Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery
With Dr. Stuart Jose & Dr. Mark Malota & Dr. Marc Levitt & Dr. Jason Frischer · hosted by Dr. Ray Hankey · Colorectal Channel
Cued at 22:48 · stops at 23:33 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Patient is 27-year-old female born with rectal vestibular fistula, repaired as newborn, with lifelong fecal incontinence
Patient was told incontinence was normal and unavoidable after initial surgery
Daily irrigations introduced at puberty allowed patient to regain social life
Patient had rectal prolapse 2–3 years prior, repaired by adult proctologist
Original operation reports from early 1990s were incomplete
Physical exam revealed anus not in correct anatomic position
Examination under anesthesia is valuable for ARM patients with previous surgery to assess anoplasty position, prolapse, stricture, and use electrical stimulation
MRI with specific protocols can show whether anoplasty is within muscle complex
Endorectal ultrasound can help assess anoplasty position within sphincter
In males, cystoscopy should be added to rule out fistula remnant and assess bladder emptying
Anus was too ventrally located; posterior dimple visible showing where anus should be positioned
Electrical stimulation of external sphincter shows muscle limits and correct anatomic position for anus
Anterior malposition means no sphincter muscle anterior to anoplasty, preventing complete closure and causing incontinence
Anterior malposition is the most common problem requiring redo surgery in females
Dehiscence of perineal body leaves C-shaped rather than O-shaped sphincter around anus
Electrical stimulation confirmed C-shaped sphincter with anterior opening not surrounded by muscle
Anal ultrasound confirmed electrical stimulation findings of C-shaped sphincter
Rectal prolapse was sign of missing/non-functioning sphincter complex
Redo PSARP was chosen as treatment for anteriorly malpositioned anus
Patient learned to manage daily life despite incontinence and felt quality of life was not bad, but recognized situation could improve
Formal colon prep performed preoperatively with antibiotics continued for several days postoperatively
Patient was not diverted for redo PSARP
Adult surgeons assisted with redo PSARP and had never seen such a procedure before
Rectum was placed in correct anatomic position and excess length was shortened
Patient kept NPO for 5 days postoperatively then started feeding
Clear liquid diet produces soft, watery stool that does not traumatize perineal repair, unlike hard stool from regular food
Clear liquids avoid need for PICC line, TPN, and NPO, making patients and families happier
At 5 days, if perineal healing looks good, diet is advanced with laxatives to keep stool liquidy
Hard stool going through repair is the problem, not stool itself, as long as wound is kept clean
Non-diversion strategy has not caused problems in redo PSARP cases
In Germany, pediatric surgeons are not allowed to treat patients over age 18
Transition discussion begins at age 12, informing parents that patient cannot stay in pediatric surgery department forever
Network built with adult colorectal surgeons interested in pediatric procedures to facilitate transition
Patients connected to adult physiotherapists, urologists, and gynecologists as needed
During annual visits, adult surgeon is present so patient and surgeon get to know each other
Soft transition lasts 3–4 years with goal that patient eventually sees only adult colorectal surgeon
Collaborative operating during transition is a key component
This case was performed in adult operating theater with adult surgeons, and patient stayed in adult surgical ward
Freestanding children's hospitals face more challenges than integrated adult-pediatric systems due to physical and financial separation
In Cincinnati, ARM patients continue to come to colorectal center at children's hospital regardless of age, partnering with adult colorectal surgeon
In United States, age line for pediatric vs. adult care is blurry, creating problems
Pediatric nurse practitioners cannot write orders on patients over age 21 due to licensing restrictions
If 40-year-old needs ICU in children's hospital, intensivists are pediatric-trained, not adult-trained
Pulmonary embolism or myocardial infarction in children's hospital creates safety concerns and potential for poor outcomes
Adult hospitals are more skilled at managing perioperative complications like PE and MI
Surgeons are making progress on transition, but struggle remains with intensive bowel management training for adult patients
Pediatric centers are adept at bowel management for patients of all ages, but adult patients requiring intensive outpatient bowel management are still being seen at children's hospitals
Bowel management expertise needs to be passed from nurse to nurse and advanced practice provider to advanced practice provider, not just doctor to doctor
Malone appendicostomy is a valuable operation many adult surgeons have never heard of
Peristeen system allows self-controlled enema administration in adults
In United States, financial incentives favor operations over medical management, which can be problematic for transition
One week of bowel management can convert a patient with decades of soiling to clean continence
Over 100 adult ARM patients presenting to outpatient clinic represents failure of transition, as problems should be addressed before they appear
Patient and parent associations in Germany, US, France, and Italy play important role in transition
Patient passport booklet documents all information from newborn period through follow-up, including surgeries, malformations, and examinations