Colorectal Quiz: Episode 46
With Dr. Jason Frischer & Dr. Lily Chang & Dr. Mark Levitt & Dr. Christy Raylan · hosted by Dr. Philippa Jalius · Marc Levitt
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Podcast
Colorectal Quiz: Episode 46
Marc Levitt · 29 min · Published Apr 2025
Video
Error Traps and Culture of Safety in Hirschsprung Disease
CCHMC Pediatric Surgery · Published Oct 2019
Podcast
Hirschsprung Disease Part 2
Marc Levitt · 44 min · Published May 2015
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Hirschsprung Disease â PediaCast 287
Marc Levitt · 38 min · Published May 2014
Podcast
The Colorectal Quiz Episode 5: Proximal Hirschsprung Disease Surgical Technique
14 min · Published Mar 2021
Podcast
Hirschsprung Disease Part I with Marc Levitt
59 min · Published Apr 2017
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(500) Days of Summer (classic Movie Review: Zooey Deschanel, Joseph Gordon-Levitt, Marc Webb) by The Cory Baker Show
Marc Levitt · Published Aug 2026
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Meeting with Marc Levitt: Clinical Discussion with Ivon Martinez
Marc Levitt · Published Jul 2026
Video
Introducing Dr. Marc Levitt: Pediatric Colorectal Surgeon Profile
Marc Levitt · Published Jul 2026
Video
Integrated Care Concept in Pediatric Colorectal Surgery by Marc Levitt
Marc Levitt · Published Jul 2026
Video
Patient Outreach and Communication in Pediatric Colorectal Surgery
Marc Levitt · Published Jul 2026
Video
Keynote Address on Pediatric Colorectal Surgery by Dr. Marc Levitt
Marc Levitt · Published Jul 2026
Podcast
Colorectal Quiz: Episode 47
Marc Levitt · 22 min · Published May 2025
Podcast
Colorectal Quiz: Episode 47
Marc Levitt · 22 min · Published May 2025
Podcast
Colorectal Quiz: Episode 43
Marc Levitt · 23 min · Published Jan 2025
Podcast
Colorectal Quiz: Episode 43
Marc Levitt · 23 min · Published Jan 2025
Video
Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery
25 min · Published Mar 2024
Podcast
Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease
20 min · Published Apr 2023
Video
Dr. Marc Levitt on the CTO Mission in Pediatric Colorectal Surgery
Marc Levitt · Published Jul 2026
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Addressing Ministers of Health: Pediatric Colorectal Surgery Advocacy and Global Healthcare Priorities
Marc Levitt · Published Jul 2026
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Colorectal and Pelvic Reconstruction Techniques with Dr. Marc Levitt
Marc Levitt · Published Jul 2026
Video
Andrea Kesar Discusses Marc Levitt's Contributions to Pediatric Colorectal Surgery
Marc Levitt · Published Jul 2026
Video
Introduction to Dr. Marc Levitt's Pediatric Colorectal Surgery Practice
Marc Levitt · Published Jul 2026
Video
The History of International Colorectal Surgery Team Development
Marc Levitt · Published Jul 2026
What the experts said
Trisomy 21 is associated with approximately 50 times higher incidence of Hirschsprung disease than in non-trisomy 21 patients
About 5 to 10 percent of trisomy 21 patients have Hirschsprung disease
In Hirschsprung patients with free air, perforation typically occurs in the cecum
When cecal perforation occurs in Hirschsprung, the transition zone is probably somewhere around the hepatic flexure
In anorectal malformation patients with perforation, the perforation typically occurs in the sigmoid colon as a longitudinal tear along the tinea
Proper irrigation technique involves instilling small aliquots of warm saline (20-40 mLs at a time) and evacuating it rather than just infusing into the colon lumen
Cold saline can change the temperature of a small child during irrigations, so warm saline should be used
The septic source in Hirschsprung is not the dilated bowel itself but the Hirschsprung enterocolitis
Hirschsprung disease is almost never an emergency operation
Irrigations usually win the day in managing Hirschsprung-associated enterocolitis
Rectosigmoid ratio less than one on contrast enema is indicative of Hirschsprung disease
Sawtoothing in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease
Definitive pathologic diagnosis of Hirschsprung requires absence of ganglion cells in 100 levels and presence of hypertrophic nerves greater than 40 microns
Frozen section can only definitively rule out Hirschsprung disease, not confirm it, because confirmation requires 100 levels with no ganglion cells
Absent calretinin stain further confirms Hirschsprung disease, while present calretinin indicates ganglion cells are nearby
Minimum wait time of four weeks from treating enterocolitis before doing definitive surgery is recommended
Literature from PCPLC shows similar outcomes for Hirschsprung surgery delayed to about three months
For leveling biopsies, the sigmoid is the 'money' location to start because 80% of Hirschsprung cases are rectosigmoid
If ganglion cells are found on frozen section of sigmoid, no further biopsies are necessary
Without frozen section available, mapping should include left colon, transverse colon, and hepatic flexure/right colon
Do not biopsy the appendix for Hirschsprung diagnosis as it is not helpful and many patients' appendixes are aganglionic
Frozen sections can be difficult to interpret in the setting of active enterocolitis due to inflammation
In resource-limited settings without easy access to healthcare, colonic ostomy is preferable to ileostomy due to dehydration risk
Ileostomy is preferred when possible because mesentery from a diverted colostomy can be shortened and inflamed, making it harder to reach during pull-through
Frozen section should be performed on the ileostomy to ensure it will function
Overstretching sphincters during pull-through prevents enterocolitis but causes fecal incontinence
Elegant pull-through technique that preserves the anal canal and sphincters will still result in some enterocolitis because patients cannot relax their internal sphincter
Botox at one month post-pull-through did not prevent enterocolitis in a published negative study
Families should be taught irrigation technique and practice it before the pull-through surgery