From
Dr. Marc Levitt
Dr. Marc Levitt on building global pediatric colorectal surgery programs
With Dr. Marc Levitt · hosted by Dr. Greg Ryan
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
Episode 19 - Interview with Dr Marc Levitt, Chief of Colorectal & Pelvic Reconstruction, Children‘s
Marc Levitt · 54 min · Published Oct 2021
Podcast
Update Course Rewind: Pediatric Colorectal Consortium 2021
14 min · Published Apr 2022
Video
Malone appendicostomy in a Patient with Prior Abdominal Surgery via a prior abdominal incision
5 min · Published Oct 2022
Video
Anorectal Malformations: Introduction and Overview for bowel management
Dr. Todd Ponsky · 26 min · Published May 2013
Video
Colorectal Quiz: Episode 46 - Hirschsprung's Disease
Marc Levitt · 29 min · Published Apr 2025
Video
Hirschsprung Disease: Cases and Complications
103 min · Published Feb 2015
Video
Validation of an anorectal malformation trainer - Can a high-fidelity model simulate real life?
1 min · Published Jun 2026
Video
Complications and Long-Term Outcomes of Patients With Cloacal Malformation After Bowel Neovagina...
1 min · Published Jun 2026
Video
Safety and utility of long-acting steroid injection for management of post-operative stricture...
1 min · Published Jun 2026
Video
Association Between Social Determinants of Health and Choice of Urinary Reconstruction in Children
1 min · Published Jun 2026
Video
The Perineal Body Preserving PSARP (PPP)
11 min · Published Jun 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Colorectal Quiz Ep. 50 -16th Annual European Pediatric Colorectal & Pelvic Reconstruction Conference
Marc Levitt · Published Mar 2026
Podcast
Colorectal Quiz: Episode 50 - 16th Annual European Pediatric Colorectal and Pelvic Reconstruction Conference, Stockholm, Sweden, October 2025 - What did we learn?
24 min · Published Mar 2026
Video
Colorectal Quiz Episode 33: Cloaca Exstrophy
Marc Levitt · 22 min · Published Sep 2025
Video
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
Marc Levitt · 15 min · Published Sep 2025
Video
Colorectal Quiz: Episode 49 – Collaborating for Kids: Colorectal & Pelvic Care (with Help from AI)
Marc Levitt · 40 min · Published Jul 2025
Podcast
Colorectal Quiz: Episode 49 - Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)
Marc Levitt · 40 min · Published Jul 2025
What the experts said
Alberto Pena performed gynecologic, urologic, and surgical procedures himself on complex colorectal patients, demonstrating the need for a collaborative multidisciplinary approach.
The first dedicated colorectal center was established at Cincinnati Children's Hospital in 2005.
Training surgeons provides exponentially greater impact than treating individual patients because trained surgeons can help hundreds or thousands more patients in their own cities.
The bowel management program is a major advance, involving focused attention for 4-5 days with good long-term follow-up to achieve fecal continence, primarily through nursing expertise.
Integration of urology and bladder management has revolutionized ARM care, with renal disease and kidney transplant now exceedingly rare compared to previously being not uncommon.
Better gynecologic care has eliminated nervousness about menstruation problems at puberty because of improved understanding of anatomy through collaboration.
The PSARP incision has gotten smaller and understanding of anatomy has improved since the procedure's introduction.
Laparoscopy has been added to many types of ARM cases as a surgical innovation.
Transition to adult care is probably the most inefficient process in ARM care, with the field being most behind in getting teenagers and young adults cared for by adult providers.
Cystic fibrosis patients now commonly survive to age 70, compared to not surviving past their 30s when Levitt was young, due to integrated care and transition programs.
There are only three surgeons in the entire world trained in both pediatric and adult colorectal surgery: Ali Gisher (Columbus, Ohio), Erin Teeple (Wilmington, Delaware), and a surgeon named Mark in Munich, Germany.
Paris's Necker Children's Hospital has an exemplary transition model where teenagers meet pediatric and adult providers together, then continue care at the adult facility.
At devoted colorectal centers, at least half of the surgical work is reoperative surgery for patients with anatomic issues causing soiling problems.
No parent has ever known anything about ARM when their baby is born, creating significant shock when the diagnosis is announced.
Many ARM patients require three surgeries within the first year of life: newborn colostomy, reconstructive operation, and colostomy closure.
ARM surgery requires months to years of tinkering and minute changes to achieve good functional results, unlike typical surgery where anatomic reconstruction immediately solves the problem.
Parents care more about functional results than anatomic reconstruction, but surgeons are often very proud of their anatomic creations and want to be done after the surgery.
A complex colorectal operation takes about 4 hours, but delivering a good result requires 96 more hours of tinkering, almost all of which is nursing care.
Most families would rather change a colostomy bag than a diaper if the colostomy is properly made.
If the anus is misaligned with sphincters due to surgical error, the problem is not discovered until potty training at age 4, making it very difficult for surgeons to improve their technique when feedback is delayed 4 years.
In a typical US pediatric surgical training program, trainees do approximately 12 ARM cases over two years, and finished surgeons average 1 case per year.
Regionalization of care and devoted teams are necessary to build sufficient experience in ARM surgery.
Levitt does not want any child to have a permanent colostomy and wants all children to be typical and normal.
With proper bowel management and good nursing care, patients can be kept clean mechanically even without innate sphincter anatomy or capacity for voluntary bowel movements.
The vast majority of patients can be perfectly clean with stool flowing through the normal anal route, even if mechanically managed.
Surgeons should not give up on pull-through surgery at 6 months of age because many patients develop bowel control even when predicted they would never achieve it, with proper nursing care and medical regimen tinkering.
Families surveyed identified the dilation process as the most stressful part of their entire colorectal care.
A randomized controlled trial comparing routine post-PSARP dilations versus no dilations found similar stricture rates of approximately 15% in both groups.
Strictures can be treated with a straightforward minor Heineke-Mikulicz anoplasty to enlarge the stricture, which can be done at the time of colostomy closure.
All families offered the choice between routine dilations or accepting a 10-15% stricture risk have chosen to avoid routine dilations.
Skin irritation after colostomy closure is a short-term problem lasting about 2 weeks, occurring because the skin has never seen stool and the distal segment needs to adapt to absorb water and thicken stool.
At 3 weeks post-closure, the problem switches to constipation, which many surgeons fail to manage aggressively, leading to colonic dilation and difficulty with potty training at age 4.
Almost all patients should be on laxatives about 3-4 weeks after colostomy closure to keep them flowing.
A good bowel movement pattern is one or two well-formed stools per day, achieved with diet providing bulk, water-soluble fiber, and laxatives containing senna or bisacodyl (not stool softeners).
Stool softeners make ARM patients worse because they prevent the bulky stool needed to feel rectal stretch, which is essential for developing bowel control in patients with surgically created anal canals and impaired sensation.
ARM patients are dependent on rectal stretch sensation because they lack typical anal canal sensation and have compromised sphincters.
Bowel management should be started at whatever age the family chooses for the child to be in normal underwear, typically age 3-5, with all children in normal underwear by age 4-5.
The bowel management program is nurse practitioner-run and involves assessing anatomy first, then developing an enema regimen with saline plus an additive to provoke stool emptying.
The goal of bowel management is to mechanically empty the colon with a flush, then have nothing pass for 24 hours, keeping the child clean in normal underwear for 23.5 hours between flushes.
The bowel management program typically lasts 4-5 days with X-rays, but a lot of tinkering is required during the year through email interaction with nurses.
An early study claimed 95% bowel management success at one week, but Levitt and Richard Wood's follow-up study showed over 80% success at one year, which is the meaningful outcome measure.
Hirschsprung's patients are the hardest group for bowel management, likely because they have overly good sphincters rather than the poor sphincters typical of ARM patients.
Approximately 75% of ARM patients should be able to develop their own voluntary bowel control based on good operation, good quality sacrum, and good quality spine.
Approximately 25% of ARM patients will not achieve their own bowel control even with perfect operation because they lack adequate sphincters or have spinal issues, and these patients need bowel management.
Levitt performs over 100 Malone procedures per year laparoscopically, with the operation taking one hour and most patients staying one night in the hospital.
The Malone procedure makes it much easier for older children to administer their enema independently without parental help.
An integrated psychologist who meets every patient is vital to a full-fledged colorectal center, rather than surgeons calling for help only when needed.
The burden of therapy investigation led to the dilation study because the goal is to achieve correct anus size while minimizing cost to the family.
Many patients receive psychological help when they actually need re-operation and good bowel management, and all psychological problems resolve once the child is clean and in normal underwear.
Fecal incontinence is a physiologic problem, not a psychologic problem, though psychology still needs to be managed.