Pull through for Hirschsprung disease without planned rectal decompression is safe

Definitive surgery for Hirschsprung disease (HD) is typically deferred to allow rectal washouts. In contrast, we have performed pull through on the next available operating list following diagnostic biopsy. Our aims are to compare outcomes of surgery without planned decompression vs. surgery where the timing of pull through was deferred.

A consecutive series undergoing pull-through. Timing of surgery was at surgeon's discretion and classified as either no planned decompression surgery or other. Outcomes were i) complications graded >3b Clavien-Dindo (CD) within 30d, or ii) a need for a revisional pull through or iii) a post-pull-through stoma. We excluded total colonic aganglionosis.

156 children (116 boys) underwent pull-through. 71 had surgery without planned decompression. The indications for timing in the other 85 were: planned after home washouts (n = 28), planned after stoma (n = 29), diagnostic error (n = 19), prematurity (n = 3), late presentation (n = 2) and other (n = 4). The mean age at surgery in the surgery without planned decompression group was 18 days (range 1-49 days) vs. 310 days (range 14-4084 days). 5/72 (7%) undergoing surgery without planned decompression experienced a complication of ≥CD 3b, compared to 7/85 (8%) of delayed surgery (p = 0.8). 3/71 (4%) of the surgery without planned decompression group required a stoma following pull through compared to 11/83 (13%) of the delayed group (p = 0.059). 5/71 (7%) of the surgery without planned decompression group required revisional pull through compared to 13/85 (15%) of the delayed surgery group (p = 0.1).

Surgery without planned rectal decompression for HD leads to no increase in significant complications, requirement for stoma or revision. Early definitive surgery is safe, and the use of pre-operative stoma or rectal washouts is not always necessary.

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