Comparative Study of Transanal Pull-Through versus Swenson Procedure in the Surgical Management of Hirschsprung's Disease

This work is licensed under a Creative Commons Attribution 4.0 International License. The license permits unrestricted use, distribution, and reproduction in any medium, on the condition that users give exact credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if they made any changes. Original article Comparative Study of Transanal Pull-Through versus Swenson Procedure in the Surgical Management of Hirschsprung’s Disease Mohammed Jabbar Kadhim Assistant professor in pediatric surgery, Department of surgery, College of Medicine, Wasit University, Kut, Iraq Abstract Hirschsprung’s disease (HD) is a genetic condition that occurs due to lack of the ganglion cells in the myenteric and submucosal plexuses within the terminal bowel. Failure to have the ganglion cells causes the affected section of bowel to always be contracted and leads to functional intestinal obstruction. HD can only be treated by doing a complete resection of the ganglionic bowel segment and an endorectal anastomosis to provide bowel continuity. Since the earliest surgical interventions to cure HD were developed, a great number of interventions have been developed to cure HD. These are open methods including Swenson procedure and minimally invasive methods including Transanal Pull-Through (TPT) procedure. To evaluate the meaningful outcome measures of clinical outcomes, postoperative recovery, bowel function, complications, and factors in successful outcomes after using either of these two operations, a retrospective cohort study was established. The sample size will consist of 60 patients who had Hirschsprung disease and were operated using TPT or Swenson surgery, the research will be conducted at AlKarama Teaching Hospital in Wasit, Iraq, during the period of January 2023 and December 2024. The demographic, intraoperative, postoperative, complications in case they occurred, long-term functional, parent satisfaction and coexisting medical conditions were included in the study. TPT group had a significant beneficial effect with a significant decrease in the duration of operation (120 + 20 vs. 180 + 30 minutes), intraoperative blood loss (25 + 10 vs. 50 + 20 mL), and a decrease in hospital stay (3.5 + 1.2 vs. 6.8 + 2.1 days), which were statistically significant (p < 0.001). No significant differences were observed between the two groups in 12 months follow-up in relation to the stool frequency, fecal continence, or laxatives dependence. Nevertheless, parents of children in the TPT group also had more high scores on satisfaction levels especially on their overall experience in the hospital and their readiness to refer other people to the procedure. In the case of the associated morbidities, such as Hirschsprung-associated enterocolitis (HAEC), inguinal hernia, gastroesophageal reflux disease (GERD), or other congenital anomalies no significant difference was observed between the two groups. Multivariate analysis indicated that the only independent variable that was associated with increased functional outcomes was going through surgery before 12 months of age (OR: 8.3; 95% CI: 1.2057.4; p = 0.03). To conclude, the TPT procedure and Swenson process are both successful in the management of Hirschsprung disease. TPT, however, has obvious advantages regarding lower stress of the operation, accelerated recovery and increased patient and parental satisfaction. The results are in line with the growing popularity of TPT as the surgical choice of preference and particularly when the intervention is performed in early infancy. Keywords: Hirschsprung’s disease, Transanal Pull-Through (TPT), Swenson procedure, postoperative outcomes, bowel function, parental satisfaction, early surgical intervention, Al-Karama Teaching Hospital, Iraq. Received: 1.07.2025 Revised: 30.07.2025 Accepted: 31.07.2025 Published: 01.08.2025 Funding: This research did not receive any financial support. Conflict of interest: The authors declare no conflict of interest. How to cite: Kadhim MJ. Comparative Study of Transanal Pull-Through versus Swenson Procedure in the Surgical Management of Hirschsprung’s Disease. J Clin Pract Med Res, 2025;1(1):39-44. DOI: 10.59324/jcpmr.2025.1(1).07 Introduction The disease is the Hirschsprung disease (HD), also referred to as the congenital megacolon, one of the most frequent causes of intestinal obstruction in the newborn baby. It is found in about 1/5,000 live births. HD is brought about by an abnormal formation during the development of the fetus wherein the migration of the neural crest cells to the bowel wall fails. This malfunction causes different lengths of absent myenteric and submucosal nerve plexuses of the distal colon or rectum that regulate normal motility of the bowel. The subsequent deficiency of this plexus produces an effective anaerobic blockage since the affected part has remained fibrotic causing proximal bowel dilation, chronic constipation and abdominal distension. In the typical presentation, HD comes soon after birth, where the child is known to exhibit late toothpaste of meconium, abdominal distention, and feeds intolerance. Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 1 | September-October 2025 40 In lighter cases of illness diagnosis may however be postponed until later in childhood when the infant is presented with chronic constipation or failure to thrive or recurrent enterocolitis. Moreover, delayed diagnosis may potentially result in the disability of diabetic Hirschsprung-associated enterocolitis (HAEC), that is a significant cause of morbidity and mortality in children with HD and, thus, needs to be diagnosed and treated at an early stage. Surgical resection of the ganglionic part and bowel continuity reconstruction through anastomosis of the normally ganglionated bowel to the anal canal is the only treatment available to cure HD. Over the years, there are numerous methods of doing this, varying in the procedures and methods of operation, but the same goals of attaining maximum functional results, reduction of risks of operative time, tissue trauma and incidence of complications, within an acceptable time frame have always been the key. Swenson procedure described in the late 1940s was one of the first methods of operative treatment of HD, it involves transabdominal resection, a selective endorectal mucosectomy, a procedure not intended to be complete thickness, and colo-anal anastomosis, the treatment of the complication of HD. Although the Swenson procedure proved to be effective, it would be time consuming to administer, both the operator and patient would be subjected to surgical stress, as more tissue would be traumatized, and the chances of developing complications are quite high. Minimally invasive methods are becoming more popular recently, and the translational pull-through (TPT) method as originally defined by De la Torre-Mondraganon and Ortega-Salgado in 1998 in Coahuila, Mexico, enabled the excision of the entire aganglionic segment via a pure transanal operation without laparotomy. The TPT could be done in the anesthetized child, as the classic techniques that we have discussed, with decreased hospitalization, fewer complications, and enhanced appearances. Despite the interest behind the TPT, and the increasing algorithms that could theoretically impact surgical education and offer more possibilities of the minimally invasive surgery in HD, there are no random comparative studies that prove the efficacy of TPT over these conventional open operations, including the Swenson technique. Although the short-term advantages of TPT have been proven sufficiently, long-term functional results especially in various age groups and disease severities need additional discoveries. This research will set out to give a detailed comparison between the Transanal Pull-Through and Swenson operations in the surgery of Hirschsprung disease. We consider such areas as intraoperative outcome after an operation, functional bowel management, morbidity and mortality related to it, parental satisfaction and predictors of a successful outcome Our aim is to add evidence-based recommendations on how to choose the optimal approach to surgery in this complicated case. Methods Study Design It was a retrospective cohort study conducted at the AlKarama Teaching Hospital, a tertiary care, a reference hospital in waste, Iraw, and specialized in maternal and child health. Every patient with Hirschsprung’s disease (HD) who either had Transanal PullThrough (TPT) or the Swenson procedure between January 2023 and December 2024 were included in the study. The IRB of AlKarama Teaching Hospital granted approval of data collection. The informed consent is waived considering the retrospective character of the study yet ethical committees have conceded that all data of patients were anonymized and followed the order of principles of the declaration of Helsinki. Setting One of the primary referral hospitals in terms of obstetics and pediatrics is AlKarama Teaching Hospital in waist, Iraq. It has a broad area coverage, having a balanced distribution of both well-known urban population and rural population with one Pediatric Surgery unit having a huge majority of the congenital gastrointestinal anomalies, such as Hirschsprungs disease. Only one group of pediatric surgeon specialists carried out all the surgeries. Multi-disciplinary ward care (MDWC), which was provided in the post-operative stage, was under the supervision of a team of committed specialists such as a neonatologist, pediatric gastroenterologist and a pediatric colorectal trained nurse practitioners. Inclusion Criteria The inclusion criteria in the study were as follows: Third, known Hirschsprung disease by biopsy of rectal suction which revealed no ganglion cells. • PT Tpt or swenson procedure is primary surgery. • Connection to full preoperative, intraoperative and postoperative medical records. Minimized follow-up post operation period of 12 months. Exclusion Criteria Exclusion criteria Patients with previous revision surgery or previous colostomy without definitive pull-through. Status I: Missing or incomplete medical records. • Existence of extreme related congenital defects that can affect bowel function on their own. • Lost to follow-up of patients prior to 6 months after surgery. • Data Collection Electronic medical records and archived operative notes were used to extract the information on a standardized data collection form. Two independent researchers collected data, and cross-verified them to eliminate any errors. The recorded variables were: Demographic and Clinical Characteristics: • Age of diagnosis and surgery (months) • Gender • Gestational age and birth weight. • Manifested symptoms (slow passage of meconium, abdominal distension, enterocolitis, etc.) • aganglionosis (short vs. full colonic involvement) Length of aganglionosis (shortvs. total colonic involvement) Operative Details: • Surgical (TPT vs. Swenson) technique. • Operative time (incision to closure) • Estimated blood loss Need to be converted to open procedure. • Length of hospital stay (LOS) Postoperative Outcomes: • 30-day complications (ileus, wound infection, anastomotic leak, HAEC) Late complications (>30 days): stenosis, fecal incontinence, constipation, would persist. • Functional outcomes on 3, 6, and 12 months after surgery (stool frequency, continence, laxative requirement) Parental Satisfaction Survey: A questionnaire was given through phone interview or during outpatient visit to determine the satisfaction of parents based on: • Overall recovery progress • Bowel control satisfaction • Hospital experience Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 1 | September-October 2025 41 Willingness to recommend the procedure Each of the items was measured on a 5-point Likert scale (1 = very poor, 5 = excellent). Morbidities: The following comorbid conditions are present: Hirschsprung-associated enterocolitis (HAEC) • Gastroesophageal reflux disease (GERD) • Inguinal hernia • Repeat intestinal obstruction preoperative. • Linear growth delay • Other birth defects (e.g., cardiac, urinary, neurological) Definitions • Short-segment HD: Aganglionosis restricted to the rectosigmoid area. • Total colonic aganglionosis (TCA): Lack of ganglion cells in all the colonies up to the cecum. • Hirschsprung-associated enterocolitis (HAEC): It is the manifestation of a known HD patient that is characterized by explosive diarrhea, abdominal distension, and sepsis, which is confirmed by radiological and clinical means. • Fecal incontinence: Against toilet training age soiling. • Regular bowel movements: No laxatives or enemas. Statistical Analysis Information was inputted in the version SPSS 26 (IBM Corp., Armonk, NY, USA). The variables of the continuous type were presented as a mean plus the SD (standard deviation) or a median and interquartile range (IQR), according to the distribution. The presentation of categorical variables was in frequencies and percentages. Comparisons of groups were done by using: • t-test or MannWhitney U of continuous variables in the student. • Chi-square or Fisher accurate test of categorical variables. A multivariate logistic regression analysis was developed to determine independent predictors of positive functional outcomes (normal bowel functioning at 12 months post-surgery). The model variables were: • Surgical method (TPT vs. Swenson) • Age of surgery (Shorter than 12 months vs. Longer than 12 months) • HD type (short-segment and total colonic) • HAEC preoperative presence. • Preoperative colostomy Odds ratios (ORs) and 95 percent confidence intervals (CIs) were estimated. The p-value of less than 0.05 was taken to be significant. Results This retrospective cohort study that was carried out at AlKarama Teaching Hospital, wasit, Iraq, involved 60 patients diagnosed with Hirschsprung disease. These patients have been treated with the Transanal Pull-Through (TPT) procedure (n = 30 ) or the Swenson open procedure (n = 30 ) during the period between January 2023 and December 2024. Demographic Characteristics and Clinical Characteristics The TPT group had an average age of surgery at 7.24241 months old and the Swenson group at 8.1493 months old, which is not significantly different between the two groups (p = 0.42) (See Table 1) . Both groups had a majority of males (23 (76.7) in TPT group and 25 (83.3) in Swenson group) (p = 0.51). TPT group had an incidence of short-segment HD in 24 (80%) as compared to the Swenson group which had 22 (73.3%) incidence (p = 0.54). In the respective groups, a total colonic aganglionosis (TCA) was detected in 3 (10%) and 4 (13.3) subjects (p = 0.71). Preoperative colostomy was done in 2 (6.7) out of the TPT group and 5 (16.7) out of the Swenson group (p = 0.26) meaning that there was a tendency towards higher elective primary operations among TPT group. These similar baseline features imply that the observed differences in the results can be ascribed to the effect of the surgical method and are not due to the presence of confounding clinical factors (See Table 1) amongst others. Table 1: Demographic and Clinical Characteristics of Patients Undergoing Transanal Pull-Through or Swenson Procedure for Hirschsprung’s Disease VARIABLE TPT GROUP (N=30) SWENSON GROUP (N=30) P-VALUE Age at surgery (months), mean ± SD 7.2 ± 4.1 8.1 ± 5.3 0.42 Male (%) 23 (76.7%) 25 (83.3%) 0.51 Short-segment HD (%) 24 (80%) 22 (73.3%) 0.54 Total colonic aganglionosis (%) 3 (10%) 4 (13.3%) 0.71 Preoperative colostomy (%) 2 (6.7%) 5 (16.7%) 0.26 Perioperative Outcomes The advantages related to the TPT technique were quite evident regarding the parameters of perioperations: Mean operative time was found to be very low in TPT group (120 ± 20 minutes ) than in Swenson group (180 ± 30 minutes ) (p < 0.001). Mean estimated blood loss also differed significantly between the TPT and Swenson group (25 pm 10 ml) and (50 pm 20 ml), respectively ( p < 0.001). • Both groups had no conversions to open procedures. • TPT group had a much shorter length of stay (3.5 + + -1.2 days ) than the Swenson group (6.8 + + -2.1 days ) (p < 0.001) (See Table 2). Table 2: Comparison of Perioperative Outcomes Between Transanal Pull-Through and Swenson Procedures VARIABLE TPT GROUP SWENSON GROUP P-VALUE Mean operative time (minutes) ± SD 120 ± 20 180 ± 30 <0.001 Estimated blood loss (ml) ± SD 25 ± 10 50 ± 20 <0.001 Length of hospital stay (days) ± SD 3.5 ± 1.2 6.8 ± 2.1 <0.001 These results emphasize the low invasiveness of TPT which results in low stress during the operation, quick recoveries and earlier hospital release. Age-Based Functional Recovery The success of functional bowel was measured using stool frequency and the presence or absence of continence 12 months after surgery. Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 1 | September-October 2025 42 The findings revealed some valuable facts about the effect of age at surgery in terms of functional recovery: In the age group less than 6 months, 83.3% (10/12) of TPT patients had normal bowel functioning as contrasted with 72.7% (8/11) in Swenson group (p = 0.54). 87.5 percent (14/16) of TPT patients in the 612 months age group reported normal bowel function compared to 80 percent (12/15) in Swenson group (p = 0.52). But in the group of >12 months, normal bowel functioning (2/2, 100%) was observed in all the TPT patients, and only 1/4 patients (25) in the Swenson group (p = 0.04) (See Table 3). Table 3: Functional Bowel Recovery by Age at Surgery in Patients with Hirschsprung’s Disease Following Pull-Through Procedures AGE GROUP (MONTHS) TPT – NORMAL BOWEL FUNCTION (%) SWENSON – NORMAL BOWEL FUNCTION (%) P-VALUE <6 10/12 (83.3%) 8/11 (72.7%) 0.54 6–12 14/16 (87.5%) 12/15 (80%) 0.52 >12 2/2 (100%) 1/4 (25%) 0.04 This implies that post-infantile surgery can adversely affect the longterm functional outcome particularly where an open approach is employed. Use of Laxatives Over Time The laxative dependence was followed at various points after the surgery to determine bowel functioning: Twenty (66.7) of the TPT group and 22 (73.3) of the Swenson group needed laxatives at discharge (p = 0.56). At 3 months after surgery, the percentage of laxative use in TPT and Swenson groups were reduced to 15 (50) and 18 (60) respectively (p = 0.44). At 6 months, 8 (26.7) in the TPT group and 10 (33.3) in the Swenson group were still in need of laxatives (p = 0.53). TPT: 5 (16.7) in the TPT group and 7 (23.3) in the Swenson group only still needed them by the age of 12 months (p = 0.51) (See Table 4). Table 4: Laxative Dependence Over Time After Surgical Intervention for Hirschsprung’s Disease TIME AFTER SURGERY TPT GROUP (%) SWENSON GROUP (%) P-VALUE Discharge 20 (66.7%) 22 (73.3%) 0.56 3 Months 15 (50%) 18 (60%) 0.44 6 Months 8 (26.7%) 10 (33.3%) 0.53 12 Months 5 (16.7%) 7 (23.3%) 0.51 Whereas there was a tendency of earlier reduction in laxative use in the TPT group, the differences had no statistical significance at any time. This implies that both methods have a similar functional outcome with time. This is the Parental Satisfaction Survey Parental satisfaction was measured with the help of the structured questionnaire, which was conducted in the form of the phone interview or during outpatient visits. The mean scores (out of 5) were as under: • General recovery improvements: 4.4 (TPT) vs 4.1 (Swenson) (p = 0.08) • Bowel control satisfaction: 4.3 vs. 4.0 (p = 0.10) • Hospital experience : 4.6 vs. 3.9 (p = 0.02) • The desire to prescribe the procedure: 4.7 vs. 4.1 (p = 0.01) (See Table 5). Table 5: Parental Satisfaction Scores Across Key Domains Following Transanal Pull-Through and Swenson Procedures QUESTIONNAIRE ITEM TPT MEAN SCORE (OUT OF 5) SWENSON MEAN SCORE (OUT OF 5) P-VALUE Overall recovery progress 4.4 4.1 0.08 Bowel control satisfaction 4.3 4.0 0.10 Hospital experience 4.6 3.9 0.02 Recommendation to others 4.7 4.1 0.01 Such findings show that the parents were more pleased with the overall care, recovery process, and cosmetic outcome in the TPT group, especially the reduced hospitalization and desirable postoperative appearance. Morbidities of the Associated Medical Morbidities We considered comorbidities that might have an impact on bowel functioning or surgical outcomes: • Hirschsprung-associated enterocolitis (HAEC) has 4 (13.3) and 5 (16.7) in TPT and Swenson group respectively (p = 0.72). Inguinal hernia was found in 3(10) and 2 (6.7), respectively (p = 0.65). • Before surgery intestinal obstruction was observed recurrently in 6(20) and 7 (23.3) (p= 0.74). • Linear growth delay was found in 5 (16.7) and 8 (26.7) (p = 0.34). Other prenatal conditions (e.g., cardiac, urinary, neurological) were identified in 4 (13.3) and 3 (10) (p = 0.69). • The presence of (0.62) gastroesophageal reflux disease (GERD) was 2 (6.7) and 3 (10), respectively (See Table 6). Table 6: Prevalence of Associated Medical Morbidities in Patients with Hirschsprung’s Disease Post-Surgery ASSOCIATED MORBIDITY TPT GROUP (N=30) SWENSON GROUP (N=30) P-VALUE HAEC (Hirschsprung-associated enterocolitis) 4 (13.3%) 5 (16.7%) 0.72 Inguinal hernia 3 (10%) 2 (6.7%) 0.65 Recurrent intestinal obstruction pre-op 6 (20%) 7 (23.3%) 0.74 Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 1 | September-October 2025 43 Linear growth delay 5 (16.7%) 8 (26.7%) 0.34 Other congenital anomalies (cardiac, urinary, neurological) 4 (13.3%) 3 (10%) 0.69 Gastroesophageal reflux disease (GERD) 2 (6.7%) 3 (10%) 0.62 There were no statistically significant differences between the two groups regarding the morbidities that were associated and thus, the morbidities did not bias the comparison of the surgical outcomes. Predictors of Functional Recovery Multivariate Logistic regression Analysis. Our multivariate logistic regression analysis was conducted to determine the independent predictors of desirable functional outcomes (normal bowel function at 12 months after surgery). Table 7 contained the following variables. It was shown in this model that younger age at surgery (<12 months) was the one and only statistically significant independent predictor of functional outcome improvement (OR: 8.3; 95% CI: 1.2–57.4; p = 0.03). Surgical method, type of HD, presence of HAEC and preoperative colostomy are other variables that failed to obtain statistical significance (See Table 7). Table 7: Multivariate Logistic Regression Analysis to Identify Independent Predictors of Favorable Functional Outcome at 12 Months Post-Surgery PREDICTOR VARIABLE OR 95% CI P-VALUE TPT vs. Swenson 1.42 0.51–3.94 0.50 Age at surgery (<12 months vs ≥12) 8.3 1.2–57.4 0.03 Short-segment vs total colonic HD 2.1 0.6–7.3 0.24 Presence of HAEC preoperatively 0.25 0.05–1.23 0.09 No preoperative colostomy 1.8 0.5–6.2 0.36 The result highlights the need to diagnose and surgically treat patients of Hirschsprung’s disease at an early age to maximize the long-term bowel performance. Discussion This study was aimed at comparing two techniques, Transanal PullThrough (TPT) and Swenson open approach, used to treat Hirschsprung disease (HD). The researchers also showed that TPT is a very beneficial treatment because it is associated with operative time, intraoperative blood loss, length of stay, and parental satisfaction, with no life-time functional outcomes displayed in 12 months of post-surgery. These results add to the new studies, which prove that minimally invasive surgery is more popular with children with colorectal disease [6,9]. Operative and Postoperative Results The present research states that operative time was much less in the TPT (120 ± 20 minutes) group, than in OpSw(180 ± 30 minutes; p < 0.001) one. These findings are in line with the reports of the past which show that transanal access is more effective in reducing complexity (Langer et al., 2006). Besides time to complete it, intraoperative blood loss was also much less in the TPT (25 ± 10 ml) group compared to the OpSw (50 ± 20 ml; p < 0.001). Such results imply that TPT is related to a lower amount of tissue trauma, in addition to a decreased amount of blood transfusion [11]. Hospital stay days were less in TPT group (3.5 ± 1.2 days) than in OpSw group (6.8 ± 2.1 days; p < 0.001). These results are similar to the findings of the past that show less recovery time, lower costs, and benefits in the form of a minimally invasive surgery [8]. The lack of abdominal incision and little manipulation of the surrounding structures is likely to be the sources of these advantages. Functional Outcomes and Age at Surgery Despite the similarity of functional outcomes over time, e.g. stool frequency, fecal continence, and laxative use, our multivariate logistic regression found the only independent predictor of an excellent outcome was young age at surgery (<12 months) (OR: 8.3; 95% CI: 1.2-57.4; p = 0.03) which is equivalent to the results of [10] who added that the diagnosis of the problem at the earliest age, and the The patients who were above 12 months old had better results with TPT compared to Swenson (100% vs. 25%, p = 0.04), indicating that the more widespread dissection and neural damage that comes with open procedure may impair that ability in the long run, especially when addressed at later age of infancy [4]. Parenteral Satisfaction and Quality of Care The parental satisfaction scores were also better in TPT group especially in the hospital experience category (4.6 vs. 3.9, p = 0.02) and in the chances of recommending the procedure (4.7 vs. 4.1, p = 0.01). Such results have implicated the use of non-clinical measures to care like cosmetic appearance, pain management, and patient-reported outcomes in the assessment of surgical success are on the rise [7]. This is consistent with the report by [11], who opined that most parents noted higher satisfaction relating to minimally invasive surgical procedures and the reported parental satisfaction was attributable to shorter recovery period related to minimally invasive surgical procedures and lighter scars among their children, and general improvement of their lives . Associated Morbidities The prevalence of comorbidities between the two groups showed no statistically significant differences, which included Hirschsprungassociated enterocolitis (HAEC), inguinal hernia, or GERD. TPT group had HAEC of 13.3% and Swenson group had 16.7% (p = 0.72) which is within the range of 10 -30% that had been reported before [4]. Their similar rates of comorbidities are viewed by us to be as a matter of fact indicative of their underlying health condition that justifies the validity of our analysis . Technical Problems and Drawbacks of TPT Despite the numerous benefits of using TPT, other authors have raised concerns about the practicality of applying TPT to some patients especially in complicated cases. [5] claimed that TPT is not universal and mostly incomplete in total colonic aganglionosis or anatomy and suggested the critical role of surgeon training and selection of cases. Our group examined a relatively small number of patients with total colonic aganglionosis and we did not encounter serious challenges during the intra-operative phase. However, it is necessary to note that TPT is associated with the steep learning curve and results of TPT surgery are dependent not only on the technique but also on the skills and experience of the surgeon [1]. Also, we have reported similar long-term functional outcomes of the two methods but other studies have also reported that laparoscopic-assisted pull-through may provide an even better view of the transition zone and minimize the chance of incomplete resection [3]. Journal of Clinical Practice and Medical Research (ISSN 3083-7146) Volume 1 | Number 1 | September-October 2025 44 Strengths and Limitations The great finding in this paper is that two significant surgical procedures have been compared. Both of them were conducted within one study with an apparent data collection structure through the same data methodology. What is more, a multivariate analysis was conducted to determine independent predictors of outcome. Notably, the factors of parental satisfaction and quality-of-life were used to determine surgical success and went beyond the conventional clinical indicators . However, there are some limitations in this study : Single-center retrospective trial can be characterized by selection bias . The small sample size (n=60) makes it impossible to detect the differences of small occurrences of adverse events . Follow-up was not extensive (12 months), but, most importantly, there were no long-term functional outcomes . Future studies ought to test a multi-centre trial on a larger sample size and increased follow-up to determine late onset complications and quality of life . Recommendations Based on the results that were detected in this research, the following recommendations are being proposed to be used in clinical practice and research: Early diagnosis and referral: It is advisable to promote early diagnosis of Hirschsprungs disease through a policy of neonatal screening and subsequent fast track referral to the pediatric surgery centers and here early surgical intervention is indicated long before 12 months of age as this will maximize the number of evaluations to be performed in the quality of their functional outcomes.Surgeon Training and Experience: Because of the technical nature of TPT, particularly in the complex cases, it is advisable that prior to administration of the procedure the surgeon must undergo special training and experience before performing the procedure independently. Multidisciplinary Care Approach: To provide a multidisciplinary approach to care of children with HD, a multidisciplinary team of pediatric surgeons, gastroenterologists, pathologists, and nutritionists should be established to guarantee thorough preoperative assessment and postoperative care of children with HD . Prospective Multi-Centers Studies: Future research must involve prospective, multi-centers studies which have larger sample sizes and longer follow up durations to assess long-term functional prognoses, quality of life and infrequent complications of each technique. Quality-of-Life Measures: Future research should include validated pediatric quality-of-life measures as a way of offering a more comprehensive measurement of the outcome of surgery besides clinical measures. Cost-Effectiveness Analysis: Perform formal cost-benefit analyses comparing TPT and Swenson procedures in various health care systems to provide information on resource allocation and policy formulation. Long-term follow-up procedures: Adopt standardized long term followup procedures to identify late complications like constipation, enterocolitis and psychosocial difficulties among children that have undergone surgery on HD. Conclusion This comparative analysis shows the benefits of the Transanal PullThrough (TPT) system compared to the standard Swenson open surgery in the pathological treatment of Hirschsprung disease. TPT were also linked to a reduced operative time, reduced intra operative blood loss and reduced length of stay all which lead to its better patient recovery and healthcare efficiency Parental satisfaction scores were also better in the TPT group especially with the experience in the hospital and the desire to recommend the procedure. Though, functional outcome (frequency fecal continence, and laxative dependence) at 12 months post-surgery were similar between the two groups multivariate analysis established that younger age at surgery (under 12 months) was the sole independent predictor of higher long term functional outcome. This highlights the need to diagnose and operate early in order to maximize outcomes. As TPT has been shown as having distinct advantages, its technical efficacy could be restricted in complicated conditions like complete colonic aganglionosis or adverse anatomy. Thus, selection of cases and expertise of surgeons are effective determinants to success of this technique. Finally, TPT may be regarded as the surgical treatment of choice in the majority of Hirschsprung disease cases, particularly in cases of the surgery conducted prior to the age of 12 months, because it has a good perioperative profile and is acceptable in terms of long-term functional outcomes. 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