Repeat pull-through surgery for complicated Hirschsprung's disease: Indications, techniques, and results

Background: Most children with Hirschsprung's disease (HD) do well after a pull-through procedure. In the occasional child in which the operation fail s, a repeat procedure may be necessary. Methods: Nine children with HD aged 20 months to 9 years underwent repeat p ull-through over a 4-year period. Original pull-throughs (six Soave, two Sw enson, one Duhamel) were performed elsewhere 12 to 95 months earlier (media n, 36 months). Indications for revision were stricture unresponsive to dila tation (n = 3) and acquired aganglionosis (n = 6). One of the latter had as sociated segmental intestinal neuronal dysplasia. One child with a strictur e after a Swenson procedure underwent a repeat Swenson. The other eight und erwent reconstruction using a Duhamel technique. Five had a defunctioning s toma before or at the time of repeat surgery. Results: Median follow-up was 15 months (range, 4 to 40 months). Complicati ons included wound infection (n = 2), anastomotic bleeding (n = 2), stoma l eak (n = 1) or stenosis (n = 1), "kinking" at the top of the Duhamel (n = 1 ), and persistent septum (n = 1). Three patients have had a good outcome wi th normal stool patterns. One has intermittent soiling, and one has what is believed to be stool-holding behavior. Four have persistent obstructive sy mptoms caused by sphincter hypertonicity, which are being successfully mana ged nonoperatively. Conclusions: Repeal pull-through surgery can be performed safely in appropr iately selected patients. Duhamel reconstruction usually is preferred for t echnical reasons, and a stoma is not always necessary. Outcome is generally favorable, but anal sphincter hypertonicity may cause persistent symptoms in some patients. J Pediatr Surg 34:1136-1141. Copyright (C) 1999 by W.B. S aunders Company.