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ACTA SCIENTIFIC paediatrics
Volume 2 Issue 6 June 2019
One Stage Pull-Through Procedure for Hirschsprung’s Disease:
Trans-Anal or Trans-Abdominal? A Comparative Study
Ahmed Elrouby*, Saber Waheeb, Ahmed Khairi, Mohamed Abouheba and Karim Badr
Pediatric Surgery Department, Alexandria University, Egypt
*Corresponding Author: Ahmed Elrouby, Lecturer of Pediatric Surgery, Faculty of Medicine, Alexandria University, Egypt.
Research Article
Received: April 05, 2019; Published: May 20, 2019
Abstract
Keywords: Hirschsprung’s Disease; Trans-anal; Trans-abdominal; Complications
Aim: The aim of our work was to compare between one stage trans-anal endorectal Soave pull-through procedure and one stage
trans-abdominal Soave endorectal pull-through in the treatment of Hirschsprung’s disease in infants.
Methods: Our retrospective study included 248 patients of Hirschsprung’s disease. Group A include 166 patients treated by one
stage trans-anal pull through and Group B include 82 patients treated by one stage trans-abdominal pull through.
Results: The operative time, intraoperative bleeding, length of the resected segment, time to passage of stool, start of oral feeding
between the two approaches except wound infection and adhesive intestinal obstruction which develops only in group (B).
Conclusion: Trans-anal approach is superior to the trans-abdominal approach due to its simplicity, cost effectiveness and less surgical
morbidity. The operative technique can be easily educated and it’s suitable for classical uncomplicated rectosigmoid aganglionosis,
high effectiveness and promising results.
Introduction
Treatment of Hirschsprung’s disease has variable techniques
through different approaches. The main idea of such techniques
is the resection of the aganglionic segment with colo-anal
procedure in 1948 following a preliminary colostomy [1].
However, one stage pull-through without a preliminary
order to protect the patient against the morbidity of colostomy as
well as repeated surgeries [2].
A great achievement in the pull-trough procedure was described
by Georgeson., et al. in the 1990s when they performed trans-anal
mucosectomy in combination with laparoscopic bowel mobilization
and resection facilitating both the harvest of intraoperative biopsies
as well as minimizing the invasiveness of the procedure [3].
A milestone in the treatment of Hirschsprung’s disease was
described by de la Torre-Mondragon and Ortega in 1998 who
performed the whole pull-through procedure through trans-anal
approach [4]. This approach offers all the advantages of minimally
invasive surgery like better pain control, shorter hospital stay
and better cosmetic results as well as the advantage of potentially
minimizing intra-peritoneal contamination, adhesion formation
and limitation of the damage of the pelvic structures and hence
potentially better postoperative functional outcome [5,6].
Since the date at which the trans-anal approach had been
described it was widely used but without absence of complications
as massive stretching of the anal sphincter during tran-sanal
mobilization of the rectum and sigmoid colon which had made
a great concern about the long term functional results regarding
constipation, soiling and continence [7].
Citation: Ahmed Elrouby., et al. “One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study”.
Acta Scientific Paediatrics 2.6 (2019): 19-24.
One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study
So the aim of our work was to compare the results of one stage
trans-anal approach and the results of one stage trans-abdominal
pull through in the treatment of Hirschsprung’s disease in infancy.
Materials and Methods
Our retrospective study included 248 patients with
Hirschsprung’s disease who were diagnosed as having agangliono-
biopsy. All of the studied patients were operated at Alexandria
Pediatric Surgery Department from 2012 to 2016 with one stage
soave pull-through procedure either through trans-anal or trans-
abdominal approaches.
We excluded cases with previous colostomy, long segment
cases, cases with protective intraoperative stoma and cases
with trans-anal approach who required assisted laparotomy or
laparoscopy.
An informed consent was obtained from the parents or the
patients’ guardians and the patients were divided into two groups;
group A which included 166 patients who were treated by one
stage trans-anal Soave pull-through and group B which included
the remaining 82 patients who were treated by one stage trans-
abdominal Soave pull-through.
The records of the studied patients were retrospectively
reviewed and the gender, age at operation and age at follow up
were recorded. The operative details including the operative
time, intraoperative bleeding, length of resected segment, level
of transition zone and proximal margin of aganglionosis as seen
by histopathological examination were documented as well as
the postoperative details involving the duration of postoperative
nasogastric tube, the time to start oral feeding, time to passage
of stools and the length of hospital stay. Development of any
complications as wound infection, urethral injury, anastomotic
leakage, rectal prolapse, cuff infection and abscess formation,
enterocolitis, stricture formation, adhesive intestinal obstruction,
missed segment, constipation, incontinence and perianal
dermatitis were recorded. Postoperative anal dilatation using
Hegar dilators was started about 21 days after surgery and
continued every month until the anastomotic ring can no longer be
felt. These dilatations were carefully monitored and were usually
required for 2 to 3 months after surgery.
Statistical analysis of the data
Data were fed to the computer and analyzed using IBM SPSS
software package version 20.0. (Armonk, NY: IBM Corp) [8]
Qualitative data were described using number and percent.
Quantitative data were described using range (minimum and
maximum), mean, standard deviation
the obtained results was judged at the 5% level.
The used tests were
• Chi-square test: For categorical variables, to compare
between different groups
• Fisher’s Exact or Monte Carlo correction: Correction for
chi-square when more than 20% of the cells have expected
count less than 5.
Results and Discussion
Results
The highest incidence was in males in the two groups
accounting for 63% of patients of group A and 57% of patients of
χ2=0.6556, P=0.418109).
The age of the studied patients at operation was between 2
months and one year old in most of the studied patients (72% of
patients of group A and 67% of patients of group B). This difference
test, χ2= 0.7189, P=0.7189).
The operative time, intraoperative bleeding as well as the length
to have aganglionosis by postoperative biopsy with the level of the
transition zone being at the recto-sigmoid region in 119 patients
in group A (71.69%) and in 55 patients in group B (33.13%). On
the other hand the transition zone was at the sigmoid level in
47 patients of group A (28.31%) and in 27 patients of group B
(66.87%). There was no missed segment among all of the studied
patients. The difference in proximal level of aganglionosis was not
χ2=0.888, p =0.455).
20
Citation: Ahmed Elrouby., et al. “One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study”.
Acta Scientific Paediatrics 2.6 (2019): 19-24.
One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study
Postoperative analgesia was in the form of Acetaminophen in
days without the need for narcotics in group A. However, some of
the patients of group B required narcotics as pain killer.
The mean time for passage of stools in patients of group A was
1.3 ± 0.4 days being lesser than in patients of group B in which it
was 2.6 ± 0.3 days. Time to start oral feeding in group A was 1.5
± 1 days; being also lesser than in patients of group B in which it
was 3 ± 0.5 days. The total duration of hospital stay was about 2
days in group A and about 6 days in group B. Difference in time
to passage of stools, feeding tolerance and length of hospital stay
food tolerance with the resulting shorter hospital stay in group A
than in group B led to lesser cost in patients of group A (Table 2).
Postoperative
Group A
(n = 166)
Group B
(n = 82)
Test of
sig. p
NPO (days) 1.5 ± 0.5 2.5 ± 1 t=10.509*<0.001*
Pass stool (day) 1.3 ± 0.4 2.6 ± 0.3 t=26.025*<0.001*
Start oral (day) 1.5 ± 1 3 ± 0.5 t=12.806*<0.001*
Hospital stay
(days) 2 ± 1 5 ± 2.5 t=13.455*<0.001*
Table 2: Operative details and hospital stay
in the two studied groups.
Operative data Group A
(n=166)
Group B
(n=82)
Test of
sig. p
Operative time
(min.) 35 ± 10 65 ± 15 t=18.707*<0.001*
Blood loss(ml.) 12.5 ± 7.5 25 ± 15 t=8.758*<0.001*
Length of
resected
segment (cm)
12 ± 3.5 18 ± 5.5 t=10.426*<0.001*
Table 1: Difference in the operative data
between the two studied groups
About one year was the mean duration of follow up of all cases
of both groups to detect functional outcome and complications
(Table 3).
Despite there was a difference in the incidence of postoperative
complications between the two studied groups; this difference was
groups had good long term continence and sphincter tone.
None of the studied patients of the two groups had postoperative
rectal prolapse, urethral injury or missed segment.
Postoperative follow up revealed anastomotic leakage in 3
patients in group A and in 4 patients in group B; a pre-anastomotic
stoma had been constructed in all of these patients.
Postoperative anastomotic stricture developed in 25 patients
in group A and in 17 patients in group B. All of these patients
were managed conservatively with regular anal dilatation with
Hegar dilators which started 21 days after surgery and continued
every two weeks until the anastomotic ring can no longer be felt.
Postoperative regular dilatation didn’t exceed 2-3 postoperative
months in all of these patients.
Postoperative
complications
(Group A)
n = 166
(Group B)
n = 82 χ2FEp
Wound
infection 5 (3%) 8(9.8%) 5.026 0.034*
Anastomotic
Leakage 3(1.8%) 4(4.9%) 1.887 0.224
Rectal prolapse 0(0%) 0(0%) - -
Enterocolitis 33(19.9%) 18(22%) 0.144 0.704
Cuff narrowing
(stricture) 25(15.1%) 17(20.7%) 1.255 0.263
Adhesive I.O. 0(0%) 8(9.8%) 16.735* <0.001*
Missed segment 0(0%) 0(0%) - -
Fecal
incontinence 0(0%) 0(0%) - -
Constipation 15(9%) 12(14.6%) 1.773 0.183
Perianal
dermatitis 13(7.8%) 7(8.5%) 0.037 0.810
Urethral injury 0(0%) 0(0%) - -
Cuff infection
and abscess
formation
2(1.2%) 3(3.7%) 1.673 0.336
Table 3: Difference in postoperative complications
in the two groups.
21
Citation: Ahmed Elrouby., et al. “One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study”.
Acta Scientific Paediatrics 2.6 (2019): 19-24.
One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study
Temporary fecal soiling was complained by 21 patients in
group A and in 8 patients in group B for 2-3 postoperative months
secondary to diarrhea and this was controlled with low –residue
diet and loperamide.
Some complications developed only in group B related to
laparotomy in the form of wound infection in 8 cases treated
by wound drainage, frequent dressing with application of local
and systemic antibiotics and adhesive intestinal obstruction
which developed in only 2 patients; one of them was managed
conservatively and the other patient had been explored with
adhesiolysis.
Discussion
-
ment of Hirschsprung's disease, which in itself shows that no
single operation achieves perfect functional outcome. The most
commonly performed operations include the Swenson, Duhamel
and Soave procedures [9]. These operations could be done either
in one-stage with or without laparoscopic assistance or in staged
procedure starting with diverting proximal colostomy followed by
-
tages and disadvantages.
Application of trans-anal endorectal pull-through in the
treatment of Hirschsprung's disease has many advantages as 75%
of patients have a transition zone at the level of the recto-sigmoid
colon which is an important criterion in selecting patients for
transanal endorectal pull-through. In this technique, the tedious
performed in abdominal Soave procedure is avoided [10].
shorter hospital stay, lesser need for postoperative narcotic
analgesia and lower cost when compared to the trans-abdominal
approach. It eliminates the time consumed in opening and
closure of the laparotomy incision and therefore abolishing the
risk of postoperative development of intestinal adhesions. In
addition, it offers the best cosmetic result in surgical correction
in Hirschsprung’s disease. The endorectal dissection preserved
anorectal sphincters as well as local blood supply and innervation
so fecal and urinary continence pathways were not touched [11].
Our study revealed that the operative time and intraoperative
this may be attributed to the time consumed for opening and closure
of the laparotomy incision in case of trans-abdominal approach
which not only increases the operative time but also augments
Torre and Ortega in their study in which they concluded that trans-
anal approach consumes lesser operative time and results into
lesser amount of intraoperative bleeding than the trans-abdominal
approach [12].
Patients who were treated by the trans-anal approach started
passing stools and tolerated oral feeding earlier than those who
were treated by the trans-abdominal approach. This may be
anal approach is strictly above the dentate line which obviates the
need for administration of postoperative narcotic analgesia and
hence minimizing the duration of postoperative ileus. Another
explanation is the absence of intra-abdominal manipulation in case
of trans-anal approach which also reduces the postoperative ileus.
Langer., et al. in their multicenter study proved that postoperative
tolerance of oral feeding is earlier in case of trans-anal approach
than in case of trans-abdominal one [13].
A shorter hospital stay was recorded in case of trans-anal
approach than in trans-abdominal one due to several factors
including absence of NGT, earlier return of bowel habits, earlier
tolerance of oral feeding and the lesser need for postoperative
analgesia. Also saving the time consumed during opening and
closure of the laparotomy incision. Shorter hospital stay both
reduces the cost and increases parent satisfaction. Lee JY., et al.
cost burden in case of trans-anal approach [14].
The postoperative functional outcome including postoperative
et al. study who found no difference between the two approaches
[15].
On the other hand Gosemann., et al. concluded in their study
that postoperative results including constipation and continence
were superior in trans-anal approach than in trans-abdominal one
[16].
22
Citation: Ahmed Elrouby., et al. “One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study”.
Acta Scientific Paediatrics 2.6 (2019): 19-24.
One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study
complications between trans-anal and trans-abdominal
approaches in our study which is similar to Saber M., et al. study
which revealed that one stage trans-anal pull-through can be safely
less need for narcotic analgesics and lower cost when compared
with open approach. The transanal approach offers the best
cosmetic results as no visible scars and no postoperative adhesions.
Endo rectal dissection avoids damaging pelvic structures, preserve
anorectal sphincters as well as local blood supply and innervations
and consequently; fecal and urinary continence are not been
touched [17].
Similar results were achieved in Langer., et al. and in Lee JY.,
et al. studies who concluded that lower rate of complications was
encountered in transanal approach versus the trans-abdominal
one in endorectal pull-through [13,14].
Conclusion
One stage transanal endorectal pull-through takes less operative
time, has minimal bleeding with earlier recovery than one stage
trans-abdominal endorectal pull-through procedures. Also the
postoperative recovery is more rapid in transanal approach than
in trans-abdominal one regarding bowel motion, feeding tolerance
and hospital stay. Postoperative complications are similar in
transanal as well as in trans-abdominal approach with similar
functional outcome regarding continence and constipation rates.
Transanal approach is superior to trans-abdominal approach
regarding better cosmetic results and absence of the occurrence
of postoperative adhesive intestinal obstruction by avoiding
laparotomy incision.
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23
Citation: Ahmed Elrouby., et al. “One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study”.
Acta Scientific Paediatrics 2.6 (2019): 19-24.
One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study
Volume 2 Issue 6 June 2019
© All rights are reserved by Ahmed Elrouby., et al.
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Citation: Ahmed Elrouby., et al. “One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study”.
Acta Scientific Paediatrics 2.6 (2019): 19-24.
