We read with interest the article concerning Hirschsprung’s associated enterocolitis (HAEC) published by Svetanoff et al. . In a series of 57 patients with a relatively high prevalence (48%) and recurrence (30%) of postoperative HAEC, the authors demonstrated that a standardized care improves some outcomes such as lower duration of IV antibiotics, lower duration of TPN, lower length of hospital stay, and more importantly a significant decrease of recurrence rate.
Risk factors for developing postoperative HAEC may, in fact, have a substantial impact on the algorithm treatment. Beyond the mentioned ones (trisomy 21, long-segment disease, obstruction and prior episodes), the histopathology of the retained proximal colon may have decisive impact on the occurrence of postoperative enterocolitis.
In the present article, there is mention of performing full-thickness rectal biopsies in patients with recurrent HAEC. Despite there is no description on pathological examination of these specimens, we agree with the objective, e.g., to rule out a transition zone or an aganglionic pull-through. However, we add another one: to rule out the presence of other dysganglionoses, mainly type B intestinal neuronal dysplasia (IND) that frequently coexist in the colon proximal to aganglionic segment. A relationship between postoperative HAEC and coexisting IND has been observed by some authors and ourselves [2,3,4,5]. Using appropriate histochemical examination, we perform colonic mapping prior to pull-through by a minimally invasive procedure; an extended proximal colonic resection has been carried out in case of coexisting IND, what has resulted in a minimal (as low as 5%) prevalence of postoperative HAEC [3, 6]. The previous procedure may be avoided if a rapid histochemical method and/or an experienced pathologist is available for the examination of frozen specimens at time of pull-through.
A standardized algorithm such as this of Svetanoff et al.  is desirable because outcomes must be more robust; nevertheless, a significant distribution of coexisting IND might be present in the two periods, what may alter the repercussion of a comparison between them. To know the results of examination of full-thickness rectal biopsies in patients with recurrent HAEC, if available, may be relevant for pediatric surgeons who deal with Hirschsprung’s disease.
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Estevão-Costa, J., Fragoso, A.C. & Carvalho, J.L. Inpatient management of Hirschsprung’s associated enterocolitis treatment: the benefits of standardized care (Svetanoff WJ et al., Pediatr Surg Int (2020) 26:1413–1421). Pediatr Surg Int (2021). https://doi.org/10.1007/s00383-021-04856-8