Patient Driven Change; The Collaborative Care Model
With Dr. Mark Levitt & Dr. Kurt Newman · hosted by Dr. David Wessel
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The bladder, gynecologic system, and rectum are anatomically adjacent structures filling the pelvis, requiring coordinated care rather than separate specialist management.
Approximately 600 anorectal malformation patients are born per year in the United States.
Pediatric surgeons in training perform about 14 anorectal malformation cases during their 2-year fellowship.
A pediatric surgeon in practice might care for one anorectal malformation patient per year after graduation.
Regionalization of care is the only solution to ensure sufficient experience for managing complicated anorectal malformation patients.
Complications of anorectal malformations include fecal incontinence, urinary incontinence, renal dysfunction, sexual dysfunction, and infertility.
Patients from 25 states and 25 countries have been seen at Children's National Hospital's colorectal program in the last year.
Many patients with colorectal problems were not known to have urology or gynecologic problems until automatic evaluation by all teams was implemented.
Anorectal malformations can be classified by bladder neck, prostatic, and bulbar level based on anatomic definitions.
Fecal continence in anorectal malformation patients can be predicted based on type of malformation, quality of the sacrum, and quality of the spine.
In cloaca patients, urethra length and common channel length are important factors in outcomes.
Colostomy closure surgical site infection rate was 22% before quality improvement interventions.
Implementation of a GI bundle of care reduced colostomy closure surgical site infection rate to 7.9%.
Changing the antibiotic regimen further reduced colostomy closure surgical site infection rate to 2.2%.
Redo surgery to correct anatomy allows patients with poor continence potential to achieve their potential for bowel control.
Fecal incontinence problems can originate from the sphincters, anal canal sensation, or motility.
Gastroenterologists assess sphincters using anorectal manometry and assess colon movement using colonic manometry to guide surgical planning.
The appendix can be connected to the belly button to allow antegrade colonic flushes, overcoming fecal incontinence through a mechanical program.
Large colon segments that are not working manometrically may need to be removed, a decision that requires GI collaboration.
35% of patients who come for bowel management with soiling ultimately need surgical intervention.
Before the collaborative approach, a colorectal surgeon might address only the rectum in a cloaca patient, not coordinating with gynecologic and urologic needs.
In the collaborative model, colorectal, urology, and gynecology teams meet families together, examine patients together, and operate together in a single surgery.
The first colorectal center was launched in Cincinnati in 2005 with the recruitment of Dr. Levitt and Alberto Pena.
Access to care depends on capacity including staffing, administrative support, pre-authorization, scheduling, diagnostic testing slots, clinic space, OR time, and inpatient beds.
Telemedicine has changed the dynamic of colorectal care, allowing better long-term follow-up for patients who previously would have been lost to follow-up or unable to return for in-person visits.
Administrators should expect to see incremental growth within a year of launching a collaborative program, with increasing impact each subsequent year.
A 10 French device for Malone appendicostomy was developed through collaboration with industry, requiring FDA approval, to replace the previously available 14 French G-tube devices that were too large for the appendix.
Follow-up care for distant patients is managed through telemedicine calls at intervals and communication with local pediatricians or surgeons who handle much of the routine follow-up.
Dr. Mark Levitt has cared for children from all 50 states and 76 different countries.
Dr. Mark Levitt has performed more than 15,000 pediatric colorectal procedures.