Clinical and manometric evaluations of anorectal function in patients after transanal endorectal pull‐through operation for Hirschsprung's disease: A multicentre study

Abstract

Aim: Transanal endorectal pull-through (TEPT) operation is one the most popular operations for Hirschsprung's disease. This aim of the present study was to evaluate its outcome by clinical and manometric assessments. Patients and Methods: This study was a multicentred study involving all three paediatric surgical centres under the Hospital Authority in Hong Kong. All patients, over the age of 3 years, who had undergone primary TEPT operation for more than 1 year, were included in the present study. Clinical evaluation with bowel function score (BFS) and anorectomanometry were carried out. A BFS > 18 and sphincter resting pressure between 30 mmHg and 60 mmHg were considered normal. Those with concomitant anorectal/neurological anomaly or who could not cooperate were excluded. Results: A total of 37 patients were enrolled in this study. The median age was 60 months (range: 36-144 months), and the median age at the time of operation was 3 months (range: 0.5-60 months).With respect to functional outcomes, six patients (16.2 per cent) suffered from constipation, but more than two-thirds of patients had satisfactory stool consistency, as well as frequency. Sixteen patients (43.2 per cent) had no report of any soiling. For the BFS, 26 patients had a BFS above 18, with the median value being 16 (range: 7-20). Manometric assessment revealed that 27 patients (72.9 per cent) had sphincteric resting pressure within the normal value, and the median value was 45 mmHg (range: 14-79 mmHg). Rectoanal inhibitory reflex was present in six patients (16.2 per cent), and the median value for the volume of air to elicit the first anal sensation was 41 mL (range: 18-126 mL). Using univariate analysis, long segment disease was identified as a risk factor for developing soiling of more than two times per week [relative risk (RR): 1.87, 95 per cent confidence interval (CI):1.03-2.22, P = 0.05], whereas the creation of stoma (RR: 1.69, 95 per cent CI: 1.41-2.14, P = 0.04) and occurrence of postoperative enterocolitis (RR: 1.58, 95 per cent CI: 1.36-1.0, P = 0.04) were risk factors for abnormal bowel function score. There was no significant risk factor identified for abnormal manometric results. Lastly, patients with abnormal sphincter resting pressure detected in the anorectomanometry study were also more likely to have an abnormal BFS. Conclusion: Most patients have satisfactory clinical and manometric outcomes after primary TEPT operation. Anorectomanometry findings can predict clinical outcomes. Patients with long segment disease, development of enterocolitis and stoma creation before operation will need more attention, as they are prone to develop abnormal bowel function. Early interventions, such as manometric assessment and proper bowel management, are recommended in order to correct bowel dysfunction, as well enabling patients to have a better quality of life.

Post‐operative anorectal manometry in children with Hirschsprung disease: A systematic review

“…A variety of manometry techniques were reported. Water or saline perfused catheters were utilized in 16 studies 10,13,15–18,20–23,25,26,28,30–32 . High‐resolution manometry was described by two 29,30 .…”

“…Resting pressure was the most commonly reported parameter, being described by all studies 10–32 . However, the location of measurement and calculation varied.…”

“…In the latter of these studies, the unchanged anal pressures, along with the absence of bowel dysfunction reported by the seven children assessed, led the authors to conclude that transanal procedures preserve sphincter complex function 23 . In contrast, while “normal” resting pressures were reported in two studies, a high proportion of those children reported fecal incontinence (57% 11 ; 33% >twice per week 10 ) and reduced Bowel Function Scores (mean BFS 16, range 7–20; normal ≥18), 10,11 suggesting a poor correlation between “normal” anal resting pressure and fecal incontinence.…”

A comparison between primary endorectal pull-through and staged procedures for patients with Hirschsprung’s disease

“…For unknown reasons, some patients restore the reflex after surgical repair, but most patients wouldn't be able to restore this reflex. [29] Loss of this reflex contributes to persistent internal sphincter spasm (Achalasia). [30] This shows that the pathology in Hirschsprung disease is not localized to the aganglionic segment.…”

Short and long-term quality of life outcomes in children after surgery for Hirschsprung Disease or Anorectal Malformations: A systematic review and meta-analysis

“…These surgical techniques have improved the results of children with HD by decreasing operation time, blood loss, length of hospital stay, and frequency of postoperative complications at three years after surgery (8)(9)(10). Despite these short-term advantages, bowel dysfunction (e.g., constipation, fecal incontinence) and enterocolitis after these surgical procedures persists long-term, and can consequently affect the psychosocial health of children with HD or ARM into adulthood (11)(12)(13)(14).…”