National centralization of Hirschsprung’s disease in Sweden: a comparison of postoperative outcome
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In brief
In brief
This Swedish retrospective study compared outcomes of 197 Hirschsprung's disease patients before and after national centralization from four to two pediatric surgery centers. While laparoscopic techniques increased significantly, centralization did not reduce severe complications, readmissions, or time to definitive surgery, though mild HAEC cases increased possibly due to heightened awareness.
- Centralization of Hirschsprung's surgery in Sweden (4→2 centers) did not reduce severe complications or readmissions within 90 days post-op.
- Laparoscopic-assisted endorectal pull-through increased significantly after centralization (8.8% to 39.8%, p<0.001).
- HAEC treated with antibiotics rose from 10.5% to 24.1% post-centralization, likely reflecting heightened clinical awareness of mild cases.
- Age at pull-through and stoma rates remained unchanged, suggesting centralization did not delay definitive surgical management.
- Pediatric surgical centralization for rare diseases may not yield the same quality improvements observed in adult complex care.
Written by the GCMD Library team from the article.
Abstract
Background
In Sweden, surgical treatment of Hirschsprung’s disease (HSCR) was centralized from four to two pediatric surgery centers 1st of July 2018. In adults, centralization of surgical care for complex or rare diseases seems to improve quality of care. There is little evidence supporting centralization of pediatric surgical care. The aim of this study was to assess surgical management and postoperative outcome in HSCR patients following centralization of care.
Methods
This study retrospectively analyzed data of patients with HSCR that had undergone pull-through at a pediatric surgery center in Sweden from 1st of July 2013 to 30th of June 2023. Patients managed from 1st of July 2013 to 30th of June 2018 (before centralization) were compared with patients managed from 1st of July 2018 to 30th of June 2023 (after centralization) regarding surgical treatment, unplanned procedures under general anesthesia or readmissions up to 90 days after pull-through as well as complications classified according to Clavien–Madadi up to 30 days after pull-through.
Results
In the 5-year period prior to centralization, 114 individuals from 4 treating centers were included and compared to 83 patients from 2 treating centers in the second period. There was no difference regarding age at pull-through or proportion of patients with a stoma prior to pull-through. An increase of laparoscopically assisted endorectal pull-through (8.8% to 39.8%) was observed (p < 0.001). No significant differences were seen in postoperative hospital stay, unplanned procedures under general anesthesia, or readmissions up to 90 days after pull-through. There was no difference in severe complications (Clavien–Madadi ≥ 3); however, HAEC treated with antibiotics increased following centralization (10.5–24.1%; p = 0.018).
Conclusion
Centralization of care for HSCR does not seem to delay time to pull-through nor reduce severe complications, unplanned procedures under general anesthesia or readmissions up to 90 days after pull-through. The increased HAEC rate may be due to increased awareness of mild HAEC.
Level of evidence: Level III.