Panel Discussion and Case Presentation Part II: Pediatric Bowel Management 2013
With Dr. Alp Numoglu & Dr. Michael Alshaus & Dr. Alberto Pena · StayCurrentMD
Cued at 12:56 · stops at 13:41 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
Hirschsprung Disease: Surgical Procedures
128 min · Published Feb 2015
Video
Hirschsprung Disease: Update Course 2013
38 min · Published Sep 2013
Video
Hirschsprung Disease: Update Course 2015
CCHMC Pediatric Surgery · 7 min · Published Nov 2015
Video
Surgical Procedures for Hirschsprung Disease
128 min · Published Nov 2018
Video
Hirschsprung Disease: Update Course 2013
38 min · Published Sep 2013
Video
Hirschsprung Disease Rapid Fire: Update Course 2015
CCHMC Pediatric Surgery · 12 min · Published Nov 2015
Only a few other public items share this expert — go deeper there →
Video
Pediatric Surgical Oncology Research Collaborative (PSORC): Studying Rare Pediatric Tumors
56 s · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Pooling Patients to Study Rare Pediatric Tumors: An Introduction to PSORC
56 s · Published May 2026
Video
The fetal frontier: A review of current and emerging fetal therapies for genetic diseases
44 s · Published May 2026
Video
Indocyanine green assists with sentinel lymph node mapping in pediatric and adolescent patients
1 min · Published May 2026
What the experts said
For total colonic Hirschsprung disease, Duhamel procedure is preferred initially.
For shorter-segment Hirschsprung disease, laparoscopic biopsy to establish the level, followed by laparoscopic-assisted pelvic dissection and perirectal dissection to join the dissection lines.
Transanal approach after de la Torre technique used for the last 40 cases, with laparoscopy in some cases to confirm ganglionosis level.
For total colonic Hirschsprung disease, delaying the pull-through and performing ileoanal anastomosis similar to total colectomy patients, with protective ileostomy.
Pure transanal approach used for shorter-segment disease and some redo pull-throughs when ganglion cell location is accurately determined.
In Spain, de la Torre technique is used; for total colonic aganglionosis, Lester Martin procedure is used.
About half of the 11 partners do Soave, the other half do Swenson procedures; laparoscopic leveling is performed, some use umbilical incisions depending on contrast enema findings.
Some partners doing Soave are switching to 'Soaven'—a very short Soave cuff transitioning to Swenson plane a couple centimeters above the dentate line.
When the anal canal is destroyed, the patient will not have bowel control; with total colonic aganglionosis producing liquid stool, there is no bowel management possible.
A permanent stoma is indicated when the anal canal is destroyed and the patient has total colonic aganglionosis.
Sometimes constipating diet and fiber are tried to convince parents that there is no other option except permanent stoma; this is one of the few indications for permanent stoma.
For a patient previously operated for Hirschsprung disease suffering from enterocolitis with normal rectal biopsy, rectal irrigation is the treatment.
Before surgery, parents must demonstrate rectal irrigations to nursing staff on the floor and be signed off before proceeding to surgery.
For patients seen in clinic while waiting for surgical date, irrigation teaching and demonstration occur in clinic.
Parents are taught rectal irrigation on the ward by nurses; personal control is performed to ensure parents know how to irrigate before hospital discharge and before surgery.
Common irrigation problems: parents hesitant to advance catheter far enough, or not using enough saline to get clear return before finishing.
In the background of Hirschsprung disease, enterocolitis is not simple gastroenteritis; children are often taken to other medical centers and treated as simple gastroenteritis by doctors unaware of enterocolitis.
Parents are continuously taught to return to the specialist hospital for enterocolitis, not general hospitals.
Families are made very comfortable with irrigations before going to the emergency room, because many places are uncomfortable with irrigations in general.
Most pediatricians worldwide do not know the difference between enterocolitis and gastroenteritis; they do not understand the entity called post-Hirschsprung enterocolitis.
Pediatricians do not understand why irrigations are necessary; they see dilated bowel on X-ray and think it is intestinal obstruction, not recognizing the entity itself.
When starting dissection 2 cm above the dentate line and pulling bowel through, the upper mucosa is often damaged, and the anastomosis ends up about 1 cm above the dentate line.
Dr. Pena does not believe that leaving 1-2 cm of rectal mucosa is the simple cause of enterocolitis.
A group in New York doing neonatal Soave primary procedures reported zero enterocolitis; when Dr. Pena followed some of those patients, many had fecal incontinence.
If you produce fecal incontinence in a patient, enterocolitis is zero; a patient with destroyed anal canal is equivalent to a stoma, and patients with stomas rarely have enterocolitis.
A good operation preserving the sphincter and anal canal creates sphincter closure, which creates stasis, and stasis produces enterocolitis.
Dr. Pena prefers to deal with enterocolitis rather than fecal incontinence; fecal incontinence is for life.
GI doctors recently started doing more anorectal manometry; it is rare for a post-op Hirschsprung patient to have normal anorectal manometry, leading to misinformation.
Some Hirschsprung patients are told by GI doctors they have chronic bacterial overgrowth syndrome and started on antibiotics, when they likely have enterocolitis; antibiotics alone are not the total solution.
Young parents often feel irrigations are a chore and tough on their babies; it is crucial to instruct them, stress the importance, and teach excellent technique.
Always use saline for irrigations, not regular water; importantly, warm the saline, especially for neonatal babies, to keep body temperature normal.
Dr. Pena's incidence of enterocolitis in pull-through patients is about 30%.
Using Duhamel technique, there is a low incidence of enterocolitis, but no explanation for this.
Resecting the rectosigmoid introduces a major pathophysiological change; children with perfect pull-throughs preserving the anal canal sometimes have toilet-training problems without explanation.
Hyperactive children with attention deficit disorder have more toilet-training problems because they have a piece of colon that does not act like a reservoir, connected to the rectum and moving constantly; significant cooperation from the child is required.
Even with a perfect operation, patients may have certain toilet-training problems; if the anal canal is destroyed, they will be totally incontinent; partial anal canal destruction causes more problems.
In manometry studies of the colon, migrating complexes or high-amplitude contractions stop in the sigmoid colon in most people and do not go to the rectum; after pull-through, these are moved down to the anus.
Toilet-training Hirschsprung patients do not always get the same warning of impending bowel movement and do not have as much time; must factor this in and use the gastrocolic reflex.
Dr. Pena does not find rectal manometry useful in Hirschsprung disease, constipation, or anorectal malformations after many years of experience.
Patients are discharged with three irrigations per day and metronidazole (Flagyl); every month the number of irrigations is decreased.
If decreasing irrigations causes recurrent enterocolitis and the patient does not tolerate lack of irrigation, and by 6 months post-op the patient is still on irrigations, parents become very nervous; at that point, other options are discussed.
For refractory enterocolitis, another option is further resection of normal ganglionic colon to remove more.
Hirschsprung disease is much more than ganglion cells vs. no ganglion cells; we do not know why some patients never have enterocolitis and toilet-train early, behaving like normal children, while others have severe enterocolitis from day one.
'Benign Hirschsprung disease' patients present at 8-10 years old with classic imaging and abdominal distention but never had enterocolitis, grew and developed normally, and do very well after surgery.
In the United States, earlier diagnosis is being made of patients with 'bad Hirschsprung'—enterocolitis from day one, very sick, and high incidence of enterocolitis after surgery.
There is much we do not know about Hirschsprung disease; the story is much more than absent ganglion cells, and taking bowel with normal ganglion cells down does not mean that bowel is 100% normal.
Some believe that ganglionic bowel may have neuronal intestinal dysplasia, but this is a very controversial histopathological diagnosis; we do not know what is wrong and must learn much more.
Another option for obstructive Soave cuff is laparotomy or laparoscopy to split the cuff in front of the sacrum without resection.
Dr. Pena is skeptical that the cuff produces obstruction; to believe it, he would need to see the cuff producing real obstruction manifested by very dilated colon above the cuff, which is very unusual.
Dr. Mark Levitt has experience dealing with obstructive cuffs transanally; laparoscopic approach is not a bad idea but Dr. Pena has never heard of it being done laparoscopically.
Patients with total fecal incontinence have no enterocolitis; all operations moving toward fecal incontinence (myectomies, myotomies, Botox, massive dilatation, putting 3 fingers in the rectum) are temporary or permanent moves toward incontinence.
Patients subjected to myotomies, myectomies, or repeated Botox injections eventually develop more severe fecal incontinence.
Dr. Pena does not believe in myectomy/myotomy/Botox procedures and does not use Botox.
In Italy, Soave approach was used initially, but switched to transanal approach in the last 2 years with laparoscopic biopsies; very satisfied with results.
For a patient with total colonic aganglionosis, previously operated, suffering from fecal incontinence and severe diaper rash, with destroyed anal canal, treatment is a permanent stoma.
The only contraindication for irrigation is a recent operation; after a recent operation, the surgeon who operated should perform irrigation immediately post-op to avoid perforating the anastomosis.
When re-biopsying patients suspected of having a transition zone or aganglionic pull-through, biopsy as high as possible above the anastomosis to avoid the problem of finding aganglionic tissue at the anastomosis level.
Metronidazole (Flagyl) is given orally for better effect; when tapering, sometimes given with irrigation through the rectum.
After a biopsy, wait 48 hours before starting rectal irrigation; patients are taught irrigation in clinic first, then biopsy is done later so it is not a fresh incision.
Fecal incontinence is more frequently seen in Swenson and Soave operations compared to Duhamel and Rehbein.