From
Dr. Nelson G. Rosen
Colorectal Quiz Episode 50: Key Takeaways from the 16th European Pediatric Colorectal Conference
With Dr. Lindsey Clarke & Dr. Meghan Mesa & Dr. Felipe Jali · hosted by Dr. Marc Levitt
Chapter 1 of 8
Irrigation strategies
Introduction and Hirschsprung irrigation strategies
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Many centers are starting irrigation competency training even with an ostomy in place, particularly for total colonic Hirschsprung patients who may have delayed takedown.
Starting irrigations 1-2 times per week early on in patients with stomas helps children and parents adapt, making the transition after takedown much easier.
Patients with total colonic Hirschsprung and stomas represent the highest risk group for enterocolitis and must receive irrigation training before pull-through.
Diet management for Hirschsprung patients is not one size fits all; families must identify individual food triggers through pattern recognition.
ICG (indocyanine green fluorescence imaging) is used to check blood supply of pull-throughs and can reduce the risk of leaks and ischemia.
Most pull-throughs that decompensate had good original pathology but were not aggressively managed post-operatively with laxatives and Botox when needed.
Proactive monitoring for obstructive behavior and early intervention with laxatives and Botox prevents pull-through decompensation.
Without good nursing care, patients with anatomically elegant reconstructions may have poor functional outcomes.
More than an adult surgeon, transition patients often need a sexologist, gynecologist, or urologist rather than a colorectal surgeon.
Adult colorectal surgeons need training to understand what Hirschsprung disease and anorectal malformation patients might need when they are 50 years old with complications like rectal prolapse.
In vestibular fistula repair, dissection does not need to reach the areolar plane between anterior rectum and posterior vagina; the key is ensuring no tension on the rectum during anoplasty.
Cloaca patients need long-term follow-up through puberty to avoid menstrual obstruction, incapacity for egress, and consequent risk of endometriosis and damage to uterus and fallopian tubes.
Mullerian structures that appear atretic may grow into useful structures over time.
In most cloaca cases after urogenital separation, the native vagina will reach the perineum; if it does not, a bowel neovagina can bridge the gap and be removed later when the native vagina is pulled through after puberty.
Enterocolitis remains a risk for Hirschsprung patients even after pull-through, at about a rate of 20% of all patients.
Regular irrigations minimize enterocolitis risk.
Most centers still do some kind of crusting, putting stool on the baby's bottom while they have a stoma for small periods of time to help get their bottom used to it.
Betel leaf used for peristomal skin in Bangladesh produced pristine skin as an effective barrier.
High frequency ultrasound measurement of internal muscle thickness can help determine the segment of aganglionic bowel and may be used together with biopsies.
Improved instrumentation is making robotic colorectal surgery feasible in children less than 10 kg.
Robotic surgery expenses have become almost equivalent to other techniques.
Goblet cells increase from proximal to distal colon, producing more mucus distally, which may explain why more extensive resection increases enterocolitis risk due to less mucosal protection.
Mechanical stress and distension on the bowel wall leads to increased gut microbial dysbiosis and breakdown of the mucosal barrier, with upregulation of pro-inflammatory factors affecting immune response.
The Ready, Steady Go program uses patient questionnaires to assess knowledge of disease, symptoms, and readiness for transition.
The PPP (perineal preserving PSARP) avoids perineal body dissection and the risk of dehiscence, potentially eliminating the need for colostomies in many patients.
The PRAA (posterectal advancement anoplasty) mobilizes only the posterior rectal wall in males with perineal fistula and some females when the fistula is in the anteriormost extent of the sphincteric ellipse.
Delaying vaginal reconstruction in cloaca may allow for other surgical options with less morbidity and potentially avoid bowel vaginoplasty.
A bowel neovagina can hold the spot in cloaca patients and may be resected later in life when the patient is older.
Removal of the skin tag in chronic anal fissure, along with injection of 20-50 units of Botox, can lead to better long-term healing.
There is a higher incidence of perianal disease in children with Crohn's disease, and this can be the first hint that the patient will develop Crohn's disease.
Enteral nutrition is as effective as steroids in treating transmural inflammation or stenosis of the small bowel in Crohn's disease.