Colorectal Quiz: Episode 50 - 16th Annual European Pediatric Colorectal and Pelvic Reconstruction Conference, Stockholm, Sweden, October 2025 - What did we learn?

Published: 2026-03-09

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Dr. Mark Levitt — host
Speaker 2 — host
Lindsay Clark — guest
Megan Misa — guest
Dr. Felipe Gli — guest

Chapters

0:00Introduction and Hirschsprung Irrigation Practices — Introduction to episode 50 and discussion of early irrigation competency in Hirschsprung patients, including those with stomas, to reduce enterocolitis risk and ease post-takedown adaptation.
3:07Skincare and Nutritional Management — Discussion of skincare strategies including crusting techniques and use of Betel leaf for peristomal protection, plus individualized dietary approaches for Hirschsprung patients.
5:23Minimally Invasive Techniques and Enterocolitis Science — Updates on robotic surgery, ICG fluorescence imaging, ultrasound for aganglionic segment identification, and new scientific understanding of goblet cells and mechanical stress in enterocolitis pathogenesis.
8:30Pull-Through Decompensation and Nursing Programs — Discussion of pull-through failure mechanisms related to inadequate post-operative management, and the expansion of dedicated allied health nursing programs at the conference.
10:50Transition of Care Challenges — Review of transition programs including Ready Steady Go questionnaires, need for adult specialists trained in congenital conditions, and multidisciplinary team requirements.
15:55Anorectal Malformation Surgical Techniques — Discussion of perineal-preserving PSARP, posterectal advancement anoplasty, vestibular fistula dissection depth, and timing of vaginal reconstruction in cloaca patients.
20:45Pediatric Proctology and Conference Attendance — Management of chronic anal fissures, Crohn's disease perianal manifestations, enteral nutrition efficacy, and reflection on the diverse international attendance at the conference.

Key claims

1:17Many centers are starting irrigation competency even with an ostomy in place, particularly for total colonic Hirschsprung patients who may have delayed takedown — Lindsay Clark
2:13Enterocolitis remains a risk for Hirschsprung patients even after pull-through at about a rate of 20% of all patients — Speaker 2
2:21Regular irrigations minimize enterocolitis risk — Speaker 2
2:45Total colonic Hirschsprung patients represent the highest risk group for enterocolitis — Dr. Mark Levitt
3:35Most centers still do some kind of crusting, putting stool on the bottom first while patients have a stoma for small periods of time to help get their bottom used to it — Megan Misa
4:11Betel leaf was used for peristomal skin protection in Bangladesh with pristine skin results — Megan Misa
4:48Diet and nutrition management is not one size fits all; families must identify individual food triggers through pattern recognition — Lindsay Clark
5:23There have been advances in robotic-assisted repair for Hirschsprung disease and use of ICG to check blood supply of pull-throughs — Dr. Felipe Gli
5:36ICG fluorescence imaging can reduce the risk of leaks and ischemia during pull-throughs — Speaker 2
5:49High frequency ultrasound measurement of muscle internal thickness can help determine the segment of aganglionic bowel — Dr. Felipe Gli
6:44More surgeons are able to perform robotic surgery on children less than 10 kg because equipment is improving — Dr. Mark Levitt
6:51Robotic surgery expenses have become almost equivalent to other techniques — Dr. Felipe Gli
7:40Goblet cells increase from proximal to distal bowel, producing more mucus distally which has a protective role — Dr. Mark Levitt
7:56The more proximal bowel that needs to be resected, the more at risk the patient is for future enterocolitis because proximal segments don't make as much protective mucus — Dr. Mark Levitt
8:37Mechanical stress and distension on the bowel wall leads to increased gut microbial dysbiosis and breakdown in mucosal lining and barrier function — Dr. Mark Levitt
9:04Bowel wall stress shows upregulation of pro-inflammatory factors affecting immune response, contributing to enterocolitis — Dr. Mark Levitt
9:39Most pull-through decompensation occurs despite originally good pathology, due to inadequate post-operative management — Dr. Mark Levitt
9:52Aggressive management with laxatives when needed and Botox when needed prevents pull-through decompensation — Dr. Mark Levitt
16:25The perineal-preserving PSARP avoids perineal body dissection altogether and avoids dehiscence possibility — Dr. Mark Levitt
16:36Perineal-preserving PSARP could potentially avoid colostomies and colostomy closures in many patients — Dr. Mark Levitt
16:57PRAA (posterectal advancement anoplasty) involves mobilization of posterior rectal wall only in males with perineal fistula and some females with perineal fistula when the fistula is in the anteriormost extent of the sphincteric ellipse — Dr. Mark Levitt
17:18In vestibular fistula repair, surgeons do not need to dissect all the way to the areolar plane separating anterior rectum from posterior vagina; they only need to ensure no tension on the rectum during anoplasty — Dr. Mark Levitt
18:07Delaying vaginal reconstruction in cloaca may allow for other surgical options with less conflict and avoid bowel vaginoplasty — Dr. Felipe Gli
18:27A vaginal replacement can hold the spot in the perineum and be resected later when the patient is older — Dr. Felipe Gli
18:44Cloaca patients need long-term follow-up especially during puberty to avoid menstrual obstruction, incapacity for egress, and risk of endometriosis and damage to uterus and fallopian tubes — Dr. Felipe Gli
19:24Structures that look atretic may actually grow into real useful structures, supporting a strategy of waiting on Mullerian structures — Dr. Mark Levitt
19:50A bowel neovagina can bridge the gap when native vagina does not reach, and may be removable in the future when native vagina can be pulled through after puberty — Dr. Mark Levitt
21:02Removal of the skin tag in chronic anal fissure can lead to better long-term healing — Dr. Felipe Gli
21:02Injection of 20 to 50 units of Botox can improve healing in chronic anal fissure — Dr. Felipe Gli
21:35There is a higher incidence of perianal disease in children with Crohn's disease, and sometimes perianal disease can be the first hint that the patient will develop Crohn's disease — Dr. Mark Levitt
21:53Enteral nutrition is as effective as steroids in treating transmural inflammation or stenosis of small bowel in Crohn's disease — Dr. Mark Levitt

Open questions

What is the optimal timing for vaginal reconstruction in cloaca patients?
How can transition programs be improved to better serve adult patients with congenital colorectal conditions?
Can high-frequency ultrasound replace rectal biopsy for determining aganglionic segments in Hirschsprung disease?
What is the long-term durability of bowel neovaginas used as temporary spacers in cloaca repair?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Post-Pull-Through Management Determines Long-Term Outcomes in Hirschsprung Disease

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

Start irrigation training before takedown

Total colonic Hirschsprung patients who will have delayed takedown benefit from beginning irrigation competency while the stoma is still in place 1:17. One to two irrigations per week familiarize both child and parent with the technique before it becomes medically necessary. Families who attempt to start irrigations at age twelve, after years without them, face significant resistance and trauma [q2]. The early training provides a method to empty the child post-operatively and smooths the transition when the stoma is finally closed. This matters most for the highest-risk group — total colonic patients face enterocolitis rates around 20% even after pull-through 2:13.

Goblet cell distribution explains proximal resection risk

Goblet cells increase in density from proximal to distal bowel, producing progressively more mucus as you move distally 7:40. That mucus layer has a protective role. When extensive proximal resection is required, less mucus-producing tissue remains, leaving the patient with less mucosal protection 7:56. This provides a mechanism for the clinical observation that patients requiring more proximal resection carry higher enterocolitis risk — they have lost the protective mucus barrier that distal bowel normally provides.

Mechanical stress drives enterocolitis through barrier breakdown

Distension and mechanical stress on the bowel wall trigger gut microbial dysbiosis and breakdown of the mucosal barrier 8:37. The stressed bowel shows upregulation of pro-inflammatory factors that affect immune response 9:04. This is not a vague concept — it explains why technically adequate pull-throughs can develop enterocolitis years later if the bowel is allowed to remain distended. The stress itself damages the barrier function, independent of the original pathology.

Most pull-through failures reflect inadequate post-operative management

A technically elegant pull-through with good initial pathology can decompensate years later 9:39. The failure mode is not surgical — it is management. When obstructive behavior emerges, aggressive intervention with laxatives and Botox prevents long-term decompensation 9:52. The key is proactive monitoring. Waiting until the patient is symptomatic enough to complain means the bowel has already been under stress long enough to trigger the dysbiosis and barrier breakdown described above. Early detection of any obstructive pattern and immediate escalation of management keeps the pull-through functional.

Vestibular fistula repair requires less dissection than traditionally taught

In vestibular fistula repair, the goal is a tension-free anoplasty, not dissection to a specific anatomic plane 17:18. Surgeons do not need to reach the areolar plane separating anterior rectum from posterior vagina. If the rectum advances without tension, the dissection is adequate. This represents a shift from anatomic completeness to functional adequacy — the rectum needs mobility, not maximal mobilization.

Mullerian structures may mature enough to avoid bowel vaginoplasty

Structures that appear atretic at initial repair may grow into functional anatomy over time 19:24. In cloaca repair, delaying vaginal reconstruction can avoid bowel vaginoplasty if the native vagina eventually reaches 18:07. When the native vagina does not reach after urogenital separation, a bowel neovagina can hold the anatomic space 18:27. That bowel segment is not necessarily permanent — it may be removable after puberty when the native vagina has matured enough to be pulled through. The critical point is that these patients require long-term follow-up through puberty to prevent menstrual obstruction, which carries risk of endometriosis and damage to uterus and fallopian tubes 18:44.

Enteral nutrition matches steroid efficacy in Crohn's transmural inflammation

Enteral nutrition is as effective as steroids for treating transmural inflammation or stenosis of small bowel in Crohn's disease 21:53. This matters because perianal disease in children carries higher incidence in Crohn's patients and can be the first presenting sign before intestinal disease becomes apparent 21:35. When perianal disease appears, consider Crohn's and consider enteral nutrition as first-line therapy rather than reflexively reaching for steroids.

Takeaways from this story

Start irrigation training 1-2x/week while stoma is in place for total colonic patients to avoid traumatic transition at takedown
Proximal resection removes goblet cells that produce protective mucus, explaining higher enterocolitis risk in extensive disease
Bowel distension triggers dysbiosis and barrier breakdown; aggressive laxative/Botox use prevents pull-through decompensation
Vestibular fistula repair needs tension-free anoplasty, not dissection to the rectovaginal areolar plane
Bowel neovagina in cloaca may be removable after puberty when native vagina matures; long-term follow-up prevents obstruction

Post-Operative Management Determines Pull-Through Outcomes More Than Operative Technique

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Teaching arc · AI-written, human-reviewed

Start irrigation training before takedown

Many centers now begin irrigation competency while the stoma is still in place, particularly for total colonic Hirschsprung patients who may face delayed takedown 1:17. Families who wait until after pull-through to learn irrigations — often when the child is twelve or older — find the process traumatic [q2]. Starting irrigations one to two times per week with the stoma in place accustoms both child and parent to the technique and provides a method to empty the child post-operatively. This matters most for total colonic patients, who carry the highest enterocolitis risk 2:45. Enterocolitis affects roughly 20% of all Hirschsprung patients even after pull-through 2:13, and regular irrigations minimize that risk 2:21.

Understand why proximal resections carry higher enterocolitis risk

Goblet cells increase in density from proximal to distal bowel, producing more protective mucus in distal segments 7:40. When more proximal bowel must be resected, there is less mucus production and therefore less mucosal protection, which may explain the increased enterocolitis risk in patients requiring extensive resection 7:56. Separately, mechanical stress and distension on the bowel wall lead to gut microbial dysbiosis, breakdown of the mucosal barrier, and upregulation of pro-inflammatory factors affecting immune response 8:37 9:04. These mechanisms — reduced mucus protection and stress-induced barrier dysfunction — provide a biological framework for understanding why certain patients develop enterocolitis despite technically sound surgery.

Prevent pull-through decompensation through aggressive post-operative management

Most pull-through decompensation occurs despite originally good pathology, due to inadequate post-operative management 9:39. A technically elegant pull-through can fail years later if the patient is not proactively monitored for obstructive behavior. Aggressive management with laxatives when needed and Botox when needed prevents this decompensation 9:52. The lesson is that the operation establishes anatomy, but long-term function depends on recognizing early signs of obstruction and intervening before the pull-through dilates and loses contractility.

Minimize dissection in vestibular fistula repair

In vestibular fistula repair, surgeons do not need to dissect all the way to the areolar plane separating the anterior rectum from the posterior vagina 17:18. The key requirement is ensuring no tension on the rectum during anoplasty, which may require less extensive dissection than traditionally taught. This represents a shift from anatomic completeness to functional adequacy — dissect only as much as needed to achieve a tension-free repair, rather than pursuing a plane because it exists.

Consider delayed vaginal reconstruction in cloaca

Delaying vaginal reconstruction in cloaca may allow for other surgical options with less conflict and avoid bowel vaginoplasty 18:07. A vaginal replacement can hold the anatomic space in the perineum and be resected later when the patient is older 18:27. Structures that appear atretic may grow into functional structures over time 19:24, supporting a strategy of waiting on Mullerian structures when possible. When the native vagina does not reach after urogenital separation, a bowel neovagina can bridge the gap and may be removable in the future when the native vagina can be pulled through after puberty 19:50. The critical point is that cloaca patients need long-term follow-up, especially during puberty, to avoid menstrual obstruction, incapacity for egress, and risk of endometriosis and damage to uterus and fallopian tubes 18:44.

Recognize perianal disease as a harbinger of Crohn's disease

There is a higher incidence of perianal disease in children with Crohn's disease, and sometimes perianal disease can be the first hint that the patient will develop Crohn's disease 21:35. When evaluating a child with chronic perianal pathology — fissures, fistulas, skin tags — consider whether this represents isolated proctologic disease or the leading edge of inflammatory bowel disease. For established Crohn's disease, enteral nutrition is as effective as steroids in treating transmural inflammation or stenosis of small bowel 21:53, offering a non-pharmacologic option for disease control.

Takeaways from this story

Start irrigation training while the stoma is in place to ease post-takedown transition, especially for total colonic patients
Proximal resections carry higher enterocolitis risk due to reduced goblet cell density and less protective mucus production
Pull-through decompensation usually reflects inadequate post-op management, not poor initial pathology—monitor and intervene early
In vestibular fistula repair, dissect only enough to achieve tension-free anoplasty—full dissection to the areolar plane is unnecessary
Perianal disease in children may be the first sign of Crohn's disease; enteral nutrition is as effective as steroids for transmural inflammation

Topic overview

This 50th episode of the Colorectal Quiz podcast reviews key clinical takeaways from the 16th European Pediatric Colorectal and Pelvic Reconstruction Conference held in Stockholm, October 2025. The discussion covers advances in Hirschsprung disease management, including early irrigation competency even with stomas in place to reduce enterocolitis risk, and emerging science on goblet cell distribution and mechanical bowel stress as factors in enterocolitis pathogenesis. The panel addresses anorectal malformation surgical techniques including perineal-preserving PSARP and posterectal advancement anoplasty, timing of vaginal reconstruction in cloaca patients, and the critical role of dedicated nursing programs in long-term functional outcomes. Additional topics include robotic surgery feasibility in small children, transition of care challenges, and management of chronic anal fissures and Crohn's-related perianal disease.

Key takeaways

Start irrigation competency training even with ostomy in place to reduce enterocolitis risk in total colonic Hirschsprung. (1:17)
ICG fluorescence imaging during pull-through reduces leak and ischemia risk by confirming adequate blood supply. (5:23)
Proximal bowel resection increases enterocolitis risk due to lower goblet cell density and reduced protective mucus production. (7:40)
Aggressive post-op management with laxatives and Botox prevents pull-through decompensation despite good initial pathology. (9:39)
Delay vaginal reconstruction in cloaca to avoid bowel vaginoplasty; native structures may grow and become functional after puberty. (18:07)

Keywords

Hirschsprung disease total colonic Hirschsprung enterocolitis anorectal malformation cloaca vestibular fistula perineal fistula chronic anal fissure Crohn's disease rectal prolapse endometriosis menstrual obstruction irrigation pull-through PSARP

Hashtags

#PediatricSurgery #HirschsprungDisease #ColorectalCare #MinimallyInvasive #PediatricColorectal #RoboticSurgery #EnterocolitisPrevention

Transcript

Click "Show Transcript" to view the full text (20258 characters)

Welcome, everyone. It's time again for the Colorectal Quiz, a podcast which has become quite popular in our colorectal pediatric circles. Believe it or not, this is number 550, unbelievable. Today, we are joined as always by our host, Doctor Mark Levitt from Children's National, Doctor Felipe Gli from Portugal, and two members of Doctor Levitt's team. Physician assistant, Lindsay Clark and nurse Megan Misa. And what we thought we were gonna do today is gonna be a total hodgepodge of topics. But basically, it is a culmination of all the things that the people assembled on this call took away from a recent, very wonderful meeting, the 16th European Pediatric Colorectal reconstruction meeting held in Stockholm. October 22nd to 24th, 2025. Let's start with Hirshrung's disease. What are some key takeaways from the meeting regarding irrigations? Lindsay, what did you take away from the meeting about that topic? I think one of the most interesting things we talked about, especially in the nursing component, was that a lot of centers are starting the irrigation competency, even with an ostomy in place. I think this is particularly important for those kids that have total colonic Hirschsprungs, and we anticipate that. That there may be a delay in their takedown, and so they'll be a bit older. We have a lot of trouble with these families after the takedown and then getting them to start irrigations when the child is 12 years old. It's very traumatic for them. So one of the things I think a lot of our European colleagues are doing is starting these irrigation. Patients, even with a stoma, early on, 1 to 2 times a week, just getting the child used to it, getting the parent used to it, and then that transition to the takedown is much easier and they have a way to help empty the child. Enterocolitis remains a risk for these patients, even after a pull-through, at about a rate of 20% of all patients. Regular irrigations minimize this risk. I actually have some additional thoughts on that. I think irrigation teaching is key. And obviously, having the families know how to do it and have the equipment to do it. Doing it before the pull-through is pretty typical for a patient without a stoma, because they irrigate for a couple days or weeks or even months. Before the actual pull through, but the ones with a stoma, like for example, total colonic, sometimes we neglect that, and we must do it, because actually that's the highest risk group. So that's an important concept. In summary, early irrigation competency, even in patients with a stoma, may reduce enterocolitis risk and ease post-takdown adaptation. Another common post-operative complications for our total colonic Hirshprung's patients is skincare. Skin breakdown can really make patients miserable. Megan, I think you made the point to me that you were noticing a lot of improvement in skincare treatment around the world. Yeah, I found it fascinating. It does seem that everyone has a little bit of a different trick, but most of them still do some kind of crusting, putting stool on their bottom first, while they have a stoma for small periods of time to help get their bottom used to it. So I thought that was fascinating as well, and they are all really proactive about it. To that point, I saw a great slide. Of using the Bettel, B E T E L leaf. For peristomal skin. Megan, what do you think about that idea? I always find things fascinating from around the world because I think a lot of times people don't have access to all the amazing products that we may have access to. I think it was in Bangladesh and the skin was perfect underneath it. It was an amazing barrier. So, I think it's a great use of resources for what each area of the world has and how amazing that was to see. Yeah, that was super cool. The skin was pristine and there was no stoma bag, but the leaf was underneath the stoma and then the cloth was on top. What about diet and nutrition? Were there any updates or key takeaways on this topic? I think the biggest takeaway is that it's not a one size fits all. Many families find that some products are fine for their child and others aren't, and that could be totally different for the next family. So, what I generally tell parents, especially if they do have the majority. Of their colon is to just be mindful as you're integrating diet into your child's everyday that some foods may be triggering and to find those associated patterns. Phillipa, did you see anything new on minimally invasive approach to Hirschprung's care? So in, in Hirschsprung care, there, there has been advances in the robotic assisted repair, and also the use of ICG. To check for the blood supply of the pull-throughs. ICG is indocyanine green fluorescence imaging, which is primarily used as described to access real-time tissue profusion and vascularity during pull-throughs. It can reduce the risk of leaks and ischemia. Another study that was presented was the measurement of the muscle internal thickness with high frequency ultrasound as a way to determine the segment of a ganglionosis, and which is very creative and can be helpful also together with the biopsies to determine the segment of this disease. I guess in theory, you could avoid a biopsy. Yeah, could have like a biopsy, actually. I'm not sure if it will be worldly available, but right now also rectal biopsies can be very hard to get a good result in some parts of the world, we know that, and some surgeons are just guided by the contrast cinema, so this could also be one of the A way of using other measurements. Is robotic colorectal surgery feasible in small children? More and more people are going to be able to do this for children less than 10 kg because the equipment is improving. Also, one thing that was very interesting to hear is that robotic surgery is not as expensive. Anymore as it used to be in the past. So, the expenses associated with it has been almost equivalent to other techniques. That's great. Improved instrumentation is reducing prior size restrictions and cost limitations of robotic-assisted surgery. Were there any discussions about single incision or ILS outcomes? Yeah, I heard about Malone's. There was a paper presented with really great results. I think it's amazing because also the post-op recovery, it's much better for these patients and it's less invasive. Yes, it's definitely wonderful to see how things are evolving. The one science point that I love to hear was that someone had studied the role of goblet cells in producing mucus. And goblet cells increase from proximal to distal. And therefore, the mucosal layer, the mucus covering of that mucosal layer has a protective role, which may explain why the more that needs to be resected, the more at risk is that patient for future enterocolitis, which is a concept I had never heard before. The more proximal segments of bowel don't make as much mucus, and therefore there's less protection. It's sort of cool. Let's talk more about the mucosal layer and bowel stress, Doctor Levitt, can you please elaborate on some of the updates? I remember there was another important science presentation which I also found very fascinating, and that was a study that reviewed the role of mechanical stress, distension on the bowel wall, which led to an increase in gut microbial dysbiosis and therefore a breakdown in the function of the mucosal lining and barrier. Even showing an upregulation of pro-inflammatory factors affecting the immune response, meaning we always never really understood why these patients get enterocolitis. So, the one concept was the mucosal layer and the mucus there, and the other is the stress on the bowel wall could lead to Breakdown of the barrier in enterocolitis. But what about breakdown of the pull through itself? Is that the compensation secondary to incorrect initial pathology or post-op management? Most of the time, the original pathology was in fact good, but the pull through decompensated. So we all know that a technically elegant pull through and then years later that kit is starting to not do well. And why? Because the patient wasn't aggressively managed, namely, laxatives when they need it, Botox when they need it. We, in, in Washington have a very proactive way of watching these patients, and we want to know as soon as they have any obstructive behavior, and we start pushing that colon to work better. And Botox, if their sphincters are withholding. I think that's a very important advance in understanding why some pull-throughs stop doing well. Let's move on to another exciting evolution in the care of colorectal patients, dedicated nursing programs. Megan and Lindsay, will you just tell us a little bit about. The nursing component of this meeting, which was exciting to see, I think it was the largest nursing attendance of any of the previous 15 European colorectal meetings. Yeah, the first day of the conference was a dedicated allied health component, where we did our own topics, some case discussions, some skincare, all kinds of topics, and there were other nurse practitioners from around the world. It seemed that there is more of a presence, and all of these nurses seemed very dedicated to their Patient population that they serve, or they're trying to have more of an understanding of this particular population with anorectal malformation and Hirschsprung's. Globally, are there many advanced practice providers? From my perspective, there weren't very many PAs. There were some, I think, nurse practitioners in a few places that they could get licensure, but it's mostly nursing care. I think I say it all the time, like we're pretty useless as surgeons. Felipe, I know you agree, without our nursing partners, uh, we are equals in this mission, and I say a lot of times if you have two PAPs going on in two simultaneous rooms, and both surgeons do a beautiful technical job and the anoplasty is perfect, and the colostomy ultimately gets closed, and then 3 years later, you have two totally different patients. One got good nursing care. They're doing great. The other did not get nursing care. Even though they have an anatomic reconstruction that's elegant, they don't have a good result. It's really becoming more and more vital. We're very thankful, Megan and Lindsay and all of your colleagues. It was very interactive and we had a lot of case discussions about bowel management and we all brought problematic cases from around the world and got to share what we would do, and it was great. It would be really interesting to hear some of them we didn't have an answer for at the time, and we just had a lot of great minds brainstorming what we could do. It seemed that most of the nurses who were there had been doing so the All of this sort of initial discussions about what ARN was or what Hirshprungs is, and sort of those basic care, they were beyond that. So, the case discussions, these difficult case discussions seem to really hit home as to where everybody has their problematic. Patients. And so having that discussion of sort of the minds of what different facilities are doing for different patients, like those total colonics who get reversed and won't irrigate. So that, going back to that, learning that is, it was super helpful. And going forward, they asked for more large case discussions at future conferences, because that seems to be where we need the most. Minds to come up with these easy ideas to help these kids. Unique ideas also come into play when working with patients and families in their transition of care. What was Felipe, you had some insight into this, right? I think we are still lacking a good answer. Transition programs aim to, to make those patients who still sometimes still have symptoms, let's say, urinary incontinence, bladder dysfunction, sexual dysfunction into adulthood. I think one of the big things that were talked during the meeting was that More than an adult surgeon, some of these patients need a sexologist, a gynecologist, a urologist, and not really a colorectal surgeon most of the time. But yes, I think the transition program is still failing or lacking in, in, in many parts of the world, and this process of preparing, planning, and moving from children to adult services is not always easy. The Ready, Steady Go program presented at the conference focuses on patients' questionnaires that access their knowledge of their disease, symptoms, and readiness for transition. We need to do more. I think, by the way, the future of that honestly is to train some colorectal surgeons that understand both pediatric and adult and obviously urologists and gynecologists. Gynecologists. is already well covered, I think, because they already know how to take care of the kid and the adult, and they all focus already on fertility issues and management of pregnancy, but I think some of the gynecology training needs to happen where adult gynecologists or obstetricians in particular that are managing the pregnancy. We need to understand what a cloaca is. So there was some discussion about that. But in urology and colorectal, we need to do some work on making sure adult colorectal surgeon needs to understand what Hirschprung's disease and what an an erectal malformation patient might need their help with when they're 50 years old with a rectal prolapse, for example. So there are ways to do that. And so I hope the parents are going to see that we are making a slow and steady progress at a system level. Adult colorectal surgeons and multidisciplinary teams must be trained to understand these congenital conditions. Functional success in pediatric colorectal surgery depends not only on operative precision, but on sustained multidisciplinary follow-up. Let's move on to new techniques for anorectal malformations. Doctor Levitt, what were some key takeaways for you? The PPP, perineal preserving PSARP, which avoids a perineal body dissection altogether and avoids the dehiscence. Possibility, which is the feared complication. I think this is a very important advance and potentially could avoid even colostomies and colostomy closures in many of these patients. Surgeons in the developing world tend to do colostomies for all of these patients, right? But if there is no potential for perineal body adhesence, maybe they don't need colostomies at all. And then, of course, the PRAA posterectal advancement anoplasty, which is a mobilization of the posterior rectal wall only in males with perineal fistula and some females with a perineal fistula, when the fistula is in the sphincteric ellipse, just in its anteriormost extent. One point I Heard, which is changed my practice right away, was, I used to have in my brain that I needed to, in a vestibular fistula. Dissect all the way to the areolar plane that separated the anterior rectum from the posterior vagina. And many people made the point that you don't have to go that deep. You don't have to go that far. You just have to make absolute certainty that their rectum has no tension when you do the anoplasty. So I like that a lot. There was a fair bit of discussion about the timing. Of, or management, I should say, of the vaginal replacement or non-replacement in Cloaca. Felipa, can you comment a little bit about what you heard there? Yes, it's been discussed, and I guess there's still no consensus or worldwide consensus on this topic, but for instance, delaying vaginal reconstruction may allow for other surgical options that may have less conflict. and in a way avoid a bowel vaginoplasty. On the other side, sometimes we need to hold the spot in the detritus, so having a replacement can be, doesn't mean the patient will have it for life and can be resected when it gets, when she gets older. So I, I guess the It's, it's still very debatable what's the best approach when there's a a a vagina that doesn't reach the perineum, but I think the biggest thing also to, to take from this is that these patients need a long-term follow-up, especially in during. Hierarchy to avoid situations of menstrual obstruction, incapacity for the egress, and consequently risk of endometriosis and damage to uterus and fallopian tubes. I think the other lesson is that even structures that look atretic may actually grow up into real useful structures. So I think that strategy of waiting. But waiting on the Mullerian structures and not doing anything about them, if you have that luxury. Now, the reality is if you do a urogenal separation for a cloaca and repair the common channel, now you have a vagina. In most cases, that vagina, the native vagina will reach. If the native vagina does not reach, you've already separated it. Now what do you do? And then to reaffirm what you just said, Felipa, one might do a bowel neovagina to bridge the gap. However, recognizing that bowel might be removable in the future. 12 years from now when the patient goes through puberty and then they could have their native vagina pulled through at that time with the neovagina holding the spot, to use your words, which I liked a lot of the ultimate path for the vaginal pull through. I like that discussion a lot. Ultimately, Mullerian structures may mature more than expected, and surveillance through puberty is critical. Finally, there was plenty of discussion of general pediatric proctology. Doctor Levitt, was there anything particular that you find interesting within that topic? Do you remember what, there was some idea about what to do when you have a chronic anal fissure? Yeah, I thought it was really interesting. I personally learned this, I didn't know before, that the removal of the skin tag in the chronic anal fissure can lead to a better healing long term, along with injection of Botox units, a little less than we are used to use in Hirschpring disease, so 20 to 50. Units of Botox can both be two strategies of better healing in this chronic anal fissure situation. Yeah, that was interesting. I'd never heard that before either. I also, with regard to perianal disease, I didn't know this, but there was a higher incidence of perianal disease in children. With Crohn's disease, and sometimes that can be the first hint that the patient will go on to actually have Crohn's disease. And the other thing I heard in Crohn's disease was that the importance of enteral nutrition, enteral nutrition is as effective as steroids in Crohn's disease in treating transmural. Inflammation or even a section of stenosis of the small bowel. Before we wrap up today, I think we should mention how well attended and diverse the audience was for this conference. There was well over 250 people, but not just from Europe. Yeah, it was a really nice group of people. Everyone was amazing and just to get to talk to everyone, nurses from Asia, Bangladesh, Thailand. Obviously surgeons, nurse practitioners, different providers. You mentioned Vietnam. Then we also had some states, California, Ohio, Washington DC, um, Kansas City. I love this meeting. It's very international. It really has expanded. I loved how many nurses were there. I loved how many trainees were there. It's really become the colorectal meeting for trainees on the European side. There's a lot of fresh things. It's not a course, it's new ideas, and uh, it's one of my most favorite meetings to go to. I really appreciate all of your insight. Everyone should just know this was a broad swath of ideas that we had come up with. That we took away. I'm sure there's lots and lots more. Looking forward to further engagement with this podcast community on any one of these subjects. Please email me M. Levitt@children'snational.org if there's a topic you'd like, um, you'd like us to cover, and we're happy to do that. And I really appreciate my friends and fellow panelists on this, on this discussion. Thank you very much and have a great rest of your week. I hope you're using these podcasts for training, education, keep you company on a long car ride or while you're walking the dog or taking a run or a bike ride. People have told me lots of ways they engage with this podcast, so it's really fun how this has grown up. Thank you all so much. To learn more about this and upcoming meetings, check out our website atan-colorectal.com.

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