Surgical Science, 2013, 4, 258-262
doi:10.4236/ss.2013.45050 Published Online May 2013 (http://www.scirp.org/journal/ss)
Literature Review of the Outcome after One-Stage
Transanal Endorectal Pull-Through Procedure for
Hirschsprung’s Disease in Children
Irene Ortiz-Rubio1*, María Pérez-Aguilera2*#, Christina Granéli3,4,
Pernilla Stenström3,4, Einar Arnbjörnsson3,4
1Autonomous University of Barcelona, Barcelona, Spain
2University of Seville, Seville, Spain
3Department of Paediatric Surgery, Skåne University Hospital, Lund, Sweden
4Lund University, Lund, Sweden
Email: email@example.com, #firstname.lastname@example.org, email@example.com,
Received January 20, 2013; revised February 22, 2013; accepted March 3, 2013
Copyright © 2013 Irene Ortiz-Rubio et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Transanal endorectal one-stage pull-through (TERPT) procedure in children with Hirschsprung’s disease
(HD) is frequently used worldwide. In order to give the families realistic expectations and to plan the medical care for
the years after TERPT, the long term outcome is of great importance. Aim: To collect information on the long term
outcome reported after one stage TERPT procedure for HD in children 0 - 15 years. Method: A literature review on the
outcome of planned TERPT from 2005 through 2012 was carried out. Information was collected on the number of daily
stools a few months postoperatively, incontinence and constipation and the measures taken to deal with these. Results:
The reports are few and prospective studies were missing. The results show an initial high frequency of daily stools,
12% had later abnormal stool patterns, 21% had fecal incontinence and 10% had problems with constipation. Conclu-
sion: In order to compare the long term outcome, it would be desirable to have uniform regular reports on the daily fre-
quency of passed stools, incontinence and constipation during the first years after TERPT. Such knowledge would be of
importance for the information given to the guardians of children with HD preoperatively to TERPT and in the planning
of the future care. The findings can, furthermore, provide a benchmark for the outcome from a single centre.
Keywords: Transendorectal Pull-Through (TERPT); Hirschsprung’s Disease (HD); Outcome; Incontinence;
The transanal endorectal pull-through (TERPT) techni-
que for Hirschsprung’s disease (HD) was introduced in
1998 . The TERPT procedure was intended to be less
invasive than previously used procedures for HD such
as Duhamel’s operation. The fact that a minimal in-
traabdominal dissection is included only in the TERPT
intervention, should lead to less postoperative pain and
shorter hospitalization. Since there are no scars in the
perineum the cosmetic results are good and the only vis-
ual scars may be on the abdominal wall after minimal inva-
sive surgery to assist performing the one stage TERPT.
Children with HD may have to cope with a lot of
symptoms, sometimes lifelong, as a result of a shortened
intestine, possible damage to the surrounding structures
in the pelvic floor and because that the left bowel may be
dysfunctional. When informing the child’s guardians
about this possible handicap, the question that arises is
which problem the child is going to have both in the
postoperative period and in the future. Therefore it is of
interest to collect knowledge from the literature about
what has been reported on the bowel symptoms after
TERPT in patients with HD. It is, for example, of great
interest to know whether the children have problems with
incontinence or severe constipation as well as the fre-
quency of stools as long term results. Such knowledge
would be useful for supporting the information given to
*I. Ortiz-Rubio and M. Pérez-Aguilera equally contributed to this work.
Copyright © 2013 SciRes. SS
I. ORTIZ-RUBIO ET AL.
the families of the children with HD as well as in the
planning of the need of medical care after TERPT.
Aim: This review was undertaken to gather informa-
tion on the long term outcome after TERPT in children
with HD. Information was collected regarding the daily
frequency of stools after three, six and twelve months
postoperatively as well as the prevalence of incontinence
and constipation. We are not aware of similar reports in
A literature review of reported TERPT operations on
children with HD was carried out. MEDLINE and EM-
BASE were searched for all studies reporting on children
who had undergone surgical intervention for HD using
TERPT between 2005 through 2012. This period was
selected with a beginning 7 years after the publication of
the TERPT method  hoping to find reports on long-
term results. Only reports written in English were in-
Reports on planned TERPT operations were included
only. Information was collected with particular emphasis
on the outcome measured in the frequency of daily stools,
rate of incontinence and constipation and any operative
intervention to cope with these problems. The definition
of “abnormal stool frequency” was missing. Detailed
general information was recorded regarding the reported
type of study, children’s age and gender and intraopera-
tive details including the length of the bowel affected by
The search terms used were: Transanal endorectal pull-
through, Hirschsprung’s disease, Newborns, Outcome: in-
continence and constipation.
The reference list from the retrieved articles was re-
viewed for additional reports on children undergoing
TERPT. All published reports and abstracts presented at
meetings were evaluated.
Of 14 published articles 11 were included [2-15]. A total
of 297 children were included in the selected material
and the demography of the children included in the sur-
vey is summarized in Table 1. The results regarding
stool frequency, incontinence and constipation are sum-
marized in different ways in Tables 2 and 3.
We noted that there are more reported problems post-
operatively when the reconstructive surgery is performed
in older children than in younger. In one report on chil-
dren operated on at ages from 17 days to 3 months the
authors did not disclose any constipation problems .
This is to be compared with a report describing 4 (20%)
Table 1. Information available on the children reported on
in the included publications.
Number of children 297 (24 not gender specified)
Females/Males (%) 98 (36%)/175 (64%)
Female/Male ratio 1/1.8
Duration of observation,
3 years (1 month - 15 years)
Table 2. A summary of the reports on normal versus ab-
normal stool frequency as well as the frequency of inconti-
nence and constipation in 277 children included in eight
reports on postoperative outcome after TERPT operation
for Hirschsprung’s disease.
Stool frequency5* 191
-normal 164 (86%)
-abnormal 27 (14%)
Incontinence 4** 22 (21%) 105
Constipation 6*** 12 (10%) 118
*Aslan 2007 (n = 22), Kim 2009 (n = 61), Tannuri 200 (n = 24), Zang 2007
(n = 58), Obermayr 2009 (n = 25); **Aworanti 2012 (n = 16), Obermayr
2009 (n = 25), Tannuri 2009 (n = 24), Zakaria 2012(n = 40); ***Aslan 2007
(n = 22), Ates 2007 (n = 15), Aworanti 2012 (n = 16), El-Sawaf 2007 (n =
16), Obermayr 2009 (n = 25), Tannuri 2009 (n = 24).
of the operated children with constipation problems when
they were 3 years or older. Two of these were resolved
using bowel management; one with laxatives and one
with enema . In another report regarding children 3
years or older the authors reported a different result with
just 1 patient (23 - 43%) with constipation . These
results are comparable with another study showing that
25% of children between 3 months and 15 years had
problems with constipation . These results were also
supported by reports describing more constipation prob-
lems among adolescents and younger patients . An-
other study that described constipation after TERPT
showed that these problems could be treated satisfacto-
rily with laxatives only. Unfortunately the authors did not
state the age of the patients at the time of surgery .
When it comes to correlating the outcome of the patients
with their age, one report provides information by ana-
lysing two groups where one includes younger children
(6 months - 3.5 years) and the other one older (3.5 - 13
years). The problem is that the authors do not specify
which patients had incontinence or constipation; they
focused on stool problems; including both. They found a
total of 5 children with problems but there was not a sig-
nificantly higher number in either age group .
In conclusion, the results should be classified by the
age at which the surgery is performed. The follow-up
Copyright © 2013 SciRes. SS
I. ORTIZ-RUBIO ET AL.
Copyright © 2013 SciRes. SS
Table 3. The number of daily stools correlated to the duration of observation in 56 reported children with Hirschsprung’s
disease operated on with TERPT.
Reported number of daily stools
Ates 2007 N = 15  Obermayr 2009 N = 25  Pratap 2007 N = 19 
Number of children
1 month 3 7 (3 - 11) 34
3 months 5 19
6 months 2 15
12 months 3 (1 - 6) 19
>3 years 3 (1 - 5) 25
time is important. The longer the follow-up has been the
better the results. However the majority of the studies
does not register the rate of constipation or do not report
them in the same way.
Incontinence was reported in 4 of the papers which in-
cluded 105 children. 22 of these 105 studied children
were reported incontinent [3,10,13,14]. One report shows
that 11 out of 16 patients (69%) had incontinence prob-
lems . Another report regarding patients between 10
days and 6 years of age says that 5 out of 25 patients
(21%) suffered from incontinence . One report pro-
vided information about two different age groups and the
number of patients with incontinence. The authors di-
vided the children into a younger group (6 months - 3.5
years) that had no incontinence and an older group (3.5 -
13 years) where some patients had problems with their
stools. Unfortunately the exact number of patients who
suffered from incontinence was not reported since the
authors did not specify which patients had incontinence
or constipation, as they focused only on stool problems
One report found a correlation between trisomy 21 and
incontinence described in 1 out of 20 patients (5%) .
3.3. Frequency of Stools
The reports on the number of daily stools passed have
not been presented in a manner making them comparable
and thus we were unable to make a summary. This is an
outcome that many authors do not report. Thus, we
gained too little information to draw any real conclusion
regarding the correlation between TERPT and amount of
daily stools passed.
The definition of normal stool frequency was vague
and differed between the studies. The frequency of stools
reported in the majority of the articles shows that on the
whole it was considered normal and there are only a low
percentage of reported children with abnormalities in
their stool patterns. One study of 61 children reports that
56 patients (91%) had normal stool patterns after 9.4 -
6.2 weeks . In another study almost all of the children
had normal stool frequency (54/58). Furthermore, the
younger the patient at surgery, the earlier the frequency
of stools is normalized . One study shows that 95% of
operated children were continent at the endpoint of fol-
low-up . Another study shows similar results where
80.5% of 22 children had normal intestinal function .
In the last study 17 out of 24 patients (70.8%) had com-
plete continence and 5 of the same patients (20.8%) had
partial continence .
The number of daily stools passed is only reported in 3
of 11 included reports. In one of the studies it was shown
that after a median follow-up of 35 months the median fre-
quency of bowel movements was 3/day (1 - 5/day) .
The results of the literature survey of reports on TERPT
for children with HD, with particular emphasis on the
frequency of incontinence and constipation, revealed that
the rate of both was reported to be low after the per-
formed operation. However, in spite of this low fre-
quency, the problem of incontinence and constipation
exits. Reports on operative interventions to relieve the
problems of incontinence and constipation are missing in
the included papers. There are no randomized studies and
reports with comparisons between different operative
methods are few [16-19]. There were no prospective
studies, only retrospective.
The duration of observation time reported in the pub-
lications is relatively short, 3 years (range 1 month - 15
years). The complications of incontinence or constipation
may be discovered later, although the majority of these
problems came to light within the first four years post-
operatively. Thus, the follow up time is too short to
evaluate the final outcome in this regard. The same ap-
plies to the evaluation of functional bowel movement.
The studies included in this paper reported results from a
pediatric population only. This population represents a
wide age range from newborns to 15-year-olds, while the
great majority of the children included here are less than
I. ORTIZ-RUBIO ET AL.
three years of age.
In this report, re-operations and postoperative compli-
cations like enterocolitis are not included. These compli-
cations have already been reported in well performed
literature reviews [16,19].
A review of the literature is necessary to evaluate both
qualitatively and quantitatively the results of different
studies. It is important, however, to address the limita-
tions of this literature review. There is a bias in the report
due to several reasons. In this context it is important to
bear in mind a no publication bias, particularly in a re-
view based on published studies. The studied material is,
moreover, biased by the fact that the authors do not re-
port their results in a way that makes them comparable
with other authors’ results. Thus, a considerable number
of children as well as several data have not been included.
Furthermore, there may be a variation in inclusion crite-
ria, study type, lack of randomization, treatment protocol,
and outcome assessment between the studies. The data-
bases MEDLINE and EBASE were the only ones used
which can mean that publications in some open access
and other indexed databases are missed.
In this report, an attempt is made to select outcome
measures that are as absolute as possible and describe the
child’s situation during the postoperative period. These
parameters that are of great importance to the parents can
become influenced by local traditions, and different
studies may have had slightly different defining criteria
for the outcome measures. The role of the child’s guar-
dians is of the utmost importance for disclosing minor
problems or concealing major problems by the way they
take care of their child.
The length of the resected bowel in the reported cases
was only 20.5 cm, thus representing the group of children
suitable for the TERPT operation. This excluded those
where laparoscopy or laparotomy is used to facilitate the
intervention due to a preoperative clinical suspicion of a
longer malformed bowel. It was not possible to differen-
tiate the length of the aganglionotic segment from rectum,
recto-sigmoideum and recto descendens and longer, due
to missing data in most of the studies. The children left
with a very short bowel are thereby excluded and those
with the most severe incontinence problems may have
In conclusion, the review provides some information
on the incidence of incontinence and constipation after
the TERPT procedure. The results of this review are of
importance in preoperative counseling and when plan-
ning for the postoperative care of children with HD un-
dergoing the TERPT procedure. However, it is obvious
that solid information on the outcome after TERPT op-
eration for HD in children is missing in the literature. We
urge the authors of reports on children with HD operated
on with the TERPT procedure to report on the outcome
in some sort of standardized fashion to enable compari-
son with other reported groups of children in the same
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