[Transanal endorectal pull-through with short muscular cuff in the treatment of Hirschsprung disease. Preliminary study with 37 patients].

Introduction: Totally transanal operation for classic Hirschsprung's disease has gained increasing popularity during the last few years. The procedure leaves no scars, is associated with less postoperative pain and discomfort and shortens hospital stay. The most commonly used technique for transanal pull-through is long endorectal dissection leaving a long muscular cuff, which is usually split posteriorly. We present our preliminary results following transanal endorectal operation with a short unsplit muscular cuff.

Materials And Methods: Thirty-seven patients underwent short-cuff transanal endorectal operation for Hirchsprung's disease between years 2000 and 2002. Patients' hospital records were analysed retrospectively. The collected data included age at the operation, associated conditions, hospital stay and time to full enteral feeds, occurrence of pre- and postoperative enterocolitis and preoperative stoma, operative complications, need for postoperative anal dilatations, postoperative perianal skin problems and preliminary data on bowel function.

Results: The median age at operation was 5 months (range 0-60 months), 13 patients were operated in the neonatal period. Six patients had Down's syndrome, 1 had cartilage-hair hypoplasia and one Ondine's syndrome. Six patients had preoperative enterocolitis. Thirteen patients had undergone levelling stoma formation for unremitting obstruction or enterocolitis, two of these had a long segment aganglionosis. The proximal ganglionic stoma was concomitantly pulled-through and anastomosed to the anus in all 13 patients with a stoma. Complications related to surgery occurred in 3 patients, 2 had prolapse of the pulled-through bowel (reduced immediately without later sequels) and 1 infection in the stoma closure wound. Median postoperative hospital stay was 4 days (range 2-21 days) and median time to full enteral feeds 3 (range 1-14) days. The median follow-up time was 6 months (range 1-22 months). Postoperative enterocolitis occurred in 1 patient, further 3 patients had symptoms suggesting mild enterocolitis. Nine patients required anal dilatations, two of those for a period of 3 weeks. Twenty-two patients had perianal skin rash, which resolved usually within 6 weeks. Early postoperative bowel function was characterised by frequent bowel movements in most patients. These usually resolved within few months; of the 17 patients with a follow-up for longer than 6 months only 2 have more than 3 bowel movements per day. At last follow-up frank soiling occurred in 2 patients, one patient needs oral laxatives for constipation.

Conclusions: Transanal endorectal pull-through with a short cuff is a safe operation with low incidence of operative and postoperative complications. Hospital stay and time to full enteral feeds is significantly shorter than following conventional procedures; this associates with lower hospital costs. Long-term functional outcome of patients having totally transanal pull-through is unclear but short tern function is very similar than after procedures where transanal mucosectomy is combined with rectosigmoid dissection through laparotomy.