Functional Evaluation of children following Modified Duhamel Procedure for Rectosigmoid Hirschsprung’s Disease

Functional Evaluation of children following Modified Duhamel Procedure for Rectosigmoid Hirschsprung’s Disease | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Functional Evaluation of children following Modified Duhamel Procedure for Rectosigmoid Hirschsprung’s Disease Nandkishor Shinde, Sunil Kalaskar, Anand Shanker, Sushmittha Bommanal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8294135/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Jan, 2026 Read the published version in Egyptian Pediatric Association Gazette → Version 1 posted 13 You are reading this latest preprint version Abstract Background Hirschsprung’s disease is a congenital disorder of intestinal innervation requiring surgical correction. The modified Duhamel retro-rectal pull-through is widely used for rectosigmoid hirschsprung’s disease, but long-term functional outcomes remain variable. This study aimed to evaluate bowel function, complications, and quality of life in children undergoing this procedure. Methods A prospective study was conducted at a tertiary care hospital (January2022 to November 2025). Fifty children with biopsy-confirmed rectosigmoid HD who underwent the modified Duhamel pull-through were included, with ≥ 3 years follow-up. Functional outcomes were assessed using the Rintala Bowel Function Score and clinical evaluation. Secondary outcomes included postoperative complications, need for medical/surgical interventions, and quality of life indicators. Results The study comprised 38 males (76%) and 12 females (24%), mean age at surgery 1.5 ± 0.5 years, and at assessment 6.2 ± 2.1 years. Early complications included anastomotic leak (2%), wound infection (8%), and Hirschsprung-associated enterocolitis (HAEC) (10%). Late morbidities included constipation requiring prolonged medical management (20%), residual spur (4%), and recurrent HAEC (14%). The mean BFS was 17.1 ± 2.9; 48% achieved good outcomes (≥ 18), 38% fair (13–17), and 14% poor (≤ 12). Symptom analysis showed no soiling in 64%, no constipation in 76%, and normal stool frequency in 76%. Quality of life was favorable, with 86% parental satisfaction, 92% regular school attendance, and 6% reporting social embarrassment. Conclusion The modified Duhamel procedure provides satisfactory long-term functional outcomes in most children with rectosigmoid hirschsprung’s disease. Constipation and recurrent HAEC remain the most significant late morbidities, underscoring the need for structured follow-up and individualized bowel management. Hirschsprung’s disease Duhamel procedure Bowel function Constipation Fecal continence Pediatric surgery Introduction Hirschsprung's disease (HD) is a congenital anomaly characterized by the absence of intrinsic ganglion cells in the distal bowel, typically extending proximally from the internal anal sphincter, most commonly involves the rectosigmoid region. Affecting approximately 1 in 5,000 live births, it is the most common cause of neonatal intestinal obstruction and requires definitive surgical management to restore intestinal continuity and function [ 1 ]. The objective of surgical treatment is to resect the aganglionic segment and perform a pull-through of the normally innervated colon to the anal canal, preserving the external anal sphincter mechanism. Over past seventy years, several techniques have been described, including the Swenson, Soave, transanal endorectal pull-through (TEPT), and the Duhamel procedure [ 2 , 3 ]. The modified Duhamel retro-rectal pull-through procedure, first described by Duhamel and subsequently refined by others, remains a widely adopted technique particularly for rectosigmoid HD, due to its technical simplicity, preservation of the sphincter mechanism, and reduced risk of injury to pelvic nerves. The procedure involves creating a side-to-side anastomosis between the ganglionic colon and the retained aganglionic rectum, followed by division of the spur with linear stapler, thereby forming a wide rectal reservoir. Despite these advantages, postoperative functional outcomes such as constipation, soiling, and enterocolitis remain important concern. In this procedure, the ganglionic colon is brought down posteriorly to the aganglionic rectum [ 4 , 5 ]. Functional assessment following pull-through surgery is critical, as anatomical success does not always translate into satisfactory bowel function. While mortality rates associated with modified Duhamel repair are low, long-term morbidity related to functional bowel outcome remains a significant concern. The primary goal of surgery is to achieve satisfactory fecal continence and defecation patterns, allowing children to integrate normally into school and social life. Persistent issues such as fecal incontinence (soiling), chronic constipation, and recurrent Hirschsprung-associated Enterocolitis (HAEC) are commonly reported complications that severely impact the quality of life for both the child and their family [ 5 , 6 ]. Factors such as the surgical technique, the integrity of the anal sphincter mechanism, the length of residual aganglionic rectal cuff, and the presence of postoperative complications (e.g., residual spur or stricture) are all believed to influence the long-term functional prognosis. Given the ongoing debate regarding the optimal surgical approach, variability in reported outcomes and the scarcity of data, there is a need to evaluate the functional results of the modified Duhamel procedure in children with rectosigmoid Hirschsprung's disease. The validated scoring systems such as the Rintala Bowel Function Score (BFS) and the Krickenbeck Consensus Classification score provide standardized measures of continence, stool frequency, overall bowel function, and social adaptation [ 7 , 8 , 9 ]. Evaluating functional outcomes in such populations is crucial to guide postoperative management, optimize bowel care protocols, and improve quality of life. The aim of this study was to evaluate the functional outcomes and complication rates, associated morbidities and quality of life in children who underwent the modified Duhamel retro-rectal pull-through procedure for rectosigmoid Hirschsprung's disease at a tertiary care center. By analyzing the Rintala Bowel Function Score, the Krickenbeck Consensus score and secondary quality of life measures, this study seeks to provide contemporary data on the effectiveness of this specific surgical approach. Methods Study Design A prospective observational study was conducted in a tertiary care hospital between January 2022 to November 2025 evaluating the functional outcomes in 50 children who underwent the Duhamel pull-through procedure for Hirschsprung's disease. Inclusion Criteria: Children diagnosed with rectosigmoid Hirschsprung's disease (confirmed by rectal biopsy showing aganglionosis) who underwent the modified Duhamel retro-rectal pull-through procedure. Participants must have a minimum follow-up period of three years and be over 3 years of age at the time of functional assessment to allow for potential toilet training. Exclusion Criteria: Long-segment or total colonic aganglionosis. Patients who underwent other pull-through procedures (e.g., Swenson, Soave, Transanal Endorectal Pull-Through). History of a redo pull-through procedure. Other associated severe congenital anomalies or associated complex anorectal malformations or neurological deficits (e.g., Down syndrome, significant learning disability). Ethical Considerations Approval was obtained from the Institutional Ethics Committee. Written informed consent taken from parents/ guardians. Confidentiality maintained throughout follow-up. Surgical Procedure All included children underwent the modified Duhamel retro-rectal pull-through procedure, typically in one or two stages. Key technical details include: Leveling: Ensuring the pull-through segment contained confirmed ganglion cells. Anastomosis : Coloanal anastomosis performed approximately 1.5 cm above the dentate line posteriorly. Spur Division: Use of a linear cutting stapler for dividing the spur between the posterior wall of the native aganglionic rectum and the anterior wall of the ganglionic pull-through colonic segment. Data Collection Demographic and Clinical Data: Age and gender. Age at diagnosis and age at definitive Duhamel pull-through. Presence of preoperative colostomy (staged vs. primary pull-through). Length of aganglionic segment (short vs. long segment HD). Postoperative complications (e.g., anastomotic leak, stricture, residual spur, Hirschsprung-associated Enterocolitis (HAEC)). Functional Assessment Functional outcomes were assessed cross-sectionally at the follow-up visit (minimum 3 years post-surgery) using a standardized, validated scoring system and clinical evaluation. 1. Bowel Function Scoring System: The Rintala's Bowel Function Score (BFS) was the primary tool(7). This is a parent-reported structured interview or questionnaire covering seven variables: Ability to hold back defecation Feeling/reporting the urge to defecate Frequency of defecation Soiling (involuntary loss of small amounts of stool/staining) Accidental fecal leakage (involuntary passage of large amounts of stool) Constipation Social problems related to bowel function Scoring: Each variable is scored from 0 to 3, except for frequency of defecation (scored 1-2), yielding a maximum total score of 20. Outcome Categorization (BFS): Outcomes are then classified into categories: Good/Normal (≥18), Fair (13–17), and Poor (≤ 12). 2. Analysis of Key Functional Symptoms: The Krickenbeck Consensus Classification was used for the scoring of key functional symptoms in Hirschsprung disease, it evaluates Fecal Incontinence (FI), Constipation, and stool frequency(8,9). 3. Secondary Outcome Measures Physical examination : Perineal inspection, assessment of nutritional status, and Digital Rectal Examination (DRE) to evaluate anal sphincter tone and rule out residual spur or stricture. Intervention Data : Need for long-term medical management (e.g., laxatives, enemas, botulinum toxin injection) or need for reoperation (e.g., spur crushing, redo pull-through, stoma formation). Hirschsprung-associated Enterocolitis (HAEC) : Documenting the incidence and severity of postoperative HAEC episodes. Quality of life assessment : parental questionnaire focusing on diet tolerance, school attendance, and psychosocial adaptation. Statistical Analysis Descriptive statistics were used to summarize patient demographics and functional outcomes (mean ± standard deviation for continuous variables, frequency and percentage for categorical variables). Functional outcome scores were compared based on factors like age at pull-through or presence of complications using appropriate non-parametric tests (e.g., Mann-Whitney U test) or Chi-square test/Fisher's exact test, with a significance level set at P < 0.05. Results A total of 50 cases were evaluated. The cases consisted of 38 males (76%) and 12 females (24%) with male to female ratio of 3.2:1. The mean age at definitive Duhamel pull-through was 1.5 ± 0.5 years. The mean age at the time of functional assessment was 6.2 ± 2.1 years (Range: 3–14 years). Operative Outcomes Early Complications (within 30 days): Anastomotic Leak: 1 child (2%) Wound Infection: 4 children (8%) Hirschsprung-associated Enterocolitis (HAEC): 5 children (10%) Perianal excoriation: 4 children (8%) (managed conservatively) Late Complications/Morbidities: Postoperative Constipation requiring prolonged medical management ( >1year): 10 children (20%) Clinically Significant Residual Spur: 2 children (4%) (all required surgical revision/crushing) Recurrent Hirschsprung-associated Enterocolitis (HAEC): 7 children (14%) No mortality reported Functional Bowel Outcome (Rintala's Bowel Function Score) The mean Rintala Bowel Function Score (BFS) for the entire cohort was 17.1 ± 2.9. The distribution of functional outcomes based on the Rintala's Bowel Function Score classification was shown in Table 1 . Overall, 86% of children achieved a Fair or Good functional outcome. Analysis of Key Functional Symptoms : The Krickenbeck Consensus Classification used to evaluate Fecal Incontinence (FI), Constipation, and stool frequency in Hirschsprung disease. An analysis of the specific components of the Bowel Function Score using Krickenbeck Consensus Classification shown in Table 2 which revealed that the majority (64%) achieved complete continence with no soiling indicates overall satisfactory continence, with mild issues in a subset. Most patients (76%) did not experience constipation. This highlights the need for ongoing bowel management protocols in a minority of patients. Hypo frequent stools (<1/day) and hyper frequent stools (≥3/day) were observed in 8% and 16% respectively. Both extremes suggest functional irregularities, though affecting a minority (Table 2). Quality of Life Parental satisfaction : 86% reported good to excellent outcomes. School attendance : 92% of children had regular attendance without restrictions. Psychosocial adaptation : Majority integrated well; 3(6%) children reported social embarrassment due to soiling. Discussion The modified Duhamel retro-rectal pull-through procedure is one of the foundational surgical techniques for treating Hirschsprung's disease (HD). The long-term success of this intervention is measured not by mere survival, but by the functional quality of life achieved by the child. This prospective observational study evaluated the long-term functional outcomes in 50 children who underwent the Duhamel procedure, utilizing the validated Rintala's Bowel Function Score (BFS) and secondary quality of life measures. The most significant finding of this study is the satisfactory overall functional outcome in the cohort. The mean Rintala's BFS was 17.1 ± 2.9 and a combined 86% of children achieved either a Good or Fair outcome, while only 14% were classified as Poor outcome. This high success rate aligns favorably with established literature [ 10 , 11 , 12 ]. Wong et al.'s systematic review highlighted variable functional outcomes across different procedures, making direct comparisons challenging, but our data suggests the modified Duhamel procedure provides robust long-term functional results, particularly regarding continence [ 10 ]. Continence outcomes in our cohort were encouraging, with 64% of children reporting no soiling and only 6% requiring protective aids for daily soiling. This aligns with the results of Trivedi et al [ 12 ], who reported that 70% of children achieved complete continence after modified Duhamel’s procedure. Similarly, Raghunath et al [ 13 ]. observed that pseudo-incontinence was uncommon and most children attained socially acceptable continence. This outcome suggests successful preservation of the anorectal inhibitory reflex and the external sphincter mechanism, which is a key advantage attributed to the Duhamel technique [ 12 , 13 ]. This highlights the effectiveness of the retro-rectal reservoir created by the Duhamel technique in preserving sphincter function. Despite the generally good overall function, several morbidities were observed that required ongoing management. Constipation remains a significant postoperative morbidity. Postoperative constipation requiring prolonged medical management (> 1 year) was present in 20% of the cases. Furthermore, 14% of children required daily laxatives or enemas at the time of assessment. While the majority (76%) were symptom-free, this persistent issue in a fifth of patients underscores the need for diligent long-term bowel management protocols. This is comparable to rates reported in other series, where constipation affected 20–30% of patients. The persistence of constipation post-pull-through can be multifactorial, stemming from residual aganglionic cuff, functional internal sphincter achalasia, or colonic dysmotility[ 13 , 14 , 15 ]. Stool frequency was within the normal range (1–3 stools/day) in 76% of patients, while 8% had hypofrequent stools and 16% had hyperfrequent stools. These findings are comparable to those of Gunadi et al [ 16 ]., who reported that most patients achieved normal stool frequency after pull-through, though a minority experienced irregularities requiring medical management [ 16 ]. A clinically significant residual spur requiring surgical revision/crushing occurred in 4% of the children. The modified Duhamel technique, which relies on a linear cutting stapler for spur division, is designed to minimize this complication [ 5 , 14 ]. The low incidence in our study confirms the technical reliability of the stapled division, though the need for secondary intervention in these few cases highlights the importance of meticulous intraoperative technique and long-term clinical vigilance for this mechanical obstruction. Hirschsprung-associated Enterocolitis (HAEC): HAEC remains the most concerning complication. We observed an early incidence of 10% and a recurrent incidence of 14% during the follow-up period. This cumulative incidence of HAEC, particularly the risk of recurrence, is consistent with rates reported globally for HD patients, irrespective of the pull-through technique [ 10 – 14 ]. Strategies to reduce HAEC episodes, including prophylactic antibiotics and aggressive bowel washouts during episodes, remain critical components of postoperative care. The strong functional results translated directly into positive quality of life outcomes. Parental satisfaction was high, with 86% reporting good to excellent results. Moreover, 92% of children maintained regular school attendance without restrictions, indicating that for the vast majority, their bowel function did not significantly impede their daily life. Only 6% of children reported social embarrassment due to soiling, underscoring the need for ongoing bowel management and counseling. These findings support the conclusion that successful surgical and functional management promotes positive psychosocial integration, a crucial long-term endpoint in pediatric surgery [ 6 ]. Limitations The primary limitation of this study is its single-center, prospective observational design and the relatively small size (N = 50). While the three-year minimum follow-up is beneficial, a longer follow-up period, extending into adolescence, would provide a more complete picture of adult continence. Furthermore, the cross-sectional nature of the functional assessment only captured the outcome at a single point in time. Future studies should employ longitudinal multicentric designs and incorporate radiological and manometric data to better correlate objective measures with the parent-reported BFS, better define predictors of poor outcomes and optimize management strategies. Conclusion The modified Duhamel retro-rectal pull-through procedure provides excellent long-term functional outcomes in children with rectosigmoid Hirschsprung's disease. The high mean Rintala's BFS score and the associated high rates of parental satisfaction and school attendance demonstrate the procedure's efficacy. While chronic constipation and recurrent HAEC necessitate careful long-term follow-up and management, the overall prognosis for functional continence is favorable in this specific cohort. Declarations Funding (Financial Support): The authors received no financial support for the research & publication of the article. Ethics approval and consent to participate: This study was conducted in strict adherence to the ethical standards outlined in the Declaration of Helsinki and its subsequent amendments. This study received approval from the Khaja Banadanawaz University, Faculty of Medical Sciences, Karnataka, India, ethics committee (Reference number No: KBNU-FOM/IEC/2021/178. Written informed consent was obtained from the caregivers/ parents of all child participants involved in the study. All participant data were anonymized to ensure confidentiality. Author Contribution (Nandkishor D Shinde:NDS; Sunil Kalasker:SK ,Anand Shankar: AS, Sushmitha Bommanal: SB) Conceptualization, NDS.; methodology, NDS, SK and AS.; validation, , NDS, SK and AS .; formal analysis, AS SB.; investigation, , NDS, SK and SB ;resources, SK,AS.; data curation, NDS, SB; writing – original draft preparation, , NDS, SK and AS; writing – review and editing, , NDS, SB and AS.; visualization, NDS..; supervision, NDS.; project administration, NDS.;All authors have read and agreed to the published version of the manuscript. References Peña A, Levitt MA (2006) Hirschsprung's disease. Semin Pediatr Surg 15(4):213–220. https://doi.org/10.1053/j.sempedsurg.2006.07.001 Duhamel B (1960) A new operation for the treatment of Hirschsprung's disease. Arch Dis Child 35(179):38–39. https://doi.org/10.1136/adc.35.179.38 Tobias–Gómez JG, Vargas–Montiel D, Marín–Vázquez MA et al (2018) Functional outcomes after Duhamel and Swenson procedures for Hirschsprung disease. Cir Pediatr 31(4):160–165. https://doi.org/10.1055/s-0038-1675767 Coran AG, Teitelbaum DH (2000) The Duhamel procedure for Hirschsprung's disease. Semin Pediatr Surg 9(2):79–84. https://doi.org/10.1053/spsu.2000.4194 Peters NJ, Menon P, Rao KLN, Samujh R (2020) Modified Duhamel’s two–staged procedure for Hirschsprung’s disease: Further modifications for improved outcomes. J Indian Assoc Pediatr Surg 25(5):269–275. https://doi.org/10.4103/jiaps.JIAPS_55_19 Hofstra L, Bax K, Ekkelkamp S et al (2017) Health–related quality of life in children and adolescents with Hirschsprung disease. J Pediatr Psychol 42(5):519–528. https://doi.org/10.1093/jpepsy/jsw086 Rintala RJ, Pakarinen MP (2012) Long–term outcomes of Hirschsprung’s disease. Semin Pediatr Surg 21(4):336–343. https://doi.org/10.1053/j.sempedsurg.2012.07.008 Holschneider A, Hutson J, Peña A et al (2005) Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations. J Pediatr Surg 40(10): 1521–1526. https://doi.org/10.1016/j.jpedsurg.2005.08.002 Kyrklund K, Sloots CEJ, de Blaauw I et al (2014) Defining a standardized outcome reporting system for Hirschsprung’s disease: A multicenter international study. J Pediatr Surg 49(1):161–167. https://doi.org/10.1016/j.jpedsurg.2013.10.012 Wong CW, Tan J, Chung T et al (2018) Long–term functional outcomes in children with Hirschsprung's disease: A systematic review and meta–analysis. J Pediatr Surg 53(12):2568–2575. https://doi.org/10.1016/j.jpedsurg.2018.06.002 Saleem M, Butt J, Shaukat Z, Hashim I, Moeezah, Majeed F et al (2023) Functional outcome of Hirschsprung's disease in children: A single center study at The Children's Hospital Lahore. Pediatr Surg Int 39(1):176. 10.1007/s00383-023-05451-9 Trivedi US, Hassan N, Pillai SK, Sarma VP (2023) Functional outcome in children with Hirschsprung’s disease after modified Duhamel’s procedure: A longitudinal study. J Clin Diagn Res 17(6):PC01–PC05. https://doi.org/10.7860/JCDR/2023/62393.18248 Raghunath SM, Maniam R, Dhanasekarapandian V, Govindarajan H (2023) Assessment of functional outcome following Duhamel retro–rectal pull–through surgery for Hirschsprung’s disease: A follow–up study. J Pediatr Surg 58(11):271–278. https://doi.org/10.1055/s-0043-1776891 Aravind KL, Nisha N, Sushmitha R, C Madiwal (2021) Duhamel’s procedure for Hirschsprung’s disease and the functional outcome in a tertiary care center. Indian J Child Health 8(1):51–55. https://doi.org/10.32677/IJCH.2021.v08.i01.010 Rehman SU, Anwar M, Fazal Z (2021) Modified Duhamel retrorectal pull–through for Hirschsprung’s disease: Short–term outcomes. Pak J Med Health Sci 15(10):2886–2889. https://doi.org/10.53350/pjmhs2115102886 Gunadi G, Carissa TM, Daulay EF, Yulianda D, Iskandar K, Dwihantoro A (2022) Long–term functional outcomes of patients with Hirschsprung disease following pull–through. BMC Pediatr 22:330. https://doi.org/10.1186/s12887-022-03450-y Tables Table 1: Rintala's Bowel Function Score classification Outcome Category BFS Range Number of Children (N=50) Percentage (%) Normal/Good ≥18 24 48% Fair 13–17 19 38% Poor ≤ 12 7 14% Table 2 : Analysis of Key Functional Symptoms by Krickenbeck Consensus score Symptom Symptom Grade Number(N=50) Percentage (%) Fecal Soiling/Incontinence Daily Soiling (requiring protective aids) 3 6% Occasional Staining (less than once per week) 15 30% No Soiling: 32 64% Constipation Requiring Daily Laxatives/Enemas 7 14% Manageable with Diet/Occasional Laxatives 5 10% No Constipation 38 76% Stool frequency <1 stool/day 4 8% 3 stools/day 8 16% 1–3 stools/day 38 76% Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Jan, 2026 Read the published version in Egyptian Pediatric Association Gazette → Version 1 posted Editorial decision: Revision requested 25 Dec, 2025 Reviews received at journal 25 Dec, 2025 Reviews received at journal 23 Dec, 2025 Reviews received at journal 17 Dec, 2025 Reviews received at journal 12 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviewers agreed at journal 11 Dec, 2025 Reviewers invited by journal 11 Dec, 2025 Editor assigned by journal 11 Dec, 2025 Submission checks completed at journal 11 Dec, 2025 First submitted to journal 06 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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16:05:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":856941,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8294135/v1/df096cda-aee3-4bd8-aca2-66edc425541a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Functional Evaluation of children following Modified Duhamel Procedure for Rectosigmoid Hirschsprung’s Disease","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHirschsprung's disease (HD) is a congenital anomaly characterized by the absence of intrinsic ganglion cells in the distal bowel, typically extending proximally from the internal anal sphincter, most commonly involves the rectosigmoid region. Affecting approximately 1 in 5,000 live births, it is the most common cause of neonatal intestinal obstruction and requires definitive surgical management to restore intestinal continuity and function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe objective of surgical treatment is to resect the aganglionic segment and perform a pull-through of the normally innervated colon to the anal canal, preserving the external anal sphincter mechanism. Over past seventy years, several techniques have been described, including the Swenson, Soave, transanal endorectal pull-through (TEPT), and the Duhamel procedure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The modified Duhamel retro-rectal pull-through procedure, first described by Duhamel and subsequently refined by others, remains a widely adopted technique particularly for rectosigmoid HD, due to its technical simplicity, preservation of the sphincter mechanism, and reduced risk of injury to pelvic nerves. The procedure involves creating a side-to-side anastomosis between the ganglionic colon and the retained aganglionic rectum, followed by division of the spur with linear stapler, thereby forming a wide rectal reservoir. Despite these advantages, postoperative functional outcomes such as constipation, soiling, and enterocolitis remain important concern. In this procedure, the ganglionic colon is brought down posteriorly to the aganglionic rectum [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFunctional assessment following pull-through surgery is critical, as anatomical success does not always translate into satisfactory bowel function. While mortality rates associated with modified Duhamel repair are low, long-term morbidity related to functional bowel outcome remains a significant concern. The primary goal of surgery is to achieve satisfactory fecal continence and defecation patterns, allowing children to integrate normally into school and social life. Persistent issues such as fecal incontinence (soiling), chronic constipation, and recurrent Hirschsprung-associated Enterocolitis (HAEC) are commonly reported complications that severely impact the quality of life for both the child and their family [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Factors such as the surgical technique, the integrity of the anal sphincter mechanism, the length of residual aganglionic rectal cuff, and the presence of postoperative complications (e.g., residual spur or stricture) are all believed to influence the long-term functional prognosis.\u003c/p\u003e \u003cp\u003eGiven the ongoing debate regarding the optimal surgical approach, variability in reported outcomes and the scarcity of data, there is a need to evaluate the functional results of the modified Duhamel procedure in children with rectosigmoid Hirschsprung's disease. The validated scoring systems such as the Rintala Bowel Function Score (BFS) and the Krickenbeck Consensus Classification score provide standardized measures of continence, stool frequency, overall bowel function, and social adaptation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Evaluating functional outcomes in such populations is crucial to guide postoperative management, optimize bowel care protocols, and improve quality of life.\u003c/p\u003e \u003cp\u003eThe aim of this study was to evaluate the functional outcomes and complication rates, associated morbidities and quality of life in children who underwent the modified Duhamel retro-rectal pull-through procedure for rectosigmoid Hirschsprung's disease at a tertiary care center. By analyzing the Rintala Bowel Function Score, the Krickenbeck Consensus score and secondary quality of life measures, this study seeks to provide contemporary data on the effectiveness of this specific surgical approach.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA prospective observational study was conducted in a tertiary care hospital between January 2022 to November 2025 evaluating the functional outcomes in 50 children who underwent the Duhamel pull-through procedure for Hirschsprung\u0026apos;s disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChildren diagnosed with rectosigmoid Hirschsprung\u0026apos;s disease (confirmed by rectal biopsy showing aganglionosis) who underwent the modified Duhamel retro-rectal pull-through procedure. Participants must have a minimum follow-up period of three years and be over 3 years of age at the time of functional assessment to allow for potential toilet training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eLong-segment or total colonic aganglionosis.\u003c/li\u003e\n \u003cli\u003ePatients who underwent other pull-through procedures (e.g., Swenson, Soave, Transanal Endorectal Pull-Through).\u003c/li\u003e\n \u003cli\u003eHistory of a redo pull-through procedure.\u003c/li\u003e\n \u003cli\u003eOther associated severe congenital anomalies or associated complex anorectal malformations or neurological deficits (e.g., Down syndrome, significant learning disability).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval was obtained from the Institutional Ethics Committee. Written informed consent taken from parents/ guardians. Confidentiality maintained throughout follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll included children underwent the modified Duhamel retro-rectal pull-through procedure, typically in one or two stages. Key technical details include:\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003e\u003cstrong\u003eLeveling:\u003c/strong\u003e Ensuring the pull-through segment contained confirmed ganglion cells.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAnastomosis\u003c/strong\u003e: Coloanal anastomosis performed approximately 1.5 cm above the dentate line posteriorly.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSpur Division:\u003c/strong\u003e Use of a linear cutting stapler for dividing the spur between the posterior wall of the native aganglionic rectum and the anterior wall of the ganglionic pull-through colonic segment.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic and Clinical Data:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAge and gender.\u003c/li\u003e\n \u003cli\u003eAge at diagnosis and age at definitive Duhamel pull-through.\u003c/li\u003e\n \u003cli\u003ePresence of preoperative colostomy (staged vs. primary pull-through).\u003c/li\u003e\n \u003cli\u003eLength of aganglionic segment (short vs. long segment HD).\u003c/li\u003e\n \u003cli\u003ePostoperative complications (e.g., anastomotic leak, stricture, residual spur, Hirschsprung-associated Enterocolitis\u0026nbsp;(HAEC)).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eFunctional Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunctional outcomes were assessed cross-sectionally at the follow-up visit (minimum 3 years post-surgery) using a standardized, validated scoring system and clinical evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Bowel Function Scoring System:\u003c/strong\u003e The Rintala\u0026apos;s Bowel Function Score (BFS) was the primary tool(7).\u003c/p\u003e\n\u003cp\u003eThis is a parent-reported structured interview or questionnaire covering seven variables:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAbility to hold back defecation\u003c/li\u003e\n \u003cli\u003eFeeling/reporting the urge to defecate\u003c/li\u003e\n \u003cli\u003eFrequency of defecation\u003c/li\u003e\n \u003cli\u003eSoiling (involuntary loss of small amounts of stool/staining)\u003c/li\u003e\n \u003cli\u003eAccidental fecal leakage (involuntary passage of large amounts of stool)\u003c/li\u003e\n \u003cli\u003eConstipation\u003c/li\u003e\n \u003cli\u003eSocial problems related to bowel function\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eScoring:\u003c/strong\u003e Each variable is scored from 0 to 3, except for frequency of defecation (scored 1-2), yielding a maximum total score of 20.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome Categorization (BFS):\u003c/strong\u003e Outcomes are then classified into categories: Good/Normal (\u0026ge;18), Fair (13\u0026ndash;17), and Poor (\u0026le;\u0026nbsp;12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAnalysis of Key Functional Symptoms:\u0026nbsp;\u003c/strong\u003eThe Krickenbeck Consensus Classification was used for the scoring of key functional symptoms in Hirschsprung disease, it evaluates Fecal Incontinence (FI), Constipation, and stool frequency(8,9).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Secondary Outcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical examination\u003c/strong\u003e: Perineal inspection, assessment of nutritional status, and Digital Rectal Examination (DRE) to evaluate anal sphincter tone and rule out residual spur or stricture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention Data\u003c/strong\u003e: Need for long-term medical management (e.g., laxatives, enemas, botulinum toxin injection) or need for reoperation (e.g., spur crushing, redo pull-through, stoma formation).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHirschsprung-associated Enterocolitis (HAEC)\u003c/strong\u003e: Documenting the incidence and severity of postoperative HAEC episodes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality of life assessment\u003c/strong\u003e: parental questionnaire focusing on diet tolerance, school attendance, and psychosocial adaptation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to summarize patient demographics and functional outcomes (mean \u0026plusmn; standard deviation for continuous variables, frequency and percentage for categorical variables).\u003c/p\u003e\n\u003cp\u003eFunctional outcome scores were compared based on factors like age at pull-through or presence of complications using appropriate non-parametric tests (e.g., Mann-Whitney U test) or Chi-square test/Fisher\u0026apos;s exact test, with a significance level set at P \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 50 cases were evaluated. The cases consisted of 38 males (76%) and 12 females (24%) with male to female ratio of 3.2:1. The mean age at definitive Duhamel pull-through was 1.5 ± 0.5 years. The mean age at the time of functional assessment was 6.2 ± 2.1 years (Range: 3–14 years).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperative Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEarly Complications (within 30 days):\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAnastomotic Leak: 1 child (2%)\u003c/li\u003e\n \u003cli\u003eWound Infection: 4 children (8%)\u003c/li\u003e\n \u003cli\u003eHirschsprung-associated Enterocolitis (HAEC): 5 children (10%)\u003c/li\u003e\n \u003cli\u003ePerianal excoriation: 4 children (8%) (managed conservatively)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eLate Complications/Morbidities:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePostoperative Constipation requiring prolonged medical management ( \u0026gt;1year): 10 children (20%)\u003c/li\u003e\n \u003cli\u003eClinically Significant Residual Spur: 2 children (4%) (all required surgical revision/crushing)\u003c/li\u003e\n \u003cli\u003eRecurrent Hirschsprung-associated Enterocolitis (HAEC): 7 children (14%)\u003c/li\u003e\n \u003cli\u003eNo mortality reported\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eFunctional Bowel Outcome (Rintala's Bowel Function Score)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean Rintala Bowel Function Score (BFS) for the entire cohort was 17.1 ± 2.9. The distribution of functional outcomes based on the Rintala's Bowel Function Score classification was shown in \u003cstrong\u003eTable 1\u003c/strong\u003e. Overall, 86% of children achieved a Fair or Good functional outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of Key Functional\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSymptoms\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThe Krickenbeck Consensus Classification used to evaluate Fecal Incontinence (FI), Constipation, and stool frequency in Hirschsprung disease. An analysis of the specific components of the Bowel Function Score using Krickenbeck Consensus Classification shown in Table 2 which revealed that the majority (64%) achieved complete continence with no soiling indicates overall satisfactory continence, with mild issues in a subset. Most patients (76%) did not experience constipation. This highlights the need for ongoing bowel management protocols in a minority of patients. Hypo frequent stools (\u0026lt;1/day) and hyper frequent stools (≥3/day) were observed in 8% and 16% respectively. Both extremes suggest functional irregularities, though affecting a minority (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality of Life\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParental satisfaction\u003c/strong\u003e: 86% reported good to excellent outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSchool attendance\u003c/strong\u003e: 92% of children had regular attendance without restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychosocial adaptation\u003c/strong\u003e: Majority integrated well; 3(6%) children reported social embarrassment due to soiling.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe modified Duhamel retro-rectal pull-through procedure is one of the foundational surgical techniques for treating Hirschsprung's disease (HD). The long-term success of this intervention is measured not by mere survival, but by the functional quality of life achieved by the child. This prospective observational study evaluated the long-term functional outcomes in 50 children who underwent the Duhamel procedure, utilizing the validated Rintala's Bowel Function Score (BFS) and secondary quality of life measures.\u003c/p\u003e \u003cp\u003eThe most significant finding of this study is the satisfactory overall functional outcome in the cohort. The mean Rintala's BFS was 17.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 and a combined 86% of children achieved either a Good or Fair outcome, while only 14% were classified as Poor outcome. This high success rate aligns favorably with established literature [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Wong et al.'s systematic review highlighted variable functional outcomes across different procedures, making direct comparisons challenging, but our data suggests the modified Duhamel procedure provides robust long-term functional results, particularly regarding continence [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eContinence outcomes in our cohort were encouraging, with 64% of children reporting no soiling and only 6% requiring protective aids for daily soiling. This aligns with the results of Trivedi et al [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], who reported that 70% of children achieved complete continence after modified Duhamel\u0026rsquo;s procedure. Similarly, Raghunath et al [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. observed that pseudo-incontinence was uncommon and most children attained socially acceptable continence. This outcome suggests successful preservation of the anorectal inhibitory reflex and the external sphincter mechanism, which is a key advantage attributed to the Duhamel technique [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This highlights the effectiveness of the retro-rectal reservoir created by the Duhamel technique in preserving sphincter function.\u003c/p\u003e \u003cp\u003eDespite the generally good overall function, several morbidities were observed that required ongoing management. Constipation remains a significant postoperative morbidity. Postoperative constipation requiring prolonged medical management (\u0026gt;\u0026thinsp;1 year) was present in 20% of the cases. Furthermore, 14% of children required daily laxatives or enemas at the time of assessment. While the majority (76%) were symptom-free, this persistent issue in a fifth of patients underscores the need for diligent long-term bowel management protocols. This is comparable to rates reported in other series, where constipation affected 20\u0026ndash;30% of patients. The persistence of constipation post-pull-through can be multifactorial, stemming from residual aganglionic cuff, functional internal sphincter achalasia, or colonic dysmotility[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStool frequency was within the normal range (1\u0026ndash;3 stools/day) in 76% of patients, while 8% had hypofrequent stools and 16% had hyperfrequent stools. These findings are comparable to those of Gunadi et al [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]., who reported that most patients achieved normal stool frequency after pull-through, though a minority experienced irregularities requiring medical management [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA clinically significant residual spur requiring surgical revision/crushing occurred in 4% of the children. The modified Duhamel technique, which relies on a linear cutting stapler for spur division, is designed to minimize this complication [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The low incidence in our study confirms the technical reliability of the stapled division, though the need for secondary intervention in these few cases highlights the importance of meticulous intraoperative technique and long-term clinical vigilance for this mechanical obstruction.\u003c/p\u003e \u003cp\u003eHirschsprung-associated Enterocolitis (HAEC): HAEC remains the most concerning complication. We observed an early incidence of 10% and a recurrent incidence of 14% during the follow-up period. This cumulative incidence of HAEC, particularly the risk of recurrence, is consistent with rates reported globally for HD patients, irrespective of the pull-through technique [\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Strategies to reduce HAEC episodes, including prophylactic antibiotics and aggressive bowel washouts during episodes, remain critical components of postoperative care.\u003c/p\u003e \u003cp\u003eThe strong functional results translated directly into positive quality of life outcomes. Parental satisfaction was high, with 86% reporting good to excellent results. Moreover, 92% of children maintained regular school attendance without restrictions, indicating that for the vast majority, their bowel function did not significantly impede their daily life. Only 6% of children reported social embarrassment due to soiling, underscoring the need for ongoing bowel management and counseling. These findings support the conclusion that successful surgical and functional management promotes positive psychosocial integration, a crucial long-term endpoint in pediatric surgery [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe primary limitation of this study is its single-center, prospective observational design and the relatively small size (N\u0026thinsp;=\u0026thinsp;50). While the three-year minimum follow-up is beneficial, a longer follow-up period, extending into adolescence, would provide a more complete picture of adult continence. Furthermore, the cross-sectional nature of the functional assessment only captured the outcome at a single point in time. Future studies should employ longitudinal multicentric designs and incorporate radiological and manometric data to better correlate objective measures with the parent-reported BFS, better define predictors of poor outcomes and optimize management strategies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe modified Duhamel retro-rectal pull-through procedure provides excellent long-term functional outcomes in children with rectosigmoid Hirschsprung\u0026apos;s disease. The high mean Rintala\u0026apos;s BFS score and the associated high rates of parental satisfaction and school attendance demonstrate the procedure\u0026apos;s efficacy. While chronic constipation and recurrent HAEC necessitate careful long-term follow-up and management, the overall prognosis for functional continence is favorable in this specific cohort.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding (Financial Support):\u003c/strong\u003e The authors received no financial support for the research \u0026amp; publication of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in strict adherence to the ethical standards outlined in the Declaration of Helsinki and its subsequent amendments. This study received approval from the Khaja Banadanawaz University, Faculty of Medical Sciences, Karnataka, India, ethics committee (Reference number No: KBNU-FOM/IEC/2021/178. Written informed consent was obtained from the caregivers/ parents of all child participants involved in the study. All participant data were anonymized to ensure confidentiality.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e(Nandkishor D Shinde:NDS; Sunil Kalasker:SK ,Anand Shankar: AS, Sushmitha Bommanal: SB) Conceptualization, NDS.; methodology, NDS, SK and AS.; validation, , NDS, SK and AS .; formal analysis, AS SB.; investigation, , NDS, SK and SB ;resources, SK,AS.; data curation, NDS, SB; writing \u0026ndash; original draft preparation, , NDS, SK and AS; writing \u0026ndash; review and editing, , NDS, SB and AS.; visualization, NDS..; supervision, NDS.; project administration, NDS.;All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePe\u0026ntilde;a A, Levitt MA (2006) Hirschsprung's disease. 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J Clin Diagn Res 17(6):PC01\u0026ndash;PC05. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7860/JCDR/2023/62393.18248\u003c/span\u003e\u003cspan address=\"10.7860/JCDR/2023/62393.18248\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaghunath SM, Maniam R, Dhanasekarapandian V, Govindarajan H (2023) Assessment of functional outcome following Duhamel retro\u0026ndash;rectal pull\u0026ndash;through surgery for Hirschsprung\u0026rsquo;s disease: A follow\u0026ndash;up study. J Pediatr Surg 58(11):271\u0026ndash;278. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/s-0043-1776891\u003c/span\u003e\u003cspan address=\"10.1055/s-0043-1776891\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAravind KL, Nisha N, Sushmitha R, C Madiwal (2021) Duhamel\u0026rsquo;s procedure for Hirschsprung\u0026rsquo;s disease and the functional outcome in a tertiary care center. Indian J Child Health 8(1):51\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.32677/IJCH.2021.v08.i01.010\u003c/span\u003e\u003cspan address=\"10.32677/IJCH.2021.v08.i01.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRehman SU, Anwar M, Fazal Z (2021) Modified Duhamel retrorectal pull\u0026ndash;through for Hirschsprung\u0026rsquo;s disease: Short\u0026ndash;term outcomes. Pak J Med Health Sci 15(10):2886\u0026ndash;2889. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.53350/pjmhs2115102886\u003c/span\u003e\u003cspan address=\"10.53350/pjmhs2115102886\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGunadi G, Carissa TM, Daulay EF, Yulianda D, Iskandar K, Dwihantoro A (2022) Long\u0026ndash;term functional outcomes of patients with Hirschsprung disease following pull\u0026ndash;through. BMC Pediatr 22:330. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12887-022-03450-y\u003c/span\u003e\u003cspan address=\"10.1186/s12887-022-03450-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Rintala\u0026apos;s Bowel Function Score classification\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBFS Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Children (N=50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormal/Good\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026ge;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e48%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFair\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e13\u0026ndash;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e38%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePoor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026le; 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 156px;\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003cstrong\u003e: Analysis of Key Functional Symptoms\u003c/strong\u003e by Krickenbeck Consensus score\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptom Grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber(N=50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFecal Soiling/Incontinence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eDaily Soiling (requiring protective aids)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e\u0026nbsp;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eOccasional Staining (less than once per week)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eNo Soiling:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e64%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstipation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eRequiring Daily Laxatives/Enemas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eManageable with Diet/Occasional Laxatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003eNo Constipation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStool frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u0026lt;1 stool/day\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e3 stools/day\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e16%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e1\u0026ndash;3 stools/day\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"egyptian-pediatric-association-gazette","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"epag","sideBox":"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)","snPcode":"43054","submissionUrl":"https://submission.springernature.com/new-submission/43054/3?","title":"Egyptian Pediatric Association Gazette","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Hirschsprung’s disease, Duhamel procedure, Bowel function, Constipation, Fecal continence, Pediatric surgery","lastPublishedDoi":"10.21203/rs.3.rs-8294135/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8294135/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHirschsprung\u0026rsquo;s disease is a congenital disorder of intestinal innervation requiring surgical correction. The modified Duhamel retro-rectal pull-through is widely used for rectosigmoid hirschsprung\u0026rsquo;s disease, but long-term functional outcomes remain variable. This study aimed to evaluate bowel function, complications, and quality of life in children undergoing this procedure.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA prospective study was conducted at a tertiary care hospital (January2022 to November 2025). Fifty children with biopsy-confirmed rectosigmoid HD who underwent the modified Duhamel pull-through were included, with \u0026ge;\u0026thinsp;3 years follow-up. Functional outcomes were assessed using the Rintala Bowel Function Score and clinical evaluation. Secondary outcomes included postoperative complications, need for medical/surgical interventions, and quality of life indicators.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study comprised 38 males (76%) and 12 females (24%), mean age at surgery 1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 years, and at assessment 6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 years. Early complications included anastomotic leak (2%), wound infection (8%), and Hirschsprung-associated enterocolitis (HAEC) (10%). Late morbidities included constipation requiring prolonged medical management (20%), residual spur (4%), and recurrent HAEC (14%). The mean BFS was 17.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9; 48% achieved good outcomes (\u0026ge;\u0026thinsp;18), 38% fair (13\u0026ndash;17), and 14% poor (\u0026le;\u0026thinsp;12). Symptom analysis showed no soiling in 64%, no constipation in 76%, and normal stool frequency in 76%. Quality of life was favorable, with 86% parental satisfaction, 92% regular school attendance, and 6% reporting social embarrassment.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe modified Duhamel procedure provides satisfactory long-term functional outcomes in most children with rectosigmoid hirschsprung\u0026rsquo;s disease. Constipation and recurrent HAEC remain the most significant late morbidities, underscoring the need for structured follow-up and individualized bowel management.\u003c/p\u003e","manuscriptTitle":"Functional Evaluation of children following Modified Duhamel Procedure for Rectosigmoid Hirschsprung’s Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-16 18:04:23","doi":"10.21203/rs.3.rs-8294135/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-25T17:29:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-25T15:49:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-23T21:25:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T08:30:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-12T15:49:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204211345031164197687903285011967862949","date":"2025-12-12T14:21:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21678524133115710990239287230488485037","date":"2025-12-12T14:03:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244499987282534456500684460109766549566","date":"2025-12-12T11:56:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309958221689762025707750036967347756015","date":"2025-12-12T03:13:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-11T13:53:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-11T10:09:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-11T10:08:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Egyptian Pediatric Association Gazette","date":"2025-12-06T10:50:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"egyptian-pediatric-association-gazette","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"epag","sideBox":"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)","snPcode":"43054","submissionUrl":"https://submission.springernature.com/new-submission/43054/3?","title":"Egyptian Pediatric Association Gazette","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8c937d3f-9063-41cd-9590-e495b99dcf0c","owner":[],"postedDate":"December 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:01:21+00:00","versionOfRecord":{"articleIdentity":"rs-8294135","link":"https://doi.org/10.1186/s43054-026-00503-w","journal":{"identity":"egyptian-pediatric-association-gazette","isVorOnly":false,"title":"Egyptian Pediatric Association Gazette"},"publishedOn":"2026-01-19 15:57:39","publishedOnDateReadable":"January 19th, 2026"},"versionCreatedAt":"2025-12-16 18:04:23","video":"","vorDoi":"10.1186/s43054-026-00503-w","vorDoiUrl":"https://doi.org/10.1186/s43054-026-00503-w","workflowStages":[]},"version":"v1","identity":"rs-8294135","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8294135","identity":"rs-8294135","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}