Dr. Natalie Durkin - Best of the Best in Pediatric Surgery 2025

we're going to move on to the final presentation of this heat. Um, and yet another person from Great Ormond Street. So Dr. Kat Ford, uh, and uh, Kat is going to present, uh, from Cheswall to esophagus, now to Cloaca, evaluating prognosis in cloaca and analysis of common channel length and bowel function outcomes. Thank you for the opportunity to present my work on evaluating prognosis in Cloaca. My name is Cat Ford and I've done my pediatric surgical training in London, UK. There is a wide spectrum of cloaca anomalies. And most simplistically, a cloaca is a defect in which the rectum, one or two vaginas, in the urinary tracts converge into a common channel and opening in the perineum. The common channel is often referred to by its length and is split into two types: long, more than 3 centimeters and short, less than 3 centimeters, with the 3 cm cutoff being described as the difference between simple and complex cloaca. Understanding the origin of the description of common channel length is important. It has reconstructive implications after being introduced by both Penia and Hendrin in the 90s. When the common channel is less than 3 centimeters, the great majority can be repaired using a posterior sagittal approach only. Subsequent to this, cloaca outcomes started to be reported as per common length category. The evidence behind the correlation between common channel length and functional outcome is limited. Although both Penia and Levit report that short common channel length cloacers are often associated with less comorbidities, which of course contribute to functional outcome. The challenge, however, to this rather binary dogma is that there are many factors which influence outcome. We wanted to explore this further and our aim was to investigate bowel function as per common channel length. The methodology we employed was a retrospective analysis of a prospectively collated database. We interrogated this cloaca cohort who were treated at Great Ormond Street and included patients who were post reconstruction over a 14 year period. We used the Rentala bowel function score to investigate the relationship between bowel function and common channel length and accounted for confounding variables in multivariate analysis. The initial cohort consisted of 61 patients, and we included 55 patients after excluding four. We had complete bowel function scores on 38 patients and common channel lengths on 50 patients. And the final common channel length analysis was conducted on 38 patients. The mean age at definitive reconstruction was 6 months and mean age at outcome analysis was 73 months. As per the Rentala bowel function score, a score of more than 17 is interpreted as normal. The median bowel function score for this cohort was eight with an interquartile range of 5 to 15. 16% of the cohort had a bowel function score of greater than or equal to 17 out of 20. The median common channel length was 2.5 centimeters. And the first thing we did was to perform univary analysis to see if the current common channel length classification had any difference in outcome in our patient cohort. We can see in this table, there was no difference in incidence of associated spinal anomaly or developmental delay between the two common channel groups. Interestingly, more patients were on transanal irrigation in the long common channel group. It was curious as to why this was, when the bowel function score was the same between the two groups. How could it be that some patients appeared to have more access to effective bowel management despite appearing no different clinically. We therefore investigated further using common channel length as a continuous variable and plotted against bowel function score. We observed no correlation. Next, we perform rock analysis to see if perhaps there was another cutoff of common channel length that wasn't 3 centimeters. And as we can see here, we found no discriminatory value of common channel length in prediction of bowel function. On finding common channel length to appear independent of bowel function, we investigated other variables. We can see that a trend in developmental delay and presence of spinal anomaly were associated with worse bowel function. However, this did not reach statistical significance. We did find a clear association between age and bowel function with the older the child being the better they do. On accounting for confounding factors, in a multivariable linear regression model with bowel function score as the dependent variable, we observed that common channel length and the presence of spinal anomaly were not associated with bowel function. Older age and less deprived socioeconomic groups were associated with better bowel function, and the presence of developmental delay was associated with worse bowel function. Of the 47 patients on whom urinary outcomes were available, 40% reported urinary continents and 32% were performing CIC. On performing univary analysis, we found no association between urinary continents and common channel length. And on multivariable linear regression, again, age was the only factor associated with urinary continents. In conclusion, we present a unique data set from the largest cohort in the UK, where we have challenged the 3 cm paradigm for bowel function outcome reporting. Common channel length alone is inadequate for guiding prognosis. We recommend individualized patient care and counseling. We would not plan bowel management based on the assumption that they do well, and if there are early symptoms of fecal incontinence, for example, we would promote a more aggressive invasive bowel management program early. Further, we'd be able to counsel based on this data that the bowel function will be expected to improve over time and that more invasive bowel management programs will be reviewed as the child gets older. I'd like to end with acknowledgement to the cloaca MDT at GS. And thank you very much for listening and I look forward to further discussion. Thank you so much Dr. Ford. Um, I know that uh Mira has a a quick question for you. Good thanks so much for this presentation. It was awesome to see and I think the spinal anomaly correlation with um bowel function, I think makes a lot of sense to to all of us. The one question I was going to ask you was about the equity piece, which you noted that those from lower socioeconomic status had higher, you know, rates of of incontinents or or poor bowel function. How in your individualized management, how do you target that to close that gap? Oh, you're muted, Dr. Ford. Thank you. Um, yeah, it's it's a really interesting variable and quite as we all know, quite difficult to quantify. So in in the UK we use a post code based measurement, which you know, incorporates several variables and is fairly reliable but has its issues. Um, so on a more ad hoc sort of practical basis, we we've been sort of, I don't um identifying families who may have problems based more than just the post code. So it's a bit more about the family setup, um, and how far away they live from the hospital and and various other things. And we've um, just been offering those families more support through the wider MDT through, you know, a nursing, um, time, extra support in the community. And I think also trying to be a bit more aggressive with those families in terms of their management. So predicting they may run into problems and supporting them with the best management that will be doable for them at home. Um, in this data, the it wasn't an independent variable in itself, socioeconomic group, it it affecting outcome, but you know, when we'd remove other factors, it then became a a dominant variable. So it's it it's actual impact on outcome is a bit unclear. I think it's probably more not a direct um, a direct influence or an outcome. It's more that that the family setup, um, and the socioeconomic group has an impact on on the child's progress over time. Fantastic. Thank you so much. Perfect timing. All right. Great. Thank you Dr. Ford. So now it's time for the voting for the end of this heat. Thank you for coming to present here. So we're going to throw all the presentations up and uh sort of see uh what people think. So everyone's going to vote, we'll take some time. Uh and while we're waiting for this to adjust and it's uh moving already. Um, I I thought this heat was phenomenal. Um, you know, really addressing the biggest problems we have. That's what was great about this. Um, um, all the way from Cloaca to Cheswall to uh esophagus. I love challenging surgical dogma. so that's uh That was great and then as somebody who does a lot of esophageal, the uh the the prospect of getting a replacement for the esophagus is boy, do we need that a lot. That will be one of the most gamechanging uh things ever. All right, well, it looks like we'll things are still moving and we could we have seen it happen where it's changed even after we announced it. Um, but it looks really close. it's very close. Uh, but it does look like, uh, peop it looks like Dr. Ford, uh, the uh cloaca paper. So it looks like people like cloaca. Uh, so uh Dr. Ford, congratulations on that. Um, and uh we'll enter you into the next heat. So, uh, first of all, Natalie, thank you for being up in the middle of the night. It's uh and thank you for Yeah, and happy birthday. And happy birthday. Thank you very much. All right. Thanks everybody.