The goals of surgery are to remove the diseased part of the large intestine, and to reconnect a healthy part of the intestine to the anus so that the body can pass waste normally. In most cases, the rectum and the sigmoid colon (the last parts of the large intestine) will need to be removed. A very key technical aspect is to preserve the anal canal and sphincters which comprise the continence mechanism.
Surgery is typically performed on a healthy newborn baby that has responded well to bowel irrigations. The operation, performed while your child is under sedation, can often be done entirely through the anus. Sometimes, laparoscopic methods are also used, allowing the surgeon to reach the bowel through 3 to 4 tiny (less than one-half inch) incisions on the abdomen (stomach area). Both approaches are minimally invasive and help reduce recovery time.
In rare cases, if a child is very ill from enterocolitis (intestinal infection), and irrigations are not working, an ileostomy or colostomy is performed. These ostomy procedures collect waste from the small or large intestines and channel it into a bag attached to the child’s side. This is a temporary measure (lasting from a few months to a few years) which allows the child’s intestines to heal until surgery can be performed.
Your doctor will give you detailed information about how to manage your child’s ostomy.
You can expect your child will remain in the hospital for about 3-7 days after their procedure, but some children may need to stay longer, depending on the severity of their disease. Your child will be given IV fluids to help maintain hydration and pain medication as needed while they are in the hospital.
The skin around your child’s anus will need special care once you get home. Your child is likely to pass several stools a day, which can cause the skin to become very irritated. Your healthcare team will talk to you about what types of topical medicine you can use to help protect your child’s bottom.
Your surgical team will also advise you on how to keep any abdominal incisions clean and dry before you leave the hospital.
While surgical outcomes are generally excellent, intestinal infections can occur even after surgery. This type of infection is called enterocolitis. No one knows why these infections happen, but they usually stop by the child’s first birthday. They are readily treated with irrigations and antibiotics.
Constipation is another potential complication, but can be easily managed and usually avoided with diet and laxatives.
In rare cases in which a child cannot control their bowel movements, a bowel management program can help them achieve cleanliness and prevent accidents.
Post pull-through problems in patients with Hirschsprung Disease
Surgical treatment for Hirschsprung disease has developed over the years, and there are several ways a surgeon can do a “pull-through”, which means to remove the non-functioning portions of the bowel, and pull-through the healthy segment above the problematic section at the bottom.
Most of the time surgery is a success, however sometimes patients do not do well after their pull-through, and there is not much written about such patients.
The Center for Colorectal and Pelvic Reconstruction has the most experience in the world managing Hirschsprung patients with post pull-through problems, many of whom need a redo of the pull-through. Patients from medical centers world wide are referred to try to find an explanation and a treatment for their post-pull through problems.
Such problems come in two forms. Patients either suffer from soiling (fecal incontinence) or they can suffer from episodes of abdominal distention which can lead to severe diarrhea episodes called enterocolitis.
Our doctors have developed a protocol for evaluating and diagnosing these problems. In nearly every case the problems are fixable.
We first start with a detailed history, asking about bowel habits, documenting episodes of constipation, soiling, or distension. We want to know how the child is eating and whether they are growing. We need to know what medicines have been used in the past, such as medicines to treat diarrhea (anti-motility agents) or constipation (laxatives or stool softeners), or if the child has needed colonic irrigations or dilations. It is also vital to know exactly what type of Hirschsprung operation was done originally. (Soave, Swenson, Duhamel, and/or whether laparoscopy was used).
After this history, patients are examined under anesthesia. On this exam, we need to determine:
This investigation divides patients with post-operative issues into two groups:
Incontinence can be managed
Fecal continence is the ability to have voluntary bowel movements without soiling and without the need for enemas. Ideally, fecal incontinence should not occur after a pull-through because patients with Hirschsprung disease are born with a normal continence mechanism including a normal anal canal, normal anal canal sensation, and normal sphincters.
If a patient after a Hirschsprung pull-through is soiling, the key first step to evaluate this problem is to determine whether the patient’s colon moves too slow (hypomotile) or too fast (hypermotile). Learn more about our Bowel Management Bootcamp.
Hypomotility, a slow-moving colon
Children with a slow colon usually have a colon that is enlarged (dilated) and suffer from constipation. The treatment for such patients is a senna-based stimulant laxative. The amount of senna is continually adjusted until the child has one to two soft both formed bowel movements each day, and with no accidents. We confirm that they are emptying their colon adequately by checking the stool content in a plain abdominal x-ray. Patients who continue to soil despite the treatment with the laxatives may not have the ability to know when the stool is coming and therefore are considered incontinent. These patients require, instead of a laxative program, an enema program. This enema usually is an amount of saline solution (500 to750 mL). Sometimes additives such as glycerin or soap are included with the saline to make the enema more powerful.
Hypermotility, fast-moving colon
Children with a fast moving colon (hypermotility) have a colon that is not enlarged (non-dilated). Instead of constipation, they have loose stool, and a tendency toward diarrhea. These patients are initially treated with loperamide, a medication that slows the colon down, with a water soluble fiber to provide bulk to the stool (Citrucel or pectin are examples), and a constipating diet, which means avoidance of oily and fatty foods, sugary foods, and encouraging foods that bulk the stool such as bananas, rice, and apple sauce. With this routine, many patients, once their fast colons are slowed, now can achieve bowel control.
Patients in this group though who are unsuccessful in avoiding soiling are considered incontinent and will often need an enema program, with a small volume enema (200-500 mL), and also need continued treatment to slow the colon.
For all patients given the enema routine, a re-evaluation is done every six to twelve months to determine if the enemas can be discontinued, and if they are now ready to try to have controlled bowel movements.
For patients who need long term enemas, a nice option to give the enema from the top down rather than the bottom up, is a surgical procedure called a Malone appendicostomy. This operation connects the appendix to the belly button (the umbilicus), and creates a valve that allows the enemas to be given from the beginning of the colon instead of through the anus. This is more comfortable and allows the patient to independently administer the enema. Another nice new option is called sacral nerve stimulation. In this procedure wires connected to a stimulator are placed in the sacral (tailbone) area and used to enhance the activity of the sphincters. With this procedure some patients can develop bowel control by improving the status of their continence mechanism.
Reoperative (Re-do) surgery for distention and enterocolitis
If after a pull-through for Hirschsprung disease a patient develops repeated episodes of abdominal distention, this may mean they are not adequately emptying the stool. This can lead to a dangerous condition called enterocolitis, in which the child can get severely dehydrated. When stool does not move through the colon, stasis of stool develops, which allows the bacteria in the colon to grow (bacterial overgrowth) which leads to diarrhea, similar to what happens in a pond as compared to a flowing stream. If this is more chronic and occurs over many years, the child's growth can be affected, which is called failure to thrive.
If enterocolitis occurs in repeated episodes, after a year of age, or after 6-12 months following the pull-through, the cause could be due a problem with the anatomy of the end of the pull-through or could be related to a problem with the nerves at the end of the pull-through. In such a case, assessment begins with the patient’s medical and surgical history, and evaluation of the anatomy, under anesthesia, to look for:
At this point, we begin a regimen of rectal irrigations with saline solution. An antibiotic called flagyl (metronidazole) is often given too, to help treat the enterocolitis. Sometimes this medicine needs to be taken for several months.
We want to find the underlying cause of the abdominal distention and figure out why the pull-through does not empty well.
The possible pathology explanations are that the segment at the bottom either has no nerves, or has a section of bowel that was the transition between normal and abnormal nerves (transition zone). Just like with a newborn with Hirschsprung disease, if there is bowel without adequate or normal nerves, that segment of bowel will not function and the bowel above this area will therefore not be able to empty leading to abdominal distension. This is and a set up for enterocolitis. A rectal biopsy is performed to detect these problems.
Problems with the pull-through anatomy can result in enterocolitis and can be related to the initial operation. Causes for this can include a narrowing of the end of the pull-through (stricture), a segment of colon that is dilated and was left in at the time of the original operation, a twist or kink of the pullthrough, a cuff related to the Soave procedure which compresses the end of the pull-through, or a large pouch related to a Duhamel procedure. Each of these can be observed on a contrast enema.
All these problems can be corrected with a redo operation, which involves a transanal removal of the end of the pull-through which is problematic and pull through of the segment of bowel above this area that is functioning well. With such a redo pull through obstructive symptoms resolve in almost all cases.