Hey there listeners, this is Amanda Jensen from Cincinnati Children's. Have you downloaded the new version of the state current pediatric surgery app? It's in the Google Play Store and in the Apple App Store. The reason I bring it up is that if you're listening to this podcast within the app, you can bring up images or X-rays in real time while Doctor Fisher, Doctor Levitt, and Doctor Rentia are talking about them. So download the app and know you are going to enjoy your time there. Today we have with us a special guest, Doctor Rebecca Rentia, who is the director of the Comprehensive Colorectal Center at Children's Mercy in Kansas City. Welcome to the Colorectal Quiz. Today we have a special topic. This is part one of a two-parter bowel Management and Spinal Patients and the need for a urologist. Along with Doctor Rentia, we have Doctor Jason Fishisher from Cincinnati Children's. And Doctor Mark Levitt from Children's National. All right. Welcome back, everyone, to the colorectal quizzes. That was Doctor Jason Fishisher from Cincinnati Children's. Well, it's a real honor to have uh Rebecca Rentia, our good friend from Kansas City, uh, Mercy Children's visiting with us today on the podcast. That was Doctor Mark Levitt from Children's National. And we're gonna talk about a special topic for many nurses and physicians and advanced practice providers struggle with bowel management for spinal patients. This is that, this is that topic. And Rebecca, you, you brought some friends with you today? I did. I brought my two amazing friends, Christine Warner and Wendy Lewis, who are both nurse practitioners at the Comprehensive Colorectal Center at Children's Mercy in Kansas City. And Doctor Levitt, you've always talked about how about 5% of what we do is surgical and the rest is bowel management. Well, nothing is truer than in this specific case. Yeah, we're, as surgeons, Jason, Rebecca, and I, we're pretty useless without the Christine and Wendy's of the world. So thank you for making us better surgeons. All right, Doctor Rentia, why don't you start by telling us about your patient? This is a 3 year old male, but I'm gonna start actually with the time that we met this 3 year old male, and that goes back to near birth. So, this is a 5 month old male who presented with a history of constipation, a perineal rash. And the concern that the patient's mother had that there was an anal fissure or possibly prolapse, and that the child's only significant past medical history was a history of myelomeningocele. So to summarize, this 5 month old is in your office with constipation, perineal rash, anal fissure or prolapse, and history of myelomeningocele. With regard to these clonic issues, we're all sort of thinking about the fact that there is very likely a, a sphincter dysfunction issue related to the spine. What happened next? So, we began by getting a KUB to assess how much of this child's problem was really due to. To this child straining for stool. And we noted that the entire, all parts of the colon, ascending, transverse, and descending were filled with a significant amount of solid stool. You can view the KUB on the Stay Current app. And so we began by giving the child both MiraLax, which was not enough. So the child would still have like some liquid and then some really hard pieces of stool. And then we also added Senna. And that's really where the story begins, because while the constipation improved greatly, the child ended up with a pretty severe, severe diaper rash. If you're on the stay current app, you should be able to see this image. Now, in a patient with spina bifida and constipation and bowel management, how would you treat them differently if they were 5 months old and still in diapers versus 3 to 4 or 5 years old trying to be potty trained and out of diapers? How would the management be different? Wendy, let's start with the 5 month old. I think that, you know, initially our hope was that we could get this kid clean with laxatives. They had a diaper, so we knew that if they were pooping more than once a day. Um, then that stool would have somewhere to be collected, but whenever he presented with that terrible rash that did eliminate and go away when we stopped the Senna, but then his colon became full of stool, we realized that we needed something more reliable, and that's Really, you know, where he ended up with around age 2, where we, we moved on to, to doing um high volume rectal enemas. So the goal at 5 months of age really is. To get them empty regularly and not impacted, you need to avoid constipation. At this age, bowel movement patterns and bowel control are not as important, given that they are still in diapers. Senna on occasion gives you this um rash, and if you have the app, you can see that photo of it. You know, we investigated this, and I think it's, um, there are two components to this. Number 1, the Senna formulation, whether that be tablet, liquid, or chocolate squares, and if the child is allergic to a component of the formulation, not necessarily the senna, and number 2, the time sitting in the stool, usually the child is still in diapers and it is more likely to be seen after sitting in stool overnight. We've seen it in all three forms, and our thought process is, it's almost like a chemical burn. The cause they're blistered usually. We treat it with silver sulfadiazine, and they've all gotten better with time. Some have, we've reintroduced to Senna, and they've been tolerant of it. I agree, I'm not sure it's an allergy versus a chemical reaction or to sitting in the stool. And what we've done is we timed the dose of Senna in these patients, usually in the early morning, so that they're pooping during the day. And their diapers changed rather quickly versus potentially being in a diaper over a long period of time at night. That's been our reaction to this type of situation. If not using Senna, what other modalities are there? So other modalities that were attempted were MiraLax, which worked to get some of the poop out. But not enough of a push to get a full clean. That was enough to decrease the risk of impaction, um, or large amounts of stool. And so what we went to after that was, before, before you say, I, you just said something quite brilliant that I just want to, um, emphasize if that's OK with you. You said the MiraLax soften the stool but doesn't push it out, and I think that's a really important point that a lot of people miss. MiraLax, also known as, uh, glycolax, I think, or Peglax. What's the generic? It's polyethylene glycol 3350. I, I just want you to sound smart. Nicely done. Patients need a kick. You're impossible. And the patients need a kick, and Senna, and I think what you're gonna suggest perhaps on your, on your list, Christine, is bisocodol. Those are the two meds that have a kick. Everything else is a stool softener. I think it's really important to emphasize what Christine said, and that is, softening the stool gets it all mushy, and it does flow, but it, you still have a full colon. It's really a problem for patients that need fullness to detect the stool, particularly anorectal malformations. MiraLax is their enemy because it makes a soft stool that just sort of mushes out. You want something with a discreet push. Now, in this case, I agree that MiraLax basically kept them From being impacted just like you just said. What were some other options? What did you end up using? We did attempt Dulcolax. Tried our two pushers, if you will, which are the biscocodol and the Senna, and then the musher, which we call MiraLax, was attempted as well. Um, once, you know, those didn't quite do what we were hoping them to do, we moved on. I'm sorry, can I ask, how do you, in the 5 or 8 month old, what form of bisocodol did you use? If I remember correctly, I believe we use enemas from the bottom and we used just about half of the enema per night to stimulate some amount of poop right at the bottom of the colon to come out. The key point here being Um, bisocodol obviously could come in an enema form or a suppository form. Wendy, tell us more about the small volume enemas. Um, yeah, so we ended up starting him on small volume enemas with the balloon Foley catheters, and he had good results with that. His rash was completely cleared up. He was only having like 1 to 2 poop diapers a day, primarily after the enema was performed, and, but he only tolerated a small, small volume of 150 saline plus 9 of castile, and the reason that we use the. Castile soap was because we had it available in clinic, and usually we try to start with glycerin. It's just more tolerated in our kids' stomachs. They always complain of cramping, discomfort with, with the Castile, but I was the one that actually started him on enemas, and I, I started him on the Castile. All right, let's say that the child is doing well, bowel movements are well controlled, and his diaper rash has resolved. What's next? I'm alone? I think it's time just to pop in them alone, right, Rebecca? That's the next step. Yeah, I mean, one of the benefits of them alone is that you, in the future can have no tubes in the belly and you can catheterize the channel once a day. But as we know, children with spinal differences may need an access to the bladder later in life, and that the beau a beautiful channel with that would actually be from the appendix. So, so you're, you're suggesting that we need to coordinate our efforts with the urologists? Yeah. Yes, I am. Whoa, wow. If there's one take-home message from this podcast, you just said it, right? I'm serious because we've all, we all run centers and we have patients coming from all over, and I have the patient who has the metrofenoff who's 4 or 5 years old, and they're fecally incontinent, and now I need to do a Neil Malone or vice versa. And so, that care coordination, collaboration with the urologist might be the most beneficial thing we could do for our patients. This patient, actually, you're sort of coordinating this patient's care from the very beginning. And a spinal patient very easily could have already had urological implications such as the need for intermittent caths and management to ensure that their bladder is successfully emptying. And now we are approaching the age where it's time to get them clean and dry for urine and stool. And we need to have a coordinated effort to do that. All right, new scenario. They're 3 years old, Rebecca. They will not tolerate rectal enemas, but urology is not ready to declare their urologic plan. What do you do? That's a tough scenario. Yeah. And you know, the other thing that's really important is if urology isn't ready to discuss their plan, they may have more reconstructive needs that they're thinking of or testing that hasn't been done yet. And so depending on how pressing it is of the bowel control or a bowel management option or access, that's where you really have to decide what is a temporizing measure that doesn't burn any bridges. Like, I would say a sycostomy. So, a sycostomy is a direct access. I call it the G tube of the colon or G tube of the cecum. So it is a tube that can be placed either laparoscopically or by interventional radiology straight from the Belly wall into the cecum. And so that should end up in the lumen of the cecum and it preserves the appendix for future reconstructive needs. Yeah, I like that idea a lot. The other thing I've done is I've done a, a non-placated malone, where I take the tip of the appendix and sew it to the right lower quadrant for access, put a tube in it, one of those uh balloon device potentially. Don't placate it. So if one day you come for your urologic reconstruction, that appendix might be splitable, that appendix might go for the metrofenoff, and then you can make a neo appendix. You haven't burned a bridge that way either. Um, and of course the icostomy as you described, basically does the same thing. So non-placated and non-trimmed, so do not take any length. That's right. That's right. And, in fact, let's talk about that for a second. Um, that's a really interesting technical point. I'm gonna give you a couple of scenarios, and you tell me if you were gonna do a Malone Metrofanov combo case. How you would handle that. OK, let's say you have a 2 centimeter appendix, and that's it. So that sounds like it may not be very long for anybody and urology may not find that as a very useful length. So you may actually use that for yourself, meaning for the colon, and urology may need to go with a different conduit. Yeah, our, our urologists insists on a 5 centimeter appendix if they're gonna use it for a metrofenov. Anything shorter. They don't want, that, that's for us. So basically, I agree with you. I would probably try to do them alone, although 2 centimeters is a little bit short. 5 centimeters, I would, that goes to the urologist and you have to make your own like a neo Malone. 7 centimeters might be splitable, 2 + 5. And then anything bigger is certainly splittable. Um, but there's no question that if you ask a urologist, they would like the appendix for Metrofanov. It is better long-term than a monti made from small bowel. So we can do a Neil Malone with a flap of colon. They prefer the appendix for the, uh, for the metrofanov. Jason, do you wanna make any comments about the splitting? I, I have a lot of comments cause I'm learning things and, and I have never used a temporary conduit before hearing this conversation for bridging the gap per se, for the time when you're ready to Do a collaborative case, and the urologic needs for that patient is known. So, I guess my question for those who do this bridging, I can't imagine that's easy when you go back in, that cecum stuck up to the anterior abdominal wall, and now you're going to try to split an appendix that needs to go to the right lower quadrant and hopefully the, the umbilicus. Has that caused problems? In, in the past. It's, uh, again, this is pretty rare. This is a kid, I, I really painted a difficult picture for Rebecca, but it's a kid who's not tolerating their rectal enemas, needs an antigrade option. Let's say, won't take their medicine, can't empty with senna, and their bladder isn't at the point where they can know whether there's an augment needed or a bladder neck sling. They don't know. So, yes, I've done both of those things that one Rebecca suggested is to do a sycostomy. Taking it down is pretty easy and it, the appendix is free. And then I've done the tip of the appendix without trimming it or placating it. And then I flipped that to become a metrofenoff. So, Um, I love it. I'm learning new things. This is why we do this. It's pretty rare that you have to do that. All right, let's, let's say, no, but let's talk about little tricks that I have, and I know, Mark, you've done this. Ah, but we're out of time, Doctor Fisher. Until next time, we'll wait for those tips and tricks. This finishes up part one of a two-parter on bowel management and spinal patients and the need for a urologist. On to our colorectal joke of the day. What did the poop say to the fart? Hm, not sure. You blow me away. Alright, that wraps up our colorectal quiz. Let's summarize the case. This was a 5 month old with a history of spina bifida since birth who presented with constipation. We discussed bowel management with use of MiraLax as our musher and Senna and bisacaal as our pushers. We discussed Senna rashes and how to prevent or reduce the risk of them. And additionally, in the older child who is ready for urinary and stool continence, it is important to consider a malone. However, with urology in mind, sometimes we need a temporizing way to forward flush, such as a sycostomy tube or a non-placated, non-trimmed malone. In this decision making, collaboration with urology is key. Again, collaboration with urology is key, as they tend to want to use the appendix for their metrofenoff. Thank you for joining us for the colorectal quiz. Download the Stay Current app if you have not already, and remember, knowledge should be free.
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