Analysis of problems, complications, avoidance and management with transanal pull-through for Hirschsprung disease.
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.


CONCLUSIONS
Patient outcomes for transanal pull-through have improved significantly as a result of combination of experience and the ability to avoid and manage associated complications. Experience, avoidance, and interdiction are key factors in complication management.
Pratap
Akshay
A
Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan 6049, Nepal. akshay_pratap2000@yahoo.com
Gupta
Devendra Kumar
DK
Shakya
Vikal Chandra
VC
Adhikary
Shailesh
S
Tiwari
Awadhesh
A
Shrestha
Pramod
P
Pandey
Sagar Raj
SR
Yadav
Rajesh Kumar
RK
D001003:Anal Canal / Q000601:surgery*; D002675:Child, Preschool; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006627:Hirschsprung Disease / Q000601:surgery*; D006801:Humans; D007223:Infant; D016015:Logistic Models; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D015999:Multivariate Analysis; D009130:Muscle, Smooth / Q000601:surgery*; D011183:Postoperative Complications / Q000517:prevention & control; D011336:Probability; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome