Transanal endorectal pull-through in children with Hirschsprung's disease--technical refinements and comparison of results with the Duhamel procedure.
OBJECTIVE
Transanal endorectal pull-through (TEPT) has drastically changed the treatment of Hirschsprung's disease (HD). A short follow-up of children submitted to TEPT reveals results that are similar to the classic transabdominal pull-through procedures. However, few reports compare the late results of TEPT with transabdominal pull-through procedures with respect to complication rates and the fecal continence. The aims of the present work are to describe some technical refinements that we introduced in the procedure and to compare the short and long-term outcome of TEPT with the outcomes of a group of patients with HD who previously underwent the Duhamel procedure.


METHODS
Thirty-five patients who underwent TEPT were prospectively studied and compared to a group of 29 patients who were treated with colostomy followed by a classical Duhamel pull-through. The main modifications introduced in the TEPT group were no preoperative colon preparation, operation conducted under general anesthesia in addition to regional sacral anesthesia, use of only one purse-string suture in the rectal mucosa before transanal submucosal dissection, and no use of retractors and electrocautery during the submucosal dissection.


RESULTS
The most frequent early complications of TEPT group were perineal dermatitis (22.8%) and anastomotic strictures (8.6%). The comparison with patients who underwent Duhamel procedure revealed no difference in the incidence of preoperative enterocolitis, the patients of the TEPT group were younger at the time of diagnosis and of surgery, they had shorter operating times, and they began oral feeding more quickly after the operation. The incidence of wound infection was lower in the TEPT group. Moreover, the TEPT and Duhamel groups showed no difference in the incidences of mortality, postoperative partial continence, and total incontinence. Although the incidences of complete continence and postoperative enterocolitis were not different, a tendency to the increased incidence in the TEPT group was observed.


CONCLUSIONS
This study further supports the technical advantages, the simplicity, and the decreased incidence of complications of a primary TEPT procedure when compared to a classical form of pull-through. Some technical refinements are described, and no preoperative colon preparation was necessary for the patients studied here. The results show that the long-term outcomes of the modified TEPT procedure are generally better than those obtained with classical approaches.
Pediatric Surgery Division and Laboratory of Pediatric Surgery (LIM-30), University of Sao Paulo Medical School, CEP: 01246-903 São Paulo-SP, Brazil. uenist@usp.br
Ana Cristina Aoun
AC
Tannuri
Uenis
U
Tannuri
Rodrigo Luiz Pinto
RL
Romão
D001003:Anal Canal / Q000601:surgery; D000714:Anastomosis, Surgical / Q000379:methods; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003125:Colostomy / Q000009:adverse effects / Q000379:methods*; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D005242:Fecal Incontinence / Q000517:prevention & control; D005260:Female; D005500:Follow-Up Studies; D006627:Hirschsprung Disease / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000503:physiopathology; D011336:Probability; D012007:Rectum / Q000601:surgery; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome