Swenson's pull-through in older children and adults: peculiar peri-operative challenges of surgery

Abstract

Introduction: The definitive treatment of Hirschsprung's disease is removal of the aganglionic bowel by a pull-through surgery. In most cases this surgery is performed in infancy or the neonatal period as presentation in older children and adulthood is rare. Nevertheless, pull-through in this age group may be necessary and present peculiar challenges.

Materials/methods: A prospective study of patients above 5 years with Hirschsprung's disease who presented at LUTH, Lagos between January 2007 and July 2010.

Results: There were fourteen patients (10 males and 4 females). The median age was 9 years (range 5-31 years). All the patients presented with constipation and abdominal distension. Seven patients presented with intestinal obstruction necessitating colostomy. Thirteen patients had short segment Hirschsprung's disease limited to the rectosigmoid. The only exception had long segment disease with the transition zone located at the transverse colon. Ten patients (71.4%) had colostomy before definitive pull-through while four patients (28.6%) had primary pull-through procedure without a colostomy. The definitive pull-through procedure done in all the patients was Swenson's abdomino-perineal pull-through and all the patients had a 2-layered colo-anal anastomoses. Due to the rigid pelvis in these patients, as well as possible scarring, simple blunt dissection was difficult in these cases. The median length of follow up was 11 months (range 6-28 months). There was one case (7.1%) of mortality.

Conclusion: Older patients with Hirschsprung's disease present with intestinal obstruction and poor nutritional status that may necessitate preoperative colostomy. Swenson's pull-through in them poses peculiar challenges of mobilization of bowel and achieving a reliable colo-anal anastomosis, however, outcome is comparable with surgery in younger children if these challenges are overcome.