title: Redo pull-through in Hirschsprung's [corrected] disease for obstructive symptoms due to residual aganglionosis and transition zone bowel.
abstract: Reoperations in Hirschsprung disease may be required for residual aganglionosis or transition-zone bowel found at the distal pull-through. We aimed to review the management of patients who had this complication and offer suggestions on how to avoid it.
  
  
  
  Ninety-three patients with Hirschsprung disease were referred to our institution with recurrent problems after a pull-through done elsewhere. All required reoperations with a variety of indications, and of these, 25 had residual aganglionosis/transition-zone histology. This was the only indication for redo in 16 children.
  
  
  
  Children (range, 2-17 years) presented 6 to 66 months after the initial pull-through. The predominant symptoms were enterocolitis (n = 9 [56%]), constipation (n = 7 [44%]), failure to thrive (n = 5 [31%]), and impaction (n = 4 [25%]). The rectal biopsy performed as part of their post pull-through work up showed hypertrophic nerves (n = 16), absent ganglion cells (n = 6), and normal ganglion cells (n = 10). The original frozen-section biopsy, determining the level of the pull-through, only sampled the seromuscular layer in 3 children, leading to misdiagnosis. Reoperations involved a transanal resection (n = 15) and a posterior sagittal approach (n = 1). In all cases, obstructive symptoms were resolved, and no patient has had recurrent enterocolitis.
  
  
  
  Patients' post pull-through with recurrent obstructive symptoms may have residual aganglionosis or transition-zone bowel. Reoperation can result in the resolution of these symptoms. A full-thickness biopsy at the time of the initial pull-through to include the mucosa and submucosa may increase the possibility of identifying hypertrophic nerves.
authors.affiliation: Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
authors.forename: Taiwo A
authors.initials: TA
authors.lastname: Lawal
authors.forename: Kaveer
authors.initials: K
authors.lastname: Chatoorgoon
authors.forename: Margaret H
authors.initials: MH
authors.lastname: Collins
authors.forename: Alex
authors.initials: A
authors.lastname: Coe
authors.forename: Alberto
authors.initials: A
authors.lastname: Peña
authors.forename: Marc A
authors.initials: MA
authors.lastname: Levitt
mesh_terms: D000293:Adolescent; D001706:Biopsy; D002648:Child; D002675:Child, Preschool; D003951:Diagnostic Errors; D013505:Digestive System Surgical Procedures / Q000379:methods*; D004760:Enterocolitis / Q000473:pathology / Q000601:surgery; D005260:Female; D006627:Hirschsprung Disease / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D007415:Intestinal Obstruction / Q000175:diagnosis / Q000601:surgery*; D008297:Male; D011183:Postoperative Complications / Q000175:diagnosis / Q000517:prevention & control / Q000601:surgery*; D012007:Rectum / Q000473:pathology / Q000601:surgery; D012086:Reoperation / Q000379:methods