Transanal endorectal pullthrough for hirschsprung disease: optimizing outcomes, reducing complications, and strengthening surgical care in resource-limited settings

Background: Hirschsprungs disease (HD) is a congenital absence of enteric ganglion cells, leading to distal bowel obstruction, chronic constipation, and progressive proximal colonic dilation. In resource-limited settings, delayed presentation and limited pathology support often necessitate staged procedures, increasing morbidity and caregiver burden. Single-stage transanal endorectal pull-through (TAPT) offers a minimally invasive alternative that avoids laparotomy and colostomy. Methods: This mixed prospective-retrospective case series included eight children (ages 2.59 years) with rectosigmoid HD who underwent single-stage TAPT between September 2024 and July 2025. Preoperative optimization involved rectal irrigations, nutritional rehabilitation, intravenous antibiotics, and fluid-electrolyte correction. Diagnosis was confirmed by contrast enema and full-thickness rectal biopsy. TAPT was performed using a Soave-type technique without intraoperative frozen section. Outcomes assessed included stool frequency, continence, enterocolitis episodes, anastomotic complications, weight gain, and quality of life. Results: All patients presented with chronic constipation and abdominal distension. Median length of resected bowel was 20 cm. Time to first stool ranged 2448 hours. One patient (12.5%) developed mild Hirschsprung-associated enterocolitis, successfully managed conservatively. No anastomotic leaks, strictures, or fecal incontinence occurred. At 36 months, all patients passed 12 soft stools daily, demonstrated improved weight gain, and achieved normal continence. Conclusion: Single-stage TAPT is a safe and effective surgical option for rectosigmoid HD in resource-limited settings. Even without frozen section support and with delayed presentation, TAPT provides excellent early functional outcomes, minimal morbidity, and reduced hospitalization. This approach should be strongly considered as first-line management for rectosigmoid HD in similar environments.