In this Update Course Rewind from the 13th Annual Update Course in Pediatric Surgery, Drs. Annie Le-Nguyen, Jamie Harris, and Elizabeth Speck discuss one of the most debated questions in Hirschsprung disease management: when is the best time to perform a pull-through procedure?

Key Highlights:

Neonatal vs Delayed Pull-Through: Audience opinions were widely split, reflecting the lack of consensus in the field. Some surgeons favor neonatal repair before NICU discharge, while others prefer waiting several months.

What the Literature Shows: A 2021 PCPLC retrospective study comparing neonatal versus delayed primary pull-through procedures found no significant difference in enterocolitis rates, postoperative complications, or long-term fecal continence outcomes.

Timing Isn’t the Only Factor: The neonatal cohort underwent surgery at a median age of 11 days, while delayed repairs occurred closer to 98 days—yet outcomes remained comparable.

The Importance of Home Irrigations: Panelists emphasized that a family’s ability to safely perform rectal irrigations at home may be more important than patient age when deciding surgical timing.

Preventing Serious Complications: Inadequate decompression at home can increase the risk of enterocolitis or perforation, making caregiver education and confidence a critical component of successful Hirschsprung management.

Individualized Decision-Making: Surgeons should consider family readiness, follow-up access, and irrigation competency when determining the timing of pull-through surgery.

This session highlights that while surgical timing remains flexible, empowering families with proper bowel management skills is essential to achieving safe outcomes in Hirschsprung disease.

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