Perioperative outcomes in primary neonatal pullthrough versus pullthrough in older children with Hirschsprung...

Primary pullthrough for Hirschsprung disease is the current standard in most uncomplicated standard segment disease. In this review and meta-analysis, we aimed to compare perioperative outcomes and functional outcomes for pullthrough done in the neonatal period compared to that in older age. PubMed, Medline, Embase, CINAHL, SCOPUS, and Web of Science were searched for relevant publications in English from inception to June 29, 2024. Twenty studies were included in the qualitative analysis with a total 3197 patients matching the review criteria. All included studies were observational in nature, with 1 prospective cohort study, 13 retrospective cohort studies, and 6 case series. Findings suggested primary pullthrough beyond 1 month of age was superior in most outcomes, including: shorter post-operative length of stay (LOS) (MD3.11 days [95% CI 1.34, 4.87]), perioperative sepsis (OR1.76, [95% CI1.26, 2.47]), anastomotic leak (OR2.68 [95% CI0.81, 8.90]), perianal excoriation up to 3 months (OR5.52 [95% CI 3.07, 9.9]), post-operative HAEC at 3 months (OR5.49 [95% CI 3.35, 9]), and anal stenosis (OR3.04 [95% CI 1.07, 8.67]). Pullthrough performed during the neonatal period was associated with a shorter operative time (MD-26.41 min [95% CI - 41.57, 11.26]). There was no significant difference in overall SSI, 30-day readmissions, and pre-operative HAEC. Functional outcomes were assessed in 8 studies showing some tendency towards constipation and incontinence in the older children, and more observed stool frequency and for longer duration post-operatively in the neonates. Older children with Hirschsprung tend to have a better post-operative course and less morbidity compared to neonates. Performing the pullthrough after 1 month is safe and likely to offer the best post-operative outcomes. This review was limited by the low level of evidence and inconsistent definitions of outcomes. Results will need to be verified with a large prospective study.