Hey there listeners, it's Amanda Jensen from Cincinnati Children's. Have you downloaded the new version of the stay current pediatric surgery app? It's in the Google Play Store and in the Apple App Store. So download the app so you are able to see those pictures in real time as we discuss them. Alright, today's episode is spinal patients and bowel management needed for a urologist, part two. If you remember from last week, we discussed 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 use of Senna and Bisciotal as our pushers. We discussed Senna rashes and how to reduce the risk of them. We additionally discussed Uh, management of urinary and stool incontinence in the older child and need for a malone. In regards to urological considerations, sometimes we need a temporizing way to forward flush such as a sycostomy tube or a non-placated, non-trimmed malone, and this decision making with collaboration with urology is key as they tend to want to use the appendix for their metrofenoff. All right. Now, back to our colorectal quiz. Today I have with me Doctor Jason Fisher from Cincinnati Children's. When you get that really short stumpy appendix, whether it be from splitting it, and the urologist, if I have a 7 centimeter appendix, the urologist takes 6.25 centimeters and I get 0.75. Um, by the way, just so you know, urologists are not very good shares. That's Doctor Mark Levitt from Children's National. You know, when you have two kids, two kids on a playground, and they're splitting a cookie, usually you split it, and the person who split it isn't the one who uses it. But when it comes to urology, a split is about 70/30. That's what I've seen. That, that's a good day, absolutely. But there are tricks. We, we are in the benefit, right, because we're you. Using the appendix that's closer to the cecum, that portion of the appendix, so we're gonna have a stronger blood supply. Also, there are tricks to extend the appendix or fake how long that appendiceal channel could be. And you could either do it by suturing, or there's a laparoscopic version of a TA or linear stapler that doesn't cut. And you could use either of those to sort of lengthen the channel along the wall, the edge of the cecum, so that you could take your 1 or 2 centimeter appendiceal stump and extend it 2 or 3 more centimeters. And the reason for that is we know that one of the problems with the alone is leakage. And we do have some tricks for leakage, right? We do, we sometimes do application that's been mentioned a couple of times here already. But the other thing that I think is important about Malone's is the actual length of the channel. The longer the channel, the less likely that Malone's going to leak. Extending the channel 23 centimeters either by suturing or stapling can be extremely helpful. Another important, you know, both to Mark, um, and Jason's point. Uh, the first one is a great reason why a child would need an unplacated malone would be they live in a rural location, they are behavioral and they kind of pull at all the tubes. We had a sycostomy that we placed in a younger child, um, for a similar situation, and within a day, they had managed. In this rural location to pull that tube out and because we'd sutured it in place, they were able to get it back in and the child didn't need additional surgery, but it was a real nail biter and so that would be a great reason to keep that, to, to, to do that approach. I also wanna mention one thing that Um, and there are all different reasons, but one of the options I give to my patients and their families when deciding about Malone's, Metrofanoffs, and bowel management, etc. is the use of rectal irrigation. And I carefully use the term rectal irrigation in that there are some devices out there that are made specifically for patients to sort of wash their colons. With a pressurized water system that is made to be used by patients that have maybe some difficulties using their, all their hands or, and can self-administer an enema that way. I know coloplast makes one. And there are a few other options out there as well. That's always an option that I give to the families if they are hesitant about the loans and Metronas, etc. uh, is one of the options out there. I just wanna make sure we mention it. Wendy, can you just comment on that? I think that's a really important point is the ambulatory status of the spinal patient and how that might influence your choice of their bowel management, be it enemas, Alone or in fact a stoma. And some of these spinal kids, you know, if they have an absent coccyx, it's really hard for them to get a good clean with the rectal enemas of the balloon because they have a really challenging time retaining any fluid, even for the short amount of time from standing up to get on the toilet. Or these kids are wheelchair bound, to your point, but at 2, expecting a kid like that to stay there to empty, it's really challenging for families. Another reason that we've chosen the ecostomy route, or if we're able to use the appendix, doing the Malone route in this, these spinal kids, is that we can usually get them a small potty on the floor or allow them to not have to, with their mobility, you know, compromise, do something rectally, and then figure out a way for them to empty. Yeah, I think that's right, and I think you have to take into consideration the um transfer. Uh, to the commode issue. Although I will say most spinal patients that I've taken care of would prefer not to have a bag and would prefer transferring to a commode and doing an anti-grade flush. There is the occasional patient that Uh, again, this is all about quality of life, so we need to talk about that with the family and make, and make the right decision. I do wanna, uh, bring up one other point to consider before, if we are in this collaborative mode and we have a nice plan with urology and urology has made a decision. And the issues for urology are, does the bladder neck need to be tightened, does the bladder need to be augmented? Does the patient need a metrofenoff? And it could be all of the above, or 1 or 2 or uh of the above. If there is an augment possibility, it's vitally important that the colorectal team has figured out what is the bowel management plan for that patient. Because you may very well have a case where the colon is very difficult to empty, and you know that because the enema is very voluminous or very concentrated, and then the urologists say, I need to do an augment. What an opportunity for sharing. Take the sigmoid out of the transit of the colon, which will make the bowel management that much easier, and instead of throwing it away or giving it to the pathologist, roll it over on its mesentery, and then the urologist can use that. As an augmentation. So just have that in mind, if that's a possibility. If the patient has an easy to empty colon, then obviously that colon can stay in, and the urologist need to do a And augment, they can use small bowel. And then, of course, there's the splitting of the appendix opportunity that we've already discussed. Go ahead. You're really saying is that you have to do a really careful assessment of the existing bowel management plan before the next surgical intervention to understand the amount of sit time, ingredients and the flush that's going in. If you have a good bowel management plan, you actually might influence the urologic plan. There are plenty of patients out there that once they're empty regularly for stool, and are never having impactions, their bladder works a lot better. Their reflux might go away. You might save a patient from a ureter reimplantation with successful bowel management. So I think it's really important that the two teams, as is really nicely demonstrated, all three of our centers, work closely together in formulating these plans, because many times the urologist will say, I need the, uh, I need the bowel work to happen first before I really know what's happening with this bladder. Great point. I, I, it's so key to understand what, exactly what Rebecca said. Understand the bowel management needs before going in there and just doing an operation. Changing the potential surgical plan of the urologist because fecal impaction is pushing up on the bladder and changing the angle of the ureter entering the bladder and causing reflux, etc. The key point being from this collaboration is key. Where do you Guys, when you do a shared, uh, Malone Merofanoff experience, whether it's a shared appendix or independent neo appendix, etc. where do you put the orifices? What goes in the umbilicus and what goes in the right or left lower quadrant? What happens in, uh, Kansas City? In Kansas City, the metrofeoff goes at the umbilicus, and the mace or appendicostomy goes in the right lower quadrant. I can tell you I've done both. Anatomically, the bladder is a midline structure, and access to the bladder going through the umbilicus makes a lot of sense. And the cecum is a right lower quadrant and popping it to the right lower quadrant makes a lot of sense. Uh, Mark, you know what I do. We've been doing it here for two decades now, is that 99% of our malones are in our umbilicus, and a few random malones are in the right lower quadrant. And almost all of our metrofinoffs are in the right lower quadrant with a, with a tunnel channel through the rectus, helping to prevent leakage from the metrofenoff. So, we do it the opposite way, I guess that At one point, we'll compare our outcomes and see from a patient satisfaction, which may or may not be better or they may be equal. Obviously, the number one driving point is where does it reach and the blood supply. So that, the few that we have that aren't in Malone's, that aren't in the umbilicus are typically due to blood supply, at least from our standpoint. So that has to be the ultimate driving point. What else do we have to consider? Make sure they're properly separated. And don't uh do your orifices until everyone has a plan in the OR. So that one team is not pulling on the other's mesentery. So what do you mean by that, Mark, is don't mature your orifice until everything's sort of been built and done, what augments, reimplants, etc. So the, the last steps of the procedure are mature the metrofenoff, mature the malone, and then close the abdomen. I would love to ask definitely this patients with spinal problems, the laxity of their pelvic floor and their Anal canal is a huge issue in many of these patients and sort of makes them a little different, especially when doing retrograde enemas. Any tricks, tips, things that you have found and learned along your careers that you could share with everyone? We have found really good success adding visacodyl to their flesh. Sometimes they do better with the smaller volumes because they dump out at different rates, you know, they, their colons. Just move different than other kids. So, um, it's one extreme or the other, you know, we, we see them in bowel management boot camp and we either have them on low rates or completely maxed out to clean out their colon. And then the other thing that, um, you know, that Doctor Rent has recommended a lot that I think has been really helpful is she asks the families or the kids, depending on their ambulation, to kind of stand up at the end of their flesh and move around and then sit back down again. And, and try to have a little bit more stool because of the fact that we know things just move through their colon differently. Any other tips or tricks? Um, one thing that we've noticed, and this is in regard to enemas through the rectum rather than through an anti-grade port, would be to put a volume of water into the balloon, and we've kind of found that that really helps to hold it into the. so that the fluid doesn't go around it. Just because they don't have the ability to hold like our other kids do, and having that little bit of heavy fluid in there really helps when we don't have integrade access for those kids to be able to hold on to that liquid volume as long as possible. So to summarize, in spinal patients with poor pelvic floor muscles, adding additional water to the balloon using a larger balloon size or a different shape, such as a cone. Really helps with administration of enemas and additionally using MiraLax for stool on the right side of the colon to help them evacuate all of their stool. Mark, I think it's that time. Yeah, you know, I, uh, I thought you were gonna say that, and I was realizing, did you, did you guys hear that there were, um, 22 red blood cells that fell in love. It's true. Sadly, though. Their love was in vain. Terrible, terrible. All right, that wraps up part two of the colorectal quiz, bowel management and spinal patients and the need for a urologist. Let's summarize the case. This was a 5 month old with a history of spina bifida since birth, who presented with constipation. In this episode, we specifically discussed tips and tricks in the OR with collaboration with urology. And specifically in patients with spinal differences, how to use different enema recipes and Foley tricks to help them evacuate. 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. Until next time. This is Amanda Jensen with Cincinnati Children's.
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