Anatomical aspects of the technique of trans anal one stage endorectal pull-through procedure in children with hirschsprung's disease

Abstract EN

Purpose : this prospective study presents the technique and results of trans anal one-stage end rectal pull-through procedure in children with recto sigmoid lesions from Hhirschsprung's disease at Pediatric Central Teaching Hospital– Baghdad–Iraq from ( jan.2007-may.2009).

Methods : twenty children aged one month to 6 years with section biopsy-proven Hhirschsprung's disease underwent trans anal one-stage end rectal pull-through procedures during a 12-month period.

A recto sigmoid transitional zone was suggested by contrast enema in 16 patients.

Preoperative colonic irrigation to evacuate feces out of the dilated colon was done in the hospital.

Bowel preparation was the same as conventional colorectal surgery.

Full–thickness rectal biopsy at 1 to 2 cm above the dentate line was submitted for pathologic diagnosis.

A rectal mucosectomy dissection was started 0.5 cm proximal to the dentate lines and was extended into the intraperitoneal rectum.

The muscular sleeve was divided circumferential at 3 to 4 cm proximal to the dentate line, exposing the Intraperitoneal rectum and allowing full-thickness mobilization of the recto sigmoid colon was pull down to anastomose with the distal end of anorectic mucosa.

Results: operating time, ranged from 110 to 180 minutes.

The length of bowel resections ranged from 9 to 25 cm.

the length of hospital stay depended on the amount of fecal impaction in the colon.

Older children with substantial fecal impaction required 2 weeks of preoperative saline enema.

One infant needed 3 days for bowel preparation, the same as for conventional colorectal surgery.

The hospital stay ranged from 6 to 7 days in children younger than 2 years and 10 to 28 days in older children.

There was no intraoperative or postoperative complication related to the pull-through procedure.

One case of colitis occurred in the 6 years old child, which required rectal tube decompression one week after the operation.

Seven patients passed stool within 24 hours after surgery.

All patients had normal bowel movements within 3 weeks.

There was no rectal cuff stricture or enter colitis during one year of follow-up.

Conclusion : trans anal one-stage end rectal pull-through operations for recto sigmoid lesions from Hhirschsprung's disease can be performed successfully in all ages of children with good results, avoiding trans abdominal exploration.

The early postoperative enter colitis in the older children might occur and should be treated urgently.

The partial colonel anastomosis obstruction found in older children could be treated by placing a rectal tube into the anus to decompress the dilated pull-through colon.

The limitation of this approach is that retroperitoneal fixation of the descending colon could not be dissected by Tran's anal route.