantly between both groups. There was a significant association between length of resection and obstructive symptoms (OR=0.92, p=0.01). ConclusionPostoperative and clinical outcomes are similar using the TERPT or L-TERPT to correct classic segment Hirschsprung's disease. Prevention of colonic torsion should be the prime concern during the TERPT procedure. L-TERPT requires laparoscopic equipment and takes more operation time, whereas TERPT leaves no visible scars. The positive relation between the larger length of resection and obstructive symptoms requires additional research.

Laparoseopy-assisted transanal endorectal pull-through surgery for Hirschsprung' s disease in 63 children

Objective To compare the efficacy of laparoseopy-assisted transanal endorectal pullthrough surgery with that of transanal Soave technique without laparoseopy for Hirschsprung' s disease.Methods We reviewed the data of 121 children with Hirsehsprung' s disease who had been treated during January 2004 to November 2012.The patients were divided into 2 groups:laparoseopy-assisted transanal endorectal pull-through surgery (n=63) and transanal Soave technique without laparoseopy (n=58).The surgical duration,time of passing feces or flatus,and complications were analyzed.Results There were no differences between the two groups in severity of enterocolitis,anal stenosis,anastomotic complications,and time of passing flatus.The surgical duration (2 ± 0.8)h was significantly shorter (t=2.586,P＜0.05); and the amount of intraoperative bleeding (20 ± 3.5)ml was smaller in laparoseopy group than in non-laparoseopy group (t=1.834,P＜0.05).Conclusions Laparoseopy-assisted transanal pull-through surgery is a more extended,effective,safer procedure. Key words: Hirschsprung' s disease; Modified Soave; Laparoscopy

Literature Review of the Outcome after One-Stage Transanal Endorectal Pull-Through Procedure for Hirschsprung’s Disease in Children

Background: Transanal endorectal one-stage pull-through (TERPT) procedure in children with Hirschsprung’s disease (HD) is frequently used worldwide. In order to give the families realistic expectations and to plan the medical care for the years after TERPT, the long term outcome is of great importance. Aim: To collect information on the long term outcome reported after one stage TERPT procedure for HD in children 0 - 15 years. Method: A literature review on the outcome of planned TERPT from 2005 through 2012 was carried out. Information was collected on the number of daily stools a few months postoperatively, incontinence and constipation and the measures taken to deal with these. Results: The reports are few and prospective studies were missing. The results show an initial high frequency of daily stools, 12% had later abnormal stool patterns, 21% had fecal incontinence and 10% had problems with constipation. Conclusion: In order to compare the long term outcome, it would be desirable to have uniform regular reports on the daily frequency of passed stools, incontinence and constipation during the first years after TERPT. Such knowledge would be of importance for the information given to the guardians of children with HD preoperatively to TERPT and in the planning of the future care. The findings can, furthermore, provide a benchmark for the outcome from a single centre.

Comparative review of functional outcomes post surgery for Hirschsprung’s disease utilizing the paediatric incontinence and constipation scoring system

We aim to analyze differences in functional outcomes in children operated on for Hirschsprung's disease (HD) using the Paediatric incontinence/constipation scoring system (PICSS) validated in a normative group. A retrospective review of the records of all children operated on for HD between 1997 and 2010 was performed. Patients had either a Soave or transanal endorectal pull-through. Children with total colonic aganglionosis and Down's syndrome were excluded. Utilizing the PICSS children who scored below their age-specific lower limit 95 % confidence interval PICSS scores were considered to have incomplete continence or constipation. The rates of incomplete continence and constipation were compared between groups. Significance was set at p < 0.05. PICSS analysis could be completed in 51 (Soave 35, transanal 16). The median age at interview was 71 months (range 6-191 months). The rate of incomplete continence was 75 % (n = 21) and 71 % (n = 10) for the Soave and transanal groups, respectively (p = 1.00). The constipation rate was 34 % (n = 12) and 25 % (n = 4) for the Soave and transanal groups, respectively (p = 0.74). The overall rates of incomplete continence and constipation rates were 74 and 31 %, respectively, compared with 14 and 10 %, respectively, when rates were calculated by review of records. The PICSS is a sensitive tool for assessing functional outcome post HD surgery. The Soave and transanal procedures have similar functional outcomes.

Release of obstructing rectal cuff following transanal endorectal pullthrough for Hirschsprung’s disease

Obstructive problems secondary to a tight or a long rectal cuff following transanal endorectal pullthrough for Hirschsprung’s disease usually require redo surgery for release. Many approaches have been described. We describe the laparoscopic approach for the release of a tight or a long rectal cuff

Primary Neonatal Transanal Pull Through for Hirschprung’s Disease: Ten-Year Experience

Transanal endorectal pull through (TEPT) is a minimally invasive technique for the surgical management of Hirschsprung’s disease. This study reviewed the early and late complications with this technique when utilized to neonates since 1999. Methods: The records of the author’s neonatal cases undergoing TEPT from 1999 to 2011 were reviewed for early and late complications. Early complications investigated were: anastomotic dehiscence, perianal excoriations, pelvic infection, wound infection and enterocolitis. Late complications included: anastomotic stricture, enterocolitis, retraction of pull through segment, rectal prolapsed, soiling and constipation. Results: Sixty-three patients were included in the study of which 54 were evaluable for long-term complications. The average weight of the patients was 3 kg (range 0.8 kg – 3.5 kg). Mean post-natal age was 16 days (range 6-28days). There were 39 males and 24 females. The rates of early complications were: Anastomotic dehiscences (1.59%), wound infection (1.59%), enterocolitis (9.52%). The late complications were: Anastomotic stricture (3.70%), enterocolitis (7.41%), retracted pull-through segment (18.52%), rectal prolapse (3.70%) and perianal excoriations (9.26%). In 26 patients, 4 years old and above, the rate of voluntary bowel movement was 80.76%. Three patients, initially, had constipation with soiling. Conclusion: TEPT, as a definitive surgery for neonates with Hirschsprung disease, provided acceptable early and late complication rates in the personal experience of the author comparable with the experience of surgeons from other institutions. The procedure provided the patients less number of operations and admissions, and lesser costs. Only 3 patients required abdominal incision. This will encourage us to continue utilizing the technique in newborns. Key words: transanal endorectal pull through, Hirschprung’s disease

Transanal endorectal pull-through for Hirschsprung’s disease using long cuff dissection and short V-shaped partially resected cuff anastomosis: early and late outcomes

Transanal endorectal pull-through was described by De la Torre-Mondragon's technique. In the original transanal pull-through procedure, a long rectal muscular cuff was dissected and left for anocolic anastomosis, which would sometimes lead to postoperative obstructive symptoms and enterocolitis. While a modified short mucosal dissection may increase the risk of injury to pelvic and perirectal nerves and other structures when dissected on the outside of the rectum deep in the pelvis. We report early and late results of the modified transanal procedure for Hirschsprung's disease (HD) over 8 years. The clinical course of all children with aganglionic rectum or sigmoid colon receiving the modified transanal pull-through between May 2003 and April 2011 were reviewed. The main modifications were rectal mucosa dissection with a long cuff, coloanal anastomosis with a short cuff and a V-shaped partial resection in the posterior wall of the muscular cuff. Children with preliminary stoma or total colonic disease were excluded. Short- and long-term follow-up was obtained in 137 patients with HD operated upon by the same surgeon. The aganglionic segment was located in the rectum or sigmoid colon in all patients. The mean age at surgery was 165 ± 74 days. The mean operating time was 108 ± 38 min. Mean intra-operative blood loss was estimated to be 15 ± 10 ml. No patient required a blood transfusion. Mean postoperative hospital stay was 7 ± 2 days. Early postoperative complications included perianal excoriation in 38 patients (27.7 %), enterocolitis in two patients (1.4 %), and anastomotic leak in two patients (1.4 %). Late postoperative complications included perianal excoriation in 16 patients (11.7 %), anal stricture in two patients (1.4 %), constipation in four patients (2.8 %), enterocolitis in 10 patients (7.3 %), and soiling problems in six patients (4.4 %). Mean follow-up was 56 months (6 months-9 years). In patients older than 4 years, 85.4 % of them had excellent/good bowel function, 9.4 % had fair bowel function, and 5.2 % of patients had bad bowel function. Transanal endorectal pull-through with a long cuff dissection and a short V-shaped resected cuff anastomosis is a safe and effective procedure for HD. It reduced incidence of anastomotic stricture and constipation without an increased soiling incidence.

Fecal incontinence after single-stage Soave’s pull-through

Purpose To compare the postoperative fecal continence and bowel functions between patients who underwent a single stage - Soave’s endorectal pull through operations whether via the classic abdominal endorectal pull through approach (TAPT) or trans-anal endorectal pull through approach (TERPT). Patients and Methods This retrospective study was performed on 50 HD consecutive patients who had undergone surgery during a period of 5 years from January 2002 to January 2007. They were two equal groups; group I (n=25) including patients who underwent TAPT; group II (n=25) including patients who underwent TERPT. Demographic, clinical data, preoperative investigations, operative records, postoperative outcome were studied. Post operative fecal continence score rate (FCSR) was assessed in children over the age of 4 years. Moreover, those with poor FCSR were further investigated by magnetic resonance imaging (MRI). Electromyography (EMG) and anorecatal manometery (AM) were also used in follow-up. Results Twenty six patients (52%) had an excellent FCSR and eighteen patients (36%) showed good FCSR. However, 5 patients (10%) had a fair FCSR and only 1 patient (2%) suffered of a poor FCSR. There was no statistical significant difference between the two groups in neither anal manometry nor EMG. MRI did not show any abnormalities on pelvic floor and anal muscle complex on those patients who had fair or poor FCSR. Conclusion The incidence of fecal incontinence is very low after Soave’s pull-through operations whether TAPT or TERPT approaches with no statistical significant difference. Keywords: fecal continence, Hirschsprung’s disease, Soave’s operation, transanal endorectal pull-through

Literature Review of the Frequency of Reoperations after One Stage Transanal Endorectal Pull-Through Procedure for Hirschsprung’s Disease in Children

Background: Transanal endorectal one-stage pull-through (TERPT) procedure in children with Hirschsprung’s disease (HD) has gained worldwide acceptance. However surgical success is often reported separately, while the necessity for true reoperation is difficult to establish. Aim: To evaluate the incidence of reoperations following TERPT procedure. The findings will be important in counseling and planning childcare for HD patients as well as providing a benchmark for single centers clinical results. Methods: A literature review of reported TERPT operations on children with HD between 1998 through 2011 was performed. Only planned TERPT operation reports were included. Information was collected with particular emphasis on reoperations and their reasons. Results: Out of 26 published articles 23 were included, reporting on 836 children, female/male ratio: 1/3.3, undergoing the TERPT procedure as the only operative intervention with described postoperative courses. The children comprised neonates, 3 years of age (12%). The average follow up was 18.5 (6 - 38) months. The resected bowel length mean was 20.5 cm. Forty-one reoperations were reported (4.9%), including 24 laparotomies, 8 laparoscopies, 6 colostomies and ileostomies in 3 children. Only 2 re-do TERPT were reported (0.2%). Seven patients were considered TERPT failures (0.8%) with 5 requiring diverting colostomies and additional transabdominal pull-through operations. Two myectomies were performed (0.2%). One child with aganglionosis underwent a Duhamel pull through. Two (0.2%) had serious damage to the urinary tract also one child with a vas deferens lesion was reoperated. Two bowel obstructions required adhesiolysis. Eight anastomotic dehiscences (0.9%) required surgery after reparation. One prolapse of the pulled through colon was reported. Six patients (0.7%) suffered anastomotic leaks. Anastomotic strictures rate was 2.8%, all repaired with anal dilatation. Conclusion: The review supports the low incidence of reported reoperations for the TERPT procedure.

One-Stage Transanal Endorectal Pull-through for Treatment of Hirschsprung’s Disease in Adolescents and Adults

BackgroundOne-stage pull-through operation has become increasingly popular for treatment of Hirschsprung’s disease. The one-stage transanal pull-through was introduced in the late 1990s and has rapidly replaced traditional procedures in infants and young children in many surgical centers. ObjectiveThe aim of this study is to determine feasibility and safety of transanal primary repair in adolescent and adults. MethodsFifteen patients who underwent transanal endorectal pull-through were prospectively studied. All patients presented by chronic refractory constipation with the age ranged from 11 to 22 years. The patients were followed up for a mean of 18 months. Anal continence and postoperative complication were evaluated. ResultsIncomplete continence in the form of soiling occurred in four patients (26.6%) and improved gradually with conservative management. No patients suffered from complete incontinence. Anastomotic strictures occurred in two patients and were successfully treated with regular dilatations. One patient had continued outlet obstruction and revision was considered for him. One patient complicated with low perianal fistula which needed fistulectomy. There was no impotence in adults. ConclusionThese findings indicate that one-stage transanal endorectal pull-through operation in adolescent and adults is feasible and safe.

Re-operations for Hirschsprung’s Disease: Long-term Complications

In some patients with Hirschsprung's disease (HD), the initial surgical procedure fails, and the patients suffer from repeated or persistent symptoms. These patients complain of severe inflammation, intestinal obstruction, fecal or urinary incontinence, abdominal pain or dystrophy. However, little data has been published on the long-term follow-up results after re-operations for HD. We followed 8 cases between 2004 and 2006, of complicated HD requiring repeated surgery and recorded prior procedures, histological results, indications for re-operation, postoperative follow-up as well as long-term clinical outcomes including stool patterns, nutrition and micturition. The follow-up period ranged from 3.0 to 5.5 years (mean: 4.4 years). Indications for repeat procedures were as follows: blind rectal pouch after a Duhamel operation (n = 2), persistent aganglionosis (n = 4), long-segment stenosis (n = 1) after a Rehbein operation, and anal stenosis following TERPT (transanal endorectal pull-through) (n = 1). In one patient who had a Duhamel-Martin operation, extirpation of the rectum and a definitive terminal ileostomy was necessary. A Duhamel procedure was performed in five patients with a primary Rehbein and 1 patient with a primary Duhamel operation. Complete stool continence was achieved in 4 patients. Partial fecal incontinence persisted in one patient with associated trisomy 21. 1 patient with total colonic aganglionosis and 1 patient with a pelvic fistula and a previous subtotal colectomy reported soiling 1-2 times per week after a repeat operation. 4 patients in our series experienced postoperative complications following repeated surgery [perianal ulceration (n = 2), repeated botulinum toxin injection for sphincter achalasia (n = 1) and functionally impaired colonic transit without stenosis (n = 1)]. Micturition was normal in 7 patients, 1 patient with associated trisomy 21 was partially continent, and 1 patient reported infrequent urge incontinence. All patients improved after further surgical intervention. However, resolution of their symptoms was delayed and partial stool incontinence or soiling persisted in 3 patients. Most complications leading to repeat procedures are preventable, especially residual aganglionosis. Therefore, great efforts should be made to minimize complications when planning and performing the primary surgery.

Outcome Comparison Among Laparoscopic Duhamel, Laparotomic Duhamel, and Transanal Endorectal Pull-Through: A Single-Center, 18-Year Experience

Transanal endorectal pull-through has changed the treatment of Hirschsprung's disease (HD) in the past decade. The aim of the study was to compare outcomes, obtained in a single center, with laparotomic Duhamel (LTD), laparoscopic Duhamel (LSD), and laparoscopic-assisted transanal endorectal pull-through (LTEPT). We retrospectively reviewed the charts of all patients operated on for HD since 1992. Preoperative, operative, and postoperative data were collected to compare short- and long-term outcomes among the three groups. From 1992 to 2010, 70 children were treated for HD. Patients were divided into three groups based on the surgical technique used: 14 LTEPT, 32 LSD, and 24 LTD. Mean ages at surgery were 4.67, 14.61, and 13.28 months, respectively. Patients in the LTEPT group had significant shorter operating times (195 versus 257 versus 291 minutes, P=.03), earlier start of feeding (1.2 versus 3.1 versus 4.7 days, P<.01), and shorter length of hospital stay (4.4 versus 6.8 versus 9.7 days, P<.011). Overall complications rate was lower in the LTEPT (14%) than in the LSD (31.2%) and LTD (29.7%) groups. Postoperative enterocolitis incidence was 3%-4% in the Duhamel groups and none in LTEPT. Long-term outcome showed less constipation and better continence for age in the LTEPT group at the 1-year follow-up (P=.033). This study further supports technical advantages, lighter impact of the surgical procedure on infants, lower incidence of complications, and better long-term outcome of the transanal pull-through compared to the Duhamel approaches.

Residual aganglionosis after pull-through operation for Hirschsprung’s disease: a systematic review and meta-analysis

Most patients with Hirschsprung's disease (HD) have a satisfactory outcome after pull-through (PT) operation. However, some children continue to have persistent bowel symptoms after the initial operation and may require redo PT. Redo PT operation in HD is usually indicated for anastomotic strictures or residual aganglionosis (RA). We designed this meta-analysis to determine the incidence and outcome of RA among patients with HD following PT operation. A meta-analysis of redo PT operations for HD reported in the literature between 1985 and 2011 was performed. Detailed information was recorded in patients with RA and transition-zone bowel (TZB), including recurrent bowel problems, histological findings on repeat rectal biopsy, type of redo PT operation and outcome. Twenty-nine articles reported 555 patients with redo PT operations. 193 (34.8%) patients demonstrated abnormal histological findings on rectal biopsy with 144 patients showing RA and 49 patients showing TZB. These 193 patients presented with persistent constipation (n=135), recurrent enterocolitis (n=45) and abnormal histology of the pulled-through bowel (n=13). Mean age at redo PT was 4.4years (range 4months-17years). Redo procedures were Duhamel (n=57), transanal endorectal PT (n=40), Soave (n=35), Swenson (n=10), posterior sagittal approach (n=1) and not reported (n=50). Follow-up information after redo PT was available in 134 (69.4%) patients and not available in 59 patients. Of the 134 patients, 99 (73.9%) patients had normal bowel habits, 19 patients had persistent constipation/soiling and 16 patients had recurrent enterocolitis. This meta-analysis reveals that RA and TZB are the underlying causes of persistent bowel symptoms in one-third of all patients with HD requiring redo PT operation. Most patients have a satisfactory outcome after redo operation. Rectal biopsy should be performed in all patients with recurrent bowel problems after PT operation.

Sa1600 Colonoscopy As a New Tool in Determining the Transition Zone in Endoanal Pull-Through in Hirschsprung's Disease - Preliminary Results

Colonoscopy As a New Tool in Determining the Transition Zone in Endoanal Pull-Through in Hirschsprung’s Disease Preliminary Results Erika P. Ortolan, Pedro L. Lourencao, Gisele O. Orsi, Bonifacio K. Takegawa Surgery, Botucatu Medical School UNESP Univ Estadual Paulista, Botucatu, Brazil Background: Surgical treatment of Hirschsprung’s disease (HD) has changed in recent decades, with attempts to reduce extensive surgical dissections. Independent of the technique used, the surgery consists in colectomy of the aganglionic region, beyond the transition zone. Since De la Torre & Ortega first described the exclusive transanal endorectal pull-through (TEPT) technique in 1998, it has become the technique of choice, especially in short aganglionic segments. However, recognizing the transition zone during TEPT is very difficult, leading to a procedure involving several frozen section biopsies and that requires an experienced pathologist. Kohno et al (2005) described the use of colonoscopy in determining a landmark for the location of pull-through with relatively accuracy, denominated the “shorebreak” finding, based on the principle that while normal bowel exhibits peristaltic movements, aganglionic bowel does not. He developed a retrospective study comparing the shorebreak finding in colonoscopy marked with India ink with pathological findings in frozen section biopsies. Based on this single report, our group decided to test this new approach, in a prospective study. The purpose of this work was to report our preliminary results concerning the prospective use of colonoscopy as a new tool to determine the transition zone in HD. Patients and Methods: Colonoscopy was prospectively performed on four patients with HD diagnosis, previously confirmed by anorectal manometry, contrast enema and suction biopsies. The exam was performed just prior to TEPT, using the same anesthetic and bowel prep procedure. The area marked with India ink was chosen following observation of colon motility during colonoscopy, in which the absence of motility identified the beginning of the aganglionic area. For endoscopic tattooing, physiological saline was injected locally submucosally to raise the mucosa, followed by the injection of India ink. All the exams were performed by the same pediatric surgery team member (main author), who was unaware of the contrast enema results. Informed consent to perform the exam was obtained. Results: In all patients, the shorebreak finding marked with India ink was equivalent to the aganglionic segment length and transition zone in contrast enemas. The patients were submitted to TEPT beyond this marked area. The excised colon was opened and the transition zone was macroscopically equivalent to the marked area. These results were confirmed by anatomopathological findings using HE, acetylcholinesterase and calretinin stains. Conclusion: Given these preliminary results, it is our conclusion that endoscopic marking of the shorebreak finding provides an important new tool for determining the point of TEPT in the treatment of HD, especially in hospitals that cannot depend on intraoperative frozen sections or experienced pathologists.

Transanal Swenson′s operation for Recto-sigmoid Hirschsprung′s disease

Transanal Swenson's operation is a relatively new single-stage procedure for Hirschsprung's disease. The results of this procedure at our centre are presented. Seventeen patients of recto-sigmoid Hirschsprung's disease underwent single-stage transanal Swenson's procedure. The diagnosis was based on the evidence of a transition zone on barium enema examination. A full thickness incision was made on the rectal wall posteriorly, 0.5 cm above the dentate line. The mobilised segment was resected about 5 cm above the transition zone. Frozen sections were performed whenever the transition zone was not clearly seen intra-operatively. The operation was completed by full thickness colo-anal anastomosis. There were fourteen male and three female patients. The ages of the patients ranged from two months to eight years (median 14 months). The median hospital stay was four days (range four to seven days). Two patients required additional abdominal mobilisation. The anatomical transition zone as seen intra-operatively correlated with the pathological transition zone in all the cases. Two patients had episodes of post-operative enterocolitis and the other two patients developed stricture of the anastomosis. The follow-up period ranged from six to 45 months (Mean 35.4 months). Post-operative soiling was observed in all the patients and lasted from two to six weeks (Mean 3.4 weeks). There were no injuries to the surrounding structures. No patient had voiding disturbances and post-void residual urine was normal in all the patients. Initial increased frequency of bowel movements had settled to one to three per day. Transanal Swenson's pull through not only avoids laparotomy, but also the problems associated with the muscular cuff of transanal endorectal pull-through. The anatomical transition zone can be safely utilised to decide the resection limits. By a meticulous technique of dissection, injury to the surrounding structures can also be avoided.

Long-term outcome of children after single-stage transanal endorectal pull-through for Hirschsprung’s disease

single-stage transanal endorectal pull-through (TEPT) is a new technique for surgery of Hirschsprung's disease (HD). TEPT can be assisted by laparoscopy (laparoscopic assisted transanal pull-through, LATP) or with non-additional procedure (total transanal endorectal pull-through, TTEP). This study was undertaken to evaluate the long-term outcome of these approaches in children with HD. we retrospectively studied 131 patients (112 males and 19 females) aged 7 days to 14 years who underwent single-stage TEPT from October 2003 to July 2008. The medical records were reviewed for pre-, intra- and immediate post-operative complications. The data on stool pattern and complications were collected during the follow-up. Outcome was measured by continence evaluation score. no patients had intraoperative complications, but 5 had minor immediate postoperative complications. Late postoperative complications in 12 patients included enterocolitis (4 patients, one with severe enterocolitis died 7 months after operation), soiling (6) and constipation (2). There was a significantly higher frequency of stool in patients aged more than 36 months and those with a resected colon more than 30 cm (P<0.05). LATP showed significantly higher frequency of stool and soiling (P<0.05). Of the 54 patients who were older than 3 years at the time of follow-up, continence score was normal in 10, good in 39, fair in 3, and poor in 2. Seventy-seven patients achieved good bowel control in 12.8 ± 8.11 months after operation, 93.5 5% of whom within 24 months. Stool function was not improved in patients more than 30 months old after operation. the long-term outcome of single stage TEPT was excellent. There were few postoperative complications, and stool pattern improved gradually to an excellent level within 24 months. Internal plication can be a good option for reducing the dilated proximal colon.

Is the Rehbein procedure obsolete in the treatment of Hirschsprung’s disease?

PurposeAfter 25 years of practice and positive results of the Rehbein-procedure (RB) for children with Hirschsprung Disease (HD), we changed to the less invasive transanal endorectal pull through (TERPT). The aim of this study was to compare short- and mid-term complications of these two procedures in our patients with HD.MethodsRetrospective data of 50 HD patients were analyzed. Of these patients, 25 underwent RB (2000–2006) and in 25 the TERPT was performed (2005–2009). Medical records were reviewed to score complications and outcomes. Differences were analyzed using Chi-Square and Mann–Whitney U tests.ResultsAll RB patients (100%) were given a colostomy compared with four patients (16%) in the TERPT group (p < 0.001). The average age at surgery in the RB group was 191 days whereas this was 72 days in the TERPT group (p < 0.01). The mean length of time of surgery in the RB group (158 min) was not significantly different from that in the TERPT group (183 min). Ganglion cells were located in all specimens at the proximal end of the specimens. The median time to first feeding significantly decreased from 2 days (range 1–11) in the RB group to 1 day (range 1–3) in the TERPT group (p < 0.01). The median length of hospital stay decreased in the TERPT group (8 days) compared with the RB group (10 days) (p < 0.001). There was a significant reduction in postoperative obstructive symptoms during the first 6 months in the TERPT group (48%) compared with the RB group (84%) (p = 0.016). Postoperative enterocolitis decreased from 40% in the RB group to 24% in the TERPT group although this was not statistically significant.ConclusionsThe introduction of TERPT reduced the need for colostomies; it shortened days to first feeding after surgery and reduced hospital stay. It also improved short-term outcome with less obstructive symptoms. We recommend TERPT surgery as a first choice in children with HD. we consider the RB now to be obsolete.

Functional outcome after operation for Hirschsprung disease—transanal vs transabdominal approach

Background It has been hypothesized that the extensive transanal dissection in transanal endorectal pull-through (TEPT) for Hirschsprung disease (HD) can impair the anal sphincters in neonates and thereby cause incontinence. Theoretically, transabdominal endorectal pull-through might have less impact on the sphincters. The aim of this study was to compare functional outcome in HD patients operated with either TEPT or laparotomy-assisted endorectal pull-through (LEPT) with particular focus on soiling and fecal incontinence. Patients and Methods Anorectal function in 52 children older than 3 years is reported. The patients were operated for HD with either TEPT (n = 28) or LEPT (n = 24) and followed prospectively. Functional outcome was recorded by standardized interviews. The Krickenbeck criteria were used to classify voluntary bowel movements, soiling, and constipation. Results The median age at follow-up was 5.7 years (3.1-13.2) for TEPT and 10.1 years (7.7-16.2) for LEPT. Twenty-nine patients reported soiling at final follow-up. There was no difference in the rate of soiling between children operated with TEPT (54%) or LEPT (58%). Constipation was reported in 11 children (TEPT, 25%; LEPT, 17%). Conclusions The functional outcome and in particular the rate of soiling did not differ between patients operated with LEPT or TEPT.

Clinical experience with a new modified transanal endorectal pull-through for Hirschsprung’s disease

Single-stage transanal endorectal pull-through (TEPT) procedure is now widely used for rectosigmoid Hirschsprung's disease (HD). However, this procedure is associated with some common complications like stricture, enterocolitis, constipation, anastomotic dehiscence and perianal excoriation. The aim of this study was to evaluate the clinical outcomes of a modified TEPT operation in the management of rectosigmoid HD. 45 patients with rectosigmoid HD admitted between August, 2004 and July, 2008 were included in this study. Pre-operative barium enema was done in all of them. Patients in whom the transition zone was well delineated were included in the study. Frozen section biopsy was done to confirm the presence of ganglion cells in the pull-through bowel. All odd number patients were included in group A, where conventional TEPT procedure was performed. All even number patients and the last five patients of the series were in group B. In this group, a modified transanal endorectal procedure was done. The initial part of submucosal dissection and mobilization of aganglionic rectum was the same as in the conventional procedure. The anorectal mucosa was anastomosed end-to-side to the seromuscular coat of the ganglionic bowel. Mobilized bowel was divided at about 2 cm distal to the anastomosis. Six hitching stitches were applied from the free edge of the bowel to the perianal skin so that the anastomosis remains outside the anal verge. The distal redundant bowel was excised on eighth post-operative day. Pre-operative bowel preparation was done in all patients in group A. The bowel preparation was not mandatory in group B patients. Post-operative results of both these groups were compared and analyzed using the Mann-Whitney U test. Mean operative time in group A was 86 min (range 75-95 min) versus 90 min (range 70-100 min) in group B. Average length of the bowel resected was 20 cm (range 10-26 cm) in group A and 22 cm (12-40 cm) in group B. Post-operative feeding was started after 48 h in group A and after 6 h in group B. Average hospital stay was about 8 days in both the groups. Median follow-up was 36 months in group A (range 14-54 months) and 32 months (range 12-52 months) in group B. Anastomotic stricture or stenosis was noted in two patients in group A and none in group B (p < 0.01). Partial anastomotic dehiscence was noted in two patients in group A and none in group B (p < 0.01). Average bowel movement in group A was 6-8 per day at 1 month and 2-6 per day at 6 months. In group B, it was 8-10 at 1 month and 2-8 at 6 months. Cuff narrowing causing constipation was noted in two patients in group A and none in group B (p < 0.01). Enterocolitis following pull-through was noted in two patients in group A and three patients in group B. Four patients in group A and one patient in group B had post-operative constipation. All of them responded to bowel management program: only one of them (group A) required enema; soiling was noted in one patient each in both the groups. Modified TEPT procedure is associated with excellent clinical outcome with fewer complications, and permits early post-operative feeding. Operating time, hospital stay and post-operative bowel movement were comparable with the conventional technique.

Endorectal pull-through for Hirschsprung's disease—a multicenter, long-term comparison of results: transanal vs transabdominal approach

Purpose Previous studies have reported decreased continence in patients undergoing transanal endorectal pull-through (TERP) for Hirschsprung's disease compared to the older transabdominal approach (TAA). To address this, we examined long-term stooling outcomes in a large, multicenter cohort of patients undergoing either TERP or TAA. Methods Data were collected from 5 large pediatric institutions. Patient families were surveyed using a stooling score system (0-40, best to worst total score). Inclusion criteria included patients older than 3 years and those who had more than 6 months of recovery after pull-through. Those with total colonic aganglionosis were excluded. Statistical analysis included univariate and multivariate linear regression (significance, P < .05). Results Two hundred eighty-one patients underwent TERP (192) or TAA (89). Interviews were completed in 149 (104 [52%] TERP vs 45 [52%] TAA). The TAA group had a significantly greater number of daily bowel movements for each respective postoperative year and experienced more early complications (3% vs 1% with >1 complication; P = .061) and late complications (19% vs 4% with >1 complication; P < .001). Although the TAA group had a higher mean enterocolitis score (3.3 ± 0.4 vs 1.8 ± 0.2; P < .001), this was not borne out by multivariate regression analysis ( P = .276). Parental survey showed that there were no significant differences between procedures in mean total, continence, or stooling pattern scores. Conclusion Transanal endorectal pull-through was associated with fewer complications and fewer episodes of enterocolitis. In contrast to prior studies, TERP patients did not have a higher rate of incontinence. These results support use of TERP as an excellent surgical approach for children with Hirschsprung's disease.