From the Guidelines
Pull-through procedures are indicated in adult patients with Hirschsprung's disease or other colorectal conditions, such as complicated perianal fistulising Crohn's disease, where conservative therapy has failed and permanent fecal diversion needs to be avoided.
Indications for Pull-through Procedure
- Complicated, therapy refractory perianal disease, where early remission rates are high, but sustained remission can only be achieved in a minority of cases 1
- Uncontrollable sepsis and tissue destruction, where a diverting stoma is required, but permanent fecal diversion needs to be avoided 1
- Failed conservative therapy, where alternative surgical options, such as coloanal pull-through or Turnbull-Cutait abdominoanal pull-through procedures, can be considered 1
Considerations for Pull-through Procedure
- The colon and anus must be intact for the procedure to be feasible 1
- The procedure may be considered as an alternative to proctectomy, which carries risks such as damage to the pelvic nerves, presacral abscesses, and delayed perineal wound healing 1 Note that the provided evidence does not specifically discuss Hirschsprung's disease, but rather perianal fistulising Crohn's disease and Lynch syndrome. However, the principles of surgical management can be applied to other colorectal conditions, and the pull-through procedure is a recognized treatment option for Hirschsprung's disease.
From the Research
Indications for Pull-Through Procedure
The indications for a pull-through procedure in adult patients with Hirschsprung's disease or other colorectal conditions include:
- Constipation that is unresponsive to conventional remedies 2
- Pathologic misdiagnosis 3
- Stricture 3
- Rectal stenosis 3
- Obstructing Duhamel pouch 3
- Remnant septum 3
- Incomplete resection of the transition zone 4
- Anastomotic strictures 4
- Fistulas 4
- Chronic constipation requiring enemas, cathartics, and multiple hospital admissions for management 5
Surgical Procedures
Various surgical procedures can be used to manage Hirschsprung's disease, including:
- Laparoscopic Swenson pull-through procedure 2
- Transanal endorectal pull-through (TEPT) 6
- Open pull-through procedure 6
- Redo Duhamel pull-through procedure 3, 4
- Soave endorectal pull-through procedure 5
- Duhamel-Martin procedure 5
- Anorectal myectomy with low anterior resection 5
Outcomes
The outcomes of pull-through procedures in adult patients with Hirschsprung's disease or other colorectal conditions can be favorable, with:
- Normal bowel function achieved in 61.5% of patients after redo pull-through procedure 3
- Improved obstructive symptoms in patients with anatomic or pathologic reasons following primary pull-through 3
- Satisfactory results without complications in 62 patients (91.2%) after TEPT procedure 6
- Normalization of stooling pattern immediately after redo procedure in 15 patients (88.2%) 4