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 UUPSA Children's National in, Washington, and the European Journal of Pediaiatric Surgery reports. We are also happy to have 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 Chaviso, 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. All right, Mark, um, We changed gears to Hirschberg's disease. Um, this is a 2 year old boy with prior pull through, has now obstructive symptoms, had, um, recurrent episode of enteroculitis. Um, responded to irrigations, um, and now you did this, um, contrast study from below and, um, Yeah, this is obviously not looking right. So, um, yeah, what is, what is striking you in this, uh, in this image? So I just want to, um, uh, yes, we're switching gears to now Hirschprung's, and this is the, one of my favorite topics is the problematic Hirschbrungs. I think everyone feels that most cases of Hirschprung's go extremely well, and it's frustrating when a Hirschprung's patient does not do well, but when they don't do well, we need to figure out why they are not doing well. And I wanna also, uh, thank the panel. Um, we have, um, our Uh, main moderator is Martin Lauer from, uh, Leipzig, who's helped coordinate this activity with, uh, UPSA and the, uh, European Journal of Pediatric Surgery case reports, Carlos Reck, yeah, from Vienna, uh, Austria, um, we have Alejandra, uh, Villanova from Madrid, Spain, and Paula Midrio from, uh, Treviso, Italy. Uh, Julia Brizigheli from Johannesburg, and you'll note the South African Italian accent because she is also from Milan. And Thomas Wester from Stockholm, and I'm Mark Levitt from Washington DC and I really appreciate uh Yupa inviting um someone from the United States to, uh, to join you. It's not often that we get such a warm welcoming, uh, from being from this country, and I really appreciate, uh, being able to be with you today. Great. So, um, so this is a typical scenario. You have a 2 year old with Hirschprung's disease who's had a pull through and is misbehaving. And what I mean by that is he is having obstructing, obstructive symptoms. He's having recurrent episodes of enterocolitis. He is successfully able to resolve those episodes with irrigations. However, the episodes keep happening. And now the time has come for us to really figure out what is wrong with this pull through. So, uh, maybe we can get an opinion. Alejandra, do you have some thoughts about this image? Sure. Um, so here we can see a narrowing of the distal column and a very dilated proximal column. There is a change of size in the left column that whether could be because a twist or a stricture. I don't know if the baby had a colostomy prior to the pull-through. Or it's just some tensional issue with the pull-through or as I said, a twist. Let's, um, let's go to the next slide and pose the question to all the viewers. So I will tell you that patient only had a primary pull through, um, no colostomy. So the possibilities are Uh, retained suave cuff, a mega Duhamel pouch, retained a ganglionosis, a twisted pull-through, or a stricture. So I want everyone who's looking on to commit to one of the answers. And then we maybe we'll have Paula give her opinion. So if, uh, I assume that we know which kind of uh operation he had, because if he had a Duomel then we. Your thinking goes in one direction, although this aspect, radiological aspect is not typical for a damel retainer pouch, so it looks like more uh as a twist, a twisted portal. Yes, and I think everyone, um, everyone on the chat has agreed that it looks like a twist, um, um, although I do like the fact that Carlos, um, um, has asked us. Uh, for a lateral, I also really like to see a lateral, and the lateral is really valuable if in fact it's a, um, it's a cuff, um, because you can see an extra space in the presacral location, um, but it was not, this was a suave, but the suave seems to have been done well from the suave point of view. It was, um, obviously not a Duhamel pouch. Uh, retained a ganglinosis is certainly possible, but it doesn't really explain the anatomic finding on the contrast study. And a stricture in that location does not make sense. Although Alejandra wanted to know something about whether there was a preceding colostomy, so that was a good thought. Maybe it's a colostomy stricture, but the patient never had a colostomy, so that one could be ruled out, and it's a twist. And let me show you what this looks like in another case, we can go to the next slide. So, um, it's a different case, uh, um, and the, you can see this, um, cutoff, very distal that never goes away on any, uh, image. Somehow, the pull-through was twisted as it was brought through the pelvis. And, um, this is a great picture of the twist in, in a, in a bird. Um, and one of the cases that I operate on for a twist looked like that. It looks like literally a corkscrew going down into the pelvis. So, let's pose some questions with the next slide. OK. So let's just, let's discuss this. Martin, what is your approach to avoiding a twist? So, uh, my approach is to do, never do pure transanal Hirschberg's pull-through. I always do laparoscopic dissection from above, and then after the pull-through, do laparoscopy again and make sure the mesenterior is posterior. And um I have actually a very nice video of a twist, uh, which was then appreciated with laparoscopy during the operation and then de-twisted and then we did the anoplasty. So laparoscopy, I think is the, is the key to me. Now, Julia, when you do a twist, do you do it the other way because you're in the southern hemisphere? I was thinking of that. Surely I do. OK, so, um, does anyone else want to give their ideas of how to avoid a twist? If, if you go, laparoscopically, you, you're safer, but if you still want to go only transenal, as soon as you detach some of the rectum, you put a stitch of a different color at 12 o'clock or 66 o'clock, you decide, and it stays there, has to go. Um, has to be your marker, that, that is the original orientation. Let me go to the next slide. I wanna show Paula's technique. You can see, um, um, here in this case, I think to um demonstrate Paula's idea, we put a stitch. Exactly in the midline, and again you can choose the top or the bottom, and I actually put several such stitches and make sure that they remain aligned, but I can promise you, you can still do a twist. You can still do 360 degrees. So go, go back, back one slide, Gaia, please. One back one. OK, um, Tim, what is your trick? At the end of the procedure, what you can do is to detect a twist if you think you made one, just to put a Hager into the colon to see if it passes easily. Yes, and I also think to reaffirm what Martin said, even when you're doing it laparoscopically, you can still twist it, but at least you can watch and double check the pull-through with your laparoscopic view. OK. Now, this is an interesting question. In this particular case, there is clearly proximal dilatation above the twist, but is that always true? Has anyone seen a twist in which the patient did not have proximal dilatation? Can the twist be intermittent? Rather partial instead of intermittent, probably not 360 or like 180 or something like that. If that's the case, maybe it won't be dilated proximally, and sometimes it's very hard to know that that's what happened because you don't see proximal dilatation. You have to be suspicious of it. I can tell you I've had the circumstance where I looked at a contrast study and it appeared normal, and then I examined the patient under anesthesia because something I knew was wrong with the pull-through. And then in retrospect, I re-looked at the contrast study, and then I saw that there was evidence of a twist. And the point I want to make here is, how do you do a rectal exam in a post pull through Hirschprung's patient to detect whether or not there is a twist. So, what I do is I do a rectal exam and I like to palpate my finger by putting my hand on the abdomen. And if I can feel inside the abdomen, then I know there's no twist. However, if there is tissue between me, my finger, and my hand, and it sometimes feels abnormal and you can't quite get into the abdomen, that's evidence that there may be a twist of the pull-through. So it's not so easy to detect, but if you do a careful exam and a good contrast study, you might find some of these. But Mark, can I ask you, in a, in a 2 year old boy, which is probably 15 kg 14 kg weight, my index finger is only 7 centimeters long or 8, so I might not, well, yours is longer, and pin is longer too. So, but my finger might not be able to reach the twist. And so the the. The attempt to feel your finger on the abdomen in a 2 year old may not be possible even if it's not twisted, you know what I mean? Because my fingers short. I mean, for a two year old. I, I understand that limitation, and if that's the case, you may need to do a rigid sigmoidoscope or look, make sure you look in and, uh, or a flexible sigmoidoscope and make sure you don't miss a twist. OK, um, because we're talking about Hirschprung's, I wanted to, um, discuss another technical challenge, and that is if you have a size discrepancy between your colocolonic anastomosis, the colon part of the pull-through, and your, um, colon that's just above the anal canal. What happens? If there's a big circle that's being connected to a small circle, does anyone have any advice for that situation? Uh, Thomas, do you have any recommendations for that technical problem? Well, I, I, I think it's, it's quite a common situation that there is a discrepancy between the size of the proximal colon and the, and the anal canal, but I, I think that usually it, if, if the, it's not too much of a discrepancy, it's Possible to, to, to placate the proximal colon and, and to adapt it to the to the anal canal and I, I think long term that will uh The, the, the discrepancy will, will get less and less. Anyone else? Tim, do you have any thoughts on this technical problem? Um, if the colon is too wide, maybe you should go somewhat higher up where it's more, um, Not so white, it's more thinner. Or you do application, but then it's a very uh difficult anastomosis to make them. I didn't mean to, I, I, I was meaning to do not placate in one location, but to try to do a harmonic anastomosis without. Uh Too much of a discrepancy. Not, not to do a formal application in one location. Martin, you want to show us something? I'm not sure whether. So, we did the first pictures of the anoplasty and then this is the laparoscopic view again, and you see the mesentery running actually over the, uh, the rectum. And now, You recognize it and you deep twist it until it looks right again, and that's why I like actually the The laparoscopic approach to to Hirschberg's. That's beautiful. Very nice. It doesn't look super smooth. Martin, this was after your anastomosis or only at the beginning of the anastomosis, this was just after the, this was just after the 12 o'clock stitch. Ah, so one stitch only. Yes, if, if a 12 o'clock switch of anoplasty and then. I predict that if I would have made a twist, I would have only realized it after I had completed the anastomosis. The fact that you realized it before you complete the anastomosis speaks to the German efficiency. OK, my one question that I had asked before, if you can go to the next slide, I want to show you a very nice trick. It's very useful when you have a big to small circle. Um, next slide. Yeah, so what I do here is I put a stitch from at 12:00, 6:00, 3 o'clock, and 9 o'clock as the first step. And then I take all 4 of those and put them on mosquitoes. And then I hold the mosquito apart. I hold them away from each other. Which straightens out the size discrepancy. And then I put a stitch in the very middle of that and put it on another mosquito. And then I do the same thing with those two mosquitoes, and I keep dividing in half every time, and that is a really nice way to make a big circle connected to a small, small circle. I've done this in the abdomen too, if you have an atresia with a dilated valve proximal and a not dilated valve distal, and you want to make a circle to a circle. Of course, you can taper. I'm not a fan of tapering or placating in Hirschberg's disease because I didn't, I don't want any opportunity for stasis. So I do this circle to circle technique. Does this make sense to everybody? Yes. Yeah. Very good. So I, I, um, let's go to Julia for a summary. Yes. So, the suggested approach is to avoid the twisting of the bowel which is pulled through are, uh, so given by Martin Lacker is to never do a pure transcendent pull-through but rather do a laparoscopic assisted pull-through, um, to start with and then confirm that it's not twisted at the end of the operation before finishing the operation. Um, then Paula instead suggested to rather mark the rectum, uh, on the midline as soon as you detach it from any anchoring structure around. But in this way, it is still possible to do a twist of the pull through segment and the slots, uh, rather suggested to, uh, at the end of the operation, uh, after the anastomosis is done, test the patency of the anastomosis and test for twisting by placing a Hager into the ends. Um, it's sometimes very difficult to diagnose a twisting because sometimes it can be either partial or intermittent, and in this case what happens is that there's no proximal dilation, so at the contrast enema, so it might be very difficult to suspect it. Um, and, um, a trick suggested by Mark Levitt is when you examine a patient in which you suspect the presence of a twist from the contrast enema, you take the patient to theater, you do a proper EUA, and then you can do at the same time a PR and with the other hand, you can examine the patient from the abdomen. And if by doing this, you feel like there's a double layer, then you need to suspect that there's possibly a twist of the bowel which was pulled through. Um, um, another, uh, trick that was given, which is, um, um, not really related to a twist, but it's actually if you have a very dilated proximal column that you need to pull through an anastomos with the anus, which has a different size, um, so tricks that were suggested is trying to go a bit higher up where the bowel is not dilated. Application can be performed, but also an elliptical anastomosis can be performed by positioning initially the four main stitches in the 4 quadrants and then leaving the, not cutting basically the suture and then placing mosquitoes at the. Edges of the sutures and pulling the stitches out while placing stitches in between. This way, the anastomosis lies outside of the anus and it's very easy to make. I think that was a great 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. There are to share. Uh, I thank everybody for joining today, and I hope the Yupi community or the Facebook community or, or whoever, um, can watch this video finds this an interesting format. 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.