Perioperative Outcomes in Primary Neonatal Pullthrough versus Pullthrough in Older Children: A Systematic Review and Meta-analysis

Primary pullthrough for Hirschsprung disease is the current standard in most uncomplicated standard segment disease. In this review and meta-analysis, we aimed to compare perioperative outcomes and functional outcomes for pullthrough done in the neonatal period compared to that in older age (<5 year). METHODS: PubMed, Medline, Embase, CINAHL, SCOPUS, and Web of Science were searched for relevant publications in English from inception to June 29, 2024. RESULTS: Twenty studies were included in the qualitative analysis with a total 3197 patients matching the review criteria. All included studies were observational in nature, with 1 prospective cohort study, 13 retrospective cohort studies, and 6 case series. Findings suggested primary pullthrough beyond 1 month of age was superior in most outcomes, including: shorter post-operative length of stay (LOS) (MD3.11days [95%CI 95%CI 1.34, 4.87]), perioperative sepsis (OR1.76, [95%CI1.26, 2.47]), anastomotic leak (OR2.71[95%CI1.02, 7.24]), perianal excoriation upto 3 months (OR5.52[95%CI 3.07, 9.9]), post-operative HAEC at 3 months (OR5.49[95%CI 3.35, 9]), and anal senosis (OR3.04[95%CI 1.07, 8.67]). Pullthrough done in neonatal age was superior in a shorter operative time (MD-26.41min [95%CI -41.57, 11.26]). There was no significant difference in overall SSI, 30-day readmissions, and pre-operative HAEC. Functional outcomes were assessed in 8 studies showing some tendency towards constipation and incontinence in the older children, and more observed stool frequency and for longer duration post-operatively in the neonates. CONCLUSION : Older children ith Hirschprung perform better post-pullthrough and have less morbidity compared to neonates. Performing the pullthrough after 1 month is safe and likely to offer the best post-operative outcomes. This review was limited by the low level of evidence and inconsistent definitions of outcomes. Results will need to be verified with a large prospective study.