title: Single-stage versus multi-stage pull-through for Hirschsprung's disease: practice trends and outcomes in infants.
abstract: OBJECTIVE
  The aim of this study was to evaluate surgical treatments and outcomes in a multi-institutional cohort of neonates with Hirschsprung's disease (HD).
  
  
  METHODS
  Using the Pediatric Health Information System (PHIS) from 1999 to 2009, neonates diagnosed with HD were identified and classified as having a single stage pull-through (SSPT) or multi-stage pull-through (MSPT). Diagnosis and classification algorithms and clinical variables and outcomes were validated by multi-institutional chart review. Groups were compared using logistic regression modeling and propensity-score matched analysis to account for baseline differences between groups.
  
  
  RESULTS
  1555 neonates with HD were identified; 77.2% underwent SSPT and 22.8% underwent MSPT. Misclassification of disease or surgical treatment was <2%. Rates of SSPT increased over time (p=0.03). Compared to SSPT, patients undergoing MSPT had significantly lower birth weights and higher rates of prematurity, non-HD gastrointestinal anomalies, enterocolitis, and preoperative mechanical ventilation. Patients undergoing MSPT had significantly higher rates of readmissions (58.5 vs. 37.9%) and additional operations (38.7 vs. 26%). Results were consistent in the propensity-score matched analysis.
  
  
  CONCLUSIONS
  Most neonates with HD undergo SSPT. In patients with similar observed baseline characteristics, MSPT was associated with worse outcomes suggesting that some infants currently selected to undergo MSPT may have better outcomes with SSPT. However, there remains a subgroup of MSPT patients who were too ill to be adequately compared to SSPT patients; for this subgroup of severely ill infants with HD, MSPT may be the best option.
authors.affiliation: Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children's Hospital, Columbus, OH.
authors.forename: Jason P
authors.initials: JP
authors.lastname: Sulkowski
authors.affiliation: Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children's Hospital, Columbus, OH.
authors.forename: Jennifer N
authors.initials: JN
authors.lastname: Cooper
authors.affiliation: Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children's Hospital, Columbus, OH.
authors.forename: Anthony
authors.initials: A
authors.lastname: Congeni
authors.affiliation: Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Erik G
authors.initials: EG
authors.lastname: Pearson
authors.affiliation: Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children's Hospital, Columbus, OH.
authors.forename: Benedict C
authors.initials: BC
authors.lastname: Nwomeh
authors.affiliation: Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Doolin
authors.affiliation: Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital, Nashville, TN.
authors.forename: Martin L
authors.initials: ML
authors.lastname: Blakely
authors.affiliation: Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children's Hospital, Columbus, OH.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Minneci
authors.affiliation: Center for Surgical Outcomes Research and Department of Surgery, Nationwide Children's Hospital, Columbus, OH. Electronic address: katherine.deans@nationwidechildrens.org.
authors.forename: Katherine J
authors.initials: KJ
authors.lastname: Deans
mesh_terms: D001003:Anal Canal / Q000601:surgery*; D003106:Colon / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D006627:Hirschsprung Disease / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D017063:Outcome Assessment, Health Care / Q000639:trends*; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies
keywords: Hirschsprung's disease; Multi-stage pull-through; Outcomes; PHIS; Pediatric Health Information System; Primary pull-through; Single stage pull-through