What is the preoperative preparation for a 6-year-old with Hirschsprung's disease who underwent a colostomy (creation of a stoma, or artificial opening, for diversion of fecal stream) years prior and is now scheduled for an endorectal pull-through procedure?

From the Guidelines

For a 6-year-old with Hirschsprung's disease undergoing endorectal pull-through after previous colostomy, the most crucial preoperative preparation is to avoid routine mechanical bowel preparation, as it is not recommended for elective colonic or gynecologic surgery, according to the most recent and highest quality study 1.

Preoperative Preparations

The key preoperative preparations for this patient include:

• No routine mechanical bowel preparation, as it is not recommended for elective colonic or gynecologic surgery, and may even be associated with dehydration and changes in electrolyte balance 1
• Antibiotic prophylaxis: Give intravenous cefazolin (30 mg/kg) and metronidazole (10 mg/kg) within 60 minutes before incision, as recommended by the ERAS society 1
• Nutritional optimization: Ensure adequate caloric intake and correct any nutritional deficiencies in the weeks leading up to surgery, as malnourished patients may benefit from preoperative specialized nutritional support 1
• Colostomy care: Clean the stoma site thoroughly and mark its location for potential closure during the procedure
• Fluid management: Start intravenous fluids (maintenance rate) 6-8 hours before surgery to ensure proper hydration, and aim for near-zero fluid balance 1
• Laboratory tests: Obtain complete blood count, electrolytes, and coagulation profile within 48 hours of surgery
• Anesthesia consultation: Arrange for pediatric anesthesia evaluation to address any specific concerns, and consider a short-acting anxiolytic in patients with severe anxiety 1
• Informed consent: Discuss the procedure, risks, and expected outcomes with the parents/guardians, and provide preoperative education in oral, written, and/or pictorial format 1 These preparations aim to reduce infection risk, optimize the child's physiological state, and ensure smooth perioperative management, while also considering the latest recommendations from the ERAS society 1.

From the Research

Preoperative Preparation

The preoperative preparation for a 6-year-old with Hirschsprung's disease who underwent a colostomy years prior and is now scheduled for an endorectal pull-through procedure involves several steps:

• Preoperative colonic irrigation to evacuate feces out of the dilated colon is done in the hospital 2
• Bowel preparation is the same as conventional colorectal surgery 2
• Full-thickness rectal biopsy at 1 to 2 cm above the dentate line is submitted for pathologic diagnosis 2
• Older children with substantial fecal impaction may require 2 weeks of preoperative saline enema 2

Considerations

• The length of hospital stay depends on the amount of fecal impaction in the colon 2
• The hospital stay can range from 6 to 7 days in children younger than 2 years and 10 to 28 days in older children 2
• The patient's age and weight should be considered when planning the surgery, as well as any associated anomalies or conditions 3

Surgical Approach

• The surgical approach may involve a transanal endorectal pull-through procedure, which can be performed successfully in all ages of children with good results, avoiding transabdominal exploration 2, 4
• Alternatively, a laparoscopic-assisted endorectal pull-through procedure may be used, which can be performed safely through a single umbilical incision with good postoperative results and excellent cosmesis 5
• A single stage transanal pull-through procedure can also be considered, which has been shown to be a feasible option in neonates with Hirschsprung's disease 3