Background: Constipation and outlet obstruction may persist after successful pull-through in Hirschsprung Disease (HD). The radiographic assessment of the faecal load is widely used but exposes the child to radiation. This study aims to evaluate whether the transrectal diameter (TRD) assessed with ultrasound correlates with symptoms of faecal load and whether the TRD normalises when symptoms disappear. Method: Children with HD after pullthrough and functional constipation presenting to our colorectal clinic between 4/23 and 4/24 were assessed for symptoms of constipation, smearing and outlet obstruction, as well as healthy controls. Ultrasound measurement of the TRD was conducted. Bowel management was initiated according to our institutional pathway using Peristeen© irrigation after an orthograde disimpaction regime. Results: A total of 193 children underwent TRD assessment. Of 60 children with HD, 26 (43.3%) presented with obstructive symptoms, and 34 (56.7%) were asymptomatic. In asymptomatic patients with HD, the mean TRD of 2.26 cm (SD 0.61) was significantly (p < 0.001) lower than in HD with symptoms, with a mean TRD of 3.35 cm (SD 1.03). Individuals without colorectal pathology had a mean TRD of 2.04 cm (SD 0.37), and children with functional constipation and symptoms showed a mean TRD of 4.36 cm (SD 1.32). The mean TRD after symptom resolution was 2.37 cm. Conclusions: Children with HD without obstructive symptoms have a TRD < 3 cm, as do controls. The transrectal diameter allows the clinician to sonographically assess the faecal load in children with HD at the bedside without radiation. The TRD is useful for monitoring a bowel management program in children with HD.

This study aimed to evaluate management strategies for anorectal malformations (ARMs) across Europe and assess the impact of institutional case volume on clinical decision-making. A cross-sectional online survey developed within the Trainees in European Pediatric Surgery (TEPS) and endorsed by the European Paediatric Surgeons' Association (EUPSA) Network Office was distributed among pediatric surgeons involved in ARM care. The questionnaire addressed diagnostic workup, surgical management, perioperative care, and long-term follow-up. European responses were analyzed and compared by institutional case volume. A total of 94 responses from 21 countries were analyzed. Substantial variability was observed across all domains of care. Ultrasound-based screening and invertogram were widely used, whereas high-pressure distal colostography was variably applied. Magnetic resonance imaging (MRI) and vaginoscopy were used more selectively. Primary neonatal repair in cases with the rectum located <1 cm from the perineal skin was commonly performed, and staged reconstruction was most frequently undertaken at 3 to 6 months. Non-divided stomas were more frequently used in high-volume centers (p = 0.002), with increasing center volume associated with higher odds of their use (odds ratio [OR] 2.98, 95% confidence interval [CI] 1.51–5.87, p = 0.002). Routine anal dilations were reported by 44.7% of respondents and were less common in high-volume centers (p = 0.005); increasing volume was associated with lower odds of routine dilation (OR 0.38, 95% CI 0.20–0.72, p = 0.003). ARM management across Europe remains highly variable. Institutional case volume is associated with practice differences, particularly in stoma configuration and postoperative dilation strategies.