Are the long-term results of the transanal pull-through equal to those of the transabdominal pull-through? A comparison of the 2 approaches for Hirschsprung disease

doi:10.1016/j.jpedsurg.2006.09.007

Journal of Pediatric Surgery

Volume 42, Issue 1, January 2007, Pages 41-47

https://doi.org/10.1016/j.jpedsurg.2006.09.007 Get rights and content

Abstract

Purpose

The transanal endorectal pull-through (TERPT) is becoming the most popular procedure in the treatment of Hirschsprung disease (HD), but overstretching of the anal sphincters remains a critical issue that may impact the continence. This study examined the long-term outcome of TERPT versus conventional transabdominal (ABD) pull-through for HD.

Methods

Records of 41 patients more than 3 years old who underwent a pull-through for HD (TERPT, n = 20; ABD, n = 21) were reviewed, and their families were thoroughly interviewed and scored via a 15-item post–pull-through long-term outcome questionnaire. Patients were operated on between the years 1995 and 2003. During this time, our group transitioned from the ABD to the TERPT technique. Total scoring ranged from 0 to 40: 0 to 10, excellent; 11 to 20 good; 21 to 30 fair; 31 to 40 poor. A 2-tailed Student t test, analysis of covariance, as well as logistic and linear regression were used to analyze the collected data with confidence interval higher than 95%.

Results

Overall scores were similar. However, continence score was significantly better in the ABD group, and the stool pattern score was better in the TERPT group. A significant difference in age at interview between the 2 groups was noted; we therefore reanalyzed the data controlling for age, and this showed that age did not significantly affect the long-term scoring outcome between groups.

Conclusion

Our long-term study showed significantly better (2-fold) results regarding the continence score for the abdominal approach compared with the transanal pull-through. The stool pattern and enterocolitis scores were somewhat better for the TERPT group. These findings raise an important issue about the current surgical management of HD; however, more cases will need to be studied before a definitive conclusion can be drawn.

Section snippets

Methods

From 1995 to 2003, 124 HD cases were treated at the CS Mott's Children Hospital, University of Michigan. The study protocol was fully approved by our hospital Institutional Review Board (IRB approval number: HUM00000592). During that time, our group transitioned from the ABD to the TERPT technique. Patients who underwent other types of pull-throughs (Duhamel or Swenson) (4 cases) were excluded from the study. In patients 3 years of age or older (79/124 cases) in whom continence could readily be

Demographics

Complete evaluation was carried out in 41 HD cases. The descriptive data of all cases are shown in Table 2. There were no statistical differences between the TERPT and ABD groups regarding sex, associated congenital anomalies, family history of HD, type of presentation, and age of pull-through in months. However, there were significant differences regarding the age at interview in years with a mean of 5.75 ± 2.04 in the TERPT group versus 8.47 ± 2.33 in the ABD group (F_1,39 = 15.82; P < .001),

Discussion

Since first described in 1998, the TERPT has become widely used because it may not require any intraabdominal or pelvic dissection, potentially obviating laparotomy or laparoscopy [9]. The risks of contamination and adhesion formation are eliminated. The procedure does not damage the pelvic structures, is not expensive, and has the most optimal cosmetic results [10], [11], [12]. To our knowledge, until now there have been no published reports addressing the long-term functional outcome of the

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Cited by (92)

Medium-Term Outcomes of Antegrade Continent Enema (ACE): Cairo University Specialized Pediatric Hospital (CUSPH) Experience
2023, Journal of Pediatric Surgery
To assess the medium-term outcomes of ACE in children with fecal incontinence (FI).
Eligible children were recruited from the colorectal clinic between December 2016 and January 2020 and were followed prospectively for 2–6 years. A series of questionnaires were used to assess QOL, patients and parent satisfaction, and to assess the outcomes of the ACE.
24 children aged 6–12 years (mean age 8.17 ± 1.95), including 18 males (75%) and 6 females (25% were studied. Cases included anorectal malformations (45.83%)., Hirschsprung disease (25%), neural tube defects (16.66%), sacrococcygeal teratoma (4.16%), and intractable pseudoincontinence (8.33%). QOL improved from (3) [3 -3] to (16) [16-16],p < 0.05. Fecal incontinence index showed significant improvement: 20 [20-20] versus 3 [0–4],p < 0.05. Bowel symptoms demonstrated improvement in the ability to decide when to pass stools and a decrease in soiling. Stooling survey showed lower scores representing better outcome. ACE questionnaire showed that the range of irrigation volumes used by parents is wide, and that all families recommend the ACE for children with similar condition. Postoperative complications were stenosis (16.66%), stomal prolapse (12.5%), leakage (4.16%), and false passage (4.16%). Satisfaction questionnaire showed a median score of 9 (range, 5–10).
ACE is an effective method to keep the child with FI clean, more socially active, and with a better QOL and FII in the medium-term. The reported complications were stenosis, false passage, and leakage. ACE mucosa prolapse is a novel complication picked up on medium-term follow up.
Histopathological perspective of the pulled-through colon in Hirschsprung disease: Impact on clinical outcome
2020, Journal of Pediatric Surgery
The outcome in HD has not been always satisfactory even after a technically sound operation.
To define the characteristic histopathological features of the pulled-through colon in patients with HD, and it is impact on clinical outcome.
The study included patients with HD who underwent surgical repair between 2010 through 2016. The proximal margin of resected bowel segments (which corresponds to the pulled through colon) was subjected to detailed histopathological examination by two experienced pathologists.
Based on the frequency of postoperative attacks of HAEC (fever, vomiting, abdominal distention, fluid offensive stools), cases included in the study were divided into two groups: Group A, those with less frequent attacks of HAEC; and Group B, those with recurrent attacks of HAEC (more than 3).
The study included 35 patients (25 in group A; and 10 in group B). Their age ranged from 0.2 to 144 months (median 6 months).
Comparing the histopathological findings in the two clinical groups, we have found that Group B (recurrent attacks of HAEC) had significantly more frequent focal disarray of nerve bundles and thicker nerve bundle diameter. Also, histopathological features of acute inflammation were more prevalent in examined specimens from group B.
Several histopathological features of the examined bowel specimens in HD, other than presence or absence of ganglion cells, are indicative of postoperative functional outcome. These include the thickness and maturity of nerve bundles, in addition to the presence of histopathological features of acute inflammation.
This is a case control study (level III evidence).
A Nordic multicenter survey of long-term bowel function after transanal endorectal pull-through in 200 patients with rectosigmoid Hirschsprung disease
2017, Journal of Pediatric Surgery
Transanal endorectal pull-through (ERPT) is the most popular technique to treat Hirschsprung disease (HD). Still, there is limited knowledge on long-term bowel function. This cross-sectional, multicenter study assessed long-term bowel function in a large HD population and examined predictors of poor outcome.
Patients older than four years or their parents filled out a validated questionnaire on bowel function. Clinical details were recorded retrospectively from medical records.
73/200 (37%) patients reported absolutely no impaired bowel function, meaning no constipation, fecal accidents, stoma, appendicostomy or need for enemas. Seven (4%) had a stoma, and 33 (17%) used antegrade or rectal colonic enemas. Most disarrangements of fecal control and constipation were significantly less common in older age group, but abnormal defecation frequency and social problems remained unchanged. Syndromic patients (n = 31) experienced frequent fecal accidents (46%) more often than nonsyndromic (14%, P < 0.001). Having a syndrome (adjusted OR 5.6, 95% CI 2.1–15, P = 0.001) or a complete transanal ERPT (adjusted OR 2.4, 95% CI 1.1–5.7, P = 0.038) was significantly associated with poor outcome defined as having a stoma, an appendicostomy, daily fecal accidents or need of regular rectal wash outs.
A significant number of HD patients experience bowel problems many years after definite surgery. Fecal control was significantly better in older than younger HD patients, but some continued to have considerable bowel problems also as adults. A total transanal ERPT was associated with poorer outcome. Long-term follow-up of HD patients is warranted.
Prognosis Study: Level II.
Antegrade continence enemas improve quality of life in patients with medically-refractory encopresis
2017, Journal of Pediatric Surgery
Fecal incontinence is a socially debilitating problem for many children. We hypothesized that in selected patients with medically-refractory encopresis, placement of an appendicostomy or cecostomy tube for administration of antegrade continence enemas (ACE) would improve quality of life (QOL).
We reviewed all patients with encopresis who underwent appendicostomy or cecostomy placement from 2003 to 2014 at our institution. We contacted subjects' parents by phone and administered 3 surveys: a survey reflecting current stooling habits, a disease-specific QOL survey, and the PedsQL™ QOL survey. QOL surveys were completed twice by parents, once reflecting pre-operative QOL, then again reflecting current QOL. Pre-procedure and post-procedure scores were compared by paired t-test.
Ten patients underwent appendicostomy/cecostomy for encopresis. Eight completed phone surveys. All procedures were performed laparoscopically. All patients experienced fecal soiling pre-operatively, whereas 5/8 surveyed patients (63%) noted complete resolution of soiling post-procedure (p < 0.01). General and disease-specific QOL improved from pre-procedure to post-procedure in the following domains: social habits, physical activity, ability to spend the night elsewhere, feeling, and overall QOL (p < 0.05). PedsQL™ scores improved significantly in physical functioning, social functioning, and overall functioning (p < 0.05).
Antegrade continence enemas significantly improve quality of life in patients with medically-refractory encopresis, likely related to resolution of soiling.
4
Long-term results of the Duhamel technique are superior to those of the transanal pullthrough: A study of fecal continence and quality of life
2017, Journal of Pediatric Surgery
Citation Excerpt :
A study from the University of Michigan also used a questionnaire to compare the transabdominal approach with the TAPT procedure. No significant difference was observed in the total scores between the groups, although a subgroup analysis could detect that the continence score was 2 times better in the transabdominal approach group compared with that in the TAPT group [21]. In a similar study, Fernandez Ibieta et al. reported a better QoL and lower rates of incontinence in patients submitted to Duhamel procedure in comparison to patients who underwent TAPT technique [22].
The Duhamel and transanal pull-through (TAPT) techniques have been commonly used for the treatment of children with Hirschsprung disease (HD). However, despite adequate treatment, some patients present with fecal incontinence that severely affects the quality of life (QoL) and lead to psychiatric disorders. The objectives of the present study were to evaluate, through previously adapted questionnaires, the incidence of fecal incontinence and the quality of life (QoL) of children with HD who underwent Duhamel or TAPT techniques. In addition, we compared the incidence of fecal incontinence and QoL indices in these patients with those in healthy children.
The Fecal Continence Index (FCI) questionnaire and the questionnaire for the Assessment of Quality of Life in Children and Adolescents with Fecal Incontinence (AQLCAFI) were used in this study. A series of 41 patients with HD were divided into 2 groups according to the utilized surgical technique: the Duhamel group (20 patients) and the TAPT group (21 patients). The patients were compared with a control group of 59 healthy children.
In the control group, 25 (42.4%) children had good continence and 34 (57.6%) had normal continence. In contrast, among patients with HD, 4 (9.8%) had poor fecal continence, 11 (26.8%) had fair continence, 18 (43.9%) had good continence, and 8 (19.5%) had normal continence. The QoL of children with HD was globally impaired in all domains of the AQLCAFI as well as in the FCI, when compared with the QoL of healthy children (P = 0.001). The comparison between children who underwent surgery with the Duhamel technique and those who underwent surgery with TAPT technique showed similar outcomes according to the FCI. However, the results were inferior in patients who underwent TAPT technique according to the AQLCAFI questionnaire (P = 0.003), lifestyle (P = 0.006), behavior (P = 0.01), depression (P = 0.01), and embarrassment (P = 0.003).
The QoL and the FCI were impaired in patients who underwent surgery for correction of HD compared with healthy children; however, the impairment in QoL was greater in patients who underwent TAPT technique.
2B.
Laparoscopic-assisted transanal pull-through (LATP) versus complete transanal pull-through (CTP) in the surgical management of Hirschsprung's disease
2016, Journal of Pediatric Surgery
Citation Excerpt :
The difference in surgery duration between the procedures, with CTP taking less time to complete than LATP, likely reduces the use of health resources as well as the occurrence of complications for the patient. On the other hand, increased fecal incontinence following CTP has been reported, probably because of prolonged dilation of the sphincter [33,19]. The risk of colonic torsion may also be higher following CTP [27,34], although we did not have any cases of torsion in our series.
It is unclear whether laparoscopic-assisted transanal pull-through (LATP) or complete transanal pull-through (CTP) is superior for the surgical management of Hirschsprung's disease. We compared outcomes between approaches.
We retrospectively reviewed patients with Hirschsprung's disease who underwent LATP or CTP at our centre between 1995 and 2014. Patients were matched based on age, birth weight, and level of aganglionosis. A systematic literature review and meta-analysis were also performed.
From our data, LATP (n = 24) took significantly longer than CTP (n = 12; 3.9 ± 1.1 vs. 2.6 ± 0.6 h, p = 0.001). There was no difference in length of stay or incidence of postoperative complications. A literature search identified 17 published studies, of which 2 were comparative. Our pooled analysis of comparative studies including our results showed that operative time was significantly longer for the LATP group (OR 1.59, 95% CI 1.21–1.96, p < 0.001). There was no significant difference in major complications (OR 1.75, 95% CI 0.76–4.04, p = 0.19) or length of stay (OR 0.33, 95% CI − 0.41 to 1.08, p = 0.38).
Clinical outcomes are comparable between LATP and CTP. CTP offers shorter operative time without the need for laparoscopic instruments.

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: Presented at the 37th Annual Meeting of the American Pediatric Surgical Association, May 20–24, 2006, Hilton Head, SC.

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APSA PaperAre the long-term results of the transanal pull-through equal to those of the transabdominal pull-through? A comparison of the 2 approaches for Hirschsprung disease

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Methods

Demographics

Discussion

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Semin Pediatr Surg

Semin Neonatol

J Pediatr Surg

Hirschsprung's disease. Evaluation of mortality and long-term function in 260 cases

Arch Surg

APSA Paper
Are the long-term results of the transanal pull-through equal to those of the transabdominal pull-through? A comparison of the 2 approaches for Hirschsprung disease