Unanswered Questions Remain

The patient’s medical history is consistent with symptomatic Hirschsprung’s disease since infancy. It would be interesting to know if the diagnosis was known back then and later during adhesiolytic procedures (1). As regards the current situation it would be important to know the following: what was the finding on digital rectal examination? Is it possible that anastomotic stenosis was present? In comparison with the described radiological diagnostics, a colon contrast enema in anterior-posterior and sagittal view would have been of interest as this might have shown the narrowed rectum, the proximal megacolon, and perhaps the transition into the healthy colon more clearly and, furthermore, would have enable to determine the resection margin. Rectal sphincter failure is unlikely as the sphincter is aganglionic, but the patient probably had overflow encopresis. It would be interesting to know the length of the aganglionic segment and whether hypoganglionosis or dysganglionosis was present proximally. By way of a differential management, a possible measure might have been antegrade ileostomy for colonic irrigation which would possibly have affected the patient’s quality of life less than a definitive ileostomy. Aganglionosis is a well know entity in pediatric surgery, and, accordingly, they are familiar with the different therapeutic options.