Pullthrough pitfalls in treating Hirschsprung disease

• Published in: World journal of pediatric surgery 2024-09, Vol.7 (3), p.e000862
• Main Authors: Rialon, Kristy L, Langer, Jacob C
• Format: Article
• Language: English
• Subjects: Anus; Colon; Colorectal Surgery; Dissection; Fecal incontinence; Gastroenterology; Laparoscopy; Pediatrics; Pelvis; Perspective; Surgeons; Surgical anastomosis; Sutures; Veins & arteries
• ISSN: 2516-5410; 2096-6938; 2516-5410
• DOI: 10.1136/wjps-2024-000862

Some of these may manifest as obstructive symptoms or constipation, which can be seen in 11% to 42% of patients.3 Other patients may develop soiling and fecal incontinence, which can be caused by sphincter injury during surgery or by loss of the dentate line.4 In a review of 46 redo pullthroughs, 71% occurred because of aganglionosis or a transition zone pullthrough, 19% from stricture or obstruction by the Duhamel pouch, and 8% from a tight Soave cuff.2 The choice of pullthrough, whether a Swenson, Yancey-Soave, or Duhamel, does not influence the rate of complication but rather each has its own unique pitfalls to avoid.5 The timing of surgery, whether performed as a neonate or delayed into infancy, continues to be debated, with a large study from the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) showing no difference in anastomotic or cuff stricture, Duhamel spur, or transition zone pullthrough, and several others showing higher rates of stricture and leak when repairs are done in the neonatal period.6 7 In this review, we discuss avoidable pitfalls during the pullthrough procedure and provide guidance for identification and prevention. To avoid excessive tension on the anastomosis, the blood supply to the pullthrough segment should be carefully examined when taken to gain length. The contrast study will provide information about bowel dilation. To avoid this when performing the pullthrough transanally, different colored sutures can be used to mark the antimesenteric and mesenteric borders of the colon every few centimeters.11 A clamp can also be placed on the bowel and its orientation maintained throughout the dissection.11 If performing the procedure with laparoscopic assistance, the colon can be visualized before and after it is pulled through to the perineum.