Per-Rectal Endoscopic Myotomy (PREM) for Hirschsprung’s Disease: A Multicentre Study Demonstrating Safety, Feasibility and Durable Clinical Outcomes

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Aims Hirschsprung’s disease (HSCR) is a congenital disorder characterized by the absence of intrinsic ganglion cells and myenteric plexuses of the hindgut . Per-rectal endoscopic myotomy (PREM) is a minimally invasive third-space endoscopic procedure used in the management of Hirschsprung’s disease. To evaluate the technical outcomes and clinical success of PREM, assessed by improvement in stool frequency, reduction in laxative requirement and Wexner constipation score pre- and post-procedure. Methods Retrospective analysis of 52 consecutive patients undergoing PREM across 12 tertiary centres (2015–2025). Demographic, procedural, postoperative recovery and functional outcome data (stool frequency, laxative requirement and Wexner score) were compared pre- and post-procedure using paired statistical testing. Results Fifty-two patients underwent PREM with a mean age of 16.38±17.9 years; 29 (55.8%) were male. Congenital Hirschsprung disease was the indication in 82.5% (33/52), acquired Hirschsprung in 26.9% (14/52) and post-surgical recurrence in 9.6% (5/52). Mean duration of symptoms was 94.80±136.22 months. The recto-anal inhibitory reflex was absent in 80.8% (42/52), a dilated colonic segment was present in all patients (100%), and barium enema findings were confirmatory for Hirschsprung disease in 65% (26/40) and suspicious in 32.5% (13/40). The mean length of the aganglionic or hypo ganglionic segment was 7.38±2.85 cm. Procedurally, the mean tunnel length was 13.4±5.1 cm, mean myotomy length 10.9±4.1 cm, and mean procedure duration 90±33 minutes, with 100% technical success. Median of first bowel sounds: 12 hours (IQR 12–12), passage of flatus: 12 hours (IQR 12–24), first bowel movement: 48 hours (IQR 24–48), and resumption of oral liquids: 24 hours (IQR 24–24). Median hospital stay was 5 days (IQR 12– 24 hours). Major adverse events occurred in 9.6% (5/52), consisting of perforation (n=1), clip dislodgement requiring surgical closure (n=1), large tunnel entry defect requiring surgical repair (n=1), surgical emphysema (n=1), and localized perirectal collection (n=1); all were managed successfully without mortality. Median follow-up was 14 months (IQR 3–46.5). Functional outcomes improved significantly with laxative usage decreasing from 4.3±2.488 units to 1.6±0.9 ( p <0.0001), stool frequency increasing from once every 7.1±4.29 days to once every 1.31±0.55 days (p<0.0001), Wexner constipation score decreasing from 23.76±3.98 to 8.13±1.19 (p<0.0001). Conclusions PREM is a safe and effective minimally invasive treatment for Hirschsprung’s disease, offering sustained symptom improvement with very low complication rates. Publication History Article published online: 05 June 2026 © 2026. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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