Does surgical approach affect Hirschsprung-associated enterocolitis risk? A comparison between transanal Swenson-like and endorectal pull-throughs

Hirschsprung-associated enterocolitis (HAEC) is a complication of Hirschsprung disease (HSCR) that may occur both before or after surgery. Transanal endorectal pull-through (TEPT) is one of the standard treatments for HSCR. In addition, transanal Swenson-like pull-through (TSLPT) is a recent technique combining the Swenson method with the posterior sagittal approach. We aimed to compare the incidence of HAEC following TSLPT versus TEPT in HSCR patients and examine their association with predictor factors. We retrospectively reviewed the medical records of HSCR patients who underwent either TSLPT or TEPT at our institution between 2018 and 2023. The diagnosis of HAEC was established using an HAEC scoring system with cut-off values of 4 and 10. This study included 29 patients who underwent TSLPT and 41 who underwent TEPT. Using a cut-off of ≥4, the proportion of HAEC in TEPT and TSLPT was 24.4% and 6.9%, respectively. When applying the cut-off of ≥10, the proportion decreased to 9.8% in TEPT and 3.4% in TSLPT. There was no statistically significant difference in the incidence of HAEC between the TSLPT and TEPT groups (p = 0.056). Postoperative albumin level was statistically associated with HAEC in the TEPT group (p = 0.03), but no other predictor factors, including sex, age at definitive surgery, type of aganglionosis, nutritional status, and postoperative hemoglobin level (p > 0.05). Subsequently, multivariate analysis indicated that albumin level was significantly associated with the occurrence of HAEC in HSCR patients following TEPT (p = 0.047). In conclusion, our study suggests that the incidence of HAEC tends to be higher following TEPT compared to TSLPT. Monitoring albumin levels postoperatively may be considered as a potential risk indicator for diagnosing HAEC in patients undergoing surgery especially TEPT, as hypoalbuminemia showed significance only within this surgical subgroup.