Laparoscopic-Assisted Swenson-Like versus Soave Pull-Through in Hirschsprung Disease: A Randomized Comparative Study of Functional Outcomes

Abstract In Hirschsprung disease (HD), the laparoscopic-assisted Yancey–Soave (LAYaSo) procedure retains an aganglionic muscular cuff, which may cause obstructive symptoms. The laparoscopic-assisted Swenson-like (LASwL) technique completely excises the aganglionic segment, potentially improving peristalsis. However, randomized evidence comparing these techniques with combined functional and quality-of-life outcomes is lacking. This study aimed to compare surgical, functional, and quality-of-life outcomes between LASwL and LAYaSo pull-through procedures in a randomized controlled trial. This prospective, single-center, randomized study included 110 children with HD at Al-Azhar University Hospitals (2020–2025). The inclusion criterion was biopsy-confirmed rectosigmoid HD. Exclusion criteria were ultrashort or total colonic aganglionosis, prior pull-through procedures, and major congenital anomalies. Patients were randomized to LASwL (n = 55) or LAYaSo (n = 55) using a computer-generated sequence and sequentially numbered, opaque, sealed envelopes (SNOSE). The primary outcome was the Rintala Bowel Function Score (BFS) at 2 years. Secondary outcomes included BFS at 1 year (exploratory), operative time, blood loss, hospital stay, Hirschsprung-associated enterocolitis (HAEC), and health-related quality of life (Pediatric Quality of Life Inventory [PedsQL] 4.0). All procedures were completed laparoscopically without conversion. Mean total operative time was shorter for LASwL (145.5 ± 36.8 vs. 160.3 ± 28.6 minutes, p = 0.081), with a significantly shorter transanal phase (p = 0.019). At the primary endpoint of 2 years, BFS was significantly higher in the LASwL group (18.20 ± 1.80 vs. 17.10 ± 2.30, p = 0.037). HAEC rates were 14.5% versus 20.0% (p = 0.61), all mild/moderate. At 2 years, total PedsQL scores were comparable (88.6 ± 7.5 vs. 86.2 ± 8.4, p = 0.12), though social functioning was numerically higher in LASwL (p = 0.055). Three LAYaSo patients required redo surgery for cuff-related stricture. Both techniques are safe and effective. LASwL offers a modest but statistically significant advantage in bowel function at intermediate follow-up (1.1 points on the Rintala score) without a corresponding improvement in overall quality of life. LAYaSo was associated with a 5.5% risk of cuff-related stricture requiring reoperation. The limited clinical magnitude of the benefit supports individualized technique selection based on surgeon experience and patient factors. Single-center design and the need for longer follow-up are limitations of this study.