Patient driven change: Is collaborative care the future of medicine?

Journal of Pediatric Surgery 58 (2023) 189–197 Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg.org Journal of Pediatric Surgery Lecture Patient driven change: Is collaborative care the future of medicine? Lessons learned from the care of children with colorectal problems Marc A. Levitt Division of colorectal and pelvic reconstruction, Children’s National Hospital, 111 Michigan Avenue NW, Washington D.C. 20016, USA a r t i c l e i n f o Article history: Received 28 September 2022 Accepted 11 October 2022 Keywords: Anorectal malformations History Multi-disciplinary care Pediatric colorectal a b s t r a c t A basic premise in the care of complex patients is that experience, increased volume of cases, and an integrated, multi-disciplinary approach yields improved outcomes. Is this true using the example of the care of children with colorectal and pelvic reconstructive needs? This review gives a brief historical con- text on how care for this patient group evolved, delineates the key elements to create a collaborative care model, and describes multiple advances that have been developed, based on the model, which have improved patient care and quality of life. Level of evidence: Review. ©2 0 2 2 Elsevier Inc. All rights reserved. 1. Introduction It is clear when one considers pelvic anatomy that the con- cerns involving the patients’ colorectal, urologic, gynecologic, and GI/motility systems are intimately connected, as they relate both anatomically and physiologically. Clearly specialists in each field are needed, and ideally, they should coordinate their efforts, be- cause what happens in one system can affect the other anatomi- cally contiguous systems. Such an approach parallels many non-medical fields, for which collaboration is an absolute requirement. Consider for a moment the building of a new house. How would such a project start? I doubt that the electricians showed up one day, without consid- ering when the cement for the foundation needed to be poured. The project began most assuredly with all parties sitting in a room (physical or virtual) and developing a comprehensive plan. For the building of a house this strategy makes perfect sense. Why then do we not have a similar process in the medical care of complex patients? How often does a urologist consider doing a bladder aug- mentation and/or ureteral reimplantation without considering the effect of an impacted colon on the patient’s bladder function? The often-read children’s book Everyone Poops , by Taro Gomi [1] makes it clear to the children and their caregivers reading it that the physiology of stooling is one that needs to be thought about, and is an important part of a child’s early development. It should be required reading because most of the parents with new- borns diagnosed with a colorectal problem that I have seen never seem to have thought that their child could have a problem with Based on the Journal of Pediatric Surgery Lecture, British Association of Paedi- atric Surgeons, Birmingham, UK, July 14, 2022. E-mail address: mlevitt@childrensnational.org stooling; it is a physiologic function that is taken for granted. Once discussing that their child will need surgery to correct their col- orectal anatomy, all parents quickly focus on whether whatever surgery is needed, will ultimately create a reconstructed anatomy that will work and will allow their child to stool without difficulty or embarrassing accidents. As surgeons we must remember what it is that the family and patient wish for us to deliver to them, and we need to strive to achieve those goals. As proud of our surgical skills as we are, it is the functional outcome that matters most. References to pediatric colorectal problems go back many thou- sands of years. In fact, the Babylonian Talmud written in 200 C.E., recommends that “an infant whose anus is not visible should be rubbed with oil and stood in the sun…and where it shows trans- parent the area should be torn crosswise with a barley grain.” [2] Surgical techniques to manage such a patient have certainly evolved since that time, but the basic principles of care remain un- changed. A recent experience I had in clinic illustrates what we are up against but also what we can achieve in this field. A six-year-old girl who had undergone a newborn repair of an anorectal mal- formation came in with the complaint of soiling. She was being teased at school and was miserable. We told her that, after the bowel management week we planned for her, she would be clean and able to wear normal underwear. She gave the team that quizzi- cal doubtful look children often give to adults. One week later after implementing a successful enema program, the child entered the clinic again, now with a big smile and said, “You guys make good promises!” It is that moment, the culmination of complex care into a desired clinical result, that makes all the effort worth it. My path in this field began as an eager medical student when, in 1992 I signed up for an elective in pediatric surgery with Alberto Peña, one of the pioneers in the field of colorectal care. ( Fig. 1 ). I https://doi.org/10.1016/j.jpedsurg.2022.10.023 0022-3468/© 2022 Elsevier Inc. All rights reserved. 190 M.A. Levitt / Journal of Pediatric Surgery 58 (2023) 189–197 Fig. 1. Marc Levitt with Alberto Peña during his medical school elective, 1992. had no idea that the month I was about to spend with him would be the start of a 30-year journey. That experience changed my ca- reer trajectory in a very dramatic and positive way. I observed Peña providing all aspects of care for a complex group of patients, and was in awe, and inspired. He would joke that if he answered a phone call from a patient who asked for the colorectal surgeon, or the urologist, gynecologist, psychologist, or social worker, he would reply “That’s me!” As I advanced in my training, I became more and more nervous that, particularly with my lack of formal uro- logic training, there was no way that I alone could provide a sim- ilar comprehensive level of service. In addition, as medicine was becoming increasingly complex, and other fields such as neonatal care, transplantation, and cardiology were benefitting from a col- laborative approach, I recognized that I would need help from key collaborators. A little bit of history of this field is instructive. The modern story of the care of patients with anorectal malformations began in the 1940s in Melbourne, Australia when Frank Douglas Stephens, following his training at Great Ormond Street Hospital, London, worked on defining the anatomy of children with anorectal mal- formations by diligently performing autopsies on twelve patients with these conditions. His-focus on this field led to major con- tributions on the subject [3] Prior to his ground-breaking work, the anatomy of such patients was only a concept that existed in surgeons’ minds, without anatomic precision, because no one had seen the anatomy with their own eyes. The anatomy was believed to look like the images shown in Fig. 2 , in the bible of pediatric surgery in North America, the textbook by Robert Gross [4] , which was, in retrospect, both oversimplified and inaccurate. Stephens, during his autopsy dissections came to several anatomic conclusions. First, that when no anorectum had devel- oped, the puborectalis muscle coalesced behind the urethra, and second, that posterior to that area, there was no muscular anatomy of surgical significance. The operation Stephens devised, involved identifying the urethra using a sound, then dissecting a space be- hind it to allow the rectosigmoid to pass anterior to the puborec- talis sling. A small incision in the perineum was made for the pulled-through bowel to exit and to create the anus. The dissection in front of the puborectalis to find the distal rectum was a blind maneuver ( Fig. 3 ). A little later, William Kiesewetter in Pittsburgh proposed his version of the sacral abdominoperineal pull-through using similar anatomic principles [5] . These ideas involving a sacral approach to the pelvis, had been promoted previously by several authors operating on adults [6] . Justin Kelly, one of Stephen’s trainees in Australia learned how to do this operation, and then travelled to Boston, USA for fur- ther training. At Boston Children’s Hospital in the late 1960 ′ s, he taught what he had learned from Stephens to the surgeons there, including another trainee, Alberto Peña. In addition to his expo- sure to Kelly and the faculty at Boston Children’s, Peña, along with other surgical residents, were greatly influenced by a master sur- geon, Hardy Hendren, who they travelled across town to the Mas- sachusetts General Hospital to watch. Hendren was the pioneer in the care of children with cloacal anomalies. After completing his training in Boston, Peña went to Mexico City in 1972 to become the head of surgery at the National Insti- tute of Pediatrics, at the age of 34. He tells the story that when he asked his new pediatric surgery faculty to choose an area of spe- cialization, no one choose colorectal, so he decided to take on that group of patients, and thus embarked on his revolutionary career. Peña at first applied the technique he had learned from Kelly to repair anorectal malformations, but he became increasingly frus- trated by the procedure because the maneuvers were blind, and they offered very poor exposure. Over time Peña’s incision grew longer and longer. This culminated in 1980, thanks to a collabo- ration with Peter Devries, who had come to Mexico City to work on these cases with Peña, with the first posterior sagittal anorecto- plasty ( Fig. 4 ) [7] . Peña presented his findings at a meeting of the Pacific Association of Pediatric Surgeons in 1980. This posterior sagittal approach opened a gift in surgery that kept on giving. It allowed for a true understanding of the pelvic anatomy and led to the care of many conditions which were pre- viously, to use Peña’s words, “too difficult to reach from above (via laparotomy) and too difficult to reach from below (perineally).” This new approach influenced the repair of cloacal malformations [8] , urogenital sinus [9] , pelvic tumors [10] , urethral problems [11] , reoperations for imperforate anus [12] and for Hirschsprung dis- ease (HD) [13] , a transpubic approach (splitting the pubis for com- plex genitourinary problems inaccessible any other way) [14] , and a comprehensive strategy for the management of cloacal exstro- phy [15] . In addition to surgical innovations, and perhaps the one which has had the most quality-of-life impact was Peña’s concept to create a focused approach to the bowel management to treat fecal incontinence [16] . Because of such programs, now available M.A. Levitt / Journal of Pediatric Surgery 58 (2023) 189–197 191 Fig. 2. Images of anorectal malformations from the Gross and Ladd textbook 1942. Fig. 3. Images from the Stephens sacroperineal technique, 1953. Fig. 4. Diagrams of the posterior sagittal anorectoplasty (PSARP). at many centers across the world, thousands of children are no longer in diapers and no longer have their stomas, an impact per- haps comparable to the way intermittent catheterization has made so many patients dry for urine [17] . The medical care of children with colorectal problems is very difficult and to achieve success, patients with anorectal malfor- mations (ARM), Hirschsprung disease, fecal incontinence (related to a variety of conditions), and colonic motility disorders, require care from a variety of specialists throughout their lives. These in- clude providers in the fields of colorectal surgery, urology, gyne- cology, gastroenterology, motility, orthopedics, neurosurgery, anes- thesia, pathology, radiology, psychology, social work, nutrition, and many others. Vital to their achievement of a good functional result is a patient’s connection to superb nursing care. I often say that a complex colorectal operation takes about four hours to perform, but to get a good result, it takes an additional 96 hours of work –t h e vast majority of which involves nursing care. From the very beginning of my time in the field of pediatric colorectal surgery, the value of good nursing partners was clear to me. Their skills in identifying problems, solving them, being willing to get down 192 M.A. Levitt / Journal of Pediatric Surgery 58 (2023) 189–197 in the weeds, and always striving to fill the gaps, are unique. I am so convinced, and often shout from the rooftops, that with- out my nursing partners, I would have achieved very little as a surgeon. The collaborative care model is certainly not unique. It has been shown to be successful in many areas of pediatric surgery, in- cluding bariatric surgery, ECMO, fetal surgery, transplant surgery, trauma, and vascular anomalies to name a few. Recently attempts to quantify the value of the collaborative model have been de- scribed. Some of these include the care at specified centers for pa- tients with biliary atresia [18] and bladder exstrophy in the United Kingdom [19] , that country’s recent GIRFT report about special- ization in pediatric surgery [20] , pediatric oncology care in the Netherlands [21] , an initiative through the American College of Sur- geons for adults with rectal cancer [22] , and the effort in the Eu- ropean Union to create rare disease Reference Networks [23] . Consider the time of your pediatric surgery training. During those years you may have performed on average 10 esophageal atresia repairs. You now embark on your career as a surgical at- tending and can expect to perform one esophageal atresia repair per year. So, in a career spanning 30 years, that is approximately 30 cases. Now imagine this scenario; 30 esophageal atresia repairs are lined up for you to perform over the next two months. You get help from many experts throughout the experience, making small changes in your technique. At that 30th case in both situations will the repair be the same? Likely the concentrated experience would lead to small improvements in technique leading to a final case that is much better. It is this level of experience for complex surgi- cal problems that is essential to develop new ideas and to improve outcomes. How does an institution go about creating such a multi- disciplinary program? The first step is to obtain unique skills – create the team that will surround the patient to solve whatever problem needs to be solved. It is vitally important then to define hospital impact. Will the hospital benefit from new surgical cases, out-patient visits, radiology studies, etc. Will providing unique care for a complex patient population bring additional revenue to the hospital? Will such an approach enhance the hospital’s reputa- tion? Will the effort save costs by improving outcomes? The pro- gram should establish metrics to show progress, i.e. new cases at- tracted, downstream revenue, cost savings (by reducing emergency room visits, admissions, re-admissions, and/or reoperations), clin- ical outcomes, quality improvement, patient satisfaction, and staff satisfaction. The personnel needed to create the center should be defined – doctors, nurses, coordinators, etc. The marketing team needs to engage to get the word out that a new clinic has been established. This process for a colorectal center has recently been reviewed [24] . In the field of colorectal and pelvic reconstruction the multi- disciplinary approach has led to numerous advances. These include new techniques and ideas that over time have made a dramatic and positive impact on the care and quality of life of children, who suffer from colorectal problems. 2. Prenatal diagnosis Prenatal diagnosis of anorectal and cloacal malformations has been progressively improving. Perinatologists have learned to look for specific findings such as a pelvic mass, in a female, with a single kidney and think about a cloaca. Assessment of perineal anatomy, pubic bone integrity, sacral development, abnormalities of the radius bone, as well as cardiac, spinal, and renal anomalies all may clue in the clinician to considering that a fetus may have an anorectal malformation [25] . 3. Newborn management Care of the complex newborn has dramatically improved as neonatal techniques have advanced [26] . Specific to the colorec- tal patient have been advances in radiology –e . g . assessments of hydronephrosis, 3D reconstruction of cloacal anomalies [27] , ultra- sound guided distal colostography [28] , as well as improved tech- niques in the management of hydrocolpos and stoma care. 4. Urologic anomalies The importance of recognizing urologic anomalies cannot be overstated. With excellent urologic care chronic renal disease is diminishing, and proactive bladder management is reducing the need for bladder augmentations and renal transplantation [ 29 , 30 ]. 5. Gynecologic concerns Understanding the importance of a gynecologic collaboration has helped clinicians define the Mullerian anatomy and better plan for menstruation, sexual function, and future obstetric potential. [ 31 , 32 ] 6. Informing the conversation with families on future continence To allay parent concerns relative to the future continence of their child, understanding associated problems with the sacrum and spine has allowed clinicians to have a more robust conversa- tion with families, even in the newborn period, about their child’s future [33] . 7. Newborn surgical interventions In patients with anorectal malformations the desire to perform a primary newborn operation must be balanced with the need to know exactly where the rectum is located. At this point the distal rectal anatomy in males, unless a perineal fistula is visible, cannot be known without a distal colostogram, which obviously needs a colostomy present to perform. In most females except for a cloaca, a primary newborn operation is possible. The decision of whether to do a newborn repair vs. a colostomy, must be guided by the surgeon’s experience and the clinical circumstances in which they find themselves [34] , and often a colostomy is the safest initial op- eration. In the case of Hirschsprung disease, to do a primary new- born repair, surgeons are dependent on good quality pathology (to avoid a poor outcome and the need for a reoperation), which is a skill not available in many parts of the world [35] . 8. Defining the anatomy Surgeons should describe the anatomy of an anorectal malfor- mation in an understandable and protocolized way, as this will in- fluence the operative approach chosen and the clinical outcomes expected ( Fig. 5 ) [36] . 9. Minimally invasive approaches Laparoscopy has dramatically advanced pediatric surgery, but it is vital to understand in which cases it is best used [37] . If one draws a line from the pubic bone to the coccyx, the PC line, this anatomic guide helps decide on the operative approach –i f the rectum lies below this line, it is reachable from a posterior sagittal incision and laparoscopy is not needed. If the rectum lies above this line, laparoscopy is the ideal approach ( Fig. 6 ). If a rectum that is too low is approached from above, complications such as leaving M.A. Levitt / Journal of Pediatric Surgery 58 (2023) 189–197 193 Fig. 5. Defining the anatomy for rectourethral fistulae. Fig. 6. The pubococcygeal (PC) line to determine if a rectum should be approached laparoscopically or via PSARP. behind the distal rectum, a remnant of the residual fistula (ROOF) can occur [38] . In HD cases, laparoscopy can avoid an abdominal incision and also limit the stretching of the sphincters which can occur during the transanal rectal dissection [39] . 10. Cloaca management Before recent work in this field, the common channel length guided the decision on how to perform a repair of a cloacal mal- formation, with a total urogenital mobilization a major tool in this reconstructive effort. However, it became clear that a total urogen- ital mobilization done for a cloaca patient with a short urethra (less than 1.5 cm), would lead to an anatomic situation whereby the bladder neck is left at the perineum and below the urogenital diaphragm, leading to urinary leakage. Or, if a total urogenital mo- bilization were done for a high confluence cloaca which does not reach, then a urogenital separation is needed which can lead to urethral loss, since the anterior aspect of the common channel had already been dissected. If the surgeon defines both the common channel and the urethral length and plans accordingly – making sure the urethra remains at least 1.5 cm at the end of the cloa- cal repair - these complications can be avoided. A total urogenital mobilization for the appropriate case offers a reconstruction that provides an accessible urethra that is of adequate length, and if the urethra is short, a urogenital separation makes the new ure- thra a combination of the common channel and the native ure- thra – preserving an adequate length urethra and the bladder neck [40–42] ( Fig. 7 ). 11. Complications after surgery for anorectal malformation and hirschsprung disease The morbidity following operations for ARM are significant. To understand why this, consider the image of a sand timer. When one does a PSARP for example and completes the operation but inadvertently places the anus in the wrong place relative to the sphincters, when would the surgeon know this complication has occurred? Likely not until the anoplasty is put to the test –a n d the child cannot achieve bowel control. How is a surgeon supposed to modify their technique for the next operation, if they only realize their misadventure four years later? Reoperations for anal mis-location, stricture, rectal prolapse, and a ROOF may be required. If the anatomy is restored, patients can achieve fecal continence [43] [ Fig. 8 ]. Re -do surgery for HD 194 M.A. Levitt / Journal of Pediatric Surgery 58 (2023) 189–197 Fig. 7. If urethral Length is > 1.5 cm (A and B) a total urogenital mobilization can be done, if < 1.5 cm (C), the cloacal repair will need a urogenital separation. Fig. 8. Results following redo for ARM patients with anal mislocation, stricture, prolapse or remnant of the original fistula (ROOF). re-do surgery for retained transition zone, stricture, retained cuff, dysfunctional Duhamel pouch or a twist can improve flow and resolve obstructive symptoms [44] . Of course, the main objective should always be to get the best initial operation possible and to that end, improve the training of surgeons with a focus on how to avoid key pitfalls in the surgical repairs. For patients with ARM, recent advances in the primary technique include a posterior rec- tal mobilization with avoidance of the anterior wall altogether for perineal fistula which avoids any periurethral or posterior vaginal dissection [45] and a modification of the traditional PSARP for rec- tovestibular fistula which avoids any perineal body incision, which can thus avoid the feared perineal body dehiscence [46] . For pa- tients with HD, injury to the sphincters was previously a guarantee of fecal incontinence, but recently a technique of sphincter recon- struction is showing promise in restoring continence [47] . 12. Management of constipation and fecal incontinence Understanding what causes fecal incontinence, what amount of incontinence can be anticipated, and what are the surgical con- tributors to achieving continence, is vital in the management of this patient population [48] . The application of bowel management techniques has been a major advance in improving patients’ qual- ity of life which benefits from an institutional commitment par- ticularly to providing a nursing team is a growing trend that will help many patients. Long term results, including patient reported outcomes, were recently published, are very positive but require a deep team and a labor-intensive effort [ 49 , 50 ]. A better understanding of motility disorders has developed be- cause of the vital collaboration between surgery and GI/motility. The clinician must know when to use medical management with laxatives, when enemas (retrograde and antegrade) are appropri- ate, and the possible techniques for antegrade access. A key deter- minant of care is defining what “failure of medical management” means, and when to offer surgical interventions. These include botulinum toxin for internal sphincter achalasia, antegrade access for colonic flushes, and removal of dysmotile segments guided by an objective assessment of colonic function [ 51 , 52 ]. New data has shown that antegrade works in the vast majority of patients, and that segmental colonic resections are only rarely necessary [53] . M.A. Levitt / Journal of Pediatric Surgery 58 (2023) 189–197 195 13. Surgical collaboration between colorectal and urology Developing a collaboration between colorectal surgery and urol- ogy is vital to plan for both systems’ management in parallel. For example, an opportunity could arise to use a segment of colon for a bladder augmentation, simultaneously improving the ability to empty the colon and bladder capacity during the same operation. Similarly, the appendix can be shared and used for both the Mal- one ACE and Mitrofanoff procedures [54] . This proactive planning has improved the lives of many patients, has reduced the numbers of operations these patients need, as well as their hospital stays [55] . 14. Sacral nerve stimulation Sacral Nerve Stimulation (SNS) has shown great promise in the management of urinary incontinence and seems to also have a role in improving fecal continence and promoting motility as an ad- junct to treatments for constipation [56] . 15. Transition of care to adulthood As with congenital heart disease and cystic fibrosis, colorectal surgeons are obligated to develop a transition plan for their pa- tients as they enter adulthood. This entails training and recruiting adult providers to collaborate with the pediatric team [57] . 16. Basic science: tissue engineering and genetics Much work is being done in the basic science aspects of col- orectal surgery. Tissue engineering is poised to revolutionize the field. The day when a cloacal reconstruction could be based on a previously tissue engineered segment of vagina, produced by the patient’s own stem cells, is now on the horizon [58] . In addition, the genetics of anorectal malformations as well as Hirschsprung disease are being vigorously pursued which will impact parental counseling and potential therapies [ 59 , 60 ]. 17. Data and working within consortiums Common in industry but rare in medicine, keeping track of complications as well as outcomes will allow for real-time adjust- ment of protocols which will improve results [61] . A great exam- ple in colorectal is to track wound infections as a routine audit, and with that data observe efforts to reduce surgical site infec- tions such as adopting a GI bundle or changing preoperative antibi- otics. Such data efforts can show trends and affect outcomes [62] . An initiative to track such data across institutions, the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC), www.pcplc.org [63] has yielded very positive results, and can help patients in a way not achievable by a single institution. When a positive change is realized, the new idea can be spread quickly. The PCPLC also allows nursing and advance practice providers the opportunity to collaborate and share best practices in bowel management and in- patient care. 18. Care in under-resourced areas There is a great deficiency in advanced colorectal care through- out the world, particularly in the developing world. The care of colorectal patients in a resource limited setting has unique chal- lenges which must be understood, and creative solutions by in- novative surgeons in those areas have a led to dramatic improve- ments in care. Some such examples include the management of Hirschsprung patients without the help of pediatric pathology by opening a colostomy in the dilated part of the colon and then pulling through that segment which has been demonstrated in vivo to work for the child. Also, operative techniques to make the anoplasty in a patient with an anorectal malformation larger antic- ipates avoiding a significant stricture if there is a lack of follow-up [64] . The complexity of care of such patients requires an organized approach to bring order to perceived chaos. A recent writing on this idea that is particularly applicable to the care of children with anorectal malformations comes from my daughter, Jess Levitt, and it is reproduced here: “A” must come before “B,” which must come before “C,” everybody knows that. But what if the Millercamp’s of this world did not have to sit next to the Millerchip’s when it comes to seating arrange- ments? Can Pat Zawatsky be called before Jack Aaronson when the teacher is taking attendance? Do those 26 letters that make up all the dialog, signs, thoughts, books, and titles in the English-speaking department of the world need their specific spots in line? Everyone can sing you the well-known jingle from A to Z, but not many peo- ple can tell you why the alphabet is the way it is. For almost as long as humans have had the English language, they have had the alphabet. The good ole ABCs. However, the alphabet represents the human need for order and stability. I believe that the same thinking that went into the construct of time and even government went into the alphabet. Justifiably, lack of order leads to chaos. Knife-throwing, gun-shooting chaos, in the case of lack of governmental order. Listen to me when I tell you that there is absolutely no reason that the alphabet is arranged the way that it is. Moreover, the alphabet is simply a product of human nature and how it leads people to establish order for things that do not require it. Now I know this sounds crazy, but bear with me. Only if you really peel away the layers of the alphabet will you find the true weight it carries. People organized the letters of our speech into a specific order simply because there wasn’t already one. Questioning this order will enlighten you on the true meaning of it. Really dig deep into the meaning behind the social construct that is the alphabet. Short and sweet as it may be, the order of the ABCs are much less than meets the eye. There is no reason that “J” should fall before “K!” Understand this. Very important as order is, it i so n l yar e s u l t of human nature. What’s next? X-rays become independent of Xylophones in chil- dren’s books of ABC’s? You know what the best part is? Zero chance you even noticed that each sentence in this essay is in alphabetical order [ 65 ]. 19. Conclusions Presenting the Journal of Pediatric Surgery Lecture at the BAPS is particularly poignant to me as it was Sir Denis Browne (who is honored with the highest award BAPS bestows) and who said, “The aim of pediatric surgery is to set a standard, not to seek a monopoly.” For caregivers who commit to helping children with colorectal and pelvic problems, seeking a high standard requires a deep understanding of the daily struggle it take to deliver on the goal of improving a patient’s quality of life, which benefits from a collaborative care model. I firmly believe that if a multi- disciplinary approach focused on collaboration and good outcomes can be applied more broadly to other parts of pediatric surgery and beyond, the lives of many more children will be improved. Pa- tients deserve this level of care, and will drive this change once the benefits are realized. 196 M.A. Levitt / Journal of Pediatric Surgery 58 (2023) 189–197 Funding None. References [1] Gomi T . Everyone poops. Chronicle Books; 2020 . [2] Talmud B., Tractate Shabbat. 200 C.E. [3] Stephens FD . Imperforate rectum: a new surgical technique. Med J Aust 1953;2:202 . [4] Gross R . The surgery of infancy and childhood. its principles and techniques. Philadelphia: W B Saunders Company; 1953 . [5] Kieswetter WB , Bill AH , Nixon HH , Santulli TV . Imperforate Anus. Arch Surg 1976;111(5):518–25 May . [6] Westbrook KC , Lang NP , Broadwater JR , Thomson BW . Posterior surgical ap- proach to the rectum. Ann Surg 1982;195:677–85 . [7] DeVries P , Peña A . Posterior sagittal anorectoplasty. J Pediatr Surg 1982;17:638–43 . [8] Peña A . The surgical management of persistent cloaca: results in 54 patients treated with a posterior sagittal approach. J Pediatr Surg 1989;24:590–8 . [9] Peña A , Filmer B , Bonilla E , Mendez M , Stolar C . Transanorectal approach for the treatment of urogenital sinus: preliminary report. J Pediatr Surg 1992;27:681–5 . [10] Jimenez JM , Poustchi-Amin M , Leonidas JC , Peña A . Extraperitoneal ab- dominopelvic inflammatory pseudotumor: report of four cases. Pediatr Radiol 1997;27(2):170–4 . [11] Alam S , Levitt MA , Sheldon CA , Peña A . The posterior sagittal approach for recurrent genitourinary pathology. J Urol 2007;178(4 Pt 2):1668–71 . [12] Peña A , Hong AR , Midulla P , Levitt M . Reoperative surgery for anorectal anomalies. Semin Pediatr Surg 2003;12(2):118–23 . [13] Ralls MW , Coran AG , Teitelbaum DH . Redo pullthrough for Hirschsprung dis- ease. Pediatr Surg Int 2017;33(4):455–60 . [14] Peña A , Bischoff A , Levitt MA . The transpubic approach for the correc- tion of complex anorectal and urogenital malformations. J Pediatr Surg 2011;46(12):2316–20 . [15] Levitt MA , Mak GZ , Falcone RA Jr , Peña A . Cloacal exstrophy–pull-through or permanent stoma? A review of 53 patients. J Pediatr Surg 2008;43(1):164–8 . [16] Peña A , Guardino K , Tovilla JM , Levitt MA , Rodriguez G , Torres R . Bowel man- agement for fecal incontinence in patients with anorectal malformations. J Pe- diatr Surg 1998;33(1):133–7 . [17] Hardy AG . Experiences with intermittent catherization in acute paraplegia. Med Serv J Can 1966;22(7):538–44 . [18] Davenport M , Ong EP , Sharif K , et al. Biliary atresia in England and Wales: results of centralization and new benchmark. J Pediatr Surg 2011;46:1689–94 . [19] Durkin N , Davenport M . Centralization of pediatric surgical procedures in the United Kingdom. Eur J Pediatr Surg. 2017;27(5):416–21 . [20] Lansdale N, Goldacre R, Wilkinson DJ, Bower P. Balancing quality and equity of access in specialist neonatal surgery: implications of the GIRFT report. Br J Surg 2022:znac205 Jun 17Online ahead of print. doi: 10.1093/bjs/znac205 . [21] Wijnen MHWA , Hulscher JBF . Centralization of pediatric surgical care in the Netherlands: lessons Learned. J Pediatr Surg 2022;57:178–81 . [22] Garfinkle R , Vasilevsky CA , Ghitulescu G , Morin N , Faria J , Boutros M . Compli- ance with preoperative elements of the American society of colon and rectal surgeons rectal cancer surgery checklist improves pathologic and postoperative outcomes. Dis Colon Rectum 2020;63(1):30–8 . [23] Tumiene B , Graessner H , Mathijssen IM , et al. European reference networks: challenges and opportunities. J Community Genet 2021;12(2):217–29 . [24] Vilanova-Sanchez A , Halleran DR , Reck-Burneo CA , Gasior AC , et al. A descrip- tive model for a multidisciplinary unit for colorectal and pelvic malformations. J Pediatr Surg 2019;54(3):479–85 . [25] Bischoff A , Levitt MA , Lim FY , Guimarães C , Peña A . Prenatal diagnosis of cloa- cal malformations. Pediatr Surg Int 2010;26(11):1071–5 . [26] Shaul DB , Harrison EA . Classification of anorectal malformations–initial ap- proach, diagnostic tests, and colostomy. Semin Pediatr Surg 1997;6:187–95 . [27] Reck-Burneo CA , Lane V , Bates DG , Hogan M , et al. The use of rotational flu- oroscopy and 3-D reconstruction in the diagnosis and surgical planning for complex cloacal malformations. J Pediatr Surg 2019;54(8):1590–4 . [28] Chow JS , Paltiel HJ , Padua HM , McNamara E , Dickie BH . Contrast-enhanced colosonography for the evaluation of children with an imperforate anus. J Ul- trasound Med 2019;38:2777–83 . [29] Kruger P , Teague WJ , Khanal R , Hutson JM , King SK . Screening for associated anomalies in anorectal malformations: the need for a standardized approach. ANZ J Surg 2019;89:1250–2 . [30] VanderBrink BA , Reddy PP . Early urologic considerations in patients with per- sistent cloaca. Semin Pediatr Surg 2016;25(2):82–9 . [31] Breech L . Gynecologic concerns in patients with anorectal malformations. Semin Pediatr Surg 2010;19(2):139–45 . [32] Pradhan S , Vilanova-Sanchez A , McCracken KA , Reck CA , Halleran DR , et al. The Mullerian black box: predicting and defining Mullerian anatomy in patients with cloacal abnormalities and the need for longitudinal assessment. J Pediatr Surg 2018;53(11):2164–9 . [33] Skerritt C , Tyraskis A , Rees C , Cockar I , Kiely E . Early reported rectal sensation predicts continence in anorectal anomalies. J Pediatr Surg 2016;51:425–9 . [34] Shirota C , Suzuki K , Uchida H , Kawashima H , et al. Investigation of the feasi- bility and safety of single-stage anorectoplasty in neonates with anovestibular fistula. Pediatr Surg Int 2018;34:1117–20 . [35] Ekenze SO , Ngaikedi C , Obasi AA . Problems and outcome of Hirschsprung’s disease presenting after 1 year of age in a developing country. World J Surg 2011;35(1):22–6 . [36] Halleran DR , Ahmad H , Bates DG , Vilanova-Sanchez A , Wood RJ , Levitt MA . A call to ARMs: accurate identification of the anatomy of the rectourethral fistula in anorectal malformations. J Pediatr Surg 2019;54:1708–10 . [37] Tainaka T , Uchida H , Tanaka Y , Hinoki A , et al. Long-term outcomes and complications after laparoscopic-assisted anorectoplasty vs. posterior sagittal anorectoplasty for high- and intermediate-type anorectal malformation. Pedi- atr Surg Int 2018;34:1111–15 . [38] Rentea RM , Halleran DR , Vilanova-Sanchez A , Lane VA , et al. Diagnosis and management of a remnant of the original fistula (ROOF) in males following surgery for anorectal malformations. J Pediatr Surg 2019;54(10):1988–92 . [39] Stensrud KJ , Emblem R , Bjornland K . Anal endosonography and bowel function in patients undergoing different types of endorectal pull-through procedures for Hirschsprung disease. J Pediatr Surg 2015;50(8):1341–6 . [40] Wood RJ , Reck-Burneo CA , Levitt MA . Cloacal malformations: technical aspects of the reconstruction and factors which predict surgical complexity. Front Pe- diatr 2019;14(7):240 . [41] Wood RJ , Reck-Burneo CA , Dajusta D , Ching C , Jayanthi R , Bates DG , Fuchs ME , McCracken K , Hewitt G , Levitt MA . Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning. J Pediatr Surg 2017 Oct 12:S0022-3468(17)30644-9 . [42] Wood RJ , Reck-Burneo CA , Vilanova-Sanchez A , Levitt MA . Organizing the care of a patient with a cloacal malformation: key steps and decision making for pre-, intra-, and post-operative repair. Semin Pediatr Surg 2020;29(6):150988 . [43] Wood RJ , Halleran DR , Ahmad H , Vilanova-Sanchez A , et al. Assessing the ben- efit of reoperations in patients who suffer from fecal incontinence after repair of their anorectal malformation. J Pediatr Surg 2020;55(10):2159–65 . [44] Levitt MA , Dickie B , Peña A . Evaluation and treatment of the patient with Hirschsprung disease who is not doing well after a pull-through procedure. Semin Pediatr Surg 2010;19(2):146–53 . [45] Halleran DR, Coyle D, Kulaylat AN, Ahmad H, et al. The cutback revisited - the posterior rectal advancement anoplasty for certain anorectal malfor- mations with rectoperineal fistula. J Pediatr Surg 2021 2021 Dec 17;S0022- 3468(21)00845-9Online ahead of print. doi: 10.1016/j.jpedsurg.2021.12.014 . [46] Badillo A.T., Tiusaba L., Jacobs S.E., et al. Sparing the perineal body –a modifi- cation of the posterior sagittal anorectoplasty (PSARP) for anorectal malforma- tions with rectovestibular fistulae presented at the American pediatric surgical association, San Diego, California, May 2022. [47] Krois W , Reck CA , Darbari A , Badillo A , Levitt MA . A technique to reconstruct the anal sphincters following iatrogenic stretching related to a pull-through for Hirschsprung disease. J Pediatr Surg 2020 Dec 13:S0022-3468(20)30902-7 . [48] Rawashdeh YF , Austin P , Siggaard C , Bauer SB , Franco I International Children’s Continence Society. International children’s continence society’s recommenda- tions for therapeutic intervention in congenital neuropathic bladder and bowel dysfunction in children. Neurourol Urodyn 2012;31(5):615–20 . [49] Halleran DR , Lane VA , Leonhart KL , Fischer B , et al. Development of a patien- t-reported experience and outcome measures in pediatric patients undergo- ing bowel management for constipation and fecal incontinence. J Pediatr Gas- troenterol Nutr 2019;69(2):e34–8 . [50] Wood RJ, Vilanova-Sanchez A, El-Gohary Y, Ahmad H, et al. One-year impact of a bowel management program in treating fecal incontinence in patients with anorectal malformations. J Pediatr Surg 2021 May 8:S0 022-3468(21)0 0369- 9PMID: 34092385. doi: 10.1016/j.jpedsurg.2021.04.029 . [51] Di Lorenzo C , Youssef NN . Diagnosis and management of intestinal motility disorders. Semin Pediatr Surg 2010;19(1):50–8 . [52] Wood RJ , Yacob D , Levitt MA . Surgical options for the management of severe functional constipation in children. Curr Opin Pediatr 2016;28(3):370–9 . [53] Ahmad H , Smith CA , Lewis KE , et al. Antegrade continence enema alone for the management of functional constipation due to segmental dysmotility: a pediatric colorectal and pelvic learning consortium study. In: Proceedings of the American pediatric surgical association, San Diego, California; 2022. May . [54] Halleran DR , Wood RJ , Vilanova-Sanchez A , Rentea RM , et al. Simultaneous robotic-assisted laparoscopy for bladder and bowel reconstruction. J Laparoen- dosc Adv Surg Tech A 2018;28(12):1513–16 . [55] Vilanova-Sánchez A , Reck CA , Wood RJ , Garcia Mauriño C , et al. Impact on pa- tient care of a multidisciplinary center specializing in colorectal and pelvic re- construction. Front Surg 2018;5:68 Nov 19 . [56] Lu PL, Koppen IJN, Orsagh-Yentis DK, Leonhart K, Ambeba EJ, et al. Sacral nerve stimulation for constipation and fecal incontinence in children: long- term outcomes, patient benefit, and parent satisfaction. Neurogastroenterol Motil 2018;30(2) Epub 2017 Aug 10. doi: 10.1111/nmo.13184 . [57] Cairo SB , Gasior A , Rollins MD , Rothstein DH Delivery of Surgical Care Com- mittee of the American Academy of Pediatrics Section on Surgery. Challenges in transition of care for patients with anorectal malformations: a system- atic review and recommendations for comprehensive care. Dis Colon Rectum 2018;61(3):390–9 2018 . [58] Atala A . Recent developments in tissue engineering and regenerative medicine. Curr Opin Pediatr 2006;18(2):167–71 . [59] Teerlink CC , Bernhisel R , Cannon-Albright LA , Rollins MD . A genealogical as- sessment of familial clustering of anorectal malformations. J Hum Genet 2018;63:1029–34 . M.A. Levitt / Journal of Pediatric Surgery 58 (2023) 189–197 197 [60] Martins JL , Macedo M , Montero EFS . anorectal malformation: state of the art in translating experimental research to the bedside. Eur J Pediatr Surg 2019;29:368–70 . [61] Minneci PC , Kabre RS , Mak GZ , Halleran DR , et al. Midwest pediatric surgery consortium. screening practices and associated anomalies in infants with anorectal malformations: results from the midwest pediatric surgery consor- tium. J Pediatr Surg 2018;53(6):1163–7 . [62] Gonzalez DO , Ambeba E , Minneci PC , Deans KJ , Nwomeh BC . Surgical site in- fection after stoma closure in children: outcomes and predictors. J Surg Res 2017;209:234–41 . [63] Reeder RW , Wood RJ , Avansino JR , Levitt MA , et al. Pediatric colorectal and pelvic learning consortium (PCPLC). The pediatric colorectal and pelvic learn- ing consortium (PCPLC): rationale, infrastructure, and initial steps. Tech Colo- proctol 2018;22(5):395–9 . [64] Poenaru D , Borgstein E , Numanoglu A , Azzie G . Caring for children with colorectal disease in the context of limited resources. Semin Pediatr Surg 2010;19(2):118–27 . [65] Levitt J, Personal communication, May 2019.