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Choueiki JM, Sales S, Callicott S, Ashman D, Worst K, Badillo A, Varda BK, Mayhew A, Xu TO, Levitt MA. Is Collaborative Care the Future of Medicine? Lessons Learned from the Care of Children with Colorectal Conditions. CHILDREN (BASEL, SWITZERLAND) 2024; 11:570. [PMID: 38790565 PMCID: PMC11119695 DOI: 10.3390/children11050570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/12/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024]
Abstract
The treatment of patients with colorectal disorders requires care from a wide variety of medical and surgical specialties over the course of their lifetime. This is ideally handled by a collaborative center which facilitates the assessment and development of patient care among multiple specialties which can enhance the quality and implementation of treatment plans, improve communication among different specialties, decrease morbidity, and improve patient satisfaction and outcomes. This collaborative approach can serve as a model for other parts of medicine requiring a similar multi-disciplinary and integrated method of care delivery. We describe the process, as well as the lessons learned in developing such a program.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Marc A. Levitt
- Division of Colorectal and Pelvic Reconstruction, Children’s National Hospital, Washington, DC 20010, USA; (J.M.C.); (S.S.); (S.C.); (D.A.); (K.W.); (A.B.); (B.K.V.); (T.O.X.)
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Patient driven change: Is collaborative care the future of medicine? Lessons learned from the care of children with colorectal problems. J Pediatr Surg 2023; 58:189-197. [PMID: 36418202 DOI: 10.1016/j.jpedsurg.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/11/2022] [Indexed: 11/21/2022]
Abstract
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 context 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.
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Gang S, Song SH, Kwon J, Kwon H, Ha S, Park J, Kim N, Yoon HM, Namgoong JM. Case report: Magnetic resonance imaging-based three-dimensional printing for reconstruction of complex cloacal malformations. Front Pediatr 2023; 11:1103401. [PMID: 36959843 PMCID: PMC10028276 DOI: 10.3389/fped.2023.1103401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 02/13/2023] [Indexed: 03/25/2023] Open
Abstract
Background Surgical reconstruction of the urinary tract, anus, and vagina is the definitive treatment for cloacal malformation. However, this procedure may be technically challenging in patients with a long common channel (>3 cm), because further reconstructive procedures, such as vaginal replacement or vaginal switch maneuver, may be required. Thus, accurate determination of spatial anatomy is essential during surgical planning. Three-dimensional (3D) reconstruction using rotational fluoroscopy, computed tomography (CT), and magnetic resonance imaging (MRI) has recently been reported to help in determining the relationship between the rectum, vagina, and bladder, and provides a more accurate measurement of the channel length compared to conventional cloacography. MRI-based 3D reconstruction provides substantial information regarding soft tissue structures around the cloaca, including the pelvic floor musculature and anus. Case A 2-year-old girl with cloacal malformation required reconstructive surgery. Colostomy and cystostomy had been performed on the first day of her life. Preoperative loopogram revealed a cloaca with a long common channel (35 mm) and short urethra (9 mm), single vaginal opening in the bladder neck, and the colon anterior to the vagina with a fistula at the vaginal neck. Because the vagina was too short to be pulled through, 3D printing based on MRI was performed to visualize structural relationships prior to surgical correction. Saline was used for cloacal visualization. Furthermore, endoscopy-assisted urogenital mobilization was performed, and vaginal substitution was performed using the rectum. No postoperative complications were observed. Conclusions We believe this is the first report of the use of MRI-based 3D imaging and printing, with saline as a contrast agent during surgical planning for correction of cloacal malformation. MRI-based 3D printing is a potentially promising technique for surgical planning of cloacal malformation correction in patients with a long common channel, as it provides detailed information about the surrounding soft tissue structures without exposure to radiation or contrasting agents.
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Affiliation(s)
- Suiin Gang
- Department of Pediatric Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Sang Hoon Song
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | | | - Hyunhee Kwon
- Department of Pediatric Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Suhyeon Ha
- Department of Pediatric Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Jueun Park
- Department of Pediatric Surgery, Asan Medical Center, Seoul, Republic of Korea
| | - Namkug Kim
- Department of Radiology, Convergence Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jung-Man Namgoong
- Department of Pediatric Surgery, Asan Medical Center, Seoul, Republic of Korea
- Correspondence: Jung-Man Namgoong
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Fetal and Newborn Management of Cloacal Malformations. CHILDREN 2022; 9:children9060888. [PMID: 35740825 PMCID: PMC9221828 DOI: 10.3390/children9060888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022]
Abstract
Cloaca is a rare, complex malformation encompassing the genitourinary and anorectal tract of the female in which these tracts fail to separate in utero, resulting in a single perineal orifice. Prenatal sonography detects a few cases with findings such as renal and urinary tract malformations, intraluminal calcifications, dilated bowel, ambiguous genitalia, a cystic pelvic mass, or identification of other associated anomalies prompting further imaging. Multi-disciplinary collaboration between neonatology, pediatric surgery, urology, and gynecology is paramount to achieving safe outcomes. Perinatal evaluation and management may include treatment of cardiopulmonary and renal anomalies, administration of prophylactic antibiotics, ensuring egress of urine and evaluation of hydronephrosis, drainage of a hydrocolpos, and creation of a colostomy for stool diversion. Additional imaging of the spinal cord and sacrum are obtained to plan possible neurosurgical intervention as well as prognostication of future bladder and bowel control. Endoscopic evaluation and cloacagram, followed by primary reconstruction, are performed by a multidisciplinary team outside of the neonatal period. Long-term multidisciplinary follow-up is essential given the increased rates of renal disease, neuropathic bladder, tethered cord syndrome, and stooling issues. Patients and families will also require support through the functional and psychosocial changes in puberty, adolescence, and young adulthood.
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Krois W, Schmölz L, Wagner M, Gröpel P, Unger E, Berger A, Metzelder M, Reck CA. Cysto-Vaginoscopy of a 3D-Printed Cloaca Model: A Step toward Personalized Noninvasive Preoperative Assessment in Patients with Complex Anorectal Malformations. Eur J Pediatr Surg 2022; 32:210-214. [PMID: 33757134 DOI: 10.1055/s-0041-1726424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION For the classification of the complexity of cloacal malformations and the decision on the operative approach, an exact anatomical assessment is mandatory. To benefit from using three-dimensional (3D)-printed models in preoperative planning and training, the practicability of these models should be guaranteed. The aim of this study was to evaluate the quality and feasibility of a real-size 3D-printed cloaca model for the purpose of cysto-vaginoscopic evaluation. MATERIALS AND METHODS We performed a 3D reconstruction and printed a real-size, rubber-like 3D model of an infant pelvis with a cloacal malformation and asked invited pediatric surgeons and pediatric urologists to perform a cysto-vaginoscopy on the model and to complete a brief questionnaire to rate the quality and feasibility of the model and to indicate whether they would recommend the model for preoperative planning and training. RESULTS Overall, 41 participants rated the model quality as good to very good (M = 3.28, standard deviation [SD] = 0.50, on a scale from 1 to 4). The model was rated as feasible for preoperative training (M = 4.10, SD = 0.75, on a scale from 1 to 5) and most participants (85.4%) would recommend the model for preoperative training. The cysto-vaginoscopy of the model was considered as a valid training tool for real-life cases and improved the confidence on the anatomy of a cloaca. CONCLUSION The results of our study indicate that patient-specific 3D-printed models might be a useful tool in the preoperative evaluation of complex anorectal malformations by simulation of cysto-vaginoscopy with an excellent view on anatomical structures to assess the whole spectrum of the individual cloacal malformation. Our model might be a valuable add-on tool for specialty training in pediatric colorectal surgery.
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Affiliation(s)
- Wilfried Krois
- Department of Pediatric Surgery, Medical University of Vienna, Vienna, Wien, Austria
| | - Lukas Schmölz
- Department of Pediatric Surgery, Medical University of Vienna, Vienna, Wien, Austria
| | - Michael Wagner
- Department of Pediatrics, Medical University of Vienna, Wien, Austria
| | - Peter Gröpel
- Department of Sport Science, University of Vienna, Wien, Austria
| | - Ewald Unger
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Wien, Austria
| | - Angelika Berger
- Department of Pediatrics, Medical University of Vienna, Wien, Austria
| | - Martin Metzelder
- Department of Pediatric Surgery, Medical University of Vienna, Vienna, Wien, Austria
| | - Carlos Albert Reck
- Department of Pediatric Surgery, Medical University of Vienna, Vienna, Wien, Austria
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Rentea RM, Halleran DR, Gasior AC, Vilanova-Sanchez A, Ahmad H, Weaver L, Wood RJ, Levitt MA. A pediatric colorectal and pelvic reconstruction course improves content exposure for pediatric surgery fellows: A three-year consecutive study. J Pediatr Surg 2021; 56:2270-2276. [PMID: 33736877 DOI: 10.1016/j.jpedsurg.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/31/2021] [Accepted: 02/02/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Interactive courses play an important role in meeting the educational needs of pediatric surgical trainees. We investigated the impact of a multimodal pediatric colorectal and pelvic reconstruction course on pediatric surgery trainees. METHODS A retrospective evaluation was performed of pre- and post-course surveys for an annual colorectal and pelvic reconstruction course over 3 consecutive years (2017-2019). The course included didactic and case-based content, interactive questions, video, and live case demonstration, and a hands-on lab. Pre- and post-course surveys were distributed to participants. Comfort with operative/case procedures was scored on a 5-point Likert scale (1 uncomfortable, 5 very comfortable). The primary outcome was improved confidence and content knowledge for pediatric colorectal surgical conditions. RESULTS 165 pediatric surgical fellow participants with a 70 responses (42.4% response rate) comprised the cohort. Participants had limited advanced pediatric colorectal experience. At the time of the course, participants reported a median of 5 [3,10] Hirschsprung pull-throughs, 6 [3,10] anorectal malformation, and 1 [0,1] cloaca cases. Participants transitioned from discomfort to feeling comfortable with pediatric colorectal operative set-up and case management (pre-course 2 [2,3] and post-course 4 [4,5] p<0.001). CONCLUSION Pediatric surgery trainees report limited exposure to advanced pediatric colorectal and pelvic reconstruction cases and management during their pediatric surgical fellowship training but report improved content knowledge- and technical understanding of complex pediatric disorders upon completion of a dedicated course. The course is an important adjunct to the experience gained in pediatric surgery fellowship for achieving competency in managing patients with Hirschsprung disease, anorectal malformation, and cloacal reconstructions.
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Affiliation(s)
- Rebecca M Rentea
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH 43205, United States; Children's Mercy Hospital- Kansas City, Pediatric Surgery- Comprehensive Colorectal Center, 2401 Gillham Road, Kansas City, MO 64108, United States.
| | - Devin R Halleran
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Alessandra C Gasior
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Alejandra Vilanova-Sanchez
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Hira Ahmad
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Laura Weaver
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH 43205, United States
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC, United States
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Levitt MA. New and exciting advances in pediatric colorectal and pelvic reconstructive surgery - 2021 update. Semin Pediatr Surg 2020; 29:150992. [PMID: 33288140 DOI: 10.1016/j.sempedsurg.2020.150992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Caring for children with colorectal and pelvic reconstructive needs is complex and requires a lifelong commitment from clinicians devoted to the field. There has been a myriad of advances that have improved care and it has become clear that an integrated, multi-disciplinary approach maximizes the goal of improving the quality of life of children afflicted with these conditions. The purpose of this review is to briefly discuss the history of this field and to describe the key advances that have improved patients' lives.
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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; 29:150988. [PMID: 33288135 DOI: 10.1016/j.sempedsurg.2020.150988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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The use of a Meckel's diverticulum for a neo-vagina in a patient with cloacal anomaly. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Halleran DR, Smith CA, Fuller MK, Durhm MM, Dickie B, Avansino JR, Tirrell TF, Vandewalle R, Reeder R, Drake KR, Bates DG, Rollins MD, Levitt MA, Wood RJ. Measure twice and cut once: Comparing endoscopy and 3D cloacagram for the common channel and urethral measurements in patients with cloacal malformations. J Pediatr Surg 2020; 55:257-260. [PMID: 31784103 DOI: 10.1016/j.jpedsurg.2019.10.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 10/26/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Precise and accurate measurement of the common channel and urethra is a critical determinant prior to the repair of cloacal malformations. Endoscopy and 3D reconstruction cloacagram are two common modalities utilized to help plan the surgical approach, however the consistency between these methods is unknown. METHODS Common channel and urethral lengths obtained by endoscopy and 3D cloacagram of cloaca patients at six pediatric colorectal centers were compared. Data are given as mean (range). RESULTS 72 patients were included in the study. Common channel measurements determined by 3D cloacagram and endoscopy were equal in 7 cases (10%). Endoscopic measurements of the common channel were longer than 3D cloacagram in 20 (28%) cases and shorter in the remaining 44 (62%) cases. The absolute difference between measurements of the common channel was 7.2 mm (0-2.4 cm). Urethral measurements by both modalities were equal in 8 cases (12%). Endoscopic measurement of the urethra was longer than that by 3D cloacagram in 20 (31%) patients and shorter in 37 (57%) of cases. The absolute difference between measurements of the urethra was 5.1 mm (0-2.0 cm). The reconstruction (e.g. TUM or urogenital separation) that would be performed according to measurements determined by 3D cloacagram and endoscopic measurements differed in 13/62 (21%) patients with each structure identified and common channel measurements of >1 cm. CONCLUSION Significant variation exists in the measurements of the common channel and urethra in patients with cloacal malformations as determined by endoscopy and 3D cloacagram. This variation should be considered as these measurements influence the decision to perform either a TUM or urogenital separation. Based on these findings, 3D cloacagram should be performed in all patients prior to cloaca repair to prevent mischaracterization of the malformation. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Devin R Halleran
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, Unites States
| | - Caitlin A Smith
- Seattle Children's Hospital, Seattle, Washington, United States
| | - Megan K Fuller
- Children's Hospital & Medical Center, Omaha, NE, United States
| | - Megan M Durhm
- Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | | | | | | | - Robert Vandewalle
- Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Ron Reeder
- Data Coordinating Center, University of Utah, Salt Lake City, UT, United States
| | - Kaylea R Drake
- Data Coordinating Center, University of Utah, Salt Lake City, UT, United States
| | - D Gregory Bates
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, Unites States
| | | | - Marc A Levitt
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, Unites States
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, Unites States.
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