Table 5 Recommendations for early postoperative management after pull-through surgery
From: ERNICA guidelines for the management of rectosigmoid Hirschsprung’s disease
Patients should receive specialist pediatric and nursing care during the early post-operative period, and anaesthetic consultation should be available on request • Use of Enhanced Recovery After Surgery (ERAS) [56] principles may reduce length of stay, requirement for narcotic analgesia and time to full enteral feeds • Parental counselling is important to ensure understanding and engagement with the care plan • Once bowel movements begin, perianal rash/skin excoriation is initially common and requires pre-emptive nursing | Level of evidence III Strength of recommendation: Conditional, for Level of agreement: 100% |
Enteral feeding can be started gradually when the patient has recovered from anaesthesia and is clinically stable • Within 24–48 h in most cases • Advance feeds as tolerated to normal diet • There is no evidence to suggest prolonged nil by mouth periods or prevent anastomotic complications | Level of evidence III Strength of recommendation: Conditional, for Level of agreement: 100% |
The urinary catheter should be removed as soon as normal micturition is expected after pelvic floor surgery • Epidural anaesthesia post-operatively is an indication for keeping a urinary catheter • Urinary retention after removal can occur following anaesthesia or post-operative tissue swelling in the pelvic floor, and adequacy of urine output should initially be monitored. | Level of evidence III Strength of recommendation: Conditional, for Level of agreement: 100% |
The coloanal anastomosis should be calibrated around 2–3 weeks after pull-through surgery • Hegar size 12 is appropriate for infants from term up to 6 months of age • Routine serial dilatations have not been shown to reduce the prevalence of enterocolitis or late anastomotic strictures. • If an anastomotic stricture is found, a course of gentle serial dilatations may be attempted, however with a low threshold for examination and dilatation under anaesthesia | Level of evidence III Strength of recommendation: Conditional, for Level of agreement: 100% |