Modified Duhamel pull-through vs. Trans-anal endorectal pull-through in children with Hirschsprung's disease: Outcome comparison from a single center over 14 years

Modified Duhamel pull-through vs. Trans-anal endorectal pull-through in children with Hirschsprung's disease: Outcome comparison from a single center over 14 years | 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Modified Duhamel pull-through vs. Trans-anal endorectal pull-through in children with Hirschsprung's disease: Outcome comparison from a single center over 14 years Gowri Shankar, Vidya Bangalore Umashankar, Vinay Jadhav, Narendrababu Munianjanappa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2816942/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To analyze and compare short-term results and long-term bowel function in patients with Hirschsprung disease (HD) following two commonly performed definitive surgeries at our institute: Modified Duhamel pull-through (MDPT) and transanal endorectal pull-through (TERP). Methods 103 cases of HSD who underwent pull-through procedures (MDPT, n = 71; TERP, n = 32) between 2007 and 2021 were included. Seventy-nine were assessed for bowel function by Rintala scoring (MDPT, n = 53; TERP, n = 26). Results The MDPT group had more early complications (40.84% MDPT vs. 25% TERP), including anastomotic leak (4.2%, n = 71) and adhesive intestinal obstruction (5.6%, n = 71). Rectal mucosal prolapse (3.1%, n = 32) and anal stricture (3.1%, n = 32) were noted exclusively following the TERP. Both groups had a similar incidence of HAEC (21% in MDPT vs. 20% in TERP). TERP group had more daily bowel movements post-pull-through (71.8% vs. 22.5% in MDPT). Bowel function was considered impaired, with Rintala score of < 17 in 61.5% of cases of TERP (vs. 16.9% of cases of MDPT, n = 53; P = 0.001). Conclusion In our institute, we found better bowel function outcomes following MDPT compared to TERP, with higher incidence of soiling and accidents following TERP. However, long-term outcomes following technical changes in performing the TERP procedure remains to be assessed. Hirschsprung’s disease Pull-through Transanal endorectal Duhamel Bowel function Continence Figures Figure 1 Introduction Hirschsprung's disease (HD), a congenital intestinal motility disorder caused by aganglionosis of the distal intestine, is a common surgical cause of constipation among children, having an estimated incidence of 4000 cases/ year in India [ 1 ]. The commonly performed standard surgical procedures for HD across the country are trans-abdominal, multi-stage, and modified Swenson, Soave, and Duhamel pull-through procedures, with a recent trend towards primary single-stage transanal endorectal pull-through procedure (TERP). The Duhamel pull-through procedure, described in 1960, was essentially a posterior colorectal end-to-side anastomosis just above the internal sphincter, with the crushing of the colorectal septum or 'common wall' [ 2 ]. Since then, the original Duhamel procedure has undergone numerous essential modifications by Martin, Ravitch, Soper, Grob, Talbert, and others. The presently popular modified Duhamel procedure (MDPT) is a combination of modifications encompassing upper and lower colorectal anastomoses and complete division of spur by the GIA stapling device [ 3 ]. MDPT is conventionally performed as a staged procedure with initial enterostomy, leveling seromuscular biopsies, followed by transabdominal pull-through procedure and subsequent stoma closure. The advent of single-staged transanal endorectal pull-through (TERP) in 1998, attributed to De la Torre-Mondragon and Ortega [ 4 ], drew attention to the reported advantages of this less invasive approach, and the past two decades have seen much literature on TERP. Despite many studies showing better immediate postoperative results [ 5 – 8 ], other studies have demonstrated similar or poorer outcomes concerning bowel function in the long term [ 9 – 12 ]. There are few systematic reviews and meta-analyses of long-term comparative data in the present literature with no uniform consensus [ 13 – 15 ]. With this background, we compared MDPT and TERP concerning short-term complications and long-term stooling outcomes. Material And Methods Patient selection Ours was a retrospective prospective cohort study of children treated for Hirschsprung's disease. We included all children with HD who underwent MDPT or TERP procedures between 2007 and 2020 at our institute. A minimum follow-up of 1-year post-pull-through procedure was necessary for inclusion into the study. Cases of total colonic aganglionosis and those who underwent redo pull-through procedures were excluded from the study. Evaluation of continence was limited to children older than three years. Data Collection We compiled data from the in-patient files: demographics, clinical presentation, operative details, histopathology reports, complications, and episodes of Hirschsprung's associated enterocolitis (HAEC). Complications were divided into early and late, with early complications occurring within 30 days of definitive surgery. We also reviewed the postoperative follow-up data collected prospectively during outpatient visits at three months, six months, one year postoperatively, and annually after that. The latest follow-up, if not completed after an outpatient visit, was done through a telephonic survey. At follow-up, the parameters assessed were episodes of HAEC, complications, and stooling pattern. In addition, Rintala's scoring system [ 16 ] was used to assess bowel function among toilet-trained children, with a score of ≥ 17 indicating normal function. Surgical Techniques The Modified Duhamel Pull-through (MDPT) was performed predominantly as a classical staged procedure or occasionally as a primary procedure. Salient steps included - a transabdominal approach via a left lower abdominal incision, resection of aganglionic segment upto peritoneal reflection, mobilization of the ganglionated colon, retro-rectal pull-through, colorectal end-to-side anastomosis 5 mm above the dentate line, completion of the colorectal longitudinal anastomosis by stapling device (GIA cutting linear staplers 60mm/80mm) and a proximal hand-sewn anastomosis. The transanal endorectal pull-through (TERP) was done by transanal approach endorectal circumferential mucosal dissection commencing 5 mm above the dentate line and aided by retraction by a Lonestar retractor. The mucosal-submucosal dissection is carried out proximally up to the peritoneal reflection assisted by traction sutures. Following this, the muscle layer is entered, and a muscular cuff of 3 cm is split longitudinally at the 6 o'clock position. The bowel is pulled through to the ganglionated biopsy site, with or without assistance, for mobilization by laparoscopy or laparotomy. The aganglionic segment is resected, and anastomosis is performed. Postoperatively, all children are started on oral feeds five days post-surgery and receive IV antibiotics for five days. Routine anal dilatation is initiated with age-appropriate dilator size for all cases of TERP from 2 weeks postoperatively for a minimum of 6 months. Laxatives are prescribed at discharge for two weeks if there is delayed recovery of bowel function postoperatively. Results Between 2007 and 2021, 198 cases of HSD underwent pull-through procedures (MDPT, n = 115; TERP, n = 84). After excluding cases with incomplete data, 103 cases were included in the study, of which 71 cases had undergone MDPT and 32 cases TERP. Among them, seventy-nine children were eligible for assessment of bowel function score (BFS) (MDPT, n = 53; TERP, n = 26). Demographics Table 1. summarizes the demographic data. There was an M: F ratio of 6:1 in the study group, with 13.5% of cases have associated anomalies. Age at presentation was significantly lower in the TERP group. 38% of children who underwent MDPT presented beyond infancy, while only two in the TERP group presented at age < 1 year. Similarly, the age at pull-through was lower in TERP. The length of follow-up was longer in the TERP group. Clinical Presentation The clinical presentation among the study group is also outlined in Table 1. 46.6% of cases presented during the neonatal period, while 27% presented at > 1 year of age. Two patients in the MDPT group presented with pre-operative HAEC. Since MDPT had children who were older at presentation, a higher incidence of chronic constipation as presenting symptom was noted. The distribution of the level of aganglionosis in both groups was comparable, with rectosigmoid HSD being 81.5%. Surgical Procedure Of the 71 cases who underwent the MDPT procedure, 68 (95.7%) had a pre-operative colostomy, while in five cases, a covering stoma was constructed at the time of pull-through, which was closed later. On the other hand, 44% of TERP cases (n = 32) were done as primary procedures, and the rest 56% of cases (n = 32) had a pre-operative stoma. Pre-operative stoma, done along with leveling seromuscular biopsies, was necessary in these cases in the absence of a facility for the frozen section at the time of pull-through. For the primary TERP cases, laparoscopic leveling biopsies with frozen sections were done during pull-through surgery. TERP was assisted by laparotomy and abdominal mobilization in 12 out of 32 cases, of which 11 had a pre-operative stoma, and 5 were long segment HSD. Complications The MDPT group experienced more early complications overall (40.84% MDPT vs. 25% TERP, as in Table 2.) Anastomotic leak (4.2%, n = 71) and adhesive intestinal obstruction (5.6%, n = 71) were seen exclusively in the MDPT group, as seen by a higher re-operation rate. There was no statistically significant difference between the two groups for HAEC postoperatively and readmission within 30 days of pull-through. The incidence of transition zone pull-through was also comparable in both groups (9.8% MDPT vs. 9.3% TERP). There was one early mortality in the MDPT group of a 13-month-old syndromic child with a seizure disorder who had an anastomotic leak postoperatively. In the intermediate term, beyond 30 days and within one year of definitive surgery, a redo pull-through was required in one case each in the MDPT and TERP groups. The child in the MDPT group had post-operative anastomotic leak for which Hartmann's procedure was done followed by redo pull-through. The child in the TERP group had twisting and retraction of the pulled-through colon, requiring redo surgery at six weeks post-surgery. Rectal mucosal prolapse (3.1%, n = 32) and anal stricture (3.1%, n = 32) were seen exclusively following the TERP procedure. Both groups had a comparable incidence of HAEC postoperatively (19.5% in MDPT vs. 15.6% in TERP), with a similar fraction having recurrent episodes of HAEC (21% in MDPT vs. 20% in TERP) (Table 1.)—one death secondary to severe untreated HAEC due to a delay in seeking medical attention. Though not statistically significant, a higher percentage of TERP patients (15.6% vs. 5.3%) underwent botulinum toxin injection for persistent high anal sphincter pressures or sphincter spasm demonstrated by anorectal manometry. Bowel Function and continence Stooling patterns at 1-year post-pull-through surgery are summarized in Table 4 . The TERP group had significantly more daily bowel movements post-pull-through (71.8% vs. 22.5% in MDPT), with a higher proportion having > six stools/day. However, the number of daily bowel movements decreased with time for both groups. At one year follow-up, constipation requiring laxatives or enemas was noted in 15.4% of cases of MDPT (n = 71) and 9.3% of TERP cases (n = 32). In addition, soiling at one-year follow-up was documented in those who were toilet trained at assessment: in the MDPT group, 9 out of 54 had soiling, while 3 out of 4 in the TERP group reported soiling. At the latest follow-up, 79 children were eligible for bowel function assessment using the Rintala bowel function score (Table 4 ). Again, bowel function was considered impaired, with a score < 17 in 61.5% of cases of TERP (vs. 16.9% cases of MDPT, n = 53; P = 0.001). In addition, there was a higher incidence of daily soiling requiring protective aids in the TERP group and a significantly higher incidence of accidents (Table 4 ). When we divided the scoring data based on the number of years following definitive surgery, we observed that in cases at 5–10 years and > ten years of follow-up, the TERP group had lower BFS. After a technically adequate pull-through, we also analyzed for factors that might affect bowel function. There was no positive correlation between the length of the aganglionic segment and bowel function. Three patients with trisomy 21 who underwent MDPT had normal BFS at follow-up. However, there was a trend toward worsening bowel function scores in the TERP group among older children during follow-up, as seen in Fig. 1 . Discussion Most institutions have recently accepted trans-anal endorectal pull-through (TERP) as the preferred surgery for the definitive management of Hirschsprung disease. Most literature reports better short-term outcomes following TERP than trans-abdominal approaches [ 4 , 5 ]. Even so, many centers encourage the time-tested approach of the Modified Duhamel Pull-through procedure (MDPT) over TERP. The reasons may be beyond the limitations of a primary approach. Presently, there is yet to be a consensus regarding the better technique as data on long-term outcomes in published literature varies. Our study compared the outcomes following MDPT and TERP procedures over 14 years. Pre-operatively 95.7% of MDPT cases and 56.2% of TERP cases had a colostomy. Unfortunately, we had a higher rate of pre-operative stoma in TERP cases than most studies, as many presented with significant abdominal distension and distress or responded poorly to rectal washouts. Early Complications In our study, MDPT had a higher incidence of short-term complications occurring within 30 days postoperatively. Rectal stump leak (4.2%) and adhesive intestinal obstruction (5.6%) were exclusively seen following MDPT, with almost all of them (6/7) requiring re-operation. With most MDPT procedures done in older children as a staged procedure involving laparotomy, short-term complications such as these are expected, and their incidence is comparable to the available literature. For example, Gunnarsdóttir et al. [ 6 ] reported a 5.8% incidence of rectal stump leak, while Giuliani et al. [ 5 ] reported a 3% rate of intestinal obstruction following laparotomic Duhamel Pull-through procedures. The incidence of transition zone pull-through (MDPT: 9.8%; TERP:9.3%) was comparable in both groups. None of them had persisting obstructive symptoms or required a redo procedure. In the intermediate term, up to 1 year postoperatively, rectal mucosal prolapse and anal stricture were seen following TERP (3.1%). Redo pull-through during this period was required for 1 case in each group. Anastomotic stricture, an exclusive complication following TERP, has been described in many studies with a reported incidence as low as 6.6% [ 5 ] to 18.9% [ 17 ]. Stricture commonly occurs secondary to ischemia, leakage, or cuff ischemia [ 18 ]. HAEC The incidence of HAEC following pull-through procedures shows wide variation across studies, primarily due to varied definitions of HAEC. Almost all comparative analyses show no significant difference in HAEC rates between Duhamel and TERP procedures [ 7 , 14 ]. In our study, pre-operative HAEC was observed in 7% of the MDPT group and 3.1% in the TERP group. Early HAEC within 30 days of surgery was higher following TERP (3.1%) compared to MDPT (1.4%) though not statistically significant. Overall, HAEC rates were only slightly higher in the MDPT group, and the incidence of recurrent episodes (> 1 episode) postoperatively was comparable in both groups. Most HAEC episodes occurred within one year of surgery. Bowel Function We compared stooling pattern data in all patients at one-year follow-up and found that the increased frequency of stooling was significantly higher following TERP (71.8%; P 10 stools/day. Also, at one-year follow-up, constipation requiring laxatives or enemas was higher in the MDPT group but not statistically significant. 79 out of 103 patients in our study group were eligible for assessment of bowel function by Rintala bowel function scoring. A score of ≥ 17 was considered normal. Impaired bowel function with a Score < 17 was seen in 61.5% of TERP cases, significantly higher than in the MDPT group (16.9%). The main reason for the lower TERP group's lower bowel function scores was higher soiling rates (16/26). Only 2 of the 16 TERP cases with soiling had associated constipation requiring enemas. In a systemic review of long-term outcomes following pull-through for HSD, the mean soiling rate was 25% (range of 2–88%) [ 18 ]. The incidence of constipation was 30.1% in the MDPT group and 26.9% in the TERP group. Many studies have reported lower rates of constipation following TERP [ 13 , 14 ]. A similar constipation rate of 30% has been described following the Duhamel procedure in a follow-up among adults [ 18 ]. Both groups' stooling frequency was comparable, showing that early increased stooling frequency is often a temporary problem. Since there was a difference in the number of years of follow-up in both groups postoperatively, we sub-grouped the BFS data based on the number of years postoperatively. We found that at 5–10 years and > ten years postoperatively, more patients had impaired bowel function in the TERP group. However, the number in each subgroup was low to demonstrate any statistical significance. In our study group, a 14-year-old boy following TERP at ten months of age, with persistent soiling, had a lax anal tone and features of sphincter damage on anorectal manometry. Hence, a potential explanation for soiling following TERP may be due to overstretching of the anal sphincter during anal traction [ 20 ]. Upon realizing these causal elements, corrective changes were made at our institution early on, using gentler traction and devices like Lonestar over conventional retractors. Another factor could be the level of commencement of mucosectomy. If commenced too low, it can cause soiling [ 20 ]. In our cases, mucosectomy was done 5mm above the dentate line. A lower age at operation in the TERP group with a more vulnerable sphincter complex can also contribute to soiling. The length of the muscular cuff was also modified over time. We currently retain a 3 cm muscular cuff with myotomy during the TERP procedure. We have noted the purported advantage of this modification which is the avoidance of a constricting ring and reduced risk of obstruction and enterocolitis. [ 21 ] Other contributors to continence, including colonic motility, anorectal sensation, and anal canal sub-epithelium, may be affected during transanal surgery, causing soiling [ 20 , 22 ]. Fosby et al. [ 23 ], in their study on functional outcomes following TERP, could not demonstrate any improvement in bowel function with increasing age. Instead, the dominant long-term complaint they found was soiling. Granstrom et al. [ 24 ] also commented that the constipation rate decreases over time, but the soiling rate remains very high, 59–67%, in their study following laparoscopy-assisted TERP. In our study, we had nine children with persistent obstructive symptoms attributable to internal sphincter spasms with high anal pressures on anorectal manometry. In these patients, Botox inter-sphincteric injection was given (5.6% MDPT; 15.6% TERP) In conclusion, contrary to current evidence and popular choice, we had better long-term bowel function with the Modified Duhamel procedure over the years. While the TERP procedure has several advantages, it has a steeper learning curve. After implementing technical changes and expertise in performing the TERP procedure, long-term bowel function remains to be documented in the children who underwent TERP over the last five years. In teaching institutes with residency training programs, conventional surgeries like MDPT remain popular across our country, and we must acknowledge the excellent outcomes. Declarations Competing interests: The authors have no competing interests to declare that are relevant to the content of this article. Funding: No funding was received to assist with the preparation of this manuscript. Ethics Approval: waived by the Institutional Review Board at Indira Gandhi Institute of Child Health considering the retrospective nature of our study and as the procedures being performed were part of the routine care. Authors’ contribution statements Study conception and design: Gowrishankar, Vidya B. U. Data acquisition: Gowrishankar, Vidya B. U., Narendra Babu M., Vinay J. Analysis and data interpretation: Gowrishankar, Vidya B. U. Drafting of the manuscript: Gowrishankar, Vidya B. U. Critical revision: Gowrishankar, Narendra Babu M., Vinay J. Presentation at a meeting: IAPSCON, National conference of Indian Association of Pediatric Surgery (IAPS) in October 2021, K. K. Sharma Award Paper category. References Samujh R. Hirschsprung's Disease: Perspectives upon Late Presentation in India and Developing Nations. J Indian Assoc Pediatr Surg. 2022;27(3):275-278. doi:10.4103/jiaps.jiaps_6_22 DUHAMEL B. A new operation for the treatment of Hirschsprung's disease. Arch Dis Child . 1960;35(179):38-39. doi:10.1136/adc.35.179.38 Canty TG. Modified Duhamel procedure for treatment of Hirschsprung's disease in infancy and childhood: review of 41 consecutive cases. J Pediatr Surg . 1982;17(6):773-778. doi:10.1016/s0022-3468(82)80445-4 De la Torre-Mondragón L, Ortega-Salgado JA. Transanal endorectal pull-through for Hirschsprung's disease. J Pediatr Surg . 1998;33(8):1283-1286. doi:10.1016/s0022-3468(98)90169-5 Giuliani S, Betalli P, Narciso A, et al. Outcome comparison among laparoscopic Duhamel, laparotomic Duhamel, and transanal endorectal pull-through: a single-center, 18-year experience. J Laparoendosc Adv Surg Tech A . 2011;21(9):859-863. doi:10.1089/lap.2011.0107 Gunnarsdóttir A, Larsson LT, Arnbjörnsson E. Transanal endorectal vs. Duhamel pull-through for Hirschsprung's disease. Eur J Pediatr Surg . 2010;20(4):242-246. doi:10.1055/s-0030-1252006 Tannuri AC, Tannuri U, Romão RL. Transanal endorectal pull-through in children with Hirschsprung's disease--technical refinements and comparison of results with the Duhamel procedure. J Pediatr Surg . 2009;44(4):767-772. doi:10.1016/j.jpedsurg.2008.08.002 De la Torre L, Ortega A. Transanal versus open endorectal pull-through for Hirschsprung's disease. J Pediatr Surg . 2000;35(11):1630-1632. doi:10.1053/jpsu.2000.18338 Kim AC, Langer JC, Pastor AC, et al. Endorectal pull-through for Hirschsprung's disease-a multicenter, long-term comparison of results: transanal vs transabdominal approach. J Pediatr Surg . 2010;45(6):1213-1220. doi:10.1016/j.jpedsurg.2010.02.087 Ishihara M, Yamataka A, Kaneyama K, et al. Prospective analysis of primary modified Georgeson's laparoscopy-assisted endorectal pull-through for Hirschsprung's disease: short- to mid-term results. Pediatr Surg Int . 2005;21(11):878-882. doi:10.1007/s00383-005-1506-6 El-Sawaf MI, Drongowski RA, Chamberlain JN, Coran AG, Teitelbaum DH. Are the long-term results of the transanal pull-through equal to those of the transabdominal pull-through? A comparison of the 2 approaches for Hirschsprung disease. J Pediatr Surg . 2007;42(1):41-47. doi:10.1016/j.jpedsurg.2006.09.007 Martins EC, Peterlini FL, Fagundes DJ, Martins JL. Clinical, manometric and profilometric evaluation after surgery for Hirschsprung's disease: comparison between the modified Duhamel and the transanal rectosigmoidectomy techniques. Acta Cir Bras . 2009;24(5):416-422. doi:10.1590/s0102-86502009000500014 Chen Y, Nah SA, Laksmi NK, et al. Transanal endorectal pull-through versus transabdominal approach for Hirschsprung's disease: a systematic review and meta-analysis. J Pediatr Surg . 2013;48(3):642-651. doi:10.1016/j.jpedsurg.2012.12.036 Seo S, Miyake H, Hock A, et al. Duhamel and Transanal Endorectal Pull-throughs for Hirschsprung' Disease: A Systematic Review and Meta-analysis. 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Long-term outcomes of Hirschsprung's disease. Semin Pediatr Surg . 2012;21(4):336-343. doi:10.1053/j.sempedsurg.2012.07.008 Levitt MA, Dickie B, Peña A. The Hirschsprungs patient who is soiling after what was considered a "successful" pull-through. Semin Pediatr Surg . 2012;21(4):344-353. doi:10.1053/j.sempedsurg.2012.07.009 De La Torre L, Langer JC. Transanal endorectal pull-through for Hirschsprung disease: technique, controversies, pearls, pitfalls, and an organized approach to the management of postoperative obstructive symptoms. Semin Pediatr Surg . 2010;19(2):96-106. doi:10.1053/j.sempedsurg.2009.11.016 De la Torre L, Cogley K, Santos K, Morales O, Calisto J. The anal canal is the fine line between "fecal incontinence and colitis" after a pull-through for Hirschsprung disease. J Pediatr Surg . 2017;52(12):2011-2017. doi:10.1016/j.jpedsurg.2017.08.040 Fosby MV, Stensrud KJ, Bjørnland K. Bowel function after transanal endorectal pull-through for Hirschsprung disease - does outcome improve over time?. J Pediatr Surg . 2020;55(11):2375-2378. doi:10.1016/j.jpedsurg.2020.04.010 Granström AL, Husberg B, Nordenskjöld A, Svensson PJ, Wester T. Laparoscopic-assisted pull-through for Hirschsprung's disease, a prospective repeated evaluation of functional outcome. J Pediatr Surg . 2013;48(12):2536-2539. doi:10.1016/j.jpedsurg.2013.07.017 tables Table 1 . Study Group demographics and clinical details. MDPT n=71 TERP n=32 p Value Age at Presentation (years), Median (Range) 0.58 (0.04 to 2.00) 0.03 (0.01 to 0.08) <0.001* Age at Pull-through (months) Median (Range) 1.42 (0.92 to 2.42) 0.42 (0.14 to 0.58) <0.001* Age at latest follow-up (years), Median (Range) 5 (1-17) 8.25 (2-14) Length of Follow-up (years), Mean (Range) 4.06 (1 – 13.75) 7.35 (1-14.25) Associated Malformations , n (%) 16 (22.5) 1 (3.1) 0.014 † Level of Aganglionosis Rectosigmoid, n (%) 58 (81.6) 26 (83.8) 0.957 † Long Segment, n (%) 13 (18.3) 6 (18.75) Presenting Symptoms Abdominal Distension, n (%) 47 (66.19) 29 (90) 0.009 † Vomiting, n (%) 17 (23.9) 9 (28.1) 0.651 † Chronic constipation, n (%) 25 (35.2) 4 (12.5) 0.018 † HAEC, n (%) 2 (2.8) 0 (0) - Cecal Perforation, n (%) 2 (2.8) 1 (3.1) 0.931 † Intestinal obstruction, n (%) 1 (1.4) 1 (3.1) 0.559 † HAEC Pre-operative, n (%) 5 (7) 1 (3.1) 0.432 † Post-operative, n (%) 14 (19.7) 5 (15.6) 0.620 † > 1 episode 3 / 14 (21%) 1 / 5 (20%) Stoma Pre-operative, n (%) 68 (95.7) 18 (56.25) <0.001 † Post-operative, n (%) 5 (7) 1 (3.1) 0.432 † * Mann Whitney U test; † Chi-square test; MDPT: Modified Duhamel Pull-through;TERP: Transanal endorectal pull-through; HAEC: Hirschsprung associated enterocolitis. Table 1. Describes the demographic and clinical details of the study group including incidence of Hirschsprung associated enterocolitis (HAEC). Table 2 . Post-operative Complications Complications MDPT n=71 TERP n=32 P value Short term (≤30 days) N (%) N (%) Anastomotic dehiscence/ Leak 3 (4.2) 0 (0) - Adhesive Intestinal Obstruction 4 (5.6) 0 (0) - HAEC 1 (1.4) 1 (3.1) 0.559† Transition Zone Pull-through 7 (9.8) 3 (9.3) 0.939† Re-admission 8 (11.2) 4 (12.5) 0.857† Re-operation 6 (8.4) 0 (0) - Overall 29 (40.84%) 8 (25%) 0.093† Intermediate Term (1 mo.- 1yr.) Re-do Pull through 1 (1.4) 1 (3.1) 0.559† Rectal Mucosal Prolapse 0 (0) 1 (3.1) - Anal Stricture 0 (0) 1 (3.1) - High anal pressures/ sphincter spasm requiring Botox 3 (5.3) 5 (15.6) 0.096† MDPT: Modified Duhamel Pull-through group; TERP: Transanal endorectal pull-through group; Mo. : Month; Yr. : Year; †: Chi-square test Legend Table 2. Describes the short term and intermediate term complications occurring in both groups following pull-through procedure. Table 3. Stooling Pattern at 1-year follow-up . Stooling Pattern MDPT (n=71) TERP (n=32) P Value Increased Frequency of Stooling 16 (22.5) 23 (71.8) 10/day 0 (0) 2 (6.25) Constipation requiring laxatives/enemas 11 (15.4) 3 (9.3) 0.402† Soiling (Of No. Toilet trained) (%) 9 of 54 (16.6) 3 Of 4 (75%) MDPT: Modified Duhamel Pull-through group; TERP: Transanal endorectal pull-through group; BFS : Bowel Function Score (Rintala); †: Chi square test. Legend Table 3. Details of the stooling pattern noted in the study groups at 1-year follow up after pull-through procedure. Table 4. Comparative Bowel Function Scores Bowel Function Score MDPT n= 53 TERP n=26 P Value Median BFS (Range) 19 (7-20) 16 (5-20) Impaired Bowel Function BFS <17 9 (16.9%) 16 (61.5%) 0.001 † Normal Bowel Function BFS ≥17 44 (83%) 10 (38.4%) 0.001 † Parameters in Rintala’s Bowel Function Scoring Feels/ Reports the urge to defecate Always 47 (88.6%) 19 (73%) - Most of the time 3 (5.6%) 4 (1.5%) Uncertain 3 (5.6%) 3 (1.1%) Absent 0 0 Ability to hold back defecation - Always 44 (83%) 13 (50%) Problems <1/week 6 (11.3%) 7 (26.9%) Weekly problems 3 (5.6%) 5 (19.2%) No voluntary control 0 1 (3.8%) Frequency of defecation - Every other day to twice a day 39 (73.5%) 19 (73%) More often 6 (11.3%) 7 (26.9%) Less often 8 (15%) 0 Soiling - Never 38 (71.6%) 7 (26.9%) Staining 1/wk.), change of underwear often required 4 (5.6%) 3 (1.1%) Daily, requires protective aids 0 10 (38.4%) Accidents 0.003† Never 38 (71.6%) 8 (34.7%) Fewer than 1/wk. 11 (20.7%) 9 (34.6%) Weekly, requires protective aids 3 (5.6%) 5 (19.2%) Daily, requires protective aids day & night 1 (1.8%) 4 (1.5%) Constipation - No constipation 36 (67.9%) 19 (73%) Managed with diet 13 (24.5%) 5 (19.2%) Managed with laxatives 3 (5.6%) 2 (7.6%) Managed with enemas 1 (1.8%) 0 Social problems - None 42 (79.2%) 15 (57.7%) Sometimes (foul odours) 8 (15%) 7 (26.9%) Problems restricting social life 3 (5.6%) 3 (1.1%) Major social/ psychological problems 0 1 (3.8%) MDPT: Modified Duhamel Pull-through group; TERP: Transanal endorectal pull-through group; BFS : Bowel Function Score (Rintala); †: Chi-square test Table 4. Shows the comparative Bowel function scores of the two study group and also details the individual parameters of the Rintala bowel function score. Table 5. Comparative BFS based on period of follow-up. Years Post-operatively Abnormal, BFS <17 P value Normal, BFS ≥17 P Value MDPT (n=9) TERP (n=16) MDPT (n=44) TERP (n=10) 1 – 5 years 5 (55.56%) 2 (12.5%) 0.058 † 7 (15.91%) 1 (10%) 0.14 † 5-10 years 1 (11.11%) 9 (56.25%) 0.040 † 8 (18.18%) 5 (50%) 0.048 † >10 years 2 (22.22%) 5 (31.25%) 1.00 † 2 (4.55%) 0 - MDPT: Modified Duhamel Pull-through group; TERP: Transanal endorectal pull-through group; BFS : Bowel Function Score (Rintala); †: Chi-square test Legend Table 5. Shows the comparative bowel function scores of the two study groups subdivided based on the period of follow-up. Additional Declarations No competing interests reported. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2816942","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":192112160,"identity":"04989bc9-e4c7-49d7-aa29-5bf6266b40db","order_by":0,"name":"Gowri Shankar","email":"","orcid":"","institution":"Indira Gandhi Institute of Child Heath, South Hospital Complex, Dharmaram College post","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gowri","middleName":"","lastName":"Shankar","suffix":""},{"id":192112162,"identity":"95b37419-a64b-4d25-bd63-a5edec7c90d5","order_by":1,"name":"Vidya Bangalore Umashankar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYDACZgYDBsYGMAtE2gAxY+MBIrWAyTQwA78WBlQth8FCeLUYHGfeJvFzh12evPvBxscVFecT17YfBtpSYxONU8thtjLJ3jPJxYZnEpsNz5y5nbjtTCJQy7G03AYcWiSbecwkeNuYEzc2JLZJNrYBtRwAamFsOIxXi+TftvrEjf0PgVr+nUvcdv4hfi38zDxm0rxthxPnS4BsaTiQuO0GAVv4mdmKrWXPHE/cIPGw2bDhWLLxthtAWxLw+IWN//DGm293VCfO708++LChxk522/n0hw8+1Njg1AIELBIg0uAAhOcIVpmAWzkIMH8AkfJQQ+3xKx4Fo2AUjIKRCAAFaWnGm3QocgAAAABJRU5ErkJggg==","orcid":"","institution":"Indira Gandhi Institute of Child Heath, South Hospital Complex, Dharmaram College post","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Vidya","middleName":"Bangalore","lastName":"Umashankar","suffix":""},{"id":192112163,"identity":"ac9bdc72-925c-4183-b247-c8e96782197a","order_by":2,"name":"Vinay Jadhav","email":"","orcid":"","institution":"Indira Gandhi Institute of Child Heath, South Hospital Complex, Dharmaram College post","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Vinay","middleName":"","lastName":"Jadhav","suffix":""},{"id":192112164,"identity":"7a253fdb-cf79-424d-ba5b-db4965eafd26","order_by":3,"name":"Narendrababu Munianjanappa","email":"","orcid":"","institution":"Indira Gandhi Institute of Child Heath, South Hospital Complex, Dharmaram College post","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Narendrababu","middleName":"","lastName":"Munianjanappa","suffix":""}],"badges":[],"createdAt":"2023-04-14 11:44:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2816942/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2816942/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":35939239,"identity":"b9c9ad33-855b-4882-8621-90b368c47455","added_by":"auto","created_at":"2023-04-18 14:18:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":87642,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe relationship between BFS and age at interview in the two study groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA scatter plot of bowel function scores in each study group against age at interview for bowel function scoring. There is a downward trend noted in bowel function score (BFS) following TERP among children who were older at follow-up.\u003c/p\u003e\n\u003cp\u003eMDPT: Modified Duhamel Pull-through group\u003c/p\u003e\n\u003cp\u003eTERP: Transanal endorectal pull-through group\u003c/p\u003e\n\u003cp\u003eBFS : Bowel Function Score (Rintala)\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2816942/v1/de2ec96052c1d92269c1af2e.png"},{"id":36513661,"identity":"ec432071-e0ac-4849-9bc0-ce8d4b1b38a3","added_by":"auto","created_at":"2023-05-02 06:14:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":494527,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2816942/v1/71f475e8-1944-40d0-b537-b6c99628b87a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Modified Duhamel pull-through vs. Trans-anal endorectal pull-through in children with Hirschsprung's disease: Outcome comparison from a single center over 14 years","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHirschsprung's disease (HD), a congenital intestinal motility disorder caused by aganglionosis of the distal intestine, is a common surgical cause of constipation among children, having an estimated incidence of 4000 cases/ year in India [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The commonly performed standard surgical procedures for HD across the country are trans-abdominal, multi-stage, and modified Swenson, Soave, and Duhamel pull-through procedures, with a recent trend towards primary single-stage transanal endorectal pull-through procedure (TERP).\u003c/p\u003e \u003cp\u003eThe Duhamel pull-through procedure, described in 1960, was essentially a posterior colorectal end-to-side anastomosis just above the internal sphincter, with the crushing of the colorectal septum or 'common wall' [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Since then, the original Duhamel procedure has undergone numerous essential modifications by Martin, Ravitch, Soper, Grob, Talbert, and others. The presently popular modified Duhamel procedure (MDPT) is a combination of modifications encompassing upper and lower colorectal anastomoses and complete division of spur by the GIA stapling device [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. MDPT is conventionally performed as a staged procedure with initial enterostomy, leveling seromuscular biopsies, followed by transabdominal pull-through procedure and subsequent stoma closure.\u003c/p\u003e \u003cp\u003eThe advent of single-staged transanal endorectal pull-through (TERP) in 1998, attributed to De la Torre-Mondragon and Ortega [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], drew attention to the reported advantages of this less invasive approach, and the past two decades have seen much literature on TERP. Despite many studies showing better immediate postoperative results [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], other studies have demonstrated similar or poorer outcomes concerning bowel function in the long term [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. There are few systematic reviews and meta-analyses of long-term comparative data in the present literature with no uniform consensus [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith this background, we compared MDPT and TERP concerning short-term complications and long-term stooling outcomes.\u003c/p\u003e"},{"header":"Material And Methods","content":"\u003cp\u003ePatient selection\u003c/p\u003e \u003cp\u003eOurs was a retrospective prospective cohort study of children treated for Hirschsprung's disease. We included all children with HD who underwent MDPT or TERP procedures between 2007 and 2020 at our institute. A minimum follow-up of 1-year post-pull-through procedure was necessary for inclusion into the study. Cases of total colonic aganglionosis and those who underwent redo pull-through procedures were excluded from the study. Evaluation of continence was limited to children older than three years.\u003c/p\u003e \u003cp\u003eData Collection\u003c/p\u003e \u003cp\u003eWe compiled data from the in-patient files: demographics, clinical presentation, operative details, histopathology reports, complications, and episodes of Hirschsprung's associated enterocolitis (HAEC). Complications were divided into early and late, with early complications occurring within 30 days of definitive surgery.\u003c/p\u003e \u003cp\u003e We also reviewed the postoperative follow-up data collected prospectively during outpatient visits at three months, six months, one year postoperatively, and annually after that. The latest follow-up, if not completed after an outpatient visit, was done through a telephonic survey. At follow-up, the parameters assessed were episodes of HAEC, complications, and stooling pattern. In addition, Rintala's scoring system [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] was used to assess bowel function among toilet-trained children, with a score of \u0026ge;\u0026thinsp;17 indicating normal function.\u003c/p\u003e \u003cp\u003eSurgical Techniques\u003c/p\u003e \u003cp\u003eThe Modified Duhamel Pull-through (MDPT) was performed predominantly as a classical staged procedure or occasionally as a primary procedure. Salient steps included - a transabdominal approach via a left lower abdominal incision, resection of aganglionic segment upto peritoneal reflection, mobilization of the ganglionated colon, retro-rectal pull-through, colorectal end-to-side anastomosis 5 mm above the dentate line, completion of the colorectal longitudinal anastomosis by stapling device (GIA cutting linear staplers 60mm/80mm) and a proximal hand-sewn anastomosis.\u003c/p\u003e \u003cp\u003eThe transanal endorectal pull-through (TERP) was done by transanal approach endorectal circumferential mucosal dissection commencing 5 mm above the dentate line and aided by retraction by a Lonestar retractor. The mucosal-submucosal dissection is carried out proximally up to the peritoneal reflection assisted by traction sutures. Following this, the muscle layer is entered, and a muscular cuff of 3 cm is split longitudinally at the 6 o'clock position. The bowel is pulled through to the ganglionated biopsy site, with or without assistance, for mobilization by laparoscopy or laparotomy. The aganglionic segment is resected, and anastomosis is performed.\u003c/p\u003e \u003cp\u003ePostoperatively, all children are started on oral feeds five days post-surgery and receive IV antibiotics for five days. Routine anal dilatation is initiated with age-appropriate dilator size for all cases of TERP from 2 weeks postoperatively for a minimum of 6 months. Laxatives are prescribed at discharge for two weeks if there is delayed recovery of bowel function postoperatively.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween 2007 and 2021, 198 cases of HSD underwent pull-through procedures (MDPT, n\u0026thinsp;=\u0026thinsp;115; TERP, n\u0026thinsp;=\u0026thinsp;84). After excluding cases with incomplete data, 103 cases were included in the study, of which 71 cases had undergone MDPT and 32 cases TERP. Among them, seventy-nine children were eligible for assessment of bowel function score (BFS) (MDPT, n\u0026thinsp;=\u0026thinsp;53; TERP, n\u0026thinsp;=\u0026thinsp;26).\u003c/p\u003e\n\u003cp\u003eDemographics\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1. summarizes the demographic data. There was an M: F ratio of 6:1 in the study group, with 13.5% of cases have associated anomalies. Age at presentation was significantly lower in the TERP group. 38% of children who underwent MDPT presented beyond infancy, while only two in the TERP group presented at age\u0026thinsp;\u0026lt;\u0026thinsp;1 year. Similarly, the age at pull-through was lower in TERP. The length of follow-up was longer in the TERP group.\u003c/p\u003e\n\u003cp\u003eClinical Presentation\u003c/p\u003e\n\u003cp\u003eThe clinical presentation among the study group is also outlined in Table\u0026nbsp;1. 46.6% of cases presented during the neonatal period, while 27% presented at \u0026gt;\u0026thinsp;1 year of age. Two patients in the MDPT group presented with pre-operative HAEC. Since MDPT had children who were older at presentation, a higher incidence of chronic constipation as presenting symptom was noted. The distribution of the level of aganglionosis in both groups was comparable, with rectosigmoid HSD being 81.5%.\u003c/p\u003e\n\u003cp\u003eSurgical Procedure\u003c/p\u003e\n\u003cp\u003eOf the 71 cases who underwent the MDPT procedure, 68 (95.7%) had a pre-operative colostomy, while in five cases, a covering stoma was constructed at the time of pull-through, which was closed later. On the other hand, 44% of TERP cases (n\u0026thinsp;=\u0026thinsp;32) were done as primary procedures, and the rest 56% of cases (n\u0026thinsp;=\u0026thinsp;32) had a pre-operative stoma. Pre-operative stoma, done along with leveling seromuscular biopsies, was necessary in these cases in the absence of a facility for the frozen section at the time of pull-through. For the primary TERP cases, laparoscopic leveling biopsies with frozen sections were done during pull-through surgery. TERP was assisted by laparotomy and abdominal mobilization in 12 out of 32 cases, of which 11 had a pre-operative stoma, and 5 were long segment HSD.\u003c/p\u003e\n\u003cp\u003eComplications\u003c/p\u003e\n\u003cp\u003eThe MDPT group experienced more early complications overall (40.84% MDPT vs. 25% TERP, as in Table\u0026nbsp;2.) Anastomotic leak (4.2%, n\u0026thinsp;=\u0026thinsp;71) and adhesive intestinal obstruction (5.6%, n\u0026thinsp;=\u0026thinsp;71) were seen exclusively in the MDPT group, as seen by a higher re-operation rate. There was no statistically significant difference between the two groups for HAEC postoperatively and readmission within 30 days of pull-through. The incidence of transition zone pull-through was also comparable in both groups (9.8% MDPT vs. 9.3% TERP). There was one early mortality in the MDPT group of a 13-month-old syndromic child with a seizure disorder who had an anastomotic leak postoperatively.\u003c/p\u003e\n\u003cp\u003eIn the intermediate term, beyond 30 days and within one year of definitive surgery, a redo pull-through was required in one case each in the MDPT and TERP groups. The child in the MDPT group had post-operative anastomotic leak for which Hartmann's procedure was done followed by redo pull-through. The child in the TERP group had twisting and retraction of the pulled-through colon, requiring redo surgery at six weeks post-surgery. Rectal mucosal prolapse (3.1%, n\u0026thinsp;=\u0026thinsp;32) and anal stricture (3.1%, n\u0026thinsp;=\u0026thinsp;32) were seen exclusively following the TERP procedure.\u003c/p\u003e\n\u003cp\u003eBoth groups had a comparable incidence of HAEC postoperatively (19.5% in MDPT vs. 15.6% in TERP), with a similar fraction having recurrent episodes of HAEC (21% in MDPT vs. 20% in TERP) (Table\u0026nbsp;1.)\u0026mdash;one death secondary to severe untreated HAEC due to a delay in seeking medical attention.\u003c/p\u003e\n\u003cp\u003eThough not statistically significant, a higher percentage of TERP patients (15.6% vs. 5.3%) underwent botulinum toxin injection for persistent high anal sphincter pressures or sphincter spasm demonstrated by anorectal manometry.\u003c/p\u003e\n\u003cp\u003eBowel Function and continence\u003c/p\u003e\n\u003cp\u003eStooling patterns at 1-year post-pull-through surgery are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. The TERP group had significantly more daily bowel movements post-pull-through (71.8% vs. 22.5% in MDPT), with a higher proportion having\u0026thinsp;\u0026gt;\u0026thinsp;six stools/day. However, the number of daily bowel movements decreased with time for both groups. At one year follow-up, constipation requiring laxatives or enemas was noted in 15.4% of cases of MDPT (n\u0026thinsp;=\u0026thinsp;71) and 9.3% of TERP cases (n\u0026thinsp;=\u0026thinsp;32). In addition, soiling at one-year follow-up was documented in those who were toilet trained at assessment: in the MDPT group, 9 out of 54 had soiling, while 3 out of 4 in the TERP group reported soiling.\u003c/p\u003e\n\u003cp\u003eAt the latest follow-up, 79 children were eligible for bowel function assessment using the Rintala bowel function score (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Again, bowel function was considered impaired, with a score\u0026thinsp;\u0026lt;\u0026thinsp;17 in 61.5% of cases of TERP (vs. 16.9% cases of MDPT, n\u0026thinsp;=\u0026thinsp;53; P\u0026thinsp;=\u0026thinsp;0.001). In addition, there was a higher incidence of daily soiling requiring protective aids in the TERP group and a significantly higher incidence of accidents (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). When we divided the scoring data based on the number of years following definitive surgery, we observed that in cases at 5\u0026ndash;10 years and \u0026gt;\u0026thinsp;ten years of follow-up, the TERP group had lower BFS.\u003c/p\u003e\n\u003cp\u003eAfter a technically adequate pull-through, we also analyzed for factors that might affect bowel function. There was no positive correlation between the length of the aganglionic segment and bowel function. Three patients with trisomy 21 who underwent MDPT had normal BFS at follow-up. However, there was a trend toward worsening bowel function scores in the TERP group among older children during follow-up, as seen in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMost institutions have recently accepted trans-anal endorectal pull-through (TERP) as the preferred surgery for the definitive management of Hirschsprung disease. Most literature reports better short-term outcomes following TERP than trans-abdominal approaches [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. Even so, many centers encourage the time-tested approach of the Modified Duhamel Pull-through procedure (MDPT) over TERP. The reasons may be beyond the limitations of a primary approach. Presently, there is yet to be a consensus regarding the better technique as data on long-term outcomes in published literature varies.\u003c/p\u003e\n\u003cp\u003eOur study compared the outcomes following MDPT and TERP procedures over 14 years.\u003c/p\u003e\n\u003cp\u003ePre-operatively 95.7% of MDPT cases and 56.2% of TERP cases had a colostomy. Unfortunately, we had a higher rate of pre-operative stoma in TERP cases than most studies, as many presented with significant abdominal distension and distress or responded poorly to rectal washouts.\u003c/p\u003e\n\u003ch3\u003eEarly Complications\u003c/h3\u003e\n\u003cp\u003eIn our study, MDPT had a higher incidence of short-term complications occurring within 30 days postoperatively. Rectal stump leak (4.2%) and adhesive intestinal obstruction (5.6%) were exclusively seen following MDPT, with almost all of them (6/7) requiring re-operation. With most MDPT procedures done in older children as a staged procedure involving laparotomy, short-term complications such as these are expected, and their incidence is comparable to the available literature. For example, Gunnarsd\u0026oacute;ttir et al. [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e] reported a 5.8% incidence of rectal stump leak, while Giuliani et al. [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e] reported a 3% rate of intestinal obstruction following laparotomic Duhamel Pull-through procedures.\u003c/p\u003e\n\u003cp\u003eThe incidence of transition zone pull-through (MDPT: 9.8%; TERP:9.3%) was comparable in both groups. None of them had persisting obstructive symptoms or required a redo procedure.\u003c/p\u003e\n\u003cp\u003eIn the intermediate term, up to 1 year postoperatively, rectal mucosal prolapse and anal stricture were seen following TERP (3.1%). Redo pull-through during this period was required for 1 case in each group. Anastomotic stricture, an exclusive complication following TERP, has been described in many studies with a reported incidence as low as 6.6% [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e] to 18.9% [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. Stricture commonly occurs secondary to ischemia, leakage, or cuff ischemia [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch3\u003eHAEC\u003c/h3\u003e\n\u003cp\u003eThe incidence of HAEC following pull-through procedures shows wide variation across studies, primarily due to varied definitions of HAEC. Almost all comparative analyses show no significant difference in HAEC rates between Duhamel and TERP procedures [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. In our study, pre-operative HAEC was observed in 7% of the MDPT group and 3.1% in the TERP group. Early HAEC within 30 days of surgery was higher following TERP (3.1%) compared to MDPT (1.4%) though not statistically significant. Overall, HAEC rates were only slightly higher in the MDPT group, and the incidence of recurrent episodes (\u0026gt;\u0026thinsp;1 episode) postoperatively was comparable in both groups. Most HAEC episodes occurred within one year of surgery.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eBowel Function\u003c/h3\u003e\n\u003cp\u003eWe compared stooling pattern data in all patients at one-year follow-up and found that the increased frequency of stooling was significantly higher following TERP (71.8%; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with many children having\u0026thinsp;\u0026gt;\u0026thinsp;10 stools/day. Also, at one-year follow-up, constipation requiring laxatives or enemas was higher in the MDPT group but not statistically significant.\u003c/p\u003e\n\u003cp\u003e79 out of 103 patients in our study group were eligible for assessment of bowel function by Rintala bowel function scoring. A score of \u0026ge;\u0026thinsp;17 was considered normal. Impaired bowel function with a Score\u0026thinsp;\u0026lt;\u0026thinsp;17 was seen in 61.5% of TERP cases, significantly higher than in the MDPT group (16.9%). The main reason for the lower TERP group's lower bowel function scores was higher soiling rates (16/26). Only 2 of the 16 TERP cases with soiling had associated constipation requiring enemas. In a systemic review of long-term outcomes following pull-through for HSD, the mean soiling rate was 25% (range of 2\u0026ndash;88%) [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe incidence of constipation was 30.1% in the MDPT group and 26.9% in the TERP group. Many studies have reported lower rates of constipation following TERP [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. A similar constipation rate of 30% has been described following the Duhamel procedure in a follow-up among adults [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Both groups' stooling frequency was comparable, showing that early increased stooling frequency is often a temporary problem.\u003c/p\u003e\n\u003cp\u003eSince there was a difference in the number of years of follow-up in both groups postoperatively, we sub-grouped the BFS data based on the number of years postoperatively. We found that at 5\u0026ndash;10 years and \u0026gt;\u0026thinsp;ten years postoperatively, more patients had impaired bowel function in the TERP group. However, the number in each subgroup was low to demonstrate any statistical significance. In our study group, a 14-year-old boy following TERP at ten months of age, with persistent soiling, had a lax anal tone and features of sphincter damage on anorectal manometry.\u003c/p\u003e\n\u003cp\u003eHence, a potential explanation for soiling following TERP may be due to overstretching of the anal sphincter during anal traction [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Upon realizing these causal elements, corrective changes were made at our institution early on, using gentler traction and devices like Lonestar over conventional retractors. Another factor could be the level of commencement of mucosectomy. If commenced too low, it can cause soiling [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. In our cases, mucosectomy was done 5mm above the dentate line. A lower age at operation in the TERP group with a more vulnerable sphincter complex can also contribute to soiling. The length of the muscular cuff was also modified over time. We currently retain a 3 cm muscular cuff with myotomy during the TERP procedure. We have noted the purported advantage of this modification which is the avoidance of a constricting ring and reduced risk of obstruction and enterocolitis. [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eOther contributors to continence, including colonic motility, anorectal sensation, and anal canal sub-epithelium, may be affected during transanal surgery, causing soiling [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eFosby et al. [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e], in their study on functional outcomes following TERP, could not demonstrate any improvement in bowel function with increasing age. Instead, the dominant long-term complaint they found was soiling. Granstrom et al. [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e] also commented that the constipation rate decreases over time, but the soiling rate remains very high, 59\u0026ndash;67%, in their study following laparoscopy-assisted TERP.\u003c/p\u003e\n\u003cp\u003eIn our study, we had nine children with persistent obstructive symptoms attributable to internal sphincter spasms with high anal pressures on anorectal manometry. In these patients, Botox inter-sphincteric injection was given (5.6% MDPT; 15.6% TERP)\u003c/p\u003e\n\u003cp\u003eIn conclusion, contrary to current evidence and popular choice, we had better long-term bowel function with the Modified Duhamel procedure over the years. While the TERP procedure has several advantages, it has a steeper learning curve. After implementing technical changes and expertise in performing the TERP procedure, long-term bowel function remains to be documented in the children who underwent TERP over the last five years. In teaching institutes with residency training programs, conventional surgeries like MDPT remain popular across our country, and we must acknowledge the excellent outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests: \u003c/strong\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eNo funding was received to assist with the preparation of this manuscript.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval: \u003c/strong\u003ewaived by the Institutional Review Board at Indira Gandhi Institute of Child Health considering the retrospective nature of our study and as the procedures being performed were part of the routine care.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution statements\u003c/strong\u003e\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eStudy conception and design: Gowrishankar, Vidya B. U.\u003c/p\u003e\n\u003cp\u003eData acquisition: Gowrishankar, Vidya B. U., Narendra Babu M., Vinay J.\u003c/p\u003e\n\u003cp\u003eAnalysis and data interpretation: Gowrishankar, Vidya B. U.\u003c/p\u003e\n\u003cp\u003eDrafting of the manuscript: Gowrishankar, Vidya B. U.\u003c/p\u003e\n\u003cp\u003eCritical revision: Gowrishankar, Narendra Babu M., Vinay J.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePresentation at a meeting:\u003c/strong\u003e IAPSCON, National conference of Indian Association of Pediatric Surgery (IAPS) in October 2021, K. K. Sharma Award Paper category.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSamujh R. Hirschsprung\u0026apos;s Disease: Perspectives upon Late Presentation in India and Developing Nations. J Indian Assoc Pediatr Surg. 2022;27(3):275-278. doi:10.4103/jiaps.jiaps_6_22\u003c/li\u003e\n\u003cli\u003eDUHAMEL B. A new operation for the treatment of Hirschsprung\u0026apos;s disease. \u003cem\u003eArch Dis Child\u003c/em\u003e. 1960;35(179):38-39. doi:10.1136/adc.35.179.38\u003c/li\u003e\n\u003cli\u003eCanty TG. Modified Duhamel procedure for treatment of Hirschsprung\u0026apos;s disease in infancy and childhood: review of 41 consecutive cases. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 1982;17(6):773-778. doi:10.1016/s0022-3468(82)80445-4\u003c/li\u003e\n\u003cli\u003eDe la Torre-Mondrag\u0026oacute;n L, Ortega-Salgado JA. Transanal endorectal pull-through for Hirschsprung\u0026apos;s disease. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 1998;33(8):1283-1286. doi:10.1016/s0022-3468(98)90169-5\u003c/li\u003e\n\u003cli\u003eGiuliani S, Betalli P, Narciso A, et al. Outcome comparison among laparoscopic Duhamel, laparotomic Duhamel, and transanal endorectal pull-through: a single-center, 18-year experience. \u003cem\u003eJ Laparoendosc Adv Surg Tech A\u003c/em\u003e. 2011;21(9):859-863. doi:10.1089/lap.2011.0107\u003c/li\u003e\n\u003cli\u003eGunnarsd\u0026oacute;ttir A, Larsson LT, Arnbj\u0026ouml;rnsson E. Transanal endorectal vs. Duhamel pull-through for Hirschsprung\u0026apos;s disease. \u003cem\u003eEur J Pediatr Surg\u003c/em\u003e. 2010;20(4):242-246. doi:10.1055/s-0030-1252006\u003c/li\u003e\n\u003cli\u003eTannuri AC, Tannuri U, Rom\u0026atilde;o RL. Transanal endorectal pull-through in children with Hirschsprung\u0026apos;s disease--technical refinements and comparison of results with the Duhamel procedure. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 2009;44(4):767-772. doi:10.1016/j.jpedsurg.2008.08.002\u003c/li\u003e\n\u003cli\u003eDe la Torre L, Ortega A. Transanal versus open endorectal pull-through for Hirschsprung\u0026apos;s disease. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 2000;35(11):1630-1632. doi:10.1053/jpsu.2000.18338\u003c/li\u003e\n\u003cli\u003eKim AC, Langer JC, Pastor AC, et al. Endorectal pull-through for Hirschsprung\u0026apos;s disease-a multicenter, long-term comparison of results: transanal vs transabdominal approach. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 2010;45(6):1213-1220. doi:10.1016/j.jpedsurg.2010.02.087\u003c/li\u003e\n\u003cli\u003eIshihara M, Yamataka A, Kaneyama K, et al. Prospective analysis of primary modified Georgeson\u0026apos;s laparoscopy-assisted endorectal pull-through for Hirschsprung\u0026apos;s disease: short- to mid-term results. \u003cem\u003ePediatr Surg Int\u003c/em\u003e. 2005;21(11):878-882. doi:10.1007/s00383-005-1506-6\u003c/li\u003e\n\u003cli\u003eEl-Sawaf MI, Drongowski RA, Chamberlain JN, Coran AG, Teitelbaum DH. Are the long-term results of the transanal pull-through equal to those of the transabdominal pull-through? A comparison of the 2 approaches for Hirschsprung disease. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 2007;42(1):41-47. doi:10.1016/j.jpedsurg.2006.09.007\u003c/li\u003e\n\u003cli\u003eMartins EC, Peterlini FL, Fagundes DJ, Martins JL. Clinical, manometric and profilometric evaluation after surgery for Hirschsprung\u0026apos;s disease: comparison between the modified Duhamel and the transanal rectosigmoidectomy techniques. \u003cem\u003eActa Cir Bras\u003c/em\u003e. 2009;24(5):416-422. doi:10.1590/s0102-86502009000500014\u003c/li\u003e\n\u003cli\u003eChen Y, Nah SA, Laksmi NK, et al. Transanal endorectal pull-through versus transabdominal approach for Hirschsprung\u0026apos;s disease: a systematic review and meta-analysis. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 2013;48(3):642-651. doi:10.1016/j.jpedsurg.2012.12.036\u003c/li\u003e\n\u003cli\u003eSeo S, Miyake H, Hock A, et al. Duhamel and Transanal Endorectal Pull-throughs for Hirschsprung\u0026apos; Disease: A Systematic Review and Meta-analysis. \u003cem\u003eEur J Pediatr Surg\u003c/em\u003e. 2018;28(1):81-88. doi:10.1055/s-0037-1607061\u003c/li\u003e\n\u003cli\u003eYan BL, Bi LW, Yang QY, Wu XS, Cui HL. Transanal endorectal pull-through procedure versus transabdominal surgery for Hirschsprung disease: A systematic review and meta-analysis. \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e. 2019;98(32):e16777. doi:10.1097/MD.0000000000016777\u003c/li\u003e\n\u003cli\u003eRintala RJ, Lindahl H. Is normal bowel function possible after repair of intermediate and high anorectal malformations?. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 1995;30(3):491-494. doi:10.1016/0022-3468(95)90064-0\u003c/li\u003e\n\u003cli\u003eMinford JL, Ram A, Turnock RR, et al. Comparison of functional outcomes of Duhamel and transanal endorectal coloanal anastomosis for Hirschsprung\u0026apos;s disease. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 2004;39(2):161-165. doi:10.1016/j.jpedsurg.2003.10.004\u003c/li\u003e\n\u003cli\u003eGosemann JH, Friedmacher F, Ure B, Lacher M. Open versus transanal pull-through for Hirschsprung disease: a systematic review of long-term outcome. \u003cem\u003eEur J Pediatr Surg\u003c/em\u003e. 2013;23(2):94-102. doi:10.1055/s-0033-1343085\u003c/li\u003e\n\u003cli\u003eRintala RJ, Pakarinen MP. Long-term outcomes of Hirschsprung\u0026apos;s disease. \u003cem\u003eSemin Pediatr Surg\u003c/em\u003e. 2012;21(4):336-343. doi:10.1053/j.sempedsurg.2012.07.008\u003c/li\u003e\n\u003cli\u003eLevitt MA, Dickie B, Pe\u0026ntilde;a A. The Hirschsprungs patient who is soiling after what was considered a \u0026quot;successful\u0026quot; pull-through. \u003cem\u003eSemin Pediatr Surg\u003c/em\u003e. 2012;21(4):344-353. doi:10.1053/j.sempedsurg.2012.07.009\u003c/li\u003e\n\u003cli\u003eDe La Torre L, Langer JC. Transanal endorectal pull-through for Hirschsprung disease: technique, controversies, pearls, pitfalls, and an organized approach to the management of postoperative obstructive symptoms. \u003cem\u003eSemin Pediatr Surg\u003c/em\u003e. 2010;19(2):96-106. doi:10.1053/j.sempedsurg.2009.11.016\u003c/li\u003e\n\u003cli\u003eDe la Torre L, Cogley K, Santos K, Morales O, Calisto J. The anal canal is the fine line between \u0026quot;fecal incontinence and colitis\u0026quot; after a pull-through for Hirschsprung disease. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 2017;52(12):2011-2017. doi:10.1016/j.jpedsurg.2017.08.040\u003c/li\u003e\n\u003cli\u003eFosby MV, Stensrud KJ, Bj\u0026oslash;rnland K. Bowel function after transanal endorectal pull-through for Hirschsprung disease - does outcome improve over time?. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 2020;55(11):2375-2378. doi:10.1016/j.jpedsurg.2020.04.010\u003c/li\u003e\n\u003cli\u003eGranstr\u0026ouml;m AL, Husberg B, Nordenskj\u0026ouml;ld A, Svensson PJ, Wester T. Laparoscopic-assisted pull-through for Hirschsprung\u0026apos;s disease, a prospective repeated evaluation of functional outcome. \u003cem\u003eJ Pediatr Surg\u003c/em\u003e. 2013;48(12):2536-2539. doi:10.1016/j.jpedsurg.2013.07.017\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e. Study Group demographics and clinical details.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e\u003cstrong\u003eMDPT n=71\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e\u003cstrong\u003eTERP n=32\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u003cstrong\u003ep Value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e at Presentation (years), Median (Range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e0.58 (0.04 to 2.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e0.03 (0.01 to 0.08)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003eAge at Pull-through (months) Median (Range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e1.42 (0.92 to 2.42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e0.42 (0.14 to 0.58)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003eAge at latest follow-up (years), Median (Range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e5 (1-17)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e8.25 (2-14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003eLength of Follow-up (years), Mean (Range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e4.06 (1 \u0026ndash; 13.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e7.35 (1-14.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cstrong\u003eAssociated Malformations\u003c/strong\u003e, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e16 (22.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e1 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026nbsp;0.014 \u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of Aganglionosis\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;Rectosigmoid, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e58 (81.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e26 (83.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e0.957\u0026nbsp;\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"52.6032315978456%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;Long Segment, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"23.6983842010772%\"\u003e\n\u003cp\u003e13 (18.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"23.6983842010772%\"\u003e\n\u003cp\u003e6 (18.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cstrong\u003ePresenting Symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003eAbdominal Distension, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e47 (66.19)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e29 (90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e0.009\u0026nbsp;\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003eVomiting, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e17 (23.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e9 (28.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e0.651\u0026nbsp;\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003eChronic constipation, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e25 (35.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e4 (12.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e0.018\u0026nbsp;\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003eHAEC, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e2 (2.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003eCecal Perforation, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e2 (2.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e1 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e0.931\u0026nbsp;\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp; Intestinal obstruction, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e1 (1.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e1 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e0.559\u0026nbsp;\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cstrong\u003eHAEC\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;Pre-operative, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e5 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e1 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e0.432\u0026nbsp;\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;Post-operative, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e14 (19.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e5 (15.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e0.620\u0026nbsp;\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026gt; 1 episode \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e3 / 14 (21%) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e1 / 5 (20%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cstrong\u003eStoma\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;Pre-operative, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e68 (95.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e18 (56.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e\u0026lt;0.001\u0026nbsp;\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"47.25806451612903%\"\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;Post-operative, n (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e5 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"21.29032258064516%\"\u003e\n\u003cp\u003e1 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.161290322580646%\"\u003e\n\u003cp\u003e0.432\u0026nbsp;\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003eMann Whitney U test; \u003csup\u003e\u0026dagger;\u003c/sup\u003e Chi-square test; MDPT: Modified Duhamel Pull-through;TERP: Transanal endorectal pull-through; HAEC: Hirschsprung associated enterocolitis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Describes the demographic and clinical details of the study group including incidence of Hirschsprung associated enterocolitis (HAEC).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e. Post-operative Complications\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003eMDPT n=71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003eTERP n=32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003e\u003cu\u003eShort term (\u0026le;30 days)\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e\u003cu\u003eN (%)\u003c/u\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003eN (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eAnastomotic dehiscence/ Leak\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e3 (4.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eAdhesive Intestinal Obstruction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e4 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eHAEC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e1 (1.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e1 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e0.559\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eTransition Zone Pull-through\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e7 (9.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e3 (9.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e0.939\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eRe-admission\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e8 (11.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e4 (12.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e0.857\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eRe-operation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e6 (8.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eOverall\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e\u0026nbsp;29 (40.84%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e\u0026nbsp;8 (25%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e0.093\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003e\u003cu\u003eIntermediate Term (1 mo.- 1yr.)\u003c/u\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eRe-do Pull through\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e1 (1.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e1 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e0.559\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eRectal Mucosal Prolapse\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e1 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eAnal Stricture\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e1 (3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"54.98338870431893%\"\u003e\n\u003cp\u003eHigh anal pressures/ sphincter spasm requiring Botox\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"19.93355481727575%\"\u003e\n\u003cp\u003e3 (5.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.950166112956811%\"\u003e\n\u003cp\u003e5 (15.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.132890365448505%\"\u003e\n\u003cp\u003e0.096\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMDPT: Modified Duhamel Pull-through group; TERP: Transanal endorectal pull-through group; Mo. : Month; Yr. : Year; \u0026dagger;: Chi-square test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eDescribes the short term and intermediate term complications occurring in both groups following pull-through procedure.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Stooling Pattern at 1-year follow-up\u003c/strong\u003e.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003eStooling Pattern\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e\u0026nbsp;MDPT (n=71)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003eTERP (n=32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003eP Value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e\u003cem\u003eIncreased Frequency of Stooling\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e16 (22.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e23 (71.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e3-6/day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e15 (21.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e17 (53.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e6-10/ day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e1 (1.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e4 (12.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e\u0026gt;10/day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e2 (6.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e\u003cem\u003eConstipation requiring laxatives/enemas\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e11 (15.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e3 (9.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e0.402\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e\u003cem\u003eSoiling (Of No. Toilet trained) (%)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e9 of 54 (16.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\n\u003cp\u003e3 Of 4 (75%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMDPT: Modified Duhamel Pull-through group; TERP: Transanal endorectal pull-through group; BFS : Bowel Function Score (Rintala); \u0026dagger;: Chi square test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eDetails of the stooling pattern noted in the study groups at 1-year follow up after pull-through procedure.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Comparative Bowel Function Scores\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u003cstrong\u003eBowel Function Score\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e\u0026nbsp;MDPT n= 53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003eTERP n=26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003eP Value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u003cem\u003eMedian BFS (Range)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e19 (7-20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e16 (5-20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp;Impaired Bowel Function\u003c/p\u003e\n\u003cp\u003eBFS \u0026lt;17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e9 (16.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e16 (61.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp;Normal Bowel Function\u003c/p\u003e\n\u003cp\u003eBFS \u0026ge;17\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e44 (83%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e10 (38.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\" valign=\"top\" width=\"99.63963963963964%\"\u003e\n\u003cp\u003e\u003cstrong\u003eParameters in Rintala\u0026rsquo;s Bowel Function Scoring\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003eFeels/ Reports the urge to defecate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Always\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e47 (88.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e19 (73%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Most of the time\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e3 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e4 (1.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Uncertain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e3 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e3 (1.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Absent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003eAbility to hold back defecation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Always\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e44 (83%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e13 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Problems \u0026lt;1/week\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e6 (11.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e7 (26.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Weekly problems\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e3 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e5 (19.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; No voluntary control\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e1 (3.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003eFrequency of defecation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Every other day to twice a day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e39 (73.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e19 (73%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; More often\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e6 (11.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e7 (26.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Less often\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e8 (15%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003eSoiling\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Never\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e38 (71.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e7 (26.9%)\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Staining \u0026lt;1/week, no change of underwear required\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e11 (20.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e6 (23%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Frequent (\u0026gt;1/wk.), change of underwear often required\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e4 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e3 (1.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Daily, requires protective aids\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e10 (38.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003eAccidents\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e0.003\u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Never\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e38 (71.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e8 (34.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Fewer than 1/wk.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e11 (20.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e9 (34.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Weekly, requires protective aids\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e3 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e5 (19.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Daily, requires protective aids day \u0026amp; night\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e1 (1.8%)\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e4 (1.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003eConstipation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"49.729729729729726%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; No constipation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e36 (67.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e19 (73%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"49.729729729729726%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Managed with diet\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e13 (24.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e5 (19.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"49.729729729729726%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Managed with laxatives\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e3 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e2 (7.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"49.729729729729726%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Managed with enemas\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e1 (1.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003eSocial problems\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; None\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e42 (79.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e15 (57.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Sometimes (foul odours)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e8 (15%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e7 (26.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Problems restricting social life\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e3 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e3 (1.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"49.369369369369366%\"\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Major social/ psychological problems\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"18.73873873873874%\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"17.117117117117118%\"\u003e\n\u003cp\u003e1 (3.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"14.414414414414415%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"49.280575539568346%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"0.3597122302158273%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"18.345323741007196%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"0.3597122302158273%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"16.906474820143885%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"0.3597122302158273%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"14.028776978417266%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMDPT: Modified Duhamel Pull-through group; TERP: Transanal endorectal pull-through group; BFS : Bowel Function Score (Rintala); \u0026dagger;: Chi-square test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eShows the comparative Bowel function scores of the two study group and also details the individual parameters of the Rintala bowel function score.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eTable 5. Comparative BFS based on period of follow-up.\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" valign=\"top\" width=\"13.658536585365853%\"\u003e\n\u003cp\u003e\u003cstrong\u003eYears Post-operatively\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"30.56910569105691%\"\u003e\n\u003cp\u003eAbnormal, BFS \u0026lt;17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" valign=\"top\" width=\"10.731707317073171%\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" valign=\"top\" width=\"33.65853658536585%\"\u003e\n\u003cp\u003eNormal, BFS\u0026nbsp;\u0026ge;17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" valign=\"top\" width=\"11.382113821138212%\"\u003e\n\u003cp\u003eP Value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"23.79746835443038%\"\u003e\n\u003cp\u003eMDPT (n=9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"23.79746835443038%\"\u003e\n\u003cp\u003eTERP (n=16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"28.60759493670886%\"\u003e\n\u003cp\u003eMDPT (n=44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"23.79746835443038%\"\u003e\n\u003cp\u003eTERP (n=10)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"13.658536585365853%\"\u003e\n\u003cp\u003e\u0026nbsp;1 \u0026ndash; 5 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"15.284552845528456%\"\u003e\n\u003cp\u003e5 (55.56%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"15.284552845528456%\"\u003e\n\u003cp\u003e2 (12.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.731707317073171%\"\u003e\n\u003cp\u003e0.058\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"18.3739837398374%\"\u003e\n\u003cp\u003e7 (15.91%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"15.284552845528456%\"\u003e\n\u003cp\u003e1 (10%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"11.382113821138212%\"\u003e\n\u003cp\u003e0.14\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"13.658536585365853%\"\u003e\n\u003cp\u003e5-10 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"15.284552845528456%\"\u003e\n\u003cp\u003e1 (11.11%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"15.284552845528456%\"\u003e\n\u003cp\u003e9 (56.25%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.731707317073171%\"\u003e\n\u003cp\u003e0.040\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"18.3739837398374%\"\u003e\n\u003cp\u003e8 (18.18%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"15.284552845528456%\"\u003e\n\u003cp\u003e5 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"11.382113821138212%\"\u003e\n\u003cp\u003e0.048\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd valign=\"top\" width=\"13.658536585365853%\"\u003e\n\u003cp\u003e\u0026gt;10 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"15.284552845528456%\"\u003e\n\u003cp\u003e2 (22.22%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"15.284552845528456%\"\u003e\n\u003cp\u003e5 (31.25%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"10.731707317073171%\"\u003e\n\u003cp\u003e1.00\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"18.3739837398374%\"\u003e\n\u003cp\u003e2 (4.55%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"15.284552845528456%\"\u003e\n\u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd valign=\"top\" width=\"11.382113821138212%\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMDPT: Modified Duhamel Pull-through group; TERP: Transanal endorectal pull-through group; BFS : Bowel Function Score (Rintala); \u0026dagger;: Chi-square test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 5.\u003c/strong\u003e Shows the comparative bowel function scores of the two study groups subdivided based on the period of follow-up.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hirschsprung’s disease, Pull-through, Transanal endorectal, Duhamel, Bowel function, Continence","lastPublishedDoi":"10.21203/rs.3.rs-2816942/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2816942/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo analyze and compare short-term results and long-term bowel function in patients with Hirschsprung disease (HD) following two commonly performed definitive surgeries at our institute: Modified Duhamel pull-through (MDPT) and transanal endorectal pull-through (TERP).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e103 cases of HSD who underwent pull-through procedures (MDPT, n\u0026thinsp;=\u0026thinsp;71; TERP, n\u0026thinsp;=\u0026thinsp;32) between 2007 and 2021 were included. Seventy-nine were assessed for bowel function by Rintala scoring (MDPT, n\u0026thinsp;=\u0026thinsp;53; TERP, n\u0026thinsp;=\u0026thinsp;26).\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe MDPT group had more early complications (40.84% MDPT vs. 25% TERP), including anastomotic leak (4.2%, n\u0026thinsp;=\u0026thinsp;71) and adhesive intestinal obstruction (5.6%, n\u0026thinsp;=\u0026thinsp;71). Rectal mucosal prolapse (3.1%, n\u0026thinsp;=\u0026thinsp;32) and anal stricture (3.1%, n\u0026thinsp;=\u0026thinsp;32) were noted exclusively following the TERP. Both groups had a similar incidence of HAEC (21% in MDPT vs. 20% in TERP). TERP group had more daily bowel movements post-pull-through (71.8% vs. 22.5% in MDPT). Bowel function was considered impaired, with Rintala score of \u0026lt;\u0026thinsp;17 in 61.5% of cases of TERP (vs. 16.9% of cases of MDPT, n\u0026thinsp;=\u0026thinsp;53; P\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn our institute, we found better bowel function outcomes following MDPT compared to TERP, with higher incidence of soiling and accidents following TERP. However, long-term outcomes following technical changes in performing the TERP procedure remains to be assessed.\u003c/p\u003e","manuscriptTitle":"Modified Duhamel pull-through vs. Trans-anal endorectal pull-through in children with Hirschsprung's disease: Outcome comparison from a single center over 14 years","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-04-18 14:18:26","doi":"10.21203/rs.3.rs-2816942/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c0835e05-c0c9-42c2-80ea-660e9193fe9e","owner":[],"postedDate":"April 18th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-05-02T06:14:26+00:00","versionOfRecord":[],"versionCreatedAt":"2023-04-18 14:18:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2816942","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2816942","identity":"rs-2816942","version":["v1"]},"buildId":"Yz8egH4vZwpy0AgOkR8nz","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}