Annals of Pediatric Surgery

Vol 5, No 1, January 2009, PP 27-30

Original Article

Hirschsprung's Disease: Early and Late Outcome after Correction by Transanal

Pull-through
Amin M. Saleh, Hassan A., Wesam A, Amr A.
Department of Surgery, Faculty of medicine, Zagazig University

Background/purpose: Transanal pull-through for patients with Hirschsprung's disease is gaining popularity in many
pediatric surgical centers. The aim of this study was to analyze the early and latepostoperative rsults.
Patients and methods: All children with Hirschsprung's disease, who were surgically treated by transanal pull- through
at Zagazig University Hospital between 2002 and 2006 were included in this study. Preoperative variables were
enterocolitis, bowel obstruction, age at surgery, and number of operations performed. Outcome measures included
intraoperative or postoperative complications, postoperative enterocolitis, bowel functional results.
Results: Forty children with Hirschsprung's disease had been treated by trans-anal pull- through. Their ages ranged from 6
months to 2 years.The minimum follow up period was 18 months. Twenty five patients (62.5%) experienced at least one or
more of the following complications : sphincter spasm (n=2, 5%); cuff abscess (n=2, 5%) , enterocolitis (n=8, 20%) , perineal
excoriation (n=10, 25%), increased stool frequency (n= 14, 35%), anal stenosis (n=3, 7.5%), constipation (n=10, 25%),
Fecal incontinence (n=3, 7.5%). Fecal continence improved with time; four patients required redo pull- through
Conclusions: Both early and late outcomes of patients with Hirschsprung's disease treated by transanal pull- through are
acceptable. However, long term follow up are needed to detect and to treat potential complication or bowel dysfuction.
Key words: Hirschsprung's disease, trananal pull through, complications, enterocolitis

INTRODUCTION

he surgical correction of Hirschsprung's disease

(HD) is usually performed early in life. Several
operative procedures have proven effective. As the
population of surgically treated patients for HD has
grown older, the long term complications have also
been investigated.1 Both constipation and fecal
incontinence have been recognized as chronic
problems in a significant proportion of these patients.1

The purpose of this study was to analyze the early

and late outcome after trans-anal endorectal pullthrough for patients with Hirschsprung's disease, and
to tivestigate the relationship between increasing age
and both bowel function and quality of life.

The transanal endorectal pull- through (TEPT)

approach represents a major revolution in treating
Hirschsprung's disease.2 This procedure can be
performed as primary pull- through as early as the
first week of life. 3

The current study included all children with

Hirschsprung's disease trated by transanal pullthrough at Zagazig University Hospital in the period
from 2002 to 2006, and follow up was performed till
2008.

PATIENTS AND METHODS

Correspondence to: Amin Saleh, MD, Department of Surgery, Faculty of Medicine, Zagazig University. E-mal:
aminsaleh65@yahoo.co.uk

Saleh A. et al
All patients had rectal biopsy verified Hirschsprung's
disease. The aganglionic segments were confined to
rectum and or sigmoid colon in all cases treated
entierly through transanal approach. Transanal pullthrough was performed by the technique described by
De la Torre. 2

fecal continence, and continence can be graded as

good (4-5 points), fair (2-3.5 points), and poor (0-1.5
points)

Data chart was designed to collect the following

information: (1) preoperative risk factors, (2) problems
encountered before surgery, (3) operative details
including the level of starting the submucosal
resection, length of seromuscular cuff, length of
excised segment, estimated blood loss and blood
transfusion, conversion to laparotomy and its cause,
and operative time, (4) early postoperative
complications particularly entercolitis, cuff abscess,
and anastomtic leak, (5) late postoperative
complications such as increased stool frequency,
anastomotic stricture, and enterocolitis. Clinical
outcome, assessed by interviews regarding stool
patterns including continence, frequency, and need
for laxatives or other medications.

Forty patients underwent transanal pull- through

procedure over a period of 4 years. Their
characteristics are shown in table 1.

Early anal dilatation started on the 7th postoperative

day in all children to relieves sphincter spasm, and to
avoid development of enterocolitis, and to keep the
coloanal anastomosis wide and patent. Dilatation
continued once daily up to 3 months.
Constipation scoring system by Agachan et al 4 was
validated using physiologic measurement of bowel
evacuation. Higher scores correspond to more severe
constipation.
Fecal continence was assessed according to the
established scoring system proposed by Templeton
and Ditesheim5,6, Higher scores correspond to better

RESULTS

Thirty patients (75%) underwent a primary transanal

pull-through and 10 (25%) underwent staged pullthrough. The minimum follow up period was 18
months and maximum was 30 months after surgery.
Postoperative complications occurred in 25 patients
(62.5%), Twenty five (62.5%) patients experienced at
least one or more of the following complications :
sphincter spasm (n=2, 5%), cuff abscess (n=2, 5%),
enterocolitis (n=8, 20%), perineal excoriation 10 (n=10,
25%), anal stenosis (n=3, 7.5%), constipation (n=10,
25%), fecal incontinence (n=3, 7.5%). Fecal continence
improved with time (Table 2).
Sixteen patients showed increased stool frequency, 10
of them developed severe perineal excoriations, their
ages were younger at time of pull- through.
Postoperative enterocolitis ocuured more frequently
in this group. Preoperative enterocolitis occurred in 20
patients (50%), 8 of them developed postoperative
enterocolitis. Another two died after developing
fulminant enterocolitis preoperatively and were not
included in this series. Constipation developed in 10
patients (25%); those patients were younger age at
operation. In those patients, a shorter segment of the
colon were removed during transanal pull- through.

Table I. Operative findings and managment of 40 patients:

Patients data

1-6 m

6-12m

1-3y

>3years

Total
N.

Preoperative enterocolitis managed conservativly

13

Preoperative enterocolitis required colostomy

Transition zone: Rectum

12

13

30

3
15

2
9

1
3

6
31

20

25

35

45

Rectosigmoid
Mid sigmiod
Length of cuff < 5cm
> 5cm
Length of excised colon (cm)

Annals of Pediatric Surgery

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Saleh A. et al
Table II Postoperative complications:

Complications
Sphincter spasm
Cuff abscess
Enterocolitis
Perineal excoriations
Increased stool frequency.
Anal stenosis
Constipation
Fecal incontinence

1-6
months
2
4
8
11
2
6
1

6-12
months
2
1
3
1
3
-

1-3
years
1
1
1
1
1

>3
years
1
1
1
1
1

No& % of
total
2( 5%)
2(5%)
8(20%)
10(25%)
16(40%)
3(7.5%)
10(25%)
3(7.5%)

DISCUSSION
Since the description of the transanal pull- through
procedure for Hirschsprung's disease by De la Torre
Mondragon and Ortega Salgado 2 , the approach has
become widely used by pediatric surgeons.3 The length
of aganglionic segment has a great impact on the
feasability of entirley transanal pullthrough approach3.
If the aganglionic segments extend beyond the sigmoid
colon, an assisted laproscopy mobilization or
abdominal mobilization of the colon becomes neessary.
Some authors reported that there is a correlation
between the length of excised segments of bowel and
the increased frequency of bowel movment and
perianal escoriation and the occurrence of fecal
incontinence.7,8 We noted that 20-25 cm of the colon
were excised in 30 patients, 8 patients of them
developed increased stool frequency, and 4 of them
developed perineal excoriation. In 10 patients 35-45cm
of the colon were excised, 8 patients of them showed
increased stool frequency and 6 developed perineal
excoriation.
Ten patients (25%) experienced constipation during
follow up periods, three of them showed stenosis at the
suture line and responded to frequent dilatations, four
equired redo transanal pull- through to excise more
length of the colon, the other 3 patients responded to
saline enemas and stimulants for intestinal motility.
Enterocolitis has been considered one of the main
problems in patients with HD both before and after
definitive treatment. The frequency of post operative
entercolitis in the current series is still less than reported
following other surgical approaches.9.10 The relative
low incidence of enterocolitis after TEPT in the current
series may be related in part to the short seromuscular
cuff, the low coloanal anastomosis, and our policy of
routine postoperative anal dilatation particularity in
neonates and infants.. We agre with finding in EPSA
29

study3 hat showed that postoperative routine anorectal

bouginage is an effective tool to prevent the occurrence
of anal stricture and to decrease both the frequency as
well as the severity of enterocolitis particularly in
neonates and young infants.
Several authors11,12 reported that preoperative
enterocolitis significantly increase the incidence of
postoperative enterocolitis. This has been attributed to
predisposing immunologic factors shared by patients of
Hirschsprung's disease, who seem to be prone to
develop enterocolitis both pre and postoperatively.
Furthermore, severe perineal excoriations are
presumably correlated to the chronic diarrhea
experienced in cases of entercolitis.13, 14 In this study, 20
patients developed preoperative enterocolitis, 8 of them
developed postoperative enterocolitis, 16 developed
postoperative diarrhea and 10 of them developed
perineal excoriations.
Sphincter spasm was noted in 2 patients (5%), those
patients showed delayed passage of stool and
abdominal distention for more than 24 hours after pullthrough. Akshay et al 9 reported 6.1% incidence of
sphincter spasm after transanal pull- through in
patients with Hirschsprung's disease.
Postoperative fecal continence improved with time,
only 3 (7.5%) patients developed incontinence, it was
not affected by the age at surgery, the level of lesion or
the length of the excised colon.

CONCLUSION
Transanal pull- through is both feasible and safe for the
management of patients with Hirschsprung's disease It
is associated with acceptable morbidity and mortality.
Preoperative enterocolitis increases the incidence of
Vol 5, No 1, January 2009

Saleh A. et al
postoperative diarrhea, enterocolits, and perineal
excoriation. Both the transitional zone and a part of the
dilated colon proximal to it should be excised to
decrease the incidence of postoperative constipation.

REFERENCES
1. Menezes M., Corbally M., Puri P. Long term results of bowel
function after treatment for hirschsprung disease :a 29 year review.
Pediatr Surg Int. 22:987-990, 2006
2. De la Torre-Mondragon L, Ortega-Salago JA. Transanal
endorectal pull-through for Hirschsprung disease. J Pediatr Surg.
33:1283-1286, 1998
3. Elhalaby E, Hashish A, Elbarbary MM, et al. Transanal OneStage Endorectal Pull-Through for Hirschsprungs Disease: A
Multicenter Study. J Pediatr Surg, 39:345-351, 2004
4. Agachan F, Chen T, Pfeifer J, et al. A constipation scoring
system to simplify evaluation and management of constipated
patients. Dis Colon Rectum. 39:681-685, 1996
5. Temleton JM, Ditesheim JA. High imperforate anus quantitative
results of long term fecal continence. J Pediatr Surg. 20:645-652,
1985

7. Ludman Spitz L, Tsuji H, et al. Hirschsprung disease: functional

and psychological follow up comparing total colonic and
rectosigmoid aganglionosis. Arch Dis Child. 86:348-351, 2002
8. Alessio P.P, Valerio G, Camilla G, et al. Hirschsprung disease:
do risk factors of poor surgical outcome exist? J Pediatr Surg.
43:612-619, 2008
9. Akshay P, Devendra KG, Vikal CS, et al. Analysis of problems,
complications, avoidance and management with transanal pullthrough for Hirschsprung disease.J Peditr Surg. 42:1869-1876, 2007
10. Elhalaby EA, Coran AG, Blane CE, et al. Enterocolitis associated
with
Hirschsprungs
disease:
A
clinical-radiological
characterization based on 168 patients. J Pediatr Surg 30:76-83, 1995
11. Gao Y, Li G, Zhang X, et al. Primary transanal
rectosigmodectomy for Hirschsprungs disease: Preliminary results
in the initial 33 cases. J Pediatr Surg 36:1816-1819, 2001
12. Fouquet V, De Lagausie P, Faure C, et al. Do prognostic factors
exist for total colonic aganglionosis with ileal involvement? J
Pediatr Surg. 37:71-75, 2002
13. Elhalaby EA, Teitelbaum DH, Coran AG, et al. Enterocolitis
associated with Hirschsprungs disease: A clinical histopathological
correlative study. J Pediatr Surg 30:1023-1027, 1995
14. Murphy F, Puri P. New insight into the pathogenesis of
Hirschsprung associated enterocolitis . Pedatr Surg Int. 21:773-779,
2005

6. Yanchar NL, Soucy P..Long term outcome after Hirschsprung

disease: patients' perspectives. J Pediatr Surg. 34:1152-1160, 1999

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