Enterocolitis After the Surgical Treatment of Hirschsprung’s Disease: Risk Factors and Financial Impact By David J. Hackam, R.M. Filler, and Richard H. Pearl Toronto, Ontario Background/Purpose: Enterocolitis (EC) represents a serious complication after the surgical correction of Hirschsprung’s disease (HD). Although previous studies have identified risk factors associated with the development of this complication before definitive repair, the factors leading to EC after pull- through have not been examined. This study was therefore designed to determine risk factors for the development of post-pull-through EC. Methods: Patients with HD treated from 1991 through 1996 at the Hospital for Sick Children in Toronto, Canada were assessed. Risk factors were examined in three areas: patient factors (gender, age at diagnosis, age and weight at pull- through), technical factors (type of repair, number of stages, location of transition zone, previous EC), and mechanical factors. Resu/&: In 105 consecutive patients, the incidence of postop- erative EC was 32%. There was no mortality. The risk of postoperative EC was significantly increased by mechanical factors related to anastomotic complications (relative risk, 2.8) and intestinal obstruction (relative risk, 3.5). This finding was not attributable to the general occurrence of any postop- erative complication because the incidence of postoperative complications was equally distributed in patients with and without EC. The presence of EC significantly increased the number of hospital admissions, mean length of stay, and total treatment cost. Conc/usio~ These findings suggest the use of measures to decrease mechanical obstruction so as to decrease the inci- dence and impact of this potentially devastating complica- tion. J Pediatr Surg 33:830-833. Copyright 0 1998 by W.B. Saun- ders Company. INDEX WORDS: Hirschsprung’s disease, enterocolitis. E NTEROCOLITIS (EC) represents one of the most significant causes of morbidity and mortality after the surgical correction of Hirschsprung’s disease (HD).le6 This serious complication, characterized by explosive watery diarrhea, abdominal distension, and fever, is reported to occur at a frequency of up to 40% after a definitive pull-through procedure,7-9 with an associated mortality rate of 3% to 30%.10-1z To further understand the pathogenesis of this complication, previous investiga- tors have identified risk factors associated with preopera- tive EC, including delayed diagnosis, long-segment dis- ease, female sex, family history, and trisomy 21.8J3-17 Although these studies are useful in identifying the child at risk before a pull-through procedure, limited informa- tion exists regarding the development of enterocolitis after surgery. We therefore investigated and report the course and outcome of patients in whom EC developed From1 the Divisiora of General Surgery, Depurtment of Surgery, The Hospital for Sick Children, and Department of S’urgeQa, University of Toronto, Toronto, Ontario, Canada. Presented at the 29th Armual Meeting of the Canadian Assouatlon of Paediatric Surgeons, Bar@ Alberta, Canada, October 3-6, 1997. Address reprint requests to Dr R.H. Pearl, Division of General Surgery. The Hosprtal for Sick Children, 5.55 UniversiQ Ave, Toronto, Ontario, Canada A45G 1X8. Copyright @ 1998 by WB. Saunders Cowpany 0022.3468/98/3306-0005$03.00/O 830 after a definitive operation for Hirschspnmg’s disease, and compared them with those without EC. Specifically, we examined the risk factors associated with the develop- ment of postoperative EC, and assessed the financial implications of this complication. MATERIALS AND METHODS Diagnosis of Hirschsprung $ Disease The charts of 109 consecutive patients admitted with HD to The Hospital for Sick Children in Toronto, Ontario, Canada between 1991 and 1996 were reviewed. The diagnosis was suspected by failme to pass mecomum, bilious vomitmg, or abdominal distension, and a definitive diagnosis was obtamed “~a rectal biopsy m all patients.ls One hundred five of the 109 patients with lnopsy-proven disease were included in the study. Of the four patients who were excluded, two ched from cardiac causes before definitive repair and two had aganglionosis involving the small intestine. Definitive pull-through was performed at a mean age of 1.5 years (range, 1 week to 7 years). by the procedures of Soave in 63, Duhamel in 17. and Swenson in 25. Primary repair was performed in 20% of patients. The selection of the type of repair and the decision to perform a primary versus a multiple-staged repair was based on the preference of the attending surgeons19 Development of Postoperative Enterocolitis and Risk Factor Assessment EC developed in 33 of the 105 patients during the postoperative period. at a mean duration from surgery of 8 ? 3 months. The admitting diagnosis of EC was made if the child had abdominal pam. fever, distension, diarrhea, and no other definable cause. To assess the risk factors for the development of enterocolitis. a control group of patients Journa/ of Pediatric Surgery, Vol 33, No 6 (June), 1998. pp 830-833