Traditionally, treatment of Hirschsprung’s disease had consisted of a colostomy at diagnosis, followed by one of varieties of pull-through procedures later on. Over the last two decades, an evolution in the surgical management of HD has occurred. The previous gold standard of multistaged procedures with a preliminary stoma were replaced by one stage pullthrough in many centers worldwide with results as favorable as multistaged procedures, and there may be a cost advantage as well.
Georgeson, in 1999 described minimally invasive procedure for pull-through that has become popular; it consisted of pull-through using laparoscopic abdominal and pelvic mobilization of the rectum and colon. De la Torre-Mondragon and Ortega, in 1998, first described the exclusive transanal endorectal pull-through technique. This may not require laparotomy or laparoscopy, and may not include any intraabdominal or pelvic dissection.
This study was conducted in the period from January 2013 to June 2015 at the pediatric surgery department, Ain Shams University. This study included 40 patients with Hirschsprung’s disease, they were 30 males and 10 females, their ages ranged from one week to 6 years old. Patients were randomly divided into two equal groups (A & B) and group B is subdivided into B1 and B2 according to the pull-through technique used. Each group included 20 patients. Patients of group "A" were subjected to totally trans-anal pullthrough, while patients of group "B" were subjected to minilaparotomy (B1) and laparoscopic (B2) assisted trans-anal pull-through. Follow up of the patients ranged from 3 months to 2 years.
In this study, one stage totally transanal endorectal pullthrough technique was compared with the assisted pullthrough technique (minilaparotomy and laparoscopy) in the treatment of patients with short segment Hirschsprung's disease regarding various points including; operative time, blood transfusion, onset of oral feeding, postoperative hospital stay and postoperative complications.
Results of this study confirmed that the comparison between one stage totally transanal endorectal pullthrough technique and the assisted pullthrough technique (minilaparotomy and laparoscopy) for Hirschsprung's disease, although the results were favorable to one stage totally transanal endorectal pullthrough technique, but in general, there were no any statistically significant differences between both groups regarding operating time, blood transfusion, onset of oral feeding, postoperative hospital stay or postoperative complications such as wound infection, ileus, enterocolitis, anal stricture, persistent constipation. Unfortunately, the functional outcomes, as sexual function and continence (which are very important parameters) could not be assessed in this study, because of the short period of follow up and the young age of the patients, therefore, it is important to assess these functions which will require several more years of evaluation.
Recently, totally transanal pull-through has become widely popular procedure for the treatment of HD (especially those patients with short segment disease), the procedure does not damage the pelvic structures, it is not expensive, and it has the best cosmetic results. But overstretching of the internal anal sphincter remains a critical issue, which may impact the long-term continence outcome (needs more several years of follow up). There has been a recent trend in the use of laparoscopic assisted pullthrough in the management of Hirschsprung's disease. The procedure can be performed with comparable results as the transanal pullthrough procedure, but it has the advantage of mobilization of the colon laparoscopically. So, less peritoneal trauma, and less bleeding, with less stretching to the sphincters, that may give good functional outcome, so further assessment of the two techniques with larger number of patients and longer period of follow up is recommended.
Finally:
• Despite the advantages of totally transanal pull-through, the results of laparoscopic assisted pull-through mentioned in many series, are comparable with that of totally transanal pull-through.
• It is found that, the younger the age of the patient, the more easily the dissection is, with the less blood loss, the earlier onset of oral feeding, and the less postoperartive hospital stay.
• One stage TEPT technique is both feasible and safe technique in properly selected patients with rectosigmoid HD, in young ages especially during infancy. The technique is easily learned and is associated with excellent clinical results.
• In the future studies, a long period of follow up in a large number of patients, to assess the functional outcomes of both techniques, is recommend.
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