Single-stage transanal endorectal pull-through for Hirschsprung's disease: perspective from a developing country

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

AIM

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.

METHODS

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.

RESULTS

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.

DISCUSSION

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.

Outcome analysis of single-stage transanal endorectal pull through in selected patients with hirschsprung disease

BACKGROUND

Hirschsprung disease is a notable cause of neonatal intestinal obstruction and constipation in older children. Transanal endorectal pull through (TEPT) is a newer technique of definitive management as against staged procedures. The aim of our study is to evaluate the feasibility and outcome of the procedure in selected children with Hirschsprung disease managed by this technique with review of the literature.

MATERIALS AND METHODS

Medical records of 12 children who underwent single-stage TEPT in a tertiary care centre over a period of 3 years from 2015 to 2018 were reviewed and retrospectively analysed on the basis of age, investigations, intraoperative parameters, complications, functional outcome and hospital stay.

RESULTS

The median age at surgery was 9 months. Nine patients were boys. The median weight of patients was 7.5 kg. The transition zone was observed at the level of the rectosigmoid in eight patients (66.6%) and sigmoid colon in four patients (33.3%). The mean length of muscle cuff was 3 cm, the mean length of resected bowel was 25 cm, the median operative time was 105 min and the mean hospital stay was 8 days. Perianal excoriation (n = 2) and enterocolitis (n = 1) were complications encountered postoperatively; however, no patient had cuff abscess, anastomotic leak or stricture. Stool frequency initially at 2 weeks was average of six to ten times a day, which gradually reduced to two to three times a day by 3 months postoperatively. None of the patients had faecal soiling or constipation on follow-up.

CONCLUSION

Single-stage transanal endorectal pull through is an effective technique in the management of Hirschsprung disease with minimal complications.

Laparoscopy-assisted Transanal Endorectal Pull-through for the Management of Hirschsprung's Disease in Nigeria: Report of Two Cases

Hirschsprung's disease is a relatively common disease in pediatric colorectal surgery. The treatment modalities have evolved from third-stage to single-stage in the past three decades. The single-stage procedure can be performed using the open, transanal or laparoscopy-assisted techniques. We use these cases to illustrate the first laparoscopically assisted procedures for Hirschsprung's disease in our center. The laparoscopic-assisted technique is described, and lessons in collaboration across institutions and within institutions are discussed.

Long-term outcomes of children with transanal endorectal pull-through and a review of the literature

INTRODUCTION

The transanal endorectal pull-through (TERPT) procedure, the latest advancement in the surgical treatment of Hirschsprung's disease, has replaced most other surgical techniques in the last decade.

PATIENTS AND METHODS

Between October 2002 and March 2014, a total of 22 patients diagnosed with Hirschsprung's disease underwent a one-stage TERPT operation.

RESULTS

Resected segments included the rectosigmoid (seven patients), the descending colon (10 patients), and the transverse colon (five patients). The minimum length of the resected segments was 15 cm and the maximum length was 65 cm. The mean length was 39.18 ± 12.05 cm. Following surgery, the start of oral ingestion was 1-8 days (mean 3 ± 1.69 days) and the hospital stay after the operation lasted 4-11 days (mean 7.04 ± 2.05 days). The mean follow-up period was 48 ± 6 months (range of 24-166 months). Out of 22 patients, three patients had an anal stricture, which responded to anal dilatations; three patients had an enterocolitis episode that required hospitalization; two patients experienced constipation; and two patients had incontinence/soiling.

CONCLUSION

Our data suggest that the TERPT operation can be safely performed in terms of long-term complications.

Economic Analysis of Children's Surgical Care in Low- and Middle-Income Countries: A Systematic Review and Analysis

Background

Understanding the economic value of health interventions is essential for policy makers to make informed resource allocation decisions. The objective of this systematic review was to summarize available information on the economic impact of children’s surgical care in low- and middle-income countries (LMICs).

Methods

We searched MEDLINE (Pubmed), Embase, and Web of Science for relevant articles published between Jan. 1996 and Jan. 2015. We summarized reported cost information for individual interventions by country, including all costs, disability weights, health outcome measurements (most commonly disability-adjusted life years [DALYs] averted) and cost-effectiveness ratios (CERs). We calculated median CER as well as societal economic benefits (using a human capital approach) by procedure group across all studies. The methodological quality of each article was assessed using the Drummond checklist and the overall quality of evidence was summarized using a scale adapted from the Agency for Healthcare Research and Quality.

Findings

We identified 86 articles that met inclusion criteria, spanning 36 groups of surgical interventions. The procedure group with the lowest median CER was inguinal hernia repair ($15/DALY). The procedure group with the highest median societal economic benefit was neurosurgical procedures ($58,977). We found a wide range of study quality, with only 35% of studies having a Drummond score ≥ 7.

Interpretation

Our findings show that many areas of children’s surgical care are extremely cost-effective in LMICs, provide substantial societal benefits, and are an appropriate target for enhanced investment. Several areas, including inguinal hernia repair, trichiasis surgery, cleft lip and palate repair, circumcision, congenital heart surgery and orthopedic procedures, should be considered “Essential Pediatric Surgical Procedures” as they offer considerable economic value. However, there are major gaps in existing research quality and methodology which limit our current understanding of the economic value of surgical care.

Laparoscopic-assisted transanal pull-through (LATP) versus complete transanal pull-through (CTP) in the surgical management of Hirschsprung's disease

BACKGROUND

It is unclear whether laparoscopic-assisted transanal pull-through (LATP) or complete transanal pull-through (CTP) is superior for the surgical management of Hirschsprung's disease. We compared outcomes between approaches.

METHODS

We retrospectively reviewed patients with Hirschsprung's disease who underwent LATP or CTP at our centre between 1995 and 2014. Patients were matched based on age, birth weight, and level of aganglionosis. A systematic literature review and meta-analysis were also performed.

RESULTS

From our data, LATP (n=24) took significantly longer than CTP (n=12; 3.9±1.1 vs. 2.6±0.6h, p=0.001). There was no difference in length of stay or incidence of postoperative complications. A literature search identified 17 published studies, of which 2 were comparative. Our pooled analysis of comparative studies including our results showed that operative time was significantly longer for the LATP group (OR 1.59, 95% CI 1.21-1.96, p<0.001). There was no significant difference in major complications (OR 1.75, 95% CI 0.76-4.04, p=0.19) or length of stay (OR 0.33, 95% CI -0.41 to 1.08, p=0.38).

CONCLUSION

Clinical outcomes are comparable between LATP and CTP. CTP offers shorter operative time without the need for laparoscopic instruments.

Laparoscopic and transanal pull-through for Hirschsprung disease

The surgical correction of Hirschsprung disease has undergone a complete evolution in the past decade. Refinements in the performance of both transanal and laparoscopic procedures have tremendously facilitated the advancement of these surgeries. This chapter presents the history of these procedures, and then discusses the various approaches and details of these techniques.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Transanal endorectal pull-through for Hirschsprung disease: technique, controversies, pearls, pitfalls, and an organized approach to the management of postoperative obstructive symptoms

The transanal endorectal pull-through emerged in the late 1990s as the most recent step in the evolution of the surgical correction of Hirschsprung disease. This operation provides the advantages of a minimal access approach with shorter hospital stay, shorter time to full feeding, less pain, and improved cosmesis with excellent outcomes. This article will review the technical principles of the transanal endorectal pull-through, and will address ongoing controversies in the application of this technique. We will also discuss an organized approach to the problem of obstructive symptoms that may affect a subgroup of patients after the transanal pull-through.