Welcome back to another episode of Colorectal Quiz. I'm Ray Hankey, pediatric colorectal surgery fellow at Children's National Hospital in Washington DC. Today, we dive into an important topic, transitional care and pediatric colorectal surgery with international experts from Germany. Our host, Doctors Levitt and Frischer are joined by Doctor Stuart Jose and Mark Malota, an adult colorectal surgeon and pediatric surgeon. They discuss the management of a young adult with anorectal malformation. The collaborative care delivered, followed by opportunities for and challenges of transitional care in this complex population. Let's join the conversation. Thanks, thanks a lot for, for having us. We're very, very happy and very proud to be with you. Maybe the best idea is to differentiate since we have two marks. We have one Mark, which is written with K. Mark Mootta will say he is K Mark and the other is just Mark. Would that be OK? I think it's really important to, in the colorectal scientific community to insist on the K if your name's Mark. Well, that doesn't leave much room for those of us with a seat, but I, I appreciate that. All right, um, well, the Gates, v. Gas Enen, welcome all of you. Um, let's, uh, let's get started. Why don't you, uh, present the case? We have seen a 27 year old patient. She came to us with a vestibular fistula, which was repaired as a newborn, and uh she had been suffering from incontinent stool uh situations uh all the time after the surgery, but uh she was told that this was quite fine and normal and there was no way to optimize the situation. Then when she went into puberty, she was told that there was a possibility to do daily irrigations, and she did that and uh with this she was, she gained social a social life back again, how she told us. But she wanted us to to have a look on the situation because she still had issues with her, with her anus. She had a rectal prolapse 2 or 3 years ago, which was operated on by a polyproctologist, an adult surgeon. But she still had some problems uh with this anorectal situation, and so, so she showed up and uh she uh underwent our examination. We looked up her reports, the original operation reports from the early 90s was not complete. She had not all the, the reports brought with her, and so it was a bit difficult to evaluate the, the operation situation. And then we did an proctology and the first thing we saw we saw was uh an anus, which was not really in the perfect place, what we would say. To summarize, we have a 27 year old female born with a rectal vestibular fistula who underwent operative repair as a newborn and rectal prolapse repair by an adult colorectal surgeon about a year before presenting for further evaluation of lifelong fecal incontinence currently managed with enemas. What should we be looking for in a physical exam in an ARM patient with previous surgical repair? I encourage you to do examinations under anesthesia. This is a very valuable maneuver for ARM patients who have had a previous surgery. Uh, you can see whether the dennoplasty is prolapsed. You can see whether it's strictured. You can use electrical stimulation to determine whether it is properly located. There are some other tools that some of us use depending on the situation. I've used MRI, um, with certain protocols that could help see if the anoplasty is within the muscle, uh, uh, complex. And we've recently also used endorectal ultrasound to help us with this as well. If it's a male, we tend to add cystoscopy to that evaluation to be absolutely certain that there's not a roof, a remnant of the original fistula. It also gives us an opportunity to assess the bladder mucosa and see if they have been successfully emptying. Of course, in a female, we can also determine whether there are um fistulas that don't belong there and things like that. To see this patient's anatomy at initial presentation, look for the associated photos below the podcast in the Stay Current app. For those listening to this on other platforms, maximize your learning by using the Stay Current app to see associated pre-intra and post-op photos. I think the exam is extremely important and in this case, and you can see it on the picture, you can basically see that the anus is too ventrally located and you can see the place where the anus should be. You can see that little dimple that is posteriorly to the place where the anus is located at the moment of the examination, and that is already a very important point that you can make. And if you stimulate that muscle, the, the external sphincter, you can see very well where the limits are and where the anus should belong. I was just going to say from a very functional point of view, what what's missing here is sphincters anterior to the anoplasty. So when the patient with very good sphincters tries to squeeze those sphincters, they simply cannot close the anterior aspect of the anus, and stool can slip out of there, whereas if the anoplasty was properly located and the sphincter was concentric. They would successfully close the hole, and that's the incontinence problem, and it's the most common problem in females that Jason and I have done redos for, uh, because there simply is no circle, and that can happen if the anus was improperly located initially or sadly, when there's a dehiscence of the perineal body, you essentially leave the patient with a C. Surrounding the hole rather than an O surrounding the hole, and the surgical technique is to get the muscle in front of the anus, in the anterior part of the anus. Major point here, if you're seeing fecal incontinence, constipation, recurrent UTIs, or rectal prolapse in a patient with previous PSA, it's critical to assess for potential underlying causes. Well, it was exactly what we did. We took her for an examination under anesthesia to do an electric stimulation and to see where the sphincter muscles are located. And we saw that it was like this, that it was like a sea with a non-open uh the anterior part of the, of the anus was not surrounded by the sphincter muscle. We did as well an anal ultrasound which confirmed that findings. We were thinking as well because she was treated by an adult surgeon by this rectal prolapse. They did a like kind of raffi of the of the mucosal uh rectum of the rectum mucosa. But we were thinking that this was, of course, a sign of the missing sphincter complex which was which was not working, so there was this rectal prolapse. So this were prodrome or signs, late signs of the missing sphincter, and so we thought the best way for treating this patient would be to redo Pisar, yeah. Doctor Jose, can you tell us more about how you prepared the patient for the operation and how you managed her care along with the adult surgeons? Well, we basically, uh, Talked to the patient, explained to her what we thought was a good idea to do, and told her that probably uh repairing this misplacement of the anus would help her in in gain continence. And what was interesting is that although she was quite incontinent, she learned somehow to manage her daily life, and she thought that her quality of life was not really bad, but on the other side, she really had the impression that not everything was really fine and that probably it was good to get her situation better. Uh, so what we did is we did a formal colon prep, uh, integrate. She got antibiotics already preoperatively, and we continued them for a few days. We did not divert her, and we did basically redo PAP and we did it together with our general adult surgeons. They, they assisted us. They were with us. They have never seen such a procedure, so they were quite amazed, but I think it is very important to show them what type of surgery we usually perform in children and what different anomalies we treat. So that was very, very interesting to see their faces during surgery and uh well, we did a redo PAP and placed the rectum where it belonged to. We shortened what was too long. See the photo of the correct location for the anus and the final anoplasty and perineal body repair and the stay current app. We, we left her with nothing orally for 5 days and then started with feeding, and everything healed so far OK, so we were happy and the patient was happy as well. I do just want to briefly comment on your strategy, um, which I completely agree with, of non-diversion and the period postoperatively to try to get some good healing. As many people know and still ask about in the old days, perhaps not even so far as 10 years ago, um, had this idea to keep the patient NPO, put them on hyper alimentation, and guess what, they still have stool. But my impression is that if you give someone real food. They make harder stool which can then blow through your perineal repair, whereas if you give the patient clear liquids, the stools that they produce are very soft and very watery, which don't do anything really to the wound care, and they're much happier. And you avoid a PICC line and you avoid TPN and you avoid NPO and the nurses and the family and the kid, patient, in this case is not a kid, are much happier over those 5 days. And if at 5 days the perineal healing looks good, then we advance their diet. And I'm not sure what Jason you do at this point, but I usually put them on some laxatives to keep them a little flowy, um, so that they still remain relatively liquidy. Um, because I think the problem is hard stool going through your repair, not stool. As long as you're keeping the wound clean, we have not had a problem, and I have not, uh, needed to divert, uh, such a patient. Yeah, I agree. I, I, I like that we keep the patient and flowy and liquidy as much as possible. We had the scriptors. Now to the main focus of this podcast, transition of care for our complex ARM patients. Doctor Maloda, as one of the few people trained in both adult and pediatric colorectal surgery, what have you found to be the best way to transition our ARM patients to adult care? Yeah, that's a very good question how to do this, because of course there is no master plan for this. It depends, of course, on each patient, how is his ability to think about his own situation, their interests, and usually we do it like this, that at the age of 12 we talk to the parents that they cannot stay forever in the peat surgery department. We are not allowed to treat over the age of 18 here in Germany, so we try to get them connected to adult colorectal surgeons. We build up a network with colorectal surgeons who know the pediatric surgery procedures, who are interested in these procedures, and so we can. Get them connected to them. If they have other issues, we do connect them as well to adult physiotherapists, but as well to adult urologists or adult gynecologists and um what we do is when we see them annually, we try to organize that the adult surgeon is present as well, so he gets to know the patient. And the patient gets to know the adult surgeon because usually they have another way of treating patients and This is something that the patient has to learn from the adult surgeon, and the adult surgeon gets to know the past medical history of the child and gets some explanations by the pe surgeons. And so this is what we called a soft transition into adulthood because it lasts 34 years. The aim of all this is that the patient only sees his adult colorectal surgeon. And at one point, no pediatric surgeon anymore. If there are still some issues, we together think which which issues there are and which, which are the best way to um to for further diagnostics. And then we can talk together, which are the best way of uh operate on the patients. I love the idea of that transition where you have a couple of clinic visits together. Everyone gets on the same page, and then if there is an operative procedure, collaborative operating as well. And I think that's a big key. Where did you perform this surgery? And I don't know your hospital system per se. Was this in an Adult hospital was this in your children's hospital and the reasons behind that? Well, we are a general hospital. We have the, the adults here and we have the pediatric part and we have a central surgical theater part with the operating theaters for the adult surgeons, and we have our pediatric surgical OR part. But this patient was operated on in the adult operating theaters with the adult surgeons, and the patient stayed in the adult surgical ward. And you have a unique situation cause your adult and children's hospital is in one unit or one entity, which I think makes it a little bit easier than compared to some of us who are in freestanding children's hospitals with completely separate entities, both physical and financial, which um Brings on more challenges. And, you know, 1015 years ago, we had no system in place. Right now, most of us have like a hybrid system in place. I could say in Cincinnati, the patients still come to the colorectal center at the Children's Hospital, whether they're 12 years old or 40 years old. And then we partner with our adult colorectal surgeon. Uh, tomorrow, I'm operating at the University of Cincinnati and doing a case. With the adult colorectal surgeon. We have an adult neurologist who really takes part in the urology part, and our ped urologist stays with the patient as well and has privileges at the university. So, that's sort of the hybrid system we have here, that partnership and operating together and going through the journey together and not just, you know, passing off and totally abandoning sounds like a key component to this transitional. I really like, Mark, what you have outlined because I think it makes the most sense. Begin the psychologic discussion when they are early in their teenage years that this is a plan for the future. Um, we need to engage our adult colleagues and find some friendly people, take them out to a nice dinner, and start some bonding. You know, most surgeons understand this question. Because I suspect most of the pediatric surgeons on this call have at some point gotten a phone call from their adult general surgery colleagues. I'm in the operating room and I found a patient with malrotation, and I haven't dealt with that in 20 years since I was a surgical resident. What am I supposed to do? So you take the pediatric surgical brain, and in this case the pediatric colorectal surgical brain. And you help your adult colleagues be smarter about that case, but I don't think it requires your physical hands on the surgery because not all of us will be blessed with a Mark Molota who has the Ability to operate in both worlds, but there are adult colleagues who are interested in this field. In Jason's case, he got privileges to operate at the adult hospital, but he's pretty much functioning as an assistant. Ian Piquette is offering the adult care and all of the nuance to the adult care that he has expertise in. And I think that's the real way to go about this. We are doing something quite similar here. We are also somewhat limited being a freestanding children's hospital, but we have a wonderful adult hospital literally across the parking lot, so we have that opportunity to cross back and forth. The challenges of caring for patients transitioning from pediatric to adult care extends beyond having surgeons to provide care. Here's Dr. Levitt with more. I do want to mention something very important that Mark brought up, Mark with a K, that in Germany there are rules that pediatric surgeons can take care of up to age 18. In the United States that line is very blurry. I think it's incredibly problematic, that blurred line, because if a patient over the age of 21, and maybe it should be 18, that's up for debate, comes to the children's hospital, what you need to recognize is not everyone has credentials to take care of adults. So for example, we have nurse practitioners. On our team that are purely pediatric, and they cannot write orders on a patient who is over the age of 21 by licensing reasons and perhaps more dramatic is the clinical care. So if a 40-year-old is sitting in a children's hospital and needs to go to the ICU, the intensivists are pediatric trained. They are not adult trained. You know, there's a safety concern here. Having a pulmonary embolism in a children's hospital or a myocardial infarction in a children's hospital, that talking about a lot of meetings after that event, and, and the, the potential for a poor outcome. The adult hospitals are much more adept and, and skilled in taking care of those unfortunate complications that sometimes happen in the perioperative period. Beyond caring for our patients at the appropriate facility, surgeons need knowledgeable gastroenterologists and advanced practice providers to help continue providing excellent bowel management. Here's Doctor Fisher on that topic. I was just recently at a meeting, and I think the physicians and the surgeons particularly are making this progress. Where I think we struggle a little more is that 35 year old patient who needs some intensive bowel management training. And I think the pediatric centers are very adept at bowel management, whether it be in a seven year old or a 2-seven-year-old. When I surveyed all the major centers, at least in the United States, the adult patients who require some more intensive bowel. Management outpatient clinical work seems to be occurring in the children's hospital at this point in time. Yeah, bowel management expertise needs to be passed, so this is not just a doctor to doctor exactly transition. This is also nurse to nurse and a danced practice provider, nurse practitioner, or PA. And the other thing that I think you should intrigue your adult colleagues with is what is a malone, which I think is a beautiful operation that many of them have never even heard of, or the use of peristine in the adult, which is self-controlled from an enema point of view. So there are many tricks that have been learned in the pediatric population. to convey to the adults. One of the important issues, unfortunately, at least in the United States, is the finances. From a financial point of view, people want operations, and many of these patients don't require operations. They just require medical management to change their life in a very positive way. In one week of bowel management, you can get a patient. Who has, you know, no chance of continence, has been soiling for decades clean with a bowel management program. Now, in your case, which is awesome, you basically converted a patient who's had fecal incontinence for 27 years. By changing their anatomy. They are now normal and they have normal bowel control. That's obviously not always the option. But the medical manager is important, so we have to do the right thing. But I do recognize in the United States some of this transition will require devoted colleagues that want to help, and they're not completely based on whether or not they get a procedure out of it. I would like to make a point. I mean, Kmart has been doing the outpatient clinic for outpatients, and he has seen over 100 patients with issues. And I think this, this shows that this is a failure of transition because those are adult patients that after many years discover that they have a problem and then they, they, they seek for help. If we are able to build a transition to accompany the patients and the families starting from childhood into adulthood, most of these problems will be solved before they appear, and we will be able to transfer them early to the adult surgeons and the adult doctors treating them later on. The second point I would like to make is the importance of the patients and parents associations. We have a very active association here in Germany. They have been doing fantastic work, and I know that in the US there is an association as well as in France and in Italy. And they, together with some interested surgeons, we created like a booklet for the patients and for the families where all the information is written down beginning and starting with the newborn period, the surgery that was done, all the malformations that children have, the examines that were performed, and all the examines that are repeated during follow up. So if we are able to do this follow up, and surgeons don't like to do this, but I think it's very important. The families and the patients will have all the information at hand, and transition will be much easier. So I think we have to work on that. I heard that um recommendation. It's sort of like a passport of what you've been through. And I'm wondering, Mark, if you could um create a template which um we could distribute to the parent organization so that each family is then responsible for having their own personal passport. Report of what they have been through, what previous surgical procedures, their dates, etc. and then they have that and they hand it to whoever they need to, um, as whoever has taken on their care. That might be a nice, a very practical solution that we can get the parents to work on for their, for themselves if they are the patient, um, for the patients themselves if they're adults or the um or the teenagers that are going to be adults soon. We all need to somehow commit to this. There are a number of places in the world that are doing this well. I saw this done extremely well in Paris, where they join each other's for clinic for the first couple of visits, just like you said, Mark. This is the future. Our obligation is to make sure we get better at this, and I think we're well on our way and we're getting there. Your model, Stuart and Mark is, you know, up there with the best. Thank you both for joining us, as is our tradition, we end this, um, podcast with a joke. Any, any good German colorectal-oriented jokes? I have a surgical joke. There was a patient fleeing from the OR. And he was picked up by an employee of the hospital who asked him, Why are you running away from surgery? And he said, Well, I was entering the OR. And then the nurse said, Don't be afraid. It is a small, easy operation. Everything will be fine. There will be no complications. So the employee said, Well, but The nurse was just trying to comfort you. And then the, the patient said no, she was talking to the surgeon. Oh, that's, that's, that's, that's lovely. Oh boy. Thank you for joining us for this Colorectal podcast. Check out the Stay Current app for more great content on the Colorectal channel. And remember, knowledge should be free.
