The goals of surgical management for Hirschsprung disease are to remove aganglionic bowel and reconstruct ganglionic bowel down to the anus while preserving normal sphincter function . We prospectively followed 20 patients with simultaneous stoma closure and pull-through for immediate and short-term complications. Overall this study found that patients did well with simultaneous stoma closure and pull-through and few early complications were observed.
Existing literature has shown that early complications such as anastomotic leakage, anal strictures, and perineal excoriations have been observed . In this study anastomotic leak was observed in one patient. The anastomotic leak was recognized on the fifth post-operative day, and proximal diversion was performed. Leaks have been shown to occur due to inadequate blood supply of the pulled-through bowel and can be avoided by minimizing tension on the anastomosis. The sigmoid colon is usually mobilized by dividing sigmoid vessels and retaining marginal vessels. Often it is necessary to mobilize the splenic flexure to obtain adequate length to avoid tension on anastomosis . The patient that got bust abdomen had significant spillage intraoperatively while pulling bowel through. Bowel preparation could have helped in this case. This caused intra-abdominal sepsis hence suture breakdown of the fascial closure. We lavaged the abdomen at re-exploration and closed and patient recovery was uneventful.
One patients had a stricture in this study. Similar literature has shown that strictures and retraction of the pull-through may occur as a result of poor blood supply and tension . To minimize this complication, the authors kept the dissection in the correct plane along the rectal wall to avoid injury to the deep pelvic nerves, vessels and other structures such as the vagina, prostate, vas deferens, and seminal vesicles  as well as maintaining the blood supply.
Late complications may include ongoing obstructive symptoms, frequent bowel movements, incontinence, soiling, and enterocolitis. During follow-up period the authors observed frequent bowel movements in two children (n = 2, 10%) at three weeks, and two children experienced enterocolitis (n = 2, 20%) at 7 and 12 weeks follow-up. Patients who developed enterocolitis were admitted and treated with rectal washouts, intravenous antibiotics, and intravenous fluids.
Longer term complications that will require future follow-up will include bowel function and enterocolitis as well as the socioeconomic impact of these conditions .
The main limitation of our study was a short follow-up period and relatively small number of patients. In spite of these limitations, we are encouraged by the success of this procedure and recommend it for our setting where stoma care has many challenges, reducing number of surgeries from three to two has significant positive impact in our patients’ lives.
We did not measure the economic impact for the patients which we believe would be substantial given the costs associated with a single surgical episode – up to 1/3 can become impoverished, many come and are turned away due to no theater space but have already spent money on transport and missed . These benefits could be measured in future studies.
Like patients with anorectal malformations (ARM), many patients with HD live with stomas and the significant impacts on their quality of life (QoL). Therefore, community awareness through support groups and stoma care groups might help improve presentation, and as a result, the outcome. We created community led support group for ARM in the Mbarara, South-Western Ugandan which could be expanded to HD. This has substantially improved awareness with more patients presenting with colostomies for definitive repair.