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Sun D, Zhang X, Xu Q, Li Y, Zhang Q, Wang D, Mu W, Hou P, Li A. Duhamel and transanal endorectal pull-throughs for Hirschsprung disease: a Bayesian network meta-analysis. BMC Surg 2024; 24:132. [PMID: 38702697 PMCID: PMC11067296 DOI: 10.1186/s12893-024-02416-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 04/17/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND To 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. METHODS PubMed, 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. RESULTS Sixty-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%). CONCLUSION LEPT 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.
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Affiliation(s)
- Dong Sun
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Xintao Zhang
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Qiongqian Xu
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Yang Li
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Qiangye Zhang
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Dongming Wang
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Weijing Mu
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Peimin Hou
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China
| | - Aiwu Li
- Department of Pediatric Surgery, Qilu Hospital, Shandong University, No.107 Wenhua West Road, Lixia District, Jinan, 250012, Shandong, China.
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Labib H, Roorda D, van der Voorn JP, Oosterlaan J, van Heurn LWE, Derikx JPM. The Prevalence and Clinical Impact of Transition Zone Anastomosis in Hirschsprung Disease: A Systematic Review and Meta-Analysis. Children (Basel) 2023; 10:1475. [PMID: 37761437 PMCID: PMC10528601 DOI: 10.3390/children10091475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Hirschsprung disease (HD) is characterized by absent neuronal innervation of the distal colonic bowel wall and is surgically treated by removing the affected bowel segment via pull-through surgery (PT). Incomplete removal of the affected segment is called transition zone anastomosis (TZA). The current systematic review aims to provide a comprehensive overview of the prevalence and clinical impact of TZA. METHODS Pubmed, Embase, Cinahl, and Web of Sciences were searched (last search: October 2020), and studies describing histopathological examination for TZA in patients with HD were included. Data were synthesized into aggregated Event Rates (ER) of TZA using random-effects meta-analysis. The clinical impact was defined in terms of obstructive defecation problems, enterocolitis, soiling, incontinence, and the need for additional surgical procedures. The quality of studies was assessed using the Newcastle-Ottawa Scale. KEY RESULTS This systematic review included 34 studies, representing 2207 patients. After excluding series composed of only patients undergoing redo PT, the prevalence was 9% (ER = 0.09, 95% CI = 0.05-0.14, p < 0.001, I2 = 86%). TZA occurred more often after operation techniques other than Duhamel (X2 = 19.21, p = <0.001). Patients with TZA often had obstructive defecation problems (62%), enterocolitis (38%), soiling (28%), and fecal incontinence (24%) in follow-up periods ranging from 6 months to 13 years. Patients with TZA more often had persistent obstructive symptoms (X2 = 7.26, p = 0.007). CONCLUSIONS AND INFERENCES TZA is associated with obstructive defecation problems and redo PT and is thus necessary to prevent.
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Affiliation(s)
- Hosnieya Labib
- Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.L.); (D.R.); (L.W.E.v.H.)
| | - Daniëlle Roorda
- Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.L.); (D.R.); (L.W.E.v.H.)
- Follow Me Program & Emma Neuroscience Group, Department of Pediatrics, Amsterdam Reproduction and Development, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - J. Patrick van der Voorn
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands;
| | - Jaap Oosterlaan
- Follow Me Program & Emma Neuroscience Group, Department of Pediatrics, Amsterdam Reproduction and Development, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
| | - L. W. Ernest van Heurn
- Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.L.); (D.R.); (L.W.E.v.H.)
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Joep P. M. Derikx
- Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.L.); (D.R.); (L.W.E.v.H.)
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Ambartsumyan L, Patel D, Kapavarapu P, Medina-Centeno RA, El-Chammas K, Khlevner J, Levitt M, Darbari A. Evaluation and Management of Postsurgical Patient With Hirschsprung Disease Neurogastroenterology & Motility Committee: Position Paper of North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN). J Pediatr Gastroenterol Nutr 2023; 76:533-546. [PMID: 36720091 DOI: 10.1097/mpg.0000000000003717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Children with Hirschsprung disease have postoperative long-term sequelae in defecation that contribute to morbidity and mortality and significantly impact their quality of life. Pediatric patients experience ongoing long-term defecation concerns, which can include fecal incontinence (FI) and postoperative obstructive symptoms, such as constipation and Hirschsprung-associated enterocolitis. The American Pediatric Surgical Association has developed guidelines for management of these postoperative obstructive symptoms and FI. However, the evaluation and management of patients with postoperative defecation problems varies among different pediatric gastroenterology centers. This position paper from the Neurogastroenterology & Motility Committee of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition reviews the current evidence and provides suggestions for the evaluation and management of postoperative patients with Hirschsprung disease who present with persistent defecation problems.
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Affiliation(s)
- Lusine Ambartsumyan
- From the Division of Gastroenterology and Nutrition, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Dhiren Patel
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children's Medical Center, Saint Louis University School of Medicine, St Louis, MO
| | - Prasanna Kapavarapu
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ricardo A Medina-Centeno
- the Division of Gastroenterology, Hepatology and Nutrition, Phoenix Children's, College of Medicine, University of Arizona, Tucson, AZ
| | - Khalil El-Chammas
- the Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Julie Khlevner
- the Division of Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Marc Levitt
- the Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC
| | - Anil Darbari
- the Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC
- the Division of Gastroenterology and Nutrition, Children's National Hospital, Washington, DC
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Celtik U, Yavuz I, Ergün O. Transanal endorectal or transabdominal pull-through for Hirschsprung's disease; which is better? A systematic review and meta-analysis. Pediatr Surg Int 2023; 39:89. [PMID: 36692536 DOI: 10.1007/s00383-023-05378-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2023] [Indexed: 01/25/2023]
Abstract
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.
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Ahmad H, Yacob D, Halleran DR, Gasior AC, Lorenzo CD, Wood RJ, Langer JC, Levitt MA. Evaluation and treatment of the post pull-through Hirschsprung patient who is not doing well; Update for 2022. Semin Pediatr Surg 2022; 31:151164. [PMID: 35690463 DOI: 10.1016/j.sempedsurg.2022.151164] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
After operative intervention for Hirschsprung disease (HD) a child should thrive, be fecally continent, and avoid recurrent episodes of abdominal distention and enterocolitis. This is unfortunately not the case for a significant number of patients who struggle following their pull-through procedure. Many clinicians are puzzled by these outcomes as they can occur in patients who they believe have had a technically satisfactory described operation. This review presents an organized approach to the evaluation and treatment of the post HD pull-through patient who is not doing well. Patients with HD who have problems after their initial operation can have: (1) fecal incontinence, (2) obstructive symptoms, and (3) recurrent episodes of enterocolitis (a more severe subset of obstructive symptoms). After employing a systematic diagnostic approach, successful treatments can be implemented in almost every case. Patients may need medical management (behavioral interventions, dietary changes, laxatives, or mechanical emptying of the colon), a reoperation when a specific anatomic or pathologic cause is identified, or botulinum toxin when non-relaxing sphincters are the cause of the obstructive symptoms or recurrent enterocolitis.
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Affiliation(s)
- Hira Ahmad
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, United States
| | - Desale Yacob
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, OH, United States; Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, United States
| | - Devin R Halleran
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Alessandra C Gasior
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Carlo Di Lorenzo
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, OH, United States; Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, United States
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Department of Surgery, University of Toronto, Hospital for Sick Children, Toronto, Canada
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, DC, United States.
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Ahmad H, Levitt MA, Yacob D, Halleran DR, Gasior AC, Di Lorenzo C, Wood RJ, Langer JC. Evaluation and Management of Persistent Problems After Surgery for Hirschsprung Disease in a Child. Curr Gastroenterol Rep 2021; 23:18. [PMID: 34633517 DOI: 10.1007/s11894-021-00819-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Ideally, after operative intervention, a child born with Hirschsprung disease (HD) should thrive, achieve fecal continence, and avoid recurrent episodes of abdominal distention and enterocolitis. However, a significant number of patients continue to struggle following their pull-through procedure. The purpose of this review is to present an organized and practical approach to the evaluation and management of the symptomatic patient post pull-through operation for HD. RECENT FINDINGS Children diagnosed with HD who are not doing well after their initial operation can be categorized in three distinct groups: (1) those that have fecal incontinence, (2) those with obstructive symptoms, and (3) those with recurrent episodes of enterocolitis. It is important to have a systematic diagnostic approach for these patients based on a comprehensive protocol. All three of these patient groups can be treated with a combination of either medical management, reoperation when a specific anatomic or pathologic etiology is identified, or botulinum toxin for non-relaxing sphincters contributing to the obstructive symptoms or recurrent enterocolitis. For patients not doing well after their initial pull-through, a systematic workup should be employed to determine the etiology. Once identified, a multidisciplinary and organized approach to management of the symptomatic patients can alleviate most post pull-through symptoms.
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Affiliation(s)
- Hira Ahmad
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marc A Levitt
- Children's National Colorectal Center, Division of Colorectal and Pelvic Reconstructive Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Desale Yacob
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Devin R Halleran
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Alessandra C Gasior
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Colorectal Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Carlo Di Lorenzo
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstruction Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Canada.
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Demehri FR, Dickie BH. Reoperative techniques and management in Hirschsprung disease: a narrative review. Transl Gastroenterol Hepatol 2021; 6:42. [PMID: 34423163 DOI: 10.21037/tgh-20-224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/12/2020] [Indexed: 11/06/2022] Open
Abstract
The majority of children who undergo operative management for Hirschsprung disease have favorable results. A subset of patients, however, have long-term dysfunctional stooling, characterized by either frequent soiling or obstructive symptoms. The evaluation and management of a child with poor function after pull-through for Hirschsprung disease should be conducted by an experienced multidisciplinary team. A systematic workup is focused on detecting pathologic and anatomic causes of pull-through dysfunction. This includes an exam under anesthesia, pathologic confirmation including a repeat biopsy, and a contrast enema, with additional studies depending on the suspected etiology. Obstructive symptoms may be due to technique-specific types of mechanical obstruction, histopathologic obstruction, or dysmotility-each of which may benefit from reoperative surgery. The causes of soiling symptoms include loss of the dentate line and damage to the anal sphincter, which generally do not benefit from revision of the pull-through, and pseudo-incontinence, which may reveal underlying obstruction. A thorough understanding of the types of complications associated with various pull-through techniques aids in the evaluation of a child with postoperative dysfunction. Treatment is specifically tailored to the patient, guided by the etiology of the patient's symptoms, with options ranging from bowel management to redo pull-through procedure. This review details the workup and management of patients with complications after pull-through, with a focus on the perioperative management and technical considerations for those who require reoperation.
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Affiliation(s)
- Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
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Mohamed W, Elsawaf MI, Shalaby AI, Arafat AE, Marei MM, Aboulfadl MH, Kaddah SN, El Tagy GH, Bahaaeldin KHK. Optimism for the Single-stage Transanal Swenson in Neonates. J Indian Assoc Pediatr Surg 2021; 26:16-22. [PMID: 33953507 PMCID: PMC8074829 DOI: 10.4103/jiaps.jiaps_187_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/14/2019] [Accepted: 05/08/2020] [Indexed: 11/04/2022] Open
Abstract
Background Hirschsprung's disease (HD) has been traditionally treated from infancy onward and different techniques have been used including Swenson, Soave, and Duhamel procedures. The purpose of this study was to evaluate the transanal Swenson's procedure for classical rectosigmoid HD in neonates. Patient and Methods This was a prospective study in which neonates diagnosed with HD were recruited from January 2017 to December 2018. Cases with a transition zone proximal to the midsigmoid were excluded. All patients underwent a transanal Swenson's procedure in the neonatal period using a unified protocol. Intraoperative course and postoperative outcomes such as leak, pelvic abscess, soiling, perianal excoriation, stricture, enterocolitis, and constipation were evaluated and all patients were followed for at least 6 months. Results Twenty-three patients (17 males and 6 females) underwent transanal Swenson's procedure. The mean age was 22 ± 5.7 days. Follow-up ranged from 6 to 30 months. No anastomotic leak, retraction, or prolapse was reported. Mild perianal excoriations occurred early in 9 (39%) cases and all responded to medical treatment and disappeared before 2 months postoperatively. Stricture occurred in 2 (8%) patients, enterocolitis in 3 (13%), and constipation in 3 (13%). Conclusion Transanal Swenson's procedure is feasible and can be performed safely in neonates with rectosigmoid HD with good short-term outcomes. Proper patient selection and standard protocol following fine procedural hall-marks and details are keys for optimal results and patient satisfaction.
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Affiliation(s)
- Wesam Mohamed
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | | | - Aly I Shalaby
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Ahmed E Arafat
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Mahmoud M Marei
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Mohamed H Aboulfadl
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Sherif N Kaddah
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Gamal H El Tagy
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
| | - Khaled H K Bahaaeldin
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
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9
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Apte A, McKenna E, Levitt MA. Image of the Month: Enterocolitis Following a Pull-through for Total Colonic Hirschsprung Disease in a 2-Year-Old Boy. European J Pediatr Surg Rep 2021; 8:e102-e104. [PMID: 33437565 PMCID: PMC7796827 DOI: 10.1055/s-0040-1721050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/18/2020] [Indexed: 12/04/2022] Open
Abstract
We present a case of a 2-year-old boy with total colonic Hirschsprung disease (HD) who underwent an ileostomy as a newborn, and then colectomy and pull-through at 10 months of age. Since then he has presented four times with enterocolitis. The case is presented with a focus on evaluating patients with HD who present with obstructive symptoms following corrective surgery. A key image is presented along with questions formatted as a quiz to guide readers through critically evaluating the case.
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Affiliation(s)
- Anisha Apte
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
| | - Elise McKenna
- Department of General and Thoracic Surgery, Children's National Medical Center, Washington, District of Columbia, United States
| | - Marc A Levitt
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States.,Department of General and Thoracic Surgery, Children's National Medical Center, Washington, District of Columbia, United States.,Division of Colorectal and Pelvic Reconstruction Surgery, Children's National Medical Center, Washington, District of Columbia, United States
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Yang J, Zhu T, Wu X, Wei M, Wang G, Feng J. Colonoscopic Diagnosis of Postoperative Gastrointestinal Bleeding in Patients With Hirschsprung's Disease. Front Pediatr 2021; 9:672767. [PMID: 34262888 PMCID: PMC8273172 DOI: 10.3389/fped.2021.672767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/04/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: Postoperative lower gastrointestinal bleeding in children with Hirschsprung's Disease (HSCR) is a non-specific symptom, which may be caused by various etiologies. Our current study aims to utilize colonoscopy to diagnose the causes of postoperative hematochezia and to analyze its feasibility, accuracy, and safety. Methods: Twenty-four patients with HSCR with postoperative lower gastrointestinal bleeding or occult blood in the stool were enrolled in this study. The postoperative onset duration, age at examination, accompanied anomalies were recorded. After bowel preparation, all patients underwent colonoscopy. According to visual findings, mucosal biopsy was performed, followed by pathological diagnosis. Further treatment was determined according to the visual findings and pathological diagnosis. All patients were followed up for 6 months including therapeutic outcomes and recurrence of symptoms. Results: The mean onset duration was (221.3 ± 216.8) days postoperatively (ranging from 25 to 768 days). The mean age at examination was (41.0 ± 29.4) months. There was no significant difference in the onset days among each group (all, p > 0.05). Based on visual and pathological findings, there were 11 cases of HSCR associated enterocolitis (HAEC), 4 cases of anastomotic leakage, 7 cases of anastomotic inflammation, 1 case of juvenile polyp, and 1 case of inflammatory pseudopolyp. Intraluminal saline irrigation, thrombin treatment or colorectal polyp electrocision was performed according to intraoperative diagnosis. Patients with HEAC and anastomotic inflammation underwent antibiotics therapy and colorectal irrigation. Patients with leakage underwent reoperation. The highest incidence of accompanied symptoms of diarrhea existed in HEAC group (p = 0.02) and fever in leakage group (p = 0.02), respectively. No perforation or aggravated bleeding occurs in any patients. All patients gained uneventful recovery during follow-up period. Conclusions: Colonoscopy is a safe, accurate and timely examination for HSCR patients with postoperative lower gastrointestinal bleeding. The visual findings and biopsy may provide accurate diagnosis and guide treatment for this subset of patients.
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Affiliation(s)
- Jixin Yang
- Department of Pediatric Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Tianqi Zhu
- Department of Pediatric Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojuan Wu
- Department of Pediatric Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Mingfa Wei
- Department of Pediatric Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Guo Wang
- Department of Pediatric Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
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Yan BL, Bi LW, Yang QY, Wu XS, Cui HL. Transanal endorectal pull-through procedure versus transabdominal surgery for Hirschsprung disease: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e16777. [PMID: 31393401 PMCID: PMC6709203 DOI: 10.1097/md.0000000000016777] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To analyze the clinical results of transanal endorectal pull-through (TERPT) and transabdominal approach (TAB) in the treatment of Hirschsprung disease. METHODS We searched all publications in the PubMed, MEDLINE, EMBASE, and Cochrane library databases between January 2003 and November 2018. The study included randomized controlled trials (RCTs) and observational clinical studies (OCSs), to compare the surgery duration, length of postoperative hospital stay, incidence of postoperative incontinence/soiling, constipation, and enterocolitis between the TERPT and TAB groups. Mantel-Haenszel method was used for continuous variables, the combined odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous variables were used. RESULTS In the 87 studies, we include 1 case of RCTs and 9 cases of OCSs. Including 392 cases of TERPT and 332 cases of TAB groups. TERPT has a short postoperative hospitalization [mean difference (MD) = -6.74 day; 95% CIs; -13.26 to -0.23; P = .04], and a low incidence of postoperative incontinence (ORs = 0.54; 95% CIs, 0.35-0.83; P = .006) and constipation (ORs = 0.50; 95% CIs, 0.28-0.90; P = .02). There was no difference in duration of surgery (MD = -30.59 min; 95% CIs, -98.01-36.83; P = .37) and incidence of postoperative enterocolitis (ORs = 0.78; 95% CIs, 0.53-1.17; P = .23). CONCLUSION TERPT is superior to TAB in terms of hospitalization time, postoperative incontinence, and constipation. However, there are still a large number of RCTs to verify, and more trials are expected to be testified in the future.
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Affiliation(s)
- Bei-lei Yan
- Department of the Graduate School, Tianjin Medical University
| | - Le-wee Bi
- Department of the Graduate School, Tianjin Medical University
| | - Qian-yu Yang
- Department of the Graduate School, Tianjin Medical University
| | | | - Hua-lei Cui
- Department of General Surgery, Tianjin Children's Hospital, Tianjin, China
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Sun S, Chen G, Zheng S, Dong K, Xiao X. Usefulness of posterior sagittal anorectoplasty for redo pull-through in complicated and recurrent Hirschsprung disease: Experience with a single surgical group. J Pediatr Surg 2017; 52:458-462. [PMID: 27712891 DOI: 10.1016/j.jpedsurg.2016.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/09/2016] [Accepted: 08/22/2016] [Indexed: 11/25/2022]
Abstract
AIM To retrospectively examine 12 patients with Hirschsprung disease (HD) who underwent posterior sagittal anorectoplasty (PSARP) for various complications. METHODS This study included patients with HD who underwent redo pull-through (PT) via PSARP at our institute between 2005 and 2014. The type of initial procedure, clinical presentations, indications, and functional results were analyzed. Postoperative excretory function was assessed using the Krickenbeck classification. RESULTS The study group comprised 9 boys and 3 girls (total, 12). Five patients were diagnosed with rectosigmoid aganglionosis, 5 with long segment aganglionosis, and 2 with total colonic aganglionosis. The primary operations performed on these patients included the Soave, Duhamel, Swenson, Rehbein, and Ikeda-Soper procedures. The interval between the primary operations and reoperation ranged from 5months to 8years (median, 3years). The indications for PSARP were rectocutaneous fistulae (6 cases), frozen pelvis (5 cases), severe anastomotic stricture (3 cases), rectovaginal fistulae (2 cases), and hemorrhagic proctitis with an inflammatory polyp (1 case). All fistulae were repaired using PSARP; only one rectocutaneous fistula recurred and required two additional surgeries. Stricture and hemorrhagic proctitis were cured in all involved cases. Nine patients were followed up for 8months to 10years after PSARP surgery (average, 5.1years). All 9 patients had voluntary bowel movements within 6months after the last PSARP and stoma closure: 3 had normal bowel movement, while 6 had varying degrees of soiling, depending on the length of residual colon. None complained of constipation. CONCLUSION PSARP is useful for treating severe complications of failed PT in HD. Complex and recurrent rectocutaneous fistulae and frozen pelvis are the main indications for PSARP, while soiling is the most common surgical complication.
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Affiliation(s)
- Song Sun
- Department of Surgery, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Gong Chen
- Department of Surgery, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Shan Zheng
- Department of Surgery, Children's Hospital of Fudan University, Shanghai 201102, China.
| | - Kuiran Dong
- Department of Surgery, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Xianmin Xiao
- Department of Surgery, Children's Hospital of Fudan University, Shanghai 201102, China
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Abstract
Colorectal pediatric surgery is a diverse field that encompasses many different procedures. The pullthrough for Hirschsprung disease, the posterior sagittal anorectoplasty for anorectal malformations including complex cloaca reconstructions and the ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis present some of the most technically challenging procedures pediatric surgeons undertake. Many children prevail successfully following these surgical interventions, however, a small number of patients suffer from complications following these procedures. Anticipated postoperative problems are discussed along with medical and surgical strategies for managing these complications.
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Affiliation(s)
- Jason S Frischer
- Colorectal Center for Children, Division of Pediatric General & Thoracic Surgery, Cincinnati Children׳s Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Ave, MLC-2023, Cincinnati, Ohio 45229.
| | - Beth Rymeski
- Colorectal Center for Children, Division of Pediatric General & Thoracic Surgery, Cincinnati Children׳s Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Ave, MLC-2023, Cincinnati, Ohio 45229
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Arts E, Botden SMBI, Lacher M, Sloots P, Stanton MP, Sugarman I, Wester T, de Blaauw I. Duhamel versus transanal endorectal pull through (TERPT) for the surgical treatment of Hirschsprung's disease. Tech Coloproctol 2016; 20:677-82. [PMID: 27628197 PMCID: PMC5040736 DOI: 10.1007/s10151-016-1524-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/06/2016] [Indexed: 02/06/2023]
Abstract
For the surgical treatment of Hirschsprung's disease, several surgical techniques are used to resect the distal aganglionic colon. Two frequently used techniques are the Duhamel procedure and the transanal endorectal pull-through procedure. During the '8th Pediatric Colorectal Course' in Nijmegen, November 2015, a workshop was organized to share experiences of both techniques by several experts in the field and to discuss (long term) outcomes. Specifically, the objective of the meeting was to discuss the main controversies in relation to the technical execution of both procedures in order to make an initial assessment of the limitations of available evidence for clinical decision-making and to formulate a set of preliminary recommendations for current clinical care and future research.
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Affiliation(s)
- E Arts
- Department of Surgery, Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - S M B I Botden
- Department of Surgery, Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - M Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
| | - P Sloots
- Department of Pediatric Surgery, ErasmusMC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M P Stanton
- Department of Pediatric Surgery, University Hospital - Southampton General Hospital, Southampton, UK
| | - I Sugarman
- Department of Pediatric Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - T Wester
- Department of Pediatric Surgery, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - I de Blaauw
- Department of Surgery, Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands.
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Abstract
Hirschsprung disease and Anorectal Malformations are congenital disorders presenting in neonates with distal intestinal obstruction. Hirschsprung disease is associated with a functional distal bowel obstruction resulting from the abnormal development of the enteric nervous system and ensuing aganglionosis of the distal gut. Anorectal Malformations comprise a spectrum of anatomical anomalies causing a mechanical bowel obstruction. Both conditions are frequently associated with congenital abnormalities/syndromes, which require careful assessment and evaluation. Surgical intervention is usually required for both conditions with careful preparation and meticulous technique. Long-term follow-up allows early identification and treatment of potentially debilitating symptoms, which include faecal incontinence.
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Podevin G. Redo Hirschsprung : un challenge. Arch Pediatr 2014. [DOI: 10.1016/s0929-693x(14)71436-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Levitt MA, Hamrick MC, Eradi B, Bischoff A, Hall J, Peña A. Transanal, full-thickness, Swenson-like approach for Hirschsprung disease. J Pediatr Surg 2013; 48:2289-95. [PMID: 24210201 DOI: 10.1016/j.jpedsurg.2013.03.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 03/01/2013] [Accepted: 03/01/2013] [Indexed: 12/14/2022]
Abstract
PURPOSE Swenson's procedure for Hirschsprung disease (HD) was thought to disturb fecal, urinary, and ejaculatory functions leading to other approaches including the Soave and Duhamel techniques. Given our Center's experience with a full-thickness rectal dissection for anorectal malformations, and using the new transanal concept, we chose to apply these ideas to the primary treatment of HD, and describe technical aspects and impact on fecal, urinary, and sexual function. METHODS We reviewed our series of HD patients who underwent a transanal, Swenson-like rectosigmoid dissection, assessing for postoperative stricture, anastomotic leak, enterocolitis, and long-term results for bowel, urinary, and sexual function. RESULTS Of 67 patients, 28 had a transanal resection, 5 had transanal plus laparoscopy, and 34 had transanal plus laparotomy, of those, 28 patients had a leveling colostomy prior to referral. The average length of resection was 27 cm ± 12.7 cm. Mean follow-up was 17.2 months (range 1-96 months). 44 patients were at least three years old at follow-up and were assessed for urinary and fecal continence; all (100%) had voluntary bowel movements and urinary continence. Enterocolitis occurred in 9 patients (14%) and constipation (requiring laxatives) occurred in 21 (32%). Of 24 male patients, 21 (88%) reported the occurrence of spontaneous erections post-operatively. CONCLUSION Our data support the fact that a modification of Swenson's original transabdominal dissection concept using the recently described transanal approach is an excellent technique for Hirschsprung, and produces excellent long-term outcomes for fecal and urinary continence, and seems to preserve erectile function.
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Affiliation(s)
- Marc A Levitt
- Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Park JS, Park TJ, Hwa JS, Seo JH, Park CH, Youn HS. Acute Urinary Retention in a 47-month-old Girl Caused by the Giant Fecaloma. Pediatr Gastroenterol Hepatol Nutr 2013; 16:200-5. [PMID: 24224155 PMCID: PMC3819695 DOI: 10.5223/pghn.2013.16.3.200] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 09/06/2013] [Accepted: 09/15/2013] [Indexed: 11/14/2022] Open
Abstract
We present a case of a 47-month-old female suffering from acute urinary bladder neck obstruction and bilateral hydronephrosis secondary to a fecaloma. Fecaloma is defined as an accumulation of inspissated feces in the colon or rectum giving the appearance of an abdominal mass. A fecaloma can be developed by diverse causes and the causes of the fecaloma in this case were septum reformation after the Duhamel procedure and long-term constipation. Chronic constipation is very common at outpatient clinic. However, acute urinary retention and voiding difficulty caused by fecaloma in the giant Duhamel pouch has never been reported in Korea. We would like to present our case with acute urinary retention due to a fecaloma and suggest that fecaloma might be considered as one of the causes for acute urinary retention, especially in cases with previous Duhamel operation for repair of Hischsprung disease.
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Affiliation(s)
- Ji Sook Park
- Department of Pediatrics, Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
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Chen Y, Nah SA, Laksmi NK, Ong CC, Chua JH, Jacobsen A, Low Y. Transanal endorectal pull-through versus transabdominal approach for Hirschsprung's disease: a systematic review and meta-analysis. J Pediatr Surg 2013; 48:642-51. [PMID: 23480925 DOI: 10.1016/j.jpedsurg.2012.12.036] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 11/11/2012] [Accepted: 12/08/2012] [Indexed: 12/16/2022]
Abstract
AIM Transanal endorectal pull-through (TERPT) has become popular for single-stage treatment of Hirschsprung's disease. The benefits of TERPT over the conventional transabdominal approach (TAB) are still unclear. We performed a comprehensive meta-analysis comparing the clinical outcomes of TERPT and TAB. METHODS Original articles published from 1998 to 2012 were searched from Medline, Embase, and Cochrane databases. Randomized controlled trials (RCT) and observational clinical studies (OCS) comparing TERPT and TAB were included. Outcomes evaluated included operative time, hospital stay and incidence of postoperative incontinence/soiling, constipation and enterocolitis. Pooled odds ratios (OR) were calculated for dichotomous variables; pooled mean differences (MD) were measured for continuous variables. RESULTS Of 93 studies, 1 RCT and 11 OCS were included, comprising 444 cases of TERPT and 348 cases of TAB (215 Soave, 94 Duhamel, 24 Swenson, 15 Rehbein procedures). TERPT had shorter operative time (MD=-57.85 min; 95% confidence interval [CI], -83.11 to -32.60; P<0.00001) and hospital stay (MD=-7.06 days; 95% CI, -10.95 to -3.16; P=0.0004). TERPT had less postoperative incontinence/soiling (OR=0.58; 95% CI 0.37-0.90; P=0.01) and constipation (OR=0.49; 95% CI 0.30-0.81; P=0.005). There was no difference in incidence of postoperative enterocolitis. CONCLUSION TERPT is superior to TAB in operative time, hospital stay, postoperative incontinence and constipation. However, more randomized controlled trials are necessary to verify the benefit of TERPT for Hirschsprung's disease.
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