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Table 3 Recommendations for preoperative care in HSCR

From: ERNICA guidelines for the management of rectosigmoid Hirschsprung’s disease

Patients should receive saline rectal irrigations 1–3 times per day to decompress the bowel until the definitive pull-through operation
• An additional colonic wash-out may be given for pre-operative bowel preparation
• See below, if there is an inadequate response to rectal irrigations
Level of evidence III
Strength of recommendation: Strong, for
Level of agreement: 100%
A stoma is indicated if rectal irrigations do not sufficiently decompress the bowel, or there are complications such as enterocolitis unresponsive to non-operative treatment, or bowel perforation.
• The safest empiric level is an ileostomy
• In pneumoperitoneum, also an ileostomy provided it is proximal to the site of perforation
• A representative circumferential ‘doughnut’ biopsy taken from the site of stoma formation is informative regarding the ganglionic status of the bowel at that level
Level of evidence III
Strength of recommendation: Strong, for
Level of agreement: 100%
When possible, a pre-operative contrast enema is recommended to guide on the likely level of aganglianosis
• A colonic caliber change suggests a histological transition zone at this level.
• Proximal to the rectosigmoid junction, colonic caliber changes are less accurate in predicting the disease level, and the possibility of long-segment HSCR should be considered
• Contrast studies are complementary tools during the pre-operative workup. They do not replace the need for histological assessment to confirm the diagnosis.
Level of evidence III
Strength of recommendation: Conditional, for
Level of agreement: 100%
At pull-through surgery, one dose of broad-spectrum intravenous antibiotics should be given preoperatively.
• The choice of antibiotics is determined by local regimens and regional resistance profiles, but should include coverage of both aerobic and anaerobic bacteria
• No additional benefit has been shown for giving more than one pre-operative dose, but antibiotics may be continued for 24–48 h post-operatively
Level of evidence II-III
Strength of recommendation: Strong, for
Level of agreement: 100%