Developing an Animal Model for Swenson Transanal Endorectal Pull-Through: A New Possibility for Training and Research Purposes.

As far as we know, no report uses the Swenson transanal endorectal pull-through technique in an animal model. Our objective is to describe the use of this technique as an experimental model for training and research purposes. Ten Norfolk hybrid rabbits were randomly selected from our experimental laboratory, with a mean weight of 3539.3 (± 678.4) g. Neither colon preparation nor fast were used before the procedures. The surgical technique was based on the description performed by Levitt et al. (2013, J Pediatr Surg. 2013;48(11):2289-2295). Information related to the surgical procedures and the clinical evolution in the postoperative period were recorded and analyzed. There were no deaths or severe complications. The anesthetic and the surgical times were significantly higher for the first three animals of the experiment. Our animal model proved adequate to perform the transanal endorectal Swenson pull-through technique, allowing the training of surgical skills through a model similar to the human, with few anesthetic complications and good postoperative evolution, including postoperative follow-up. We believe that it will serve as a learning tool in many institutions that are continuously searching for improved new techniques and will support new researches in this area.

Duhamel Versus Swenson Pull-Through for Total Colonic Aganglionosis: A Multi-Institutional Study.

BACKGROUND: Total colonic aganglionosis (TCA) is a rare variant of Hirschsprung disease (HD) where the colon and portion of distal ileum lack ganglion cells. Most pediatric use either a straight ileoanal (Swenson or Yancey-Soave) or a short Duhamel pull-through for TCA. There are no large studies comparing these techniques. We aimed to compare short-and medium-term outcomes between these approaches. METHOD: A retrospective review was performed among children with TCA from 2001 to 2019 undergoing a primary Duhamel or Swenson pull-through across three large children's hospitals. Patients undergoing redo and patients with greater than 30 % small bowel aganglionosis were excluded. We gathered data on demographics, operative approach, and outcomes at one, two, and three years. Continuous variables were analyzed with t-tests and categorical variables with Chi square or Fisher's tests. RESULTS: There were 54 patients, with 26 (48 %) undergoing Duhamel and 28 (52 %) undergoing Swenson pull-through. There were no differences in sex, age, medical comorbidities, or operative details, including age at pull-through, laparoscopic vs open, length of involved small bowel, and operative time. Length of stay and post-operative complications were not different. Three years after pull-through, patients undergoing Duhamel had fewer stools per day (1-3 stools 69.6 % vs 14.3 %, p = 0.003) and were less likely to be prescribed fiber supplementation (4.2 % vs 43.8 %, p = 0.003). There were no differences in irrigations, botulinum toxin administration, loperamide, or HD admissions. CONCLUSION: Both Duhamel and straight pull-throughs are safe for treatment of TCA, with acceptable short- and medium-term outcomes. Further studies on patient-reported outcomes are necessary to examine long-term differences. LEVEL OF EVIDENCE: III.

Adopting the Swenson-like technique for patients with Hirschsprung disease in Vietnam.

PURPOSE: To evaluate outcomes of adopting the Swenson-like technique in transanal pull-through for Hirschsprung disease (HD) at a children's institution in Southeast Asia. METHODS: A retrospective chart review was performed over 42 months at a safety-net pediatric hospital in Vietnam. RESULTS: From January 2019 to June 2022, the Swenson-like technique was implemented and performed on 139 patients (115 male, 24 female, mean age 6.4 ± 11.96 months). There were 123 transanal-only resections, 5 transanal plus laparoscopic, and 11 transanal plus laparotomy. The mean operative time was 70.9 ± 43.6 min. The average length of the resected specimen was 18.8 ± 10.9 cm. No urethral or vaginal injuries occurred. Postoperative complications included 1 anastomotic leak (0.7%), 4 anastomotic stenoses (2.8%), and 2 perianal abscesses in the setting of recurrent enterocolitis (1.4%). With a mean follow-up of 26 ± 11.9 months (range 3-48 months), there were 25 enterocolitis cases (17.9%), 45 patients with constipation (32.3%), 1 episode of fecal incontinence lasting longer than 6 months (0.7%), and 1 rectal-vestibular fistula noted one year postoperatively (0.7%). There were no deaths. CONCLUSION: The Swenson-like technique in transanal pull-through for Hirschsprung's disease was safely adopted at our institution. The results show that applying this technique uniformly in a single institution led to excellent outcomes.

Changes in postoperative quality of life of pediatric total colonic aganglionosis patients: effect of pull-through technique.

AIM: To assess mid-/long-term quality of life (QOL) of total colonic aganglionosis (TCA) patients. METHODS: Modified pre-existing QOL assessment tools for general lifestyle (GL), bowel function (BF), and mental health (MH) were administered to postoperative TCA patients from five institutions, who were at least 7 years old to compare Duhamel (with pouch) and Swenson/Soave (without pouch) techniques between children (Ch 7-12 years old), teenagers (Tn 13-19), and adults (Ad 20 and over). For MH, caregivers were also interviewed, but separately. Maximum scores were 12 for GL/MH and 18 for BF. RESULTS: There were 32 subjects. GL and BF scores increased significantly from Ch (GL 4.8 ± 2.5, BF: 11.3 ± 4.6) to Tn (GL 7.8 ± 2.6, BF 16.2 ± 3.0); scores for MH did not change significantly. Mean caregiver MH scores were significantly lower than mean subject MH scores for all age groups (subject scores: 10.1, 10.7, 10.7 versus caregiver scores: 6.8, 7.8, 8.1 for Ch, Tn, Ad, respectively). PT technique/presence of a pouch did not influence the incidence of enterocolitis or QOL scores. CONCLUSION: MH responses showed subjects felt better than caregivers believed. This discrepancy could cause conflict despite steadily improving GL/BF. QOL was unaffected by PT technique/presence of a pouch.

Modified Swenson-like pull-through with temporary stump for redo pull-through after failed Transanal Endorectal Pull-through.

Hirschsprung's disease is a congenital anomaly in the distal part of the gastrointestinal tract, characterised by the absence of neuronal ganglion cells in the myenteric and submucosal plexus, causing the accumulation of faeces in the proximal portion. Dehiscence of coloanal anastomosis is one of the complications of Transanal Endorectal Pull-through (TEPT) surgery. This paper reports a case of Hirschsprung's disease in a six-year-old girl who experienced anastomotic dehiscence after undergoing TEPT. Due to post-TEPT anastomotic dehiscence, we performed a re-do pull-through with the modified Swenson-like method using a temporary stump. The stump is maintained for two weeks, then removed. On long-term evaluation, there was normal digestive function, no incontinence, and an excellent anal outcome. The modified Swenson-like pull-through with temporary stumps can be an alternative surgical technique for re-do pull-through after failed TEPT, with satisfactory results.

Routine botulinum toxin injection one month after a Swenson pull-through does not change the incidence of Hirschsprung associated enterocolitis.

PURPOSE: Patients with Hirschsprung disease (HD) are at risk of Hirschsprung associated enterocolitis (HAEC) following pull-through. The purpose of this study was to determine if routine Botulinum toxin (BT) injected one-month post pull-through decreases the incidence of HAEC. METHODS: We reviewed patients who underwent a primary (not redo) pull-through operation for HD between April 2014 to December 2019. Over the most recent 18 months, BT was administered routinely one-month post-pull-through procedure; these patients were compared to the prior group that did not receive routine BT. A HAEC episode was defined as one that required initiation of treatment for obstructive symptoms in the inpatient or outpatient setting with antibiotics and irrigations. Categorical variables were compared using the nonparametric chi-square test or Fisher's exact test. Continuous variables were compared using the two-tailed Student's t-test. P-value <0.05 was determined to be statistically significant. RESULTS: A total of 70 patients underwent Swenson pull-through during the study period (52% male). There were no statistically significant differences in demographics in the BT vs. non-BT group. Routine post-pull-through BT was given in 28 patients and did not significantly change HAEC incidence compared to the non-BT group (12/28, 43% vs. 16/42, 38%. P = 0.691). Of note, the BT group patients developed HAEC significantly sooner than the patients in the non-BT group (37.5 days vs. 253 days, p = 0.029). More patients in the BT group (n = 18, 64%) required at least one subsequent BT injection compared to the patients in the non-BT group (n = 11, 26%. P = 0.001). CONCLUSIONS: We conclude that routine postoperative botulinum toxin injection given one month postoperatively from Swenson pull-through did not change the incidence of HAEC. A prospective controlled study is necessary to confirm these findings.

Minimally invasive surgery in older children with Hirschsprung's disease in a North African Country.

Introduction: Hirschsprung's disease (HSD) is a bowel congenital anomaly affecting mainly the enteric nervous system of the rectosigmoid region. Surgical resection of the aganglionic segment and restoration of bowel continuity via coloanal anastomosis is the main stay of treatment. In 1999, Georgeson et al. introduced a new minimally invasive approach as a standard for the pull-through mechanism. This study aims to evaluate the safety and possibility of the use of a laparoscope in older children with HSD with various techniques for HSD surgery. Methods: This study was performed based on 20 patients diagnosed with HSD. The patients are older children, whose mean age is 3 years. The cases showing enterocolitis or obstruction were excluded from the study. We divided these cases into two groups: Group A, consisting of 10 cases where laparoscopic-aided transanal pull-through was done, and group B, in which the laparoscopic Duhamel procedure was done. Results: We compared between two groups for the first year follow-up period. In Group A, there were two cases of stenosis that respond to regular dilation: one case of enterocolitis and one case of fecal incontinence. In Group B, we had two cases of constipation and three cases of enterocolitis. There was no anastomotic leak in both groups. Conclusion: Minimally invasive surgery is safe in management of HSD in older children in one stage, either by using the Duhamel or transanal Swenson procedure.

Factors Affecting Higher Readmission Rates and Costs in Pediatric Patients With Hirschsprung Disease.

BACKGROUND: Hirschsprung disease is a relatively uncommon disorder of the developing gastrointestinal tract that requires surgical intervention to restore long-term function. While readmission for Hirschsprung-related complications is a known concern in these patients, we sought to identify patient-level factors associated with a prolonged hospital stay, increased costs at the time of a pull-through operation, as well as the risk for all-cause inpatient readmission after surgery. We hypothesized that higher level of care requirement during the operative stay, age at operation, and length of stay (LOS) would portend increased readmissions and disease-related complications such as Hirschsprung-associated enterocolitis. METHODS: Data was obtained from the Pediatric Health Information System database on all Hirschprung patients who underwent a pull-through operation between 2004 and 2019. Regression analyses were performed on this cohort of 3345 patients. Multivariable regression models were utilized to analyze the key outcome variables of postoperative LOS and adjusted charges. RESULTS: Post-operative LOS was significantly increased by the presence of a surgical complication, congenital/genetic defect, or neurologic/neuromuscular defect. Increased LOS was also seen in Black patients. The cost of pull-through operations was significantly higher in patients admitted to the NICU and ICU during index hospitalization, with a cost increase of approximately $75,000 and $57,000 respectively. Presence of a surgical complication, comorbid congenital/genetic defect, and need for mechanical ventilation were associated with higher odds of inpatient readmission. CONCLUSION: The management of patients with Hirschsprung disease is longitudinal and complex. Identification of key patient metrics can aid clinicians in developing targeted care and education strategies to minimize readmission and excessive hospital charges.

Optimism for the Single-stage Transanal Swenson in Neonates.

BACKGROUND: Hirschsprung's disease (HD) has been traditionally treated from infancy onward and different techniques have been used including Swenson, Soave, and Duhamel procedures. The purpose of this study was to evaluate the transanal Swenson's procedure for classical rectosigmoid HD in neonates. PATIENT AND METHODS: This was a prospective study in which neonates diagnosed with HD were recruited from January 2017 to December 2018. Cases with a transition zone proximal to the midsigmoid were excluded. All patients underwent a transanal Swenson's procedure in the neonatal period using a unified protocol. Intraoperative course and postoperative outcomes such as leak, pelvic abscess, soiling, perianal excoriation, stricture, enterocolitis, and constipation were evaluated and all patients were followed for at least 6 months. RESULTS: Twenty-three patients (17 males and 6 females) underwent transanal Swenson's procedure. The mean age was 22 ± 5.7 days. Follow-up ranged from 6 to 30 months. No anastomotic leak, retraction, or prolapse was reported. Mild perianal excoriations occurred early in 9 (39%) cases and all responded to medical treatment and disappeared before 2 months postoperatively. Stricture occurred in 2 (8%) patients, enterocolitis in 3 (13%), and constipation in 3 (13%). CONCLUSION: Transanal Swenson's procedure is feasible and can be performed safely in neonates with rectosigmoid HD with good short-term outcomes. Proper patient selection and standard protocol following fine procedural hall-marks and details are keys for optimal results and patient satisfaction.

Transanal-only Swenson-like pull-through for late diagnosed Hirschsprung disease.

Hirschsprung disease (HD) is an obstructive colonic process usually diagnosed in the neonatal period. A small subset of cases are diagnosed late, present with severe constipation without enterocolitis and have low rectosigmoid disease. A transanal-only pull-through is a well-described approach but in the newborn period risks a situation whereby the transition zone is higher than the sigmoid. We present our experience with the unique patient population of older HD patients in whom the transition zone was reliably reachable via a single-stage transanal approach, performed in prone position. Patients between 2 and 6 years of age with a rectal or sigmoid transition zone and minimal proximal colonic dilation can undergo a primary transanal pull-through surgical approach.

Experience with the Redo Pull-Through for Hirschsprung's Disease.

AIM: This study aims to evaluate the need of Redo pull-through (Re PT) procedures for Hirschsprung's disease (HD) and suggest preventive strategies. MATERIALS AND METHODS: Patients who underwent redo procedures for HD from 1980 to 2016 by a single surgeon were retrospectively reviewed. RESULTS: Of 167 patients operated for HD, 32 underwent Re PT; 7 were previously operated by the same surgeon, while 25 were referred from outside. Indication for Re PT included residual disease including the rectal pouch following-Duhamel (12), false-negative biopsy (3), retraction of bowel (5), anorectal stricture (2), bowel twist (1), cuff inversion (2), postmyectomy continued symptoms after primary PT (1), fecal fistula (1), Re PT after surgery for adhesive intestinal obstruction (3), bleeding (1), and combination of causes, including scarred perineum (1). Age at follow-up ranged from 2.5 to 26 years. Proximal diversion was performed in 19 and 14 underwent open Scott Boley's/Soave PT and 5 ileoanal anastomosis. Of the remaining, nondiverted 13 patients, 5 underwent transanal endorectal PT and 8 underwent PT of colostomy. CONCLUSIONS: Most patients of Re PT came after an initial Duhamel's procedure. Retraction of bowel, inversion of cuff, twist, distal bowel stricture, and perianal fibrosis were found after Scott Boley procedure. Proper planning with an initial diversion, nutritional buildup, barium study evaluation, frozen section facility, experienced pathologist, and an expert surgeon are prerequisites for a successful outcome after an initial as well as Re PT.

Single-stage laparoscopic transanal pull-through modified Swenson procedure without leaving a muscular cuff for short- and long-type Hirschsprung disease: a comparative study.

PURPOSE: The Soave procedure (SO) is performed most commonly for Hirschsprung disease. SO reduces the risk of injury to the pelvic structures; however, a residual aganglionic muscle cuff could interfere with bowel movement and lead to obstructive enterocolitis. The Swenson procedure is considered ideal in terms of peristalsis. Currently, laparoscopic surgery provides better visualization and facilitates precise dissection, possibly leading to feasible performance of the laparoscopic modified Swenson procedure (SW). We present our operative technique and the efficacy of the SW compared with that of SO. METHODS: We retrospectively reviewed the records of 16 and 27 patients who underwent SW and SO, respectively, between 2012 and 2017. RESULTS: Operative time, blood loss, length of stay, and frequency of bowel movements showed no significant difference between the two groups. In the SW group, temporary dysuria occurred in one patient, postoperative enterocolitis in two, wound infection in one, and severe perianal excoriation in four, whereas in the SO group, obstructive symptoms occurred in three patients, small-bowel obstruction in one, and severe perianal excoriation in three. The complications and outcomes were comparable between both groups. CONCLUSION: Laparoscopic SW was safe and feasible for the short-term follow-up outcomes.

Comparative analysis of the modified laparoscopic swenson and laparoscopic soave procedure for children with short-segment hirschsprung disease / 实用医学杂志

Objective To compare the characteristics,complications and outcomes of the modified lapa-roscopic Swenson(MLSw)and laparoscopic Soave(LS)procedures for children with short-segment Hirschsprung disease(HD). Methods Seventy-seven pediatric patients with HD who underwent surgery from March 2007 to December 2016 were enrolled in this retrospective study. Twenty-six patients were treated with LS and 51 cases un-derwent MLSw. The preoperative,operative and postoperative data was collected,with follow-up periods ranging from 12 to 48 months. The perioperative/operative characteristics,postoperative complications,and outcomes were compared between the two groups. Results On average,the patients in the LS group had a longer operating time than that in the MLSw group(P < 0.05). Blood loss was significantly less in the MLSw group than that in the LS group(P < 0.05). There was no significant difference in feeding time between the two groups(P > 0.05). The MLSw group was discharged after a shorter hospitalization time than that in the LS group(P < 0.05). The MLSw group had lower incidences of postoperative complications than those in the LS group in the early postoperative period,with no significant difference in the rate of complications during the late postoperative period was found between the two groups. Conclusions Both LS and MLSw are suitable for treatment of children with short-segment HD. However,the MLSw operation is much simpler,with less operating time,less intraoperative blood loss,shorter hospitalization time and better bowel control in the early postoperative period. We favor this approach because it allows complete removal of the entire original aganglionic bowel,without leaving behind a cuff.

A 5-year follow-up study of neonates with Hirschsprung's disease undergoing transanal Soave or Swenson surgery.

OBJECTIVE: To investigate different outcomes and long-term efficacy of transanal Soave or Swenson surgery in treatment for neonates with Hirschsprung's disease (HD). METHODS: In the present study, a total of 29 neonatal patients were included, with 20 patients undergoing the Soave procedure and nine patients undergoing the Swenson procedure. Data collected from the patients included basic demographics, age and weight at the time of operation, pathological typing, type of operation, operative time, blood loss, length of hospital stay, bowel function, and complications. The follow-up lasted for 5 years for all patients via the outpatient clinics or by telephone. Results were statistically analyzed using SPSS version 18.0. RESULTS: The age, weight, and pathological type of patients with different surgical approaches showed no significant difference. The operation time and blood loss of patients who underwent Swenson procedure were significantly lower than those who underwent Soave procedure; P<0.05. However, intraoperative complications showed no significant difference between the two groups; P>0.05. Bowel function (Rintala score) and postoperative complications in the two groups also showed no significant difference when evaluated 3 months after the surgery; P>0.05. Patients were followed-up for a 5-year period at 3 months, 6 months, 2 years, and 5 years after surgery, respectively. Results showed that complications and bowel function recovery during the 5-year follow-up showed no significant difference between the two methods. CONCLUSION: The operation time and blood loss of the transanal Swenson pull-through procedure was lower than transanal Soave method; however the long-term outcomes of the two methods showed no significant difference. These results may give more clinical evidence in this field.

Transanal pullthrough for Hirschsprung disease: matched case-control comparison of Soave and Swenson techniques.

BACKGROUND: Both the Swenson and the Soave procedures have been adapted to a transanal approach. The purpose of this study was to compare outcomes following the transanal Swenson and Soave procedures using a matched case control analysis. METHODS: A retrospective chart review was performed to identify all transanal Soave and Swenson pullthroughs done at 2 tertiary care children's hospitals between 2000 and 2010. Patients were matched for gestational age, mean weight at time of the operation, level of aganglionosis, and presence of co-morbidities. Student's t-test and chi-squared analysis were performed. RESULTS: Fifty-four patients (Soave 27, Swenson 27) had adequate data for matching and analysis. Mean follow-up was 4±1.6 years and 3.2 ±2.7 years for the Soave and Swenson groups, respectively. No significant differences in mean operating time (Soave:191±55, Swenson:167±61 min, p=0.6), overall hospital stay (6±4 vs 7.8±5 days, p=0.7), and number with intra-operative complications (3 vs 4, p=1.0), post-operative obstructive symptoms (6 vs 9, p=0.5), enterocolitis episodes (4 vs 4, p=1.0), or fecal incontinence (0 vs 2, p=0.4) were noted. CONCLUSION: After controlling for potential confounders, there were no significant differences in the short and intermediate term outcome between transanal Soave and transanal Swenson pullthrough procedures.

Transanal, full-thickness, Swenson-like approach for Hirschsprung disease.

PURPOSE: Swenson's procedure for Hirschsprung disease (HD) was thought to disturb fecal, urinary, and ejaculatory functions leading to other approaches including the Soave and Duhamel techniques. Given our Center's experience with a full-thickness rectal dissection for anorectal malformations, and using the new transanal concept, we chose to apply these ideas to the primary treatment of HD, and describe technical aspects and impact on fecal, urinary, and sexual function. METHODS: We reviewed our series of HD patients who underwent a transanal, Swenson-like rectosigmoid dissection, assessing for postoperative stricture, anastomotic leak, enterocolitis, and long-term results for bowel, urinary, and sexual function. RESULTS: Of 67 patients, 28 had a transanal resection, 5 had transanal plus laparoscopy, and 34 had transanal plus laparotomy, of those, 28 patients had a leveling colostomy prior to referral. The average length of resection was 27 cm ± 12.7 cm. Mean follow-up was 17.2 months (range 1-96 months). 44 patients were at least three years old at follow-up and were assessed for urinary and fecal continence; all (100%) had voluntary bowel movements and urinary continence. Enterocolitis occurred in 9 patients (14%) and constipation (requiring laxatives) occurred in 21 (32%). Of 24 male patients, 21 (88%) reported the occurrence of spontaneous erections post-operatively. CONCLUSION: Our data support the fact that a modification of Swenson's original transabdominal dissection concept using the recently described transanal approach is an excellent technique for Hirschsprung, and produces excellent long-term outcomes for fecal and urinary continence, and seems to preserve erectile function.

Posterior sagittal approach in complicated Swenson's pull-through.

CONTEXT: Swenson's pull-through is one of the standard operations for the treatment of children with Hirschsprung's disease. Complications arising from the operation are difficult to treat because of fibrosis in the pelvis. The posterior sagittal approach may be a safer alternative. AIMS: The aim of this paper is to highlight our experience with the use of the posterior sagittal trans-sphincteric approach to treat unusual complications of Swenson's pull-through. SETTINGS AND DESIGN: A retrospective study of four patients who had posterior sagittal repair of their complications of Swenson pull-through at the Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria. MATERIALS AND METHODS: Four cases of Hirschsprung's disease that developed post-Swenson pull-through complications are presented. There were three males and one female. Their age ranged between 10 months and 15 years. The patients had rectovaginal fistula, rectourethral fistula, high trans-sphincteric fistula-in-ano and complete anastomotic disruption. RESULT: All the patients were successfully treated using the posterior sagittal approach. The approach was used twice in one patient without significant sequelae. The three patients were old enough to be assessed and had a Kelly score of 4-6 at follow-up. CONCLUSION: The posterior sagittal technique offers a safe approach to treat the complications of Swenson pull-through.