Review Article
Transanal endorectal pull-through versus transabdominal approach for Hirschsprung's disease: A systematic review and meta-analysis

https://doi.org/10.1016/j.jpedsurg.2012.12.036Get rights and content

Abstract

Aim

Transanal endorectal pull-through (TERPT) has become popular for single-stage treatment of Hirschsprung's disease. The benefits of TERPT over the conventional transabdominal approach (TAB) are still unclear. We performed a comprehensive meta-analysis comparing the clinical outcomes of TERPT and TAB.

Methods

Original articles published from 1998 to 2012 were searched from Medline, Embase, and Cochrane databases. Randomized controlled trials (RCT) and observational clinical studies (OCS) comparing TERPT and TAB were included. Outcomes evaluated included operative time, hospital stay and incidence of postoperative incontinence/soiling, constipation and enterocolitis. Pooled odds ratios (OR) were calculated for dichotomous variables; pooled mean differences (MD) were measured for continuous variables.

Results

Of 93 studies, 1 RCT and 11 OCS were included, comprising 444 cases of TERPT and 348 cases of TAB (215 Soave, 94 Duhamel, 24 Swenson, 15 Rehbein procedures). TERPT had shorter operative time (MD =  57.85 min; 95% confidence interval [CI], − 83.11 to − 32.60; P < 0.00001) and hospital stay (MD =  7.06 days; 95% CI, − 10.95 to − 3.16; P = 0.0004). TERPT had less postoperative incontinence/soiling (OR = 0.58; 95% CI 0.37–0.90; P = 0.01) and constipation (OR = 0.49; 95% CI 0.30–0.81; P = 0.005). There was no difference in incidence of postoperative enterocolitis.

Conclusion

TERPT is superior to TAB in operative time, hospital stay, postoperative incontinence and constipation. However, more randomized controlled trials are necessary to verify the benefit of TERPT for Hirschsprung's disease.

Section snippets

Literature search and data extraction

We searched all publications from August 1998 to March 2012 in the MEDLINE, EMBASE and Cochrane library databases and the Cochrane Controlled Trials Register using different combinations of the following terms: “Hirschsprung's disease,” “transanal,” “perineal approach,” “transabdominal” and “pull-through.” The reference lists of the full articles were also manually searched to identify additional eligible studies. After identifying relevant titles and abstracts, the studies were assessed for

Results

Of 93 studies reporting the outcome of the transanal approach in treating Hirschsprung's disease, 18 studies that compared outcome after TERPT with those after TAB were eligible for inclusion in our analysis. Two studies used a different methodology for assessment of postoperative results from other studies and were excluded [26], [27]. Four studies contained data that overlapped with later studies from the same centers [13], [25], [28], [29], leaving 1 RCT and 11 OCS for meta-analysis [10],

Discussion

Our meta-analysis suggests that the TERPT is superior to the conventional TAB pull-through for Hirschsprung's disease. To our knowledge, this study is the first systematic review and meta-analysis comparing TERPT to TAB pull-through for Hirschsprung's disease.

TERPT is a minimally invasive procedure, with the advantages of better cosmesis, less postoperative pain and avoidance of abdominal contamination [8]. Many studies have also suggested that TERPT reduces operative time and hospital stay

Limitations

Our results appear to favor TERPT for most postoperative outcomes. However, this result must be interpreted cautiously due to the limitations of this study. The lack of randomized trials is a key problem. Only one RCT was available and this RCT compared TERPT with the multi-stage Swenson procedure that has fallen out of favor in recent years. Most of the included studies were small retrospective studies which are prone to selection bias and may result in uneven distribution of confounding

Acknowledgments

The authors would like to thank Mr. Fahad Javaid Siddiqui, Assistant Professor of Epidemiology, Singapore Clinical Research Institute, for his invaluable help with statistical analysis.

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    These authors contributed equally to this work.

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