Case Summary
A case was shared of a newborn with respiratory failure, seizures, and bowel distension, which led to a series of diagnostic tests and eventual surgery. Dr. Castrillon discussed the appropriate next steps for the patient, with most attendees agreeing on a leveling biopsy with a stoma. The discussion also covered the timing for the pull-through procedure, with most agreeing on when the patient is toilet trained for urine and accepts rectal irrigations.
Dr. Castrillon outlined the postoperative care protocol for patients at the colorectal center, which includes 7 days of total parenteral nutrition, rectal irrigations, and Flagyl medication. Dr. Bischoff emphasized the importance of patients being toilet-trained and accepting rectal irrigations before undergoing surgery. He explained that operating too early on babies with total colonic aganglionosis can lead to severe diaper rash and enterocolitis, making it difficult for the baby to accept rectal irrigations. Dr. Bischoff suggested a protocol to close the ileostomy only when the patient is fully toilet-trained for urine and cooperative with rectal catheter insertion. This approach aims to preserve bowel control and minimize complications.
Dr. Luis de la Torre discussed the Duhamel procedure, stating that it is the most effective type of pull-through in patients with total colonic aganglionosis, but it requires a very good execution to avoid obstructive symptoms. He recommended not to perform the Duhamel procedure in total colonic aganglionosis cases.
Dr. Peña discussed the use of pouches in bowel movements and their potential to create retention and central colitis. He also addressed the issue of bucket handle development and the creation of a fistula. Alberto explained the importance of rectal irrigations in total colonic aganglionosis to prevent enterocolitis, particularly in the first three months post-operation. He emphasized the need for preventive measures, such as irrigation and Flagyl, to avoid enterocolitis. The moderators also clarified the difference between enema and irrigation, stating that irrigation is the preferred method for decompressing the bowel. Mothers are advised to perform rectal irrigation before seeking medical attention for enterocolitis symptoms.
Takeaways
Continue post-operative care for the total colonic aganglionosis patient, including 7 days of total parenteral nutrition and rectal irrigations. Colorectal team to follow up with the total colonic aganglionosis patient in clinic at one month post-op for digital examination and adjustment of irrigation/medication regimen.
Patient Case Discussion