Transanal endorectal pull-through for Hirschsprung disease: technique, controversies, pearls, pitfalls, and an organized approach to the management of postoperative obstructive symptoms (original) (raw)
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Journal of Pediatric Surgery, 2013
Background: It has been suggested that the outcome of transanal endorectal pull-through for classic Hirschprung's disease can be improved by laparoscopically mobilizing the colon before the pullthrough. Methods: Charts of 43 patients (2005)(2006)(2007)(2008)(2009) with proven recto-sigmoid aganglionosis were retrospectively analyzed with respect to postoperative outcomes. Twenty-one had been treated with the transanal endorectal pull through (TERPT) and 22 with the laparoscopically assisted TERPT (LTERPT). Results: Gender ratio, congenital anomalies, preoperative enterostomy, and follow up did not differ between the groups. More colon was resected in the TERPT group: median 25 cm vs. 15 cm in the L-TERPT group (p b 0.001). The TERPT-procedure took less time: median 153 min. vs. L-TERPT 263 min (p b 0.001). Postoperatively, three patients showed colonic torsions after TERPT (p = 0.07). The long-term clinical outcomes did not differ significantly between both groups. There was a significant association between length of resection and obstructive symptoms (OR = 0.92, p = 0.01). Conclusion: Postoperative and clinical outcomes are similar using the TERPT or L-TERPT to correct classic segment Hirschsprung's disease. Prevention of colonic torsion should be the prime concern during the TERPT procedure. L-TERPT requires laparoscopic equipment and takes more operation time, whereas TERPT leaves no visible scars. The positive relation between the larger length of resection and obstructive symptoms requires additional research.
Pediatric Surgery International, 2008
Background/Purpose The authors compared the clinical outcome between laparoscopically assisted endorectal pullthrough (EPT) with an extraanal approach (EA) and conventional abdominal approach (AB) in Hirschsprung's disease (HD), and found that the former approach was less invasive and can provide a better clinical outcome. Recently, they introduced transanal approach (TA) without laparoscopical assistance and compared the clinical outcomes of these three approaches. Methods In the period between 1990 and 1997, 20 cases of HD underwent EPT with AB (Group A), between 1998 and 2001, 21 cases underwent EPT with EA (Group E), and between 2004 and 2005, eight cases underwent EPT with TA (Group T). There was no difference in age and weight distribution among three groups. Clinical outcome was assessed 3 years after surgery. Results The operation time in Groups A, E and T was comparable (4.9 ± 0.8, 5.2 ± 0.8 and 4.3 ± 0.8 h), whereas blood loss (98 ± 52, 36 ± 30 and 36 ± 30 ml) and the incidence of postoperative complications requiring surgical intervention (25, 0 and 0%) was significantly lower in Groups E and T compared with Group A. The incidence of postoperative enteritis (25, 29 and 13%) was lower in Group T compared with Groups A and E. In Group E, two cases had persistent constipation, which required anorectal myotomy. Voluntary defecation ([once/ 2 days) was comparable among the groups (70, 87 and 88%). Soiling (small amount of involuntary passage of stool) was significantly less frequent in Groups E and T (45, 14 and 0%). Conclusion EPT with perineal approaches is less invasive and can provide a better clinical outcome than EPT with AB in terms of postoperative soiling. Compared with EA and TA, EA tended to develop stagnant enteritis or residual constipation.
BMC Surgery, 2021
Background To present a surgical technique of single-incision laparoscopic-assisted endorectal pull-through (SILEP) with suspension sutures using conventional instruments for Hirschsprung disease (HD) and its long-term follow-up outcomes. Methods The procedure began with a 1 cm transumbilical skin incision. Three separate punctures were made in the fascia with a 5 mm scope in the middle and 5 mm and 3 mm ports for working instruments on the left and right, respectively. The first suspension suture was placed to secure the sigmoid colon to the abdominal wall. A window was created through the rectal mesentery, and dissection around the rectum was carried out. The second suspension suture was performed to suspend the rectovesical peritoneal fold or the rectovaginal peritoneal fold to the abdominal wall. Dissection around the rectum was continued downward to approximately 1 cm below the peritoneal fold. Then, the operation was completed by a transanal approach. Results Forty patients un...
Al-Azhar Medical Journal, 2018
Background: Several operative techniques have been developed for the treatment of Hirschsprung's disease (HD) in the past decades. One-stage trans-anal pull-through (TAPT) was first performed in 1998. Objectives: To evaluate fecal continence after laparoscopicassisted and trans-anal endo-rectal pull-through (TERPT) for recto-sigmoid Hirschsprung's disease (HSD). Patients and Methods: This prospective study was performed on 40 pediatric patients with Hirschsprung's disease from July 2013 to July 2016 at Al-Azhar University Hospitals. The patients were divided into two equal groups: group (A) underwent laparoscopic assisted trans-anal endo-rectal pull-through, and group (B) underwent pure trans-anal endo-rectal pull-through (TERPT). Demographic, clinical data, preoperative investigations, operative records, postoperative outcome were studied. A continence evaluation questionnaire (CEQ, max score = 10) assessing frequency of motions, severity of staining, severity of perianal erosions, anal shape, and requirement for medications was used. Severity of staining was graded as none = 2, occasional = 1.5, often = 1, and always =0. Electromyogram (EMG) and magnetic resonance imaging (MRI) were also used in follow-up. Results: After one year of follow up , group A, continence score was normal in 10 (50%), good in 9 (45 %), and fair in 1 (5%); while group B, continence score was normal in 5 (25 %), good in 14 (70%), and fair in 1 (5%). However, staining/soiling in group A was present in 2(occasional staining); while group B, staining/soiling was present in 2(occasional staining). Statistically significant difference was found between groups according to continence score after 1month and 6 months, but no statistical significance clinically after 12 months. Conclusion: Laparoscopically assisted trans-anal endo-rectal pull through was less invasive and can provide a better clinical outcome compared with trans-anal endo-rectal pull through as regard fecal continence and stooling function.
Acta Scientific Paediatrics, 2019
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 and hospital stay were the only statistically significant variables. Most of the postoperative complications didn't differ significantly 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, in patients with aganglionosis which doesn't exceed the splenic flexure or even in those having marked dilated colon because of its high effectiveness and promising results.
Journal of Pediatric Surgery, 2007
Background: The primary aim of this study is to detail the problems, complications, their avoidance, and management with transanal pull-through developed from experience with 65 patients. Methods: A retrospective study of 65 patients who underwent transanal pull-through between January 2002 and December 2006 was conducted. Their medical charts and operative notes were reviewed for problems encountered during surgery, postoperative period, and follow-up. Results: In 46 patients, a primary transanal pull-through was performed, whereas in 19 with a prior colostomy, followed staged pull-through was done. The minimum follow-up was 6 months, with an average of 22 months after surgery (range, 6-47 months). Sixteen patients (25%) experienced at least 1 complication. These included inadvertent full-thickness mobilization of the rectum in 3 (4.6%), retraction and bleeding of colonic mesenteric vessels in 2 (3.7%), difficulty in mobilizing intraperitoneal colon in 1 (1.5%), and a false-positive frozen section in 2 patients (3%). Early postoperative complications occurred in 7 patients (11%), which included sphincter spasm in 3 (4.6%), anastomotic leak in 1 (1.5%), cuff abscess in 2 (3%), and enterocolitis in 1 (1.5%). Late postoperative complications in 46 patients (70%), occurring from 1 week till 3 months of follow-up included perianal excoriation in 22 (34%), increased stool frequency in 20 (31%), anal stenosis in 3 (4.6%), and enterocolitis in 2 patients (3%). Methodology is detailed for avoidance and management of problems and complications. Individual patient analysis, complications timing, and strategy for management are discussed.