Transanal Endorectal Pull ThroughEdit

Transanal Endorectal Pull-Through is a pediatric surgical technique designed to treat Hirschsprung disease by removing the aganglionic segment of the bowel through the anal canal and connecting the normally innervated proximal bowel to the anus. The approach emphasizes a transanal route to reduce abdominal incisions and to streamline recovery in appropriate patients. Over time, TERPT has become part of a broader family of pull-through methods that includes traditional abdominal techniques and newer laparoscopic adaptations, with outcomes shaped by patient selection, surgeon experience, and center resources Hirschsprung disease.

The method is one option among several strategies to restore bowel continuity in children with congenital aganglionosis. While TERPT can often be performed as a one-stage operation, many centers tailor the plan to the individual patient, sometimes starting with a temporary colostomy or ileostomy in neonates or in cases where perfusion, transition-zone assessment, or other intraoperative concerns warrant caution. In contemporary practice, TERPT is frequently discussed alongside historical approaches such as the Soave, Swenson, and Duhamel procedures, each of which has its own indications, technical nuances, and long-term functional considerations Soave procedure, Swenson procedure, Duhamel procedure.

Indications and patient selection

Primary indication: short-segment Hirschsprung disease, where the aganglionic portion is limited to the rectum and distal sigmoid colon, allowing a transanal approach to resect the abnormal segment and pull the healthy bowel down to the anal canal.
Selected cases of longer-segment disease can be considered when imaging and intraoperative assessment show a favorable transition zone and adequate proximal bowel mobility.
Contraindications or high-risk situations include an uncertain transition zone, significant proximal dilatation, or poor bowel perfusion where a staged approach with a temporary ostomy may improve safety and outcomes Hirschsprung disease.

Pathophysiology and diagnostic context - Hirschsprung disease results from failure of neural crest cells to form enteric nerves in the distal bowel, leading to functional obstruction. Typical diagnostic workups include contrast studies, anorectal manometry, and confirmation of ganglion cells via biopsy when needed. The goal of any pull-through is to resect the aganglionic segment and establish a reliable, normo-neural conduit for stool passage through the anal canal Hirschsprung disease.

Procedure overview

Preoperative evaluation focuses on anatomy, bowel caliber, and the presence of a clearly defined transition zone. Intraoperatively, surgeons assess the mobility of the proximal bowel and often use frozen-section analysis to confirm the presence of ganglion cells at the intended anastomotic level.
The core step is mobilization and resection of the aganglionic segment via the anal canal, followed by a pull-through of the normo-neural proximal bowel to the anal sphincter complex. The anastomosis is typically performed intraluminally or at the distal rectum, and meticulous hemostasis and preservation of pelvic nerves are emphasized to reduce complications.
Some procedures are performed as laparoscopy-assisted TERPT, where the abdominal phase is addressed with minimally invasive techniques before completing the pull-through transanally. Others are performed purely via the transanal route. Decisions about using a defunctioning stoma (colostomy or ileostomy) depend on patient factors and intraoperative findings; stomas may be temporary to protect a delicate anastomosis in neonates or high-risk cases colostomy anastomosis laparoscopy.

Variants and modifications

Pure transanal TERPT: relies solely on a transanal corridor for dissection and pull-through, often favored for select short-segment disease in centers with substantial experience.
Laparoscopy-assisted TERPT: combines laparoscopic mobilization and assessment with a transanal pull-through, potentially improving evaluation of the transition zone and bowel length while reducing overall invasiveness laparoscopy.
One-stage versus staged approaches: one-stage TERPT aims to complete resection and pull-through in a single operation, whereas staged approaches may start with a temporary ostomy to reduce the risk of anastomotic complication in neonates or in complex anatomy. The choice depends on intraoperative assessment, perioperative risk, and surgeon preference; there is ongoing discussion about relative advantages in different patient groups Hirschsprung disease.
Comparative alternatives: historically and clinically relevant, the Soave, Swenson, and Duhamel procedures remain referenced as alternative pull-through strategies, each with distinctive methods of managing the diseased segment and the rectal cuff. Contemporary practice often involves selecting among these options based on anatomy, surgeon expertise, and institutional protocols Soave procedure, Swenson procedure, Duhamel procedure.

Outcomes and complications

Functional outcomes after TERPT are influenced by the length of the aganglionic segment, patient age at surgery, and the surgeon’s experience. Many centers report favorable bowel function and continence in appropriately selected patients, with reduced abdominal recovery compared with older abdominal-only approaches.
Common risks include anastomotic stricture, residual aganglionosis or transition-zone issues, enterocolitis, stool frequency changes, and, less commonly, anastomotic leak or rectal prolapse. Long-term function depends on preserved sphincter dynamics, bowel adaptation, and management of constipation or soiling when they arise. Follow-up often includes coordination with pediatric gastroenterology and colorectal specialists to monitor growth, stooling patterns, and quality of life enterocolitis.
The presence and management of a temporary ostomy, when used, also shape outcomes, including stoma-related complications and the timeline for restoration of bowel continuity. Outcomes data emphasize that center experience and careful patient selection are major drivers of success colostomy.

Controversies and debates

Stage versus single-stage strategy: Proponents of one-stage TERPT argue for reduced hospital stays, quicker recovery, and avoidance of stoma-related issues, provided the patient is a suitable candidate and intraoperative conditions are favorable. Critics point to the risk of anastomotic problems or suboptimal transition-zone management in less-than-ideal scenarios, advocating staged approaches in neonates or when perfusion and anatomy are uncertain. The balance between these strategies depends on real-time assessment and institutional expertise; large, randomized comparisons are limited, so guidance often rests on observational data and expert consensus Hirschsprung disease.
Laparoscopy-assisted versus purely transanal approaches: Advocates for laparoscopy highlight better visualization of the transition zone and abdominal mobilization with potentially fewer abdominal incisions. Critics note longer operative times, the need for specialized equipment, and mixed evidence on long-term functional advantage. The choice largely reflects surgeon training, patient anatomy, and institutional resources laparoscopy.
Long-term function and quality of life: While many children recover good continence and function, some patients experience constipation, soiling, or other pelvic-floor issues later in childhood or adolescence. Debates persist about how to optimize nerve preservation, prevent functional sequelae, and tailor follow-up care to improve long-term outcomes pediatric surgery continence.
Access and equity considerations: As with many specialized pediatric procedures, outcomes are closely tied to center volume and expertise. Ensuring access to high-quality surgical care for diverse populations remains an ongoing policy and health-system topic, even as TERPT becomes more widespread Hirschsprung disease.

History

Transanal approaches to pull-through techniques emerged and evolved in the late 20th century as surgeons sought to minimize abdominal incisions and improve recovery in infants and young children. TERPT emerged as a refinement aimed at translating transanal access into reliable resection and anastomosis, drawing on a broader family of pull-through methods and adapting to advances in imaging, intraoperative assessment, and minimally invasive techniques. The ongoing evolution reflects a collaborative effort among pediatric surgeons to optimize safety, efficacy, and patient-centered outcomes pediatric surgery.

Training and centers of excellence

TERPT requires specialized training in pediatric colorectal surgery and familiarity with both transanal dissection and the management of potential intraoperative challenges. Successful outcomes are often associated with high-volume centers that maintain multidisciplinary teams, including pediatric anesthesiology, radiology, and gastroenterology, to address the full spectrum of care pediatric surgery.
Access to experienced surgeons and standardized protocols helps reduce variation in outcomes and supports ongoing quality improvement in the management of Hirschsprung disease.