Questions and Answers from Hirschsprung Disease and Colitis

Question: Can you redo a pull through?

Answer: Yes, we can do a redo. We need to evaluate the anal canal and to know the length of the residual colon and the type of pull-through that was done.

Question: Stenosis can cause colitis? How can we eliminate stenosis?

Answer: If you or the surgeon can “open” the stenosis with anorectal dilation is good. Just the surgeon needs to confirm that the stenosis after the dilations is elastic and not a fibrotic ring.

Question: If a male patient has an ileostomy, would he have more problems later on?

Answer: If there is an adequate length of colon, usually not.

Question: Is contrast study not contraindicated with colitis?

Answer: If you use Isoviue no.

Question: We start irrigation at day 2 post op. That is good?

Answer: Perfect.

Question: We instated that after prof did a work shop in our Center.

Answer: Yes.

Question: Do you believe in ultrashort HD?

Answer: Ultrashort Hirschsprung is not an act of faith. Hirschsprung affects always the rectum and the anal canal. Thus, if you do a good anastomosis and the patient will have 0.5 cm of rectum, this is an ultrashort. Achalasia anal is not ultrashort Hirschsprung.

Question: During colitis is rectal biopsy indicated or not?

Answer: If you want to rule out residual aganglionosis, I suggest doing irrigations some days, probably 3 days, metronidazole, and then the biopsy.

Question: How can we prevent twisting of ganglionic bowel during pull-through?

Answer: You need to place the mesenteric side in the proper direction, you can (1) pass a rectal tube or (2) perform a rectoscopy. I do the first option.

Question: With your experience, what is your advice about cuff length?

Answer: Until you have a floppy cuff. In other words, when you are in the peritoneal reflection.

Question: What are the risks of bringing down a damage vascularization of the ganglionic pull-through colon?

Answer: Necrosis, estenosis, fistulas dehiscente, abscess.

Question: Post-operative protocol of irrigation,when to start and for how long?

Answer: Oh, this is large answer. But, if the patient needs irrigation you need to do it as soon as the patient tells you. I send my patient home with irrigations for 1 month (once a day, usually, and start 2-4 days after the pull-through).

Question: HD is a histopathology depended disease. With a lack of experts in hisopathology and in HD, what do you advise: to operate or not?

Answer: Depends on your own circumstances, you can you use different tricks. One is to demonstrate a clear TZ during the contrast enema. Another is to obtain a clear TZ during the PT.

Question: Is there any benefit to add Flagel during irrigation

Answer: Yes.

Question: Do you use barium or hidrosoluble contrast?

Answer: No barium, I use ISOVOUE (iopamidol).

Question: Do you split the muscular cuff?

Answer: Yes.

Question: Do you agree that a good pull-through is a perfect Swenson?

Answer: I love the three techniques: Swenson, Duhamel, and Soave.

Question: How many cm above the first normal biopsy do you resect?

Answer: 5 cm,

Question: What is your opinion about the probiotic use for enterocolitis prevention?

Answer: I have not seen any difference yet. But the microbiota is a significant factor, so this is a line of research.

Question: I thought anal canal normally has no ganglion?

Answer: Correct. The anal canal in all the humans is aganglionic. But in patients with Hirschsprung the function of the anal canal is abnormal. 

Question: The anal canal is normally hypoganglionic, how we can justify anal canal Hirschsprung's disease?

Answer: Correct. The anal canal in all the humans is aganglionic. But in patients with Hirschsprung the function of the anal canal is abnormal.

Question: If even with preop irrigations the proximal colon is chronically dilated, you suggest to resect all the dilated bowel until it is normal in diameter? Even if it means resecting all the left colon?

Answer: In chronic – older patients I must probably resect the dilated segment and do the PT with the splenic flexure.

Question: What is the right time for pull through?

Answer: When the patient does not have colitis, and based on the surgeon's professional experience.

Question: Is your typical regimen to start irrigations after surgery? 

Answer: Yes.

Question: How soon after surgery and for how long? 

Answer: Usually on day 2-5 postop. I do 1 to 3 times a day based on the clinical outcome. I keep the irrigations for 1 to 4 weeks also based on the clinical outcome. We will talk bout this in our next webinar.

Question: Do you recommend antibiotics for prophylaxis after surgery?

Answer: Usually not, but it depends on your own circumstances.

Question: In your opnion, what is the indication of colostomy in cases of enterocolitis?

Answer: When the irrigations are not resolving the obstruction, this happens in 20% of the patients.

Question: What, if any, is your choice of antibiotics?

Answer: Metronidazole

Question: Is there any age limit you would accept frequent Hirschsprung associated enterocolitis before actively investigating further?

Answer: Nice question. Recurrent bout of colitis obligates an investigation.