Abstract:
Background: The pull-through procedure is the definitive surgical management of Hirschsprung's disease. With the emergence of modern procedures, pull-through surgery has undergone significant changes. Despite single-stage transanal-endorectal pull-through (TERPT) indisputable success, there is yet no optimal multistage approach.
Objective: This study aimed to compare outcomes following multistage Rehbein’s and Swenson’s procedures among Hirschsprung’s (HD) patients at MNH.
Methods: A retrospective cross-sectional study was conducted at Muhimbili National Hospital (MNH), Tanzania. The study involved 49 patients, aged <11years who underwent Swenson’s and Rehbein’s pull-through from January 2018 to July 2020. Data was retrieved from the patient’s medical files and divided into two groups; Rehbeins and Swenson’s. The comparison was done in terms of short and long-term complications, operative time, rate of additional operation, length of hospital stay, and rate of redo-pull through. Multivariate logistic regression was performed to determine statistical differences between the two groups.
Results: A total of 49 patients (male 36 and female 11) were included, with median ages at diagnosis and pull-through of 35 and 45 months, respectively. Thirty-one (63.3%) had Swenson's surgery, and 18 (36.7%) had Rehbein's procedure. Overall, there were 27/49 (55.1%) patients who had complications. In multivariate logistic regression, Rehbein's surgery had a larger proportion of total complications, 14/18 (77.8%) than Swenson's 13/31 (41.9%); (OR=6.5 (1.4-30.7); p=0.018). The Swenson’s group had a significant large number of patients with Voluntary Bowel Movement (22/29 (75.8%) compared to the Rehbeins group's 5/15 (33.3%); p=0.019. Constipation was more common in Rehbein’s group 8 (53.3%) than in the Swenson group 5 (17.3%), 6.3 (1.2-33.7); p=0.031. Rehbein's operation had a greater rate of residual-aganglionic 4/15 (26.7%) than Swenson's 1/29 (3.4%), but was not significant in multivariate analysis p=0.080. Soiling and anastomotic stricture did not differ significantly. In Rehbein's procedure, 9/18 (50%) had more additional operations than Swenson's procedure on 6/31 (19.4%), (OR=4.9 (1.1-21.2); p=0.038). Redo pull-through was significantly higher in Rehbein's group than in Swenson's group (OR=7.1 (1.2-40.9); p=0.028). In terms of operating time, hospital stay length, and readmission rate, there was no difference. The mortality rate was 10.2% and was caused by sepsis and hemorrhage.
Conclusion and Recommendation: In terms of bowel functional outcome, fewer additional operations, and a reduced rate of redo pull-through, the Swenson procedure outperforms Rehbein’s technique. The majority of Swenson's patients have a voluntary bowel movement, which is the primary goal of pull-through.
Sepsis is the major cause of post-pull-through mortality.
Even though these study findings favor Swenson's method over Rehbein's, a bigger prospective multicenter study is needed.
