Pull-Through of Ganglionic Stoma in Children with Hirschsprung’s Disease Living in a Low Resource Context Spares Further Surgery for Colostomy Reverse

Abstract

Background: One-step pull-through for Hirschsprung’s disease (HSCR) is already standard in many tertiary African paediatric surgical centres where radiology and frozen sections are available. However, limited resources in many peripheral areas associated with advanced age at referral or complicated presentation make recourse to colostomy often unavoidable with a consequent three-step surgery. To simplify these children’s clinical course and spare the burden of a third procedure for colostomy reverse, a direct pull-through of the proximal ganglionic stoma is proposed. Materials and Methods: Twenty children (male/female ratio 19/1) between 3 months and 13 years with a colostomy for a suspected HSCR were selected for stoma pull-through among patients admitted to a regional Tanzanian hospital between 2016 and 2022. Histological diagnosis was always confirmed by rectal biopsies and, in some cases, colonic specimens taken during the stoma confection or revision. A ganglionic stoma was always ascertained before the pull-through procedure (11 Transanal Endorectal, 4 Soave and 5 Duhamel). Results: One death was registered in a child with Down syndrome, unrelated to surgery, and another due to HSCR acute associated enterocolitis. One stenosis required stricturoplasty, and one anastomotic leakage needed temporary ileostomy. No relationship was found between complications and the procedure of choice. Passage of stools started on the 2nd day and became regular and without soiling in a week. Conclusions: Straightforward pull-through of the ganglionic stoma may be a feasible solution for patients with HSCR and a diverting colostomy to avoid a three-step procedure. The correct position of the stoma at the transition zone must be ascertained to avoid the risk of including in the resection segment of the ganglionic bowel.