Decision making in pediatric colorectal surgery

So, welcome everybody to the um webinar, Decision Making in Pediatric Colorectal Surgery. Um, I have the privilege to moderate this collaboration of the um UUSA Children's National in Washington, and the European Journal of Pediatric Surgery reports. We are also happy to have uh Mark Levitt. He is Chief of Division of Colorectal and Pelvic Reconstructive Surgery at the Children's National Hospital in Washington DC. And on top, we have an expert panel that you will see later. Nature and during the session of colorectal surgeons, international colorectal surgeons, um, Julia Brizigheli, uh, from, um, Johannesburg, um, Paula Mitria from Treviso, Alejandra Villanova from Madrid. Uh, Pim Slots from Rotterdam, Carlos Reck from Vienna, and, um, our, yeah, how do you say, the heart, the, uh, of everything, Gaia Tamaro from the um UUSA office. So Mark, um, it's a big honor um to have you here, here today and that you share your knowledge and expertise in decision making in colorectal surgery. How are you today? I'm great, Martin. It's so nice to see you and I look forward to being together again when the world returns to normal. Great. OK, so let's jump right into it. Um, maybe Gaia, you can show the next slide. Um. You know, there's always, um, uh, every distal cholestergram is uh a big challenge, especially in inexperienced colorectal surgery. So Mark, let's say you have this distal cholestergram of this male RM patient, um, treated in the newborn period with a colostomy, and, um, how do you approach this um study? So I selected this image. It's one of my favorite images because I think it gives us an opportunity to talk a lot about the management of an anorectal malformation patient, of course, relative to the surgical plan. So maybe we could get our panelists to participate. Uh, Paolo What do you think about this image? OK, this is a later, later, um, image of a distal colostrogram, uh, that shows, uh, the whole, uh, sacrum, which is what, what we want to have in the picture, and, uh, there is a pinpoint at the bottom of the, uh, on the right that shows where the perineal area, um, is, and that's something we want to have in the picture. And then the whole, uh, column is, um, is shown that is, uh, uh, well distended. And then, um, if we are able to see, we can recognize a thin, um, projection, um, anterior to the column that joins another thin structure, which is the urethra, and then the second bulvos. Uh, contrast, uh, uh, image in front of the column, which is the beginning of the, um, like the, the, the bladder. So within this image, there are all the figures that allows you to say, uh, This is a, a well done colossogram. Yes, that was, uh, that was very good, um, very clear analysis. Paula just said a lot of very, very important things in a very short amount of time. Um, so a couple things I wanna, uh, look for here. First of all, you commented on the sacrum. It shows that it's a lateral image, but also I like this image because it shows me that the sacrum looks quite normal, um, and it does not look very foreshortened, which I think is an important thing to note relative to the patient's pelvic development and potential future bowel control, um. Let's, uh, let's delve into a little bit more deeply of where is the fistula and how do we determine whether it's bulbar, prostatic, or bladder neck. OK, Julia, can you, um, give some thoughts as to how you know this is bulbar, prosthetic, or bladder neck? Yes, uh, sure, I can. So, it is, uh, basically what you have to look at is where does the fistula insert into the urethra. And a way to uh better and easily describe it is think of it, think of the urethra as an elbow. So if, um, of like an arm basically, so if the fistula inserts at the elbow, you can assume it's a recobulbar fistula, and if it inserts above the elbow, then you can assume it's a prostatic fistula in the midline and then higher up, you can assume it's a rectal bladder neck fistula. Very good. And then the other thing I would like to um um comment on, maybe, uh, Thomas from uh uh from Stockholm has joined us. Hi, Thomas. Nice to see you. Um, um, something very interesting here is how is the bladder filling? Does that have any meaning to you, whether you can get the bladder to fill or not? Uh, yes, I, I think it has, and I, I think normally with the rectobulbar fistula, you would have a feeling of the, of the anterior urethra. And in this case, you have this contrast. A bit about the junction between what I think is the fistula and the urethra. Which means that there is contrast coming back up towards the bladder. Yeah, so your observations are quite correct, and I think it's an important thing to note. If you can fill preferentially the bladder, then the fistula is likely above the urinary sphincter. If you, if you fill the distal urethra only and not the bladder, then the fistula is below the urinary sphincter. So I think putting all of this together, Paula, Julia, and Thomas's contribution. I'm gonna consider this a prosthetic fistula, um, and, uh, let's talk about whether how we're gonna manage this. I think, Gay, if you could just advance to the next, uh, slide, uh, good, perfect. So when I was at the Musee d'Orsay in Paris. Um, I was on the hunt for a good elbow. And this is a Rodin statue, and I thought it had a beautiful arm and elbow to use for this illustration. So this is what I saw, next slide. I saw this. I saw a bladder superimposed onto the man. And the urethra represented by the arm as uh Julia described. And the next slide. Shows us the different locations of the fistula just like Julia explained at the elbow, bulbar, at the humerus area, uh, triceps area, prostatic, and at the deltoid axillary area that would be, um, bladder neck. All right, so the main purpose of this case is to make a correct diagnosis. And then plan surgical treatment. So maybe we could um uh Gaia switch up a little bit and get Alejandro. In Alejandro, you, you were the one that uh taught me a very nice trick for figuring out whether to approach a rectum transabdominally or perineally, and when I say transabdominally, I mean. Either laparoscopically or laparotomy. Obviously laparoscopically if you have those skills and equipment, and perineally, I would mean posterior sagittally. So, this is a tricky one. How would you figure out whether to approach this, or how to approach this surgically? Well, um, in the lateral view, we can draw a line from the pubis to the coccyx, which is called the PC line, and you see, um, what is the first structure you will find posterior sagitally when you open up from the coccyx, from the coccyx to deeper down. And if the first structure you find is the rectum, So the rectum is easily reachable from a posterior surgittal approach. If the first structure is the urinary tract, then you will need to do laparoscopy to detach the rectum from the urinary tract. So, in this case, um, I can see the tip of the coccyx there. Yes. So, it's a tricky one. Um, but I think that it would be reachable from below. Um, mm. I don't know. It's a, it's a tricky, it's a tricky one. It's a tricky one. I put this case here because it's a tricky one. Yeah, so that's, that's called the puococcygeal line. We considered naming it the Alejandra line, but, uh, I think the PC line is maybe a name that would be more reproducible. Um, if you draw a line from the pubic bone to the coccyx, you get a good sense of where the rectum is. And maybe we can have Carlos uh Rec uh join us. And for his assessment. Yeah, so in this case we have a very nice angle from the urethra and the fistula. It would almost look like 90 degrees and there seems to be some space between the rectum and the bladder. So this makes it a case that could. be uh reachable through laparoscopy. So I think that's would be a case that uh where we can strongly consider doing laparoscopy first. Art, may I ask you this question? If you would do that, uh, with a PSAP and not with laparoscopy, where would you look for the fistula if you, in, um, relation to the coccyx? So this is the, this is the reason why I put this case is because it's really shows a very important distinction between what can be approached perineally and what can be approached laparoscopically. My personal assessment of this case is that Because of where the fistula is located. And it seems to be just at or above the urinary sphincter and therefore contrast quickly flows towards the bladder. We don't have the ideal representation of where is the true distal rectum. I don't know if you can see it, but there's sort of a flattening of the distal rectum, and I would bet that there's more rectum lower than that that you just simply can't see when the contrast is filling. But true, true enough, um, as Alejandra has noted, the rectum is above the pubococcygeal line. However, I don't think approaching this posterior sagitally is the wrong answer. Um, laparoscopically is very elegant. And maybe Martin, you can talk about some tricks relative to the point I'm about to make. The distal rectum, when it's nice and tapered, makes for a much easier laparoscopic case, but when it's very bulbous at the bottom, it's quite difficult. So that concerns me about this case. Now, in answer to your question, if I open posterior sagittally, I would look right under the coccyx, and I'm very confident that just under the coccyx I would find the distal rectum, and I believe that this could be approached posterior sagittally. In fact, I probably would try it because I don't like the bulbous nature to the rectum. What are your thoughts about the laparoscopic version of this rectal dissection? Well, I think, um, the, the, the key is to get good access to the fistula. So I, I hitch the posterior part of the bladder to the abdominal wall with a hit stitch, that's first of all, and then start very distally on the rectum, not to compromise the blood supply after the pull, pull through. And you're really the, the fistula, the, the, the, the, the rectum is like very wide and then suddenly it narrows down to get to the fistula, and you have to put almost a 5 millimeter like a weck clip or something over it. This has to be the diameter of the fistula until you divide it. If it's still too wide that you even need a stapler or something, you're not there. So you really have to get to the point where it's so narrow that you can place a clip over it almost. So these are my points. Thomas, or Thomas, do you have an opinion about uh closing of the fistula? What material do you like to use? But I, I have also mainly used absorbable sutures. Can you give us your thoughts about this? Yeah, I, I, I don't like to use the clip. That stays down in the, in the pelvis and, um, I, I like to use a vessel loop with a 3 millimeter um right angle or detector. You catch the fistula and actually, if you can catch it within, sorry, within a, uh, 3 millimeters, it's a reasonable 3 to 5 millimeters that a reasonable, uh, um. A small diameter to be the fistula, and, and once you hold it in the, uh, dissector, you cut it and then put the vessel loop um through the trochar in which you have cut the fistula and you close it over the sector, uh, like for uh an appendicitis where you tie it around the The, the loop. 11 very nice uh trick that Keith Jorgeson taught me is to put the um the Maryland dissector on the fistula, but before you do that preload it through the loop of the endo loop. So now it's the endo loop is already ready to go then you put the. Uh, Maryland over the fistula, and I agree with Martin. I like to make sure that a 3 millimeter instrument can completely close the fistula, otherwise you should do a little bit more dissection until it's thinner. Then you cut. And now over the vessel over the Maryland, you put the vessel loop that you have already prepared. It's a very nice, uh, very nice trick. Carlos, do you have a comment about this technical point? Uh, not exactly about the technical point, but what I wanted to remark is, uh, this is probably a high pressure distalustrogram. So even though it looks quite bulbous in this picture, I'm not sure once we look inside, um, it's gonna be that wide, and then I agree with Martin. I would also put a stitch to, uh, to the bladder to, to keep it away, and then you can have an easier dissection plane to go down to the fistula. OK, so let's uh come to some conclusions here. Um, let's take a vote. Who would approach this case with laparoscopy? Everyone is, so Martin, you would do laparoscopy? Yes, OK, and, and, uh, Carlos, laparoscopy, yes, I would at least, um, inspect and then probably try to do it laparoscopically. And, uh, Thomas, you're on mute. I, I, I would, would, would go for a PSA. PSAP. I'm gonna vote with Thomas. I would also go with the PSAP. Um, well, so we're 2 to 2, um, Alejandra. Yes, I wanted to say a little trick that I, that I sometimes do in this type of um borderline cases. I put a Foley catheter into the mus fistula before I start the PSA. And I have, I have some difficulties finding the rectum. I put some saline into the distal rectum to blow a little bit, the rectum, and it, it helps sometimes to help you find the rectum. I like that trick. That's a very nice trick. I love that. Um, can you vote laparoscopic or PSARP? PSAP. OK, so we're 3 to 2. Uh, Paula Peter. 4 to 2 and Julia, peace up as well. And Pim. Uh, I would do laparoscopy, and maybe if the dissection of the fistula is difficult, I would turn the baby, flip the baby, and, uh, do a Pop. So as you can see, um, we have 8, people that do a lot of colorectal surgery on the line, and we have perfect consensus on what the plan should be. I hope everyone is reassured how straightforward it is to do colorectal surgery. Um, no, I'm just kidding, and, and I can tell you this is the beauty of the field, but also I think what frustrates people is everyone wants protocols about the things that they don't have a lot of experience with. But everyone has a different feeling and they bring their own experiences to each case. And you see here that you have 8 very well thought out opinions, but they are somewhat different. But the truth of the matter is, if you dissect the fistula elegantly and don't injure it or don't cut it off too high, leaving behind a remnant. Of the original fistula, and you don't injure the urinary tract and you mobilize the rectum satisfactorily so there's no tension, that is success. However you would like to achieve that. By all means, that's the way to go, so you have to just respect the principles. So maybe we could have Julia give a little summary of what we talked about and we can then move on to the next case. OK, sure. I will try and give a summary. So, regarding the first part which was uh trying to interpret her at the high pressure disarcholostogram, so it's important to look at the sacrum and describe the sacrum, uh, describe the marker and um uh look at how distended the bowel is and, uh, visualize obviously the fistula if there is one and see the urinary tract. Um, it's, um, it's sometimes, well, like in this image, it's not very clear initially where it's the fistula, but, uh, then, um, to determine the position of the fistula, there are two things that need to be considered. One is the position of the fistula itself compared to the urethra. Uh, so comparing the urethra to an arm. And then the second thing is how filled the bladder is basically, which gives a hint of where the posses about the position of the fistula compared to the urinary sphincter. So if the bladder is seen easily, then it means that it's most likely a bladder neck fistula. If it's difficult to feel the bladder, then it's most likely a rectobulbar fistula. In this case, it was a prosthetic. And then the decision to approach it from the abdominally or from the perineum, it it really depends um on um Also on the surgical skills, but to have a quick, um, it's a quick, quick trick. You can draw a PC line again here and if the first structure you will find when you approach posterior surgitally at the level of the PC line is the rectum, then you can approach posterior saggittally. Otherwise, you should use a laparoscopy or laparotomy as a. The, the, the other thing I, I also want to point out is the, the score was actually 5 to 3. versus laparoscopy, but as is typical, maybe from a, uh, a soccer or football analogy, I think Julia would have preferred a 4 to 4, which is a tie. Italy gets more points for a tie, but a 5 to 3 is a win, right? Isn't that correct? You know, it's the wisdom of the crowd, right? Yeah, so the, the one thing I do want to comment is that we didn't talk about and then we can finish this case is on the distal colostrogram you can see that the original colostomy was done beautifully. It was done very high in the sigmoid, and there's plenty of distal bowel for the pull through. The most common mistake made at the initial colostomy. Is the choice of where to put the colostomy is done to distal and in this kind of case, if that were to happen at the time of the definitive repair, the surgeon really is potentially going to risk losing the rectum. And then having to be forced to pull through the colostomy. So please be careful to make your colostomy in the proximal sigmoid, so you have plenty of length for the ultimate pull through. Great one. case, what is, what is your take on this one? OK, so did, let's see if we learned anything. Well, I see, um, a very nice, uh, sacrum, very nice lateral image. There's, um, we're missing the, uh, perineal marker. And I don't know how much distal colon there is, but this is a very bulbous distal rectum. So let's see what everyone would do, um, but I think it's important to notice that just because the fistula is at the bulbar level, and I picked this slide intentionally, the rectum is actually much higher. Um, so don't only look at the fistula, also look at the features of the distal rectum. So likewise, this is a very dilated rectum, in fact, more dilated than the other case, which makes laparoscopy that much more difficult. But once again, the rectum is quite high and certainly above the PC line. But I think this case is, well, I'm not gonna say. Let's see what, so Martin, you choose PSAP. Yeah, but it gotta be tough. It gotta be tough. I would, I would make sure I was present in the radiology suite when the radiologist did the distal cholestergram. So, but, well, I'm torn between PSA and laparoscopy. I'm not really, OK, you, you, you can be torn, but the one thing about being a surgeon is you have to make a decision at some point. Thank you, sir. So, um. Let's, let's go with laparoscopy here because it's really very high. That's my. And by the way, for anyone watching this, um, once it's posted to Facebook, I want you to commit to your decision before you hear what everyone else has to say, because that's the, that's the fun part of medicine. All right, Thomas, Thomas, what would you decide? Well, I, I agree that the rectum is, is, is quite high, but I, when first when I saw it, I, I thought that I would try to go for a PAP anyway, but I, it is high, I agree. Paula, So, uh, if the, the column is too short to reach that we don't know, and you think you would detach the colostomy anyway, then I would try laparoscopically to dissect it. But if the colon is long enough, I would, I would go PSA first. OK, the colon is long enough, so you choose PSARP. Yes, still, yes. OK, Julia. Um, I think I would, I would go laparoscopy in this case, I think. OK, um, Carlos, laparoscopy laparoscopy for Carlos. All right, do we. All right, Alejandra, I would do laparoscopy in this case. Yeah, uh, Pim. Hi Tim. Hi, what's your the system seems to be working. Uh, I would do a laparosco laparoscopy also, also, OK, and I am going to choose PSAP. And the reason why I'm choosing PSARP is because I'm very nervous of dissecting this fistula with a very bulbous rectum in my way, and I think the fistula part is easiest through PSARP, and I believe that the rectum can be found, although I know it's going to be very high. So once again we have consensus, but now it's the reverse 5 to 3, but in the other direction, so. All we can tell you is that. It's not easy to make these decisions, but you need to go with what you feel you are most comfortable with, where your skill set lies, and there is no wrong answer here as long as you respect the principles that we've discussed. OK, very nice. Yes. Um, I think that was a great, uh, session. I really enjoyed it and also to having so many friends online at the same time. Uh, I did not expect it to be that long, but that tells me also how much lessons there are to learn and how much tips and tricks, um, there are to share. Uh, I thank everybody for joining today, and I hope that Yupi community or the Facebook community or or whoever um can watch this video finds this an interesting format, educational form format and um I guess I hope we have a, a, a new session um that, that is as much fun as this one. Mark, you wanna say something? So again, thank you all very much. It's always great to be together. Um, obviously we wanna be really together, but we need, um, one of your brilliant scientists in one of your countries to create a vaccine and then we can be together again. Um, we have a few more cases we'll do with another session. I think it's nice that each case is about 15 to 20 minutes and that can be then posted individually and um. Hope to see you again soon. Gaia will create a new invitation, um, and, uh, we'll do this again.