Contrary to previous reports suggesting that laparoscopic pull-through is universally feasible, our cohort demonstrates that a primary stoma remains necessary in late-presenting cases involving severe colonic dilation or clinical instability. In our previous published work, our surgical strategy was based on the principle that laparoscopic pull-through was feasible for all cases, considering that most children reached surgery after adequate preoperative preparation, which allowed acceptable decompression of the dilated colon.

In this current study, however, some children showed marked colonic dilatation or insufficient response to preoperative bowel preparation, making a direct one-stage laparoscopic pull-through potentially unsafe. In such selected cases, the more appropriate initial intervention was to perform a primary stoma (colostomy or ileostomy) first, followed later by the definitive pull-through procedure.

Thus, the fundamental difference between the two papers is:

Previous paper:

Concluded that all patients can undergo laparoscopic pull-through without diversion

This modification reflects real-world, patient-specific surgical decision-making and advances treatment planning without duplicating our earlier findings. Furthermore, it addresses a critical clinical gap not covered in our previous publication. Hirschsprung disease is most often identified in infancy, although presentation may be delayed until later childhood in some cases (1). It is characterized by the absence of enteric ganglion cells over a segment of the bowel, most commonly involving the rectosigmoid colon. Surgical management aims to resect the aganglionic segment and restore continuity; many centers now employ minimally invasive, single-stage pull-through techniques (e.g., Duhamel, Soave, Swenson), yet staged approaches with a proximal diversion remain necessary in selected patients with marked colonic dilatation or clinical instability (2–5).

The study included 30 patients diagnosed with HSD (17 males and 13 females), all of whom were over three years of age. Hirschsprung-associated enterocolitis (HAEC) was diagnosed based on clinical and radiological findings (6–8). Patients with mild to moderate (minor) signs of enterocolitis who responded to conservative management were included. Patients with severe (major) enterocolitis who failed to respond to conservative treatment and required urgent surgical intervention were excluded from the study.

Minor signs included mild abdominal distension, diarrhea, low-grade fever, and mild radiological bowel dilatation. Severe HAEC was defined by systemic toxicity, severe abdominal distension, or failure of conservative management.

So, we excluded cases of intestinal obstruction or enterocolitis that did not respond to conservative treatment and were in urgent need of stoma.

All surgical procedures, including direct pull-through or stoma formation followed by definitive surgery, were performed by experienced pediatric surgeons at our institution following a standardized surgical protocol.

All procedures were performed by consultant pediatric surgeons with experience in managing Hirschsprung disease.

All patients received a preoperative regimen consisting of rectal irrigation and oral fluid intake over approximately two months to reduce colonic dilatation. Those who did not achieve adequate decompression proceeded to proximal diversion (ileostomy or colostomy) according to the level of transition. The preoperative regimen and diversion strategy followed established protocols for late-presenting Hirschsprung disease (9).

An anal dilation program was initiated three weeks after the pull-through procedure. Among the Swenson cases, three patients developed stenosis that responded to regular dilation. Additionally, two cases of postoperative enterocolitis were successfully managed with conservative treatment, namely parenteral antibiotics, rectal irrigation, intravenous fluids, and NPO status, and one case of fecal incontinence was reported. For Duhamel cases, we had three cases of constipation and three cases of enterocolitis; there were no cases of anastomotic leak.

There were four cases of stomal prolapse, and skin excoriation occurred in all operations.

Chan et al. (2) reported 41 cases with a median age of 9.9 years, whereas Nam et al. (10) reported a median age of 3 years among 8 children, which is consistent with our study. Male predominance was reported by several authors [Maerzheuser S et al. (1), Baeza et al. (3)]; this was also reflected in our study, which had 17 male and 13 female patients.

Nasir et al. (11), reported associated neurologic, cardiovascular, urologic, and gastrointestinal abnormalities as well as a connecting with Down's syndrome, however, we excluded patients with Down's syndrome and cardiac anomalies from our study.

Maerzheuser S et al. (1), had 10 patients with late-diagnosed Hirschsprung disease; their main presentation was recurrent gastrointestinal infection but, in our cases, the main presentation was chronic constipation.

Full-thickness rectal biopsy remains the diagnostic gold standard and was performed in all patients in our series. Barium enema and laparoscopic inspection were used adjunctively to map the transition zone and guide the decision between single-stage pull-through and staged management—a decision influenced primarily by the degree of colonic dilatation after preoperative decompression (1, 2), Barium enema and laparoscope were also used to determine aganglionosis level and to detect if the operation could be completed in one stage or needed multiple stages, which also depended on the size of the dilated pull-through colon after the preoperative preparation regimen.

Chan et al. (2) and Nam et al. (10) used a one-stage laparoscopic-assisted endorectal pull-through for all patients following preoperative preparation with rectal irrigation under general anesthesia. Similarly, Baeza et al. (3) performed the Duhamel procedure in all eight of their cases. In contrast, the current study of 30 cases utilized both Duhamel and Swenson procedures, performed in either one or multiple stages.

Baeza et al. (3) and Mabula et al. (4) performed a colostomy on all their patients; they allowed time for the dilated colon to recover to reduce the incidence of postoperative enterocolitis.

In this study, the selective use of a primary stoma in our series reflects individualized, response-based surgical planning, representing an optimization of the laparoscopic pathway rather than a deviation from it.

This approach underscores clinical decision-making tailored to colonic decompression response and patient stability, enhancing pull-through safety without contradicting prior evidence supporting laparoscopic feasibility.

Stomas were performed only in cases refractory to rectal irrigation. Seven patients required a proximal ileostomy because the transition zone was proximal to the sigmoid colon. In the remaining eight cases, where the transition zone was distal to the sigmoid, a sigmoid colostomy was performed just above the funnel. Excision of the aganglionic segment and the pull-through procedure were then completed after two months. Eight cases of Laparoscopic Duhamel were done in one stage, while seven cases of Laparoscopic Swenson were done in one stage.

Mabula et al. (4), reported colostomy-related complications, skin excoriations, and colostomy prolapse in more than half of their patients, colostomy retraction in 16% of their patients, and parastomal hernia in 4%. In our study, we had four cases of stomal prolapse, and skin excoriation occurred in all operations, especially with ileostomy.

Tang et al. (5), had perianal excoriation in 32 cases, enterocolitis in 14 cases, anastomotic leakage in three cases, postoperative adhesive bowel obstruction in two cases (1.1%), anastomotic stenosis in four cases, and soiling in seven cases, while Chan et al. (2), had soiling in more than half of their cases, although no stricture was reported. Mabula et al. (4), reported fecal incontinence in only 2.1% of cases; in this study, we had three Swenson cases that responded to regular dilation, two cases of postoperative enterocolitis that responded to conservative treatment only in the form of parenteral antibiotics, rectal irrigation, intravenous fluids, and NP0, and one case of fecal incontinence. In our Duhamel cases, we had three cases of constipation and three cases of enterocolitis; there were no cases of anastomotic leak.

Hirschsprung's disease typically presents early in life, making its occurrence in older children rare. Despite advancements in minimally invasive techniques that facilitate one-stage repairs, the management of late-presenting cases remains challenging and often necessitates a multi-stage approach.