Laparoscopic−assisted versus purely transanal Soave procedures for Hirschsprung disease in children aged ≤ 4 years: an age−stratified retrospective study

Abstract

Laparoscopic−assisted and purely transanal Soave procedures are commonly used for Hirschsprung disease, but whether their comparative outcomes differ according to age remains uncertain. This single−center retrospective cohort study included 188 children aged ≤ 48 months who underwent primary Soave pull−through and were classified according to surgical approach and age: laparoscopic−assisted Soave at < 24 months ( n = 60) or 24–48 months ( n = 37), and purely transanal Soave at < 24 months ( n = 55) or 24–48 months ( n = 36). The primary outcome was the occurrence of at least one postoperative complication within 12 months. Regression models included surgical approach, age group, and a surgical approach × age group interaction term, with adjustment for measured demographic, clinical, anatomical, and calendar−era factors. Firth penalized logistic regression was additionally performed as a sensitivity analysis for sparse−event bias. Among children aged < 24 months, the primary outcome occurred in 11.7% of the laparoscopic−assisted group and 14.5% of the purely transanal group (adjusted odds ratio (OR), 0.92; 95% confidence interval (CI), 0.29–2.90; P = 0.893). Among children aged 24–48 months, the corresponding rates were 8.1% and 33.3%, respectively (adjusted OR, 0.18; 95% CI, 0.04–0.76; P = 0.019). However, the surgical approach × age group interaction was not statistically significant ( P = 0.082). Laparoscopic assistance was associated with a longer total operative time and a substantially shorter anal operative time in both age groups. Postoperative hospital stay was shorter with laparoscopic assistance in the 24–48−month group, although the interaction by age was not significant. Laparoscopic−assisted Soave was associated with shorter anal operative time in both age groups and with more favorable short−term outcomes in children aged 24–48 months. However, formal interaction testing did not establish an age−dependent benefit. Firth penalized sensitivity analyses yielded broadly consistent estimates and did not materially change the interaction results. Surgical approach should therefore be individualized according to disease anatomy, bowel dilatation, anticipated operative complexity, and the overall clinical context rather than age alone. Clinical trial number: Not applicable.