Pull through for Hirschsprung disease without planned rectal decompression is safe

  • Chloe Roy
    Department of Paediatric Surgery, The Great North Children's Hospital, Newcastle upon Tyne, UK
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  • Bruce Jaffray
    Corresponding author at: Department of Paediatric Surgery, The Great North Children's Hospital, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, United Kingdom.
    Department of Paediatric Surgery, The Great North Children's Hospital, Newcastle upon Tyne, UK
    Search for articles by this author


      • Largest series comparing immediate with delayed surgery.
      • Immediate surgery does not lead to an increase in complications.
      • Immediate surgery does not lead to an increase in revisions.
      • Immediate surgery does not lead to an increased need for subsequent stomas.



      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.

      Level of Evidence



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        • Pierro A.
        • Fasoli L.
        • Kiely E.M.
        • Drake D.
        • Spiz L.
        Staged pull-through for rectosigmoid Hirschsprung's disease is not safer than primary pull-through.
        J Pediatr Surg. 1997; 32: 505-509
        • Kenny S.E.
        Get it right first time paediatric general surgery and urology. London.
        • Teitelbaum D.H.
        • Cilley R.E.
        • Sherman N.J.
        • Bliss D.
        • Uitvlugt N.D.
        • Renaud E.J.
        • et al.
        A decade of experience with the primary pull-through for hirschsprung disease in the newborn period: a multicenter analysis of outcomes.
        Ann Surg. 2000; 232: 372-380
        • Wester T.
        • Rintala R.J.
        Early outcome of transanal endorectal pull-through with a short muscle cuff during the neonatal period.
        J Pediatr Surg. 2004; 39 (discussion -60): 157-160
        • Albanese C.T.
        • Jennings R.W.
        • Smith B.
        • Bratton B.
        • Harrison M.R.
        Perineal one-stage pull-through for Hirschsprung's disease.
        J Pediatr Surg. 1999; 34: 377-380
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Allin B.S.R.
        • Bradnock T.
        • Kenny S.
        • Kurinczuk J.J.
        • Walker G.
        • Knight M.
        • et al.
        NETS1HD study: development of a Hirschsprung's disease core outcome set.
        Arch Dis Child. 2017; 102: 1143-1151
        • Shankar K.R.
        • Losty P.D.
        • Lamont G.L.
        • Turnock R.R.
        • Jones M.O.
        • Lloyd D.A.
        • et al.
        Transanal endorectal coloanal surgery for Hirschsprung's disease: experience in two centers.
        J Pediatr Surg. 2000; 35: 1209-1213
        • Kyrklund K.
        • Sloots C.E.J.
        • de Blaauw I.
        • Bjornland K.
        • Rolle U.
        • Cavalieri D.
        • et al.
        ERNICA guidelines for the management of rectosigmoid Hirschsprung's disease.
        Orphanet J Rare Dis. 2020; 15: 164
        • Westfal M.L.
        • Okiemy O.
        • Chung P.H.Y.
        • Feng J.
        • Lu C.
        • Miyano G.
        • et al.
        Optimal timing for Soave primary pull-through in short-segment Hirschsprung disease: a meta-analysis.
        J Pediatr Surg. 2022; 57: 719-725
        • Bjornland K.
        • Pakarinen M.P.
        • Stenstrom P.
        • Stensrud K.J.
        • Neuvonen M.
        • Granstrom A.L.
        • et al.
        A Nordic multicenter survey of long-term bowel function after transanal endorectal pull-through in 200 patients with rectosigmoid Hirschsprung disease.
        J Pediatr Surg. 2017; 52: 1458-1464
        • Elhalaby E.A.
        • Hashish A.
        • Elbarbary M.M.
        • Soliman H.A.
        • Wishahy M.K.
        • Elkholy A.
        • et al.
        Transanal one-stage endorectal pull-through for Hirschsprung's disease: a multicenter study.
        J Pediatr Surg. 2004; 39 (discussion -51): 345-351
        • Hackam D.J.
        • Reblock K.K.
        • Redlinger R.E.
        • Barksdale Jr., E.M.
        Diagnosis and outcome of Hirschsprung's disease: does age really matter?.
        Pediatr Surg Int. 2004; 20: 319-322
        • Nasr A.
        • Langer J.C.
        Evolution of the technique in the transanal pull-through for Hirschsprung's disease: effect on outcome.
        J Pediatr Surg. 2007; 42 (36-9; discussion): 9-40
        • Gosemann J.H.
        • Friedmacher F.
        • Ure B.
        • Lacher M.
        Open versus transanal pull-through for Hirschsprung disease: a systematic review of long-term outcome.
        Eur J Pediatr Surg. 2013; 23: 94-102