P2D329: Evaluating the Impact of Home Irrigations Before Pull-though: Risky or Beneficial for Care?

Background: A pull-through for Hirschsprung disease (HD) can be performed either in the neonatal period or following several weeks of home irrigations after Neonatal Intensive Care Unit (NICU) discharge. This study evaluated the outcomes of neonates discharged on irrigations compared with those who underwent a primary neonatal pull-through. The use of irrigations has been associated with increased expertise in performing the procedure and increased engagement in the child's care among families, potentially leading to improved postoperative outcomes and delayed episodes of Hirschsprung-associated enterocolitis (HAEC).

Methods: A retrospective review of patients managed at a single institution for HD between July 2018 and July 2022. The study included neonates diagnosed with HD and managed at the institution, with a one-year follow-up period. Patients diagnosed at an older age or requiring an emergent stoma creation for failure to decompress the abdomen, HAEC, colon perforation, or severe comorbidities were excluded (Figure 1). The records matching the criteria were assessed for the treatment course, length of stay (LOS), and postoperative outcomes one year after the pull-through. Total LOS included hospitalization in NICU and on the floor following the pull-through.

Results: Of the sixty patients diagnosed with HD in the NICU and started on irrigations, 30 were included in the study. 18 patients were discharged from NICU on irrigations and were followed in the clinic until their pull-through. Of these, 4 (22%) patients failed at-home irrigations and required a stoma creation. In comparison, 14/18 (78%) were successful on irrigations at home and underwent a delayed elective surgery – either a pull-though (12/14, 86%) at the median age of 3 months (IQR 1.2-4.8) or an ostomy (2/14, 14%). Of the patients who had primary surgery performed in the NICU, 50% underwent a pull-through, while the remaining patients received a stoma. Of patients from the irrigation group, 7/12 (58%) developed HAEC at a median of 16.3 weeks (IQR 2-57) after their pull-through procedure, compared to 3/6 (50%) patients who developed enterocolitis at a median of 11.4 weeks (IQR 2-63) after neonatal reconstruction (see Figure 2). Total hospital stay in the irrigation group was 15 days (IQR 7-25) with a median NICU stay of 8 days (IQR 4-23), whereas patients with a primary pull-through in a neonatal period stayed in the NICU for 19 days (IQR 13-24).

Conclusion: Using irrigations to manage HD in neonates may lead to a longer time to the development of enterocolitis after the pull-through procedure and a reduced NICU LOS, compared to neonates who undergo primary pull-through surgery during their NICU stay. These results support the potential benefits of utilizing irrigation as a part of the management strategy for HD in neonates.