Hirschsprung disease is defined as a developmental abnormality followed by migratory breakdown of neural crest cells. Generally, 98% of neonates pass meconium within 24 - 48 hours after delivery, but this passage fails in 90% of neonates with HD. Harold Hirschsprung, a Danish pediatrician presented the first definitive description of the disease in 1888 (
There are various techniques for treatment of HD. The outcome of any method for HD is calculated based on early and late complications. The aim is to achieve a regular bowel movement without incontinence or constipation.
The initial classic procedure was done by Swenson and Bill in 1948 (
1). Swenson described resection of aganglionic colon bowel and anastomosis of ganglionated colon to the distal rectum.
In 1964, Soave (
8) explained endorectal approach for pullthrough. In this procedure, distal rectal mucosa-submucosa removes and normal ganglionic colon pulls through the muscular cuff of aganglionic colon and coloanal anastomosis is done. This method avoids widespread dissection of rectum and preserves inner region of anal sphincter. One problem in this procedure is the presence of aganglionic muscular cuff around normal ganglionic colon and this portion of dysfunctional muscle perhaps enhances constipation cuff abscess and enterocolitis.
There are few reports about 2-stage Soave procedures. Khaleghnejad-Tabari and Moslemi-Kebria (
9) reported results of two-stage Soave for surgical management of HD in a 10-year period. They used two-stage Soave procedure in 54 cases and reported normal defecation in 90.1% of the patients. Early complications were present in 9 cases (14.7%) and late complications were seen in 14 cases (22.9%). The mortality rate was 4.9% (3 patients) ( 9). In our study, both groups were followed for an average of at least 3 years. Rate of complication was 47% for Soave group and 40% in Swenson group. Complications are usually postoperative obstructive symptoms, enterocolitis, fecal incontinence, perianal abscess and fistula, anastomotic leakage, peritonitis, and pelvic abscess formation.
Some studies examined the variable length of cuff for Soave procedure and found that incidence of enterocolitis was lower (9% vs. 30%) in the short cuff group (
10, 11). In our study in both groups, the risk of enterocolitis was the same (16.7%). The length of the cuff in this study was approximately 7 cm.
Nasr et al. (
12) studied transanal pullthrough for Hirschsprung disease by matched case–control comparison of Soave and Swenson techniques (2014).They matched patients with regard to gestational age, mean weight of patients at time of the surgery, length of aganglionosis, and comorbidities. They analyzed 54 patients (Soave 27, Swenson 27) and found no significant differences regarding mean operating time, hospital stay, complications during surgery, postoperative obstructive symptoms, number of enterocolitis, or fecal incontinence. In the present study, although numbers of enterocolitis were the same but risk of stricture, fecal peritonitis, and pelvic abscess formation were more in Soave group. On the other hand, anastomotic leak and constipation were more in Swenson group.
Zain et al. (
13) studied Swenson and Soave pullthrough from June 2006 to June 2010. A total of 25 patients (62.5%) underwent Swenson pullthrough and 15 patients (37.5%) underwent Soave pullthrough. Complication rate after Swenson procedure was 24% while following Soave procedure, it was 20%. Commonest complications after Swenson pullthrough technique were wound infection and adhesive intestinal obstruction (12%) while commonest complication after Soave procedure was anastigmatic stricture (20%). In their study, the rate of complications was higher subsequent Swenson pullthrough compared to Soave procedure. In our study, the commonest complication was enterocolitis that had the same rate in both groups.
Our study has the typical limitations of retrospective studies, including selection bias due to the preference of the operating surgeon, and the relatively small study population that could decrease statistical power. We should review results in longer terms and follow up in multiple centers.
After controlling the potential confounders, no signiﬁcant differences were seen in the short and late term complications between Soave and Swenson pullthrough procedures.