Background: Most children have a successful outcome after a pull-through for Hirschsprung's disease. Some may have persisting symptoms after the pull-through. They could be managed conservatively, need minor surgical procedures, or a redo pull-through will be required. In this study, we presented our results in the management of the obstructive complications after pull-through for Hirschsprung's disease. Results: During the specified time period from January 2011 to December 2015, 21 patients presented to our department with persistent constipation or recurrent enterocolitis after a pull-through for Hirschsprung's disease. Their age ranged between 4 months and 5 years (mean 2 years, median 2.5 years). They were 13 males and 8 females. Eleven patients underwent initial trans-anal endorectal pull-through, 4 underwent Duhamel procedure, and 6 underwent abdominal Soave technique. Three of the 11 patients with initial trans-anal endorectal pull-through had a tight anastomotic stricture which responded well to dilatation, 2 had a long muscular cuff which was incised laparoscopically, 4 had spasm of the internal anal sphincter which was relieved by sphincterotomy, and 2 had residual aganglionosis which required a redo pull-through. Two of the 4 patients who underwent initial Duhamel procedure had a long spur which was divided using a stapler, and the other 2 patients had residual aganglionosis which required a redo pull-through. One of the 6 patients who underwent abdominal Soave technique developed a long tight stricture and required a redo pull-through; in 1 patient, biopsy confirmed hypoganglionosis of the whole colon and was managed medically, and 4 patients had spasm of the internal anal sphincter which was relieved in 1 of them by sphincterotomy and in 2 by botulinum toxin injection while the remaining patient did not improve by either sphincterotomy or botulinum toxin injection. Conclusion: Persistent constipation or recurrent enterocolitis after pull-through for Hirschsprung's disease should be managed according to the cause; they could be managed medically by simple surgical procedures, or a redo pull-through may be required.

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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACTPurpose: to include the most relevant preoperative imaging features of sacrococcygeal teratoma (SCT) in a grading system that would provide guidance to surgeons during excision of such rare tumors.Patients and Methods: The medical records of patients with SCT, who were managed at our hospital during the period 2009 through 2016, were retrospectively reviewed. Only cases of SCT with available preoperative cross-sectional imaging studies (MRI and/or CT scans) were included in the study. The preoperative imaging features were correlated to the operative and pathological findings.Results: The study included 24 cases of SCT (20 females and 4 males). Their age at presentation ranged from day one to 36 months. The following were identified as relevant preoperative imaging features to be included in our proposed grading system: tumor size, level of deep extension of the tumor, and tumor consistency. Among predominantly cystic SCT, a special subtype C3 could be identified with its characteristic irregular internal cyst wall thickening caused by the in-growth of solid tumor component. These cases were always associated with immature pathology.Conclusion: MRI is a useful modality in the preoperative assessment of cases of SCT by providing a grading system that can indicate for the prognosis and degree of expected surgical challenge.

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