Pediatric colon surgery treats conditions of the large bowel, rectum and anus in babies, children and teenagers, including Hirschsprung disease, anorectal malformations, ulcerative colitis, familial polyposis and bowel emergencies. At Biruni Hospital in Istanbul, our pediatric surgeons perform pull-through, PSARP and ileal pouch operations, plan staged surgery and temporary stomas, and run bowel management with video follow-up for families abroad.
About This Department
Pediatric Surgery
Children's colon and rectal conditions need surgeons who plan for the decades ahead. Pediatric colon surgery aims for a child who is clean, continent and free of a stoma.
Pediatric colon surgery covers operations on the large bowel, rectum and anus in babies, children and teenagers, from Hirschsprung disease and anorectal malformations in the newborn to ulcerative colitis, familial polyposis and bowel emergencies in older children. Each condition has its own operation, and the long-term goal is the same for all of them, normal bowel control in a growing child. In Hirschsprung disease, a review of 792 children found that the transanal pull-through shortened the hospital stay by seven days and lowered soiling and constipation compared with the older abdominal operations (Chen and colleagues, Journal of Pediatric Surgery, 2013). For children who need the colon removed, a review of 763 young patients found pouch loss in 10.6 percent of those with ulcerative colitis and 1.5 percent of those with polyposis (Drews and colleagues, Journal of Pediatric Surgery, 2019). This page explains the main conditions, the operations, staged surgery and stomas, enterocolitis, bowel management, emergencies, and how families from abroad arrange pediatric colon surgery at Biruni Hospital in Istanbul.
7
Days shorter hospital stay with transanal pull-through for Hirschsprung disease
18
Percent of children with Hirschsprung disease who develop enterocolitis after surgery
75
Percent of families or more satisfied with bowel management by video follow-up
Free
Review of your child's reports and imaging by our pediatric surgery team
Children are not small adults. Their colon surgery is planned around growth, toilet training, school and the years until adulthood.
Many of these conditions are found in the first days of life, and early referral to a pediatric surgeon shapes the result.
1
One team
Pediatric surgeons, pediatric gastroenterologists, neonatal and pediatric intensive care, radiologists, pathologists, dietitians and stoma nurses plan each child's care together.
Some operations are done once. Others come in stages over months, with a temporary stoma between them, and a few need lifelong follow-up.
Conditions treated with pediatric colon surgery
Condition
Age at diagnosis
Main operation
Hirschsprung disease
Newborn or infant
Pull-through
Anorectal malformation
At birth
Anoplasty or posterior sagittal anorectoplasty
Ulcerative colitis
School age and teenagers
Colectomy with ileal pouch
Familial adenomatous polyposis
Teenagers
Colectomy with ileal pouch or ileorectal joining
Intussusception, volvulus, perforation
Any age
Emergency surgery
Constipation alone almost never needs an operation. When it resists treatment, we look for an underlying cause before any surgery is discussed.
Hirschsprung disease
Signs of Hirschsprung disease
Age
What parents notice
What it means
First two days
No meconium, swollen belly, green vomiting
Bowel blocked at the end
Infancy
Severe constipation, poor weight gain
Short affected segment
Any time
Fever, swollen belly, foul diarrhea
Enterocolitis, an emergency
How is the diagnosis confirmed?
A rectal suction biopsy, taken at the bedside without anesthesia, shows whether nerve cells, called ganglion cells, are missing from the bowel wall. A contrast enema shows where the narrow, nerve-free bowel ends. The biopsy confirms the diagnosis and the enema guides planning.
In Hirschsprung disease, nerve cells are missing from the last part of the bowel, so it cannot relax and push stool through. It affects one in 5,000 newborns, boys four times more than girls. In eight of ten children only the rectum and sigmoid colon are affected, and in a small number the whole colon. Until surgery, parents learn to wash out the bowel at home with saline through a soft tube.
The pull-through operation
Transanal against abdominal pull-through, 792 children
Outcome
Transanal
Abdominal operations
Operating time
58 minutes shorter
Longer
Hospital stay
Seven days shorter
Longer
Soiling and constipation later
Lower, odds near half
Higher
Enterocolitis
No difference
No difference
The pull-through removes the bowel without nerve cells and brings healthy bowel down to just above the anus, keeping the sphincter muscles intact.
In the transanal operation the surgeon works through the anus, with no abdominal cut for short segment disease. A frozen section during surgery confirms healthy nerve cells at the new end of the bowel (Chen and colleagues, 2013).
Long segment disease adds a laparoscopic step to free the colon from above.
Babies feed within a day or two and go home within a week, and gentle anal dilatations, which parents learn on the ward before discharge, start two weeks after the operation.
1
Timing
We operate between the first weeks and the first months of life, once the baby is growing well on washouts.
Enterocolitis after Hirschsprung surgery
Enterocolitis is an inflammation of the bowel that occurs before and after the pull-through. A review of 57 studies found it in 18.3 percent of children before surgery and 18.2 percent after, with no difference between operations (Hagens and colleagues, Pediatric Surgery International, 2022).
Total colonic disease carries the highest risk, 26.1 percent before surgery.
1
Warning signs
Fever, a swollen belly, explosive foul smelling diarrhea, vomiting and a child who looks unwell.
At home
What should we do if we see these signs?
Go to the nearest children's emergency department the same day and show the letter we give at discharge. Treatment is bowel washouts, fluids through a drip and antibiotics. Repeated episodes lead us to look for a narrowing or a remaining nerve-free segment, and some children benefit from botulinum toxin injected into the anal sphincter.
Anorectal malformations
Main types of anorectal malformation
Type
Who
First step
Perineal fistula
Boys and girls
Anoplasty in the newborn period
Rectourethral or bladder fistula
Boys
Colostomy, repair at one to three months
Vestibular fistula
Girls
Repair in the first months
Cloaca, one shared opening
Girls
Colostomy, complex repair later
In an anorectal malformation the anus is missing or misplaced, and the rectum ends blindly or opens through a small channel, a fistula, onto the skin, the urinary tract or the vagina. It affects one in 5,000 babies. Associated differences in the spine, kidneys, heart and limbs are checked in the first days with ultrasound and an echocardiogram.
The type of malformation and the quality of the sacrum and spine predict future bowel control better than any single test.
Rebuilding the anus
The posterior sagittal anorectoplasty, called PSARP, opens a midline cut between the buttocks. The surgeon separates the rectum from the urinary tract or vagina and places it inside the sphincter muscle complex, guided by an electrical muscle stimulator.
Closing the fistula.
Placing the rectum in the center of the sphincter muscle complex, where the muscles can squeeze it shut.
Creating a new anus of the right size for age.
The usual sequence for higher malformations
Step
Timing
Purpose
Colostomy
First days of life
Protects the repair, allows imaging
Distal colostogram
Before repair
Shows the fistula exactly
PSARP
One to three months of age
Rebuilds the anus
Anal dilatations
From two weeks after repair
Prevent narrowing
Colostomy closure
Once the anus reaches target size
Restores normal stool passage
Laparoscopic help is added when the rectum sits high, near the bladder neck.
1
Cloaca
Girls with a cloaca need repair of the rectum, vagina and urinary tract together, a long operation planned with pediatric urology and gynecology.
After colostomy closure, babies pass frequent stools and develop diaper rash, which settles within weeks with barrier creams.
Bowel management
Surgery does half the work.
Many children after anorectal malformation repair or Hirschsprung pull-through stay constipated or soil their underwear, and a structured bowel management program keeps them clean and in normal underwear at school, with a daily enema, a laxative adjusted week by week against abdominal X-rays, fiber and diet, all planned by the surgical team and the family together. A systematic review of programs run by video and telephone found that more than three quarters of families were satisfied, that bowel scores and quality of life improved, and that laxative use fell (Bokova and colleagues, Children, 2024). For older children who manage the enemas themselves, a small channel to the appendix, the Malone procedure, lets them flush the colon from above while sitting on the toilet. Families who live far away gain the most from this model.
We start it before school age.
Most families reach the goal, a clean child at school, within the first week of an intensive program.
Ulcerative colitis and polyposis
Complications after colectomy and ileal pouch in 763 young patients
Complication
Ulcerative colitis
Familial polyposis
Pouch loss
10.6 percent
1.5 percent
Leak from the joining
4.9 percent
8.7 percent
Pouchitis, inflammation of the pouch
36.4 percent
Uncommon
When surgery is needed
1
Ulcerative colitis
Colitis that does not respond to steroids, biologic drugs and other medicines, severe flares, growth failure and precancerous change lead to colectomy, which removes the disease.
In the ileal pouch operation, the colon and rectum are removed, and the end of the small bowel is folded into a pouch and joined to the anus, so the child passes stool normally without a permanent stoma (Drews and colleagues, 2019).
Familial adenomatous polyposis causes hundreds of colon polyps that turn into cancer without treatment. Colectomy is planned in the teenage years according to the number and size of polyps, with yearly colonoscopy until then.
Staged operations
Stages for children with ulcerative colitis
Approach
Operations
Note
Three stage
Colectomy and ileostomy, then pouch with protective ileostomy, then closure
Lowest leak rate in children on biologics
Modified two stage
Colectomy and ileostomy, then pouch without protective stoma
Higher leak rate in children
Two stage
Colectomy and pouch with ileostomy, then closure
Children in good condition
A review of 1,727 patients found more leaks in children after the modified two stage approach than after three stages (Luo and colleagues, International Journal of Colorectal Disease, 2020). Very sick children and those on high dose steroids or biologic drugs gain from starting with colectomy alone.
1
Our approach
We choose the number of stages for each child from nutrition, medicines and the severity of colitis, and explain the timeline before the first operation.
A temporary stoma
1
What it is
A stoma brings the end of the bowel out through the skin of the abdomen, and stool collects in a small bag. In children it is temporary in almost every case.
Our stoma nurses teach parents bag changes, skin care and the warning signs of problems before discharge.
Babies feed, grow, crawl and bathe with a stoma.
Older children attend school, swim with a waterproof cover and take part in sport.
Closure is a smaller operation through the same opening and is done weeks to months later, once the main repair has healed. After closure, stools come frequently at first and settle over weeks.
Living with a stoma at home
Issue
What to do
When to call
Sore skin around the stoma
Barrier powder, correct bag size
Bleeding or deep breakdown
High output
Extra fluids, adjust diet
Dry diaper, lethargy
Stoma changes color or sinks
Check the bag fit
Dark or black stoma, call at once
Bowel emergencies
Colon emergencies in children
Condition
Typical age
Treatment
Intussusception
Six months to three years
Air enema first, surgery if it fails
Volvulus
Any age
Emergency untwisting and fixation
Necrotizing enterocolitis
Premature babies
Medical care, surgery for perforation
Perforation or abscess
Any age
Surgery or drainage
Green vomiting in a baby is a surgical emergency until proven otherwise.
How is intussusception treated without surgery?
The radiologist pushes air gently into the bowel through the anus under X-ray or ultrasound guidance, and the pressure unfolds the telescoped bowel. It succeeds in most children. Surgery follows when the enema fails, when the child has peritonitis or when a lead point such as a polyp is found.
Our neonatal and pediatric intensive care units support these children before and after surgery.
Laparoscopic and transanal surgery
Laparoscopy uses three to five small cuts and a camera to free the colon, find the fistula in high anorectal malformations or perform colectomy, with less pain and a faster return to feeding. Transanal surgery works through the anus with no abdominal cut at all. Some children with dense adhesions from earlier surgery need an open operation, and we discuss this with the family beforehand.
The approach follows the condition, the child's size and earlier operations. Scar size never comes before safety or function.
Preparing your child
Children cope better when they know what to expect.
Toddlers and school children understand simple words, a tummy operation, a bag for a while, a doctor checking the bottom, and our play specialists use dolls with stomas and drawings to explain each step, while teenagers with colitis or polyposis join every discussion, see the stoma nurse before surgery and meet the dietitian to plan eating after the pouch is made. Parents stay with the child during induction of anesthesia and in the room throughout the stay.
Honest answers build trust.
For families from abroad
1
Length of stay
Plan for two to three weeks in Istanbul for a pull-through or PSARP, so that feeding, wound healing and the first dilatation are checked before fitness to fly is confirmed. A colostomy closure needs a separate visit of around ten days.
Send biopsy reports, contrast studies, operative notes from earlier surgery, colonoscopy results and a list of medicines. For anorectal malformations, a distal colostogram and spine ultrasound help us plan before you travel.
Visits for staged treatment
Condition
Visits
Time between
Hirschsprung, short segment
One
None
Anorectal malformation with colostomy
Two or three
One to three months
Ulcerative colitis, three stage
Three
Two to six months
2
After you return home
Dilatation schedules, bowel management and stoma care continue with video consultations, and your local pediatrician receives a detailed letter.
One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number after you return. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages, and it arranges the visa invitation letter, airport transfers, daily transport and accommodation near the hospital. Halal, vegetarian and diabetic meals, a prayer room on site, and a female physician on request wherever the rota allows.
Stoma supplies for the first weeks are given at discharge, with brand names so you can buy the same products at home.
We send a written quote after reviewing reports and imaging, before you travel.
Compare quotes for the same operation and number of stages, and check that follow-up, dilatations and bowel management are part of the plan.
Prices are not published because each child's plan differs in the number of stages, the days in intensive care and the supplies needed after discharge.
References
Chen Y, Nah SA, Laksmi NK, et al. Transanal endorectal pull-through versus transabdominal approach for Hirschsprung's disease. A systematic review and meta-analysis. J Pediatr Surg. 2013;48(3):642-651.
Hagens J, Reinshagen K, Tomuschat C. Prevalence of Hirschsprung-associated enterocolitis in patients with Hirschsprung disease. Pediatr Surg Int. 2022;38(1):3-24.
Drews JD, Onwuka EA, Fisher JG, et al. Complications after proctocolectomy and ileal pouch-anal anastomosis in pediatric patients. A systematic review. J Pediatr Surg. 2019;54(7):1331-1339.
Luo WY, Singh S, Cuomo R, Eisenstein S. Modified two-stage restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis, a systematic review and meta-analysis of observational research. Int J Colorectal Dis. 2020;35(10):1817-1830.
Bokova E, Elhalaby I, Saylors S, Lim IIP, Rentea RM. A systematic review of telehealth utilization for bowel management programs in pediatric colorectal surgery. Children (Basel). 2024;11(7):786.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Assoc. Prof. Dr. Aysel TAKTAK, Pediatric Nephrology.
