1
|
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.
Collapse
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.)
| |
Collapse
|
2
|
Lazarte-Rantes C, Chirinos-Gambarini M, Sulca-Cruzado GJ, Ramirez-De la Cruz R, Trigoso V, Cerron-Vela C, De la Torre-Mondragon L. T2-based magnetic resonance genitography in children with complex anorectal malformations: experience at a tertiary pediatric hospital in Latin America. Pediatr Radiol 2024; 54:430-437. [PMID: 38273134 DOI: 10.1007/s00247-023-05849-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024]
Abstract
In children with anorectal malformations (ARMs), it is essential to have a diagnostic imaging method that helps with the evaluation of the internal anatomy. In patients with a persistent cloaca, an ARM variant, in which the measurement of the urethral channel and common channel determines surgical management, there are multiple options for imaging. Magnetic resonance imaging (MRI) is an excellent method for this purpose, from which accurate measurements of channel length can be obtained. Additionally, the use of volumetric/isotropic sequences allows multiplanar reformatting. We present our experience with pelvic MRI and intracavitary non-paramagnetic contrast (MR genitography). This method uses volumetric T2-weighted images and the instillation of saline solution as a contrast agent to distinguish the common channel, length of the urethra, anatomy of the vagina, and presence and location of the rectal fistula. We believe this technique to be particularly useful for those working in settings with limited MRI resources.
Collapse
Affiliation(s)
- Claudia Lazarte-Rantes
- Department of Diagnostic Imaging, Instituto Nacional de Salud del Niño San Borja, Av. Javier Prado Este 3101, 15037, Lima, Peru.
| | - Mario Chirinos-Gambarini
- Department of Diagnostic Imaging, Instituto Nacional de Salud del Niño San Borja, Av. Javier Prado Este 3101, 15037, Lima, Peru
| | | | - Raul Ramirez-De la Cruz
- Department of Neonatal and Pediatric Surgery, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Victor Trigoso
- Department of Neonatal and Pediatric Surgery, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Carmen Cerron-Vela
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Luis De la Torre-Mondragon
- International Center for Colorectal and Genitourinary Care, Children's Hospital Colorado, Denver, CO, USA
| |
Collapse
|
3
|
Pellegrino C, Agamennone M, Iacobelli BD, Turchi B, Capitanucci ML, Beati F, Forlini V, Sollini ML, Marras CE, Esposito G, Palma P, Bella GD, D'Urzo R, Caldaro T, Castelli E, Conforti A, Bagolan P, Mosiello G. Long-term urological outcome of cloaca patients with multidisciplinary management. Pediatr Surg Int 2023; 39:247. [PMID: 37584865 DOI: 10.1007/s00383-023-05539-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE Urological management of Cloacal Malformation (CM) focuses on preserving renal function and continence. Study aim was to analyze urinary and intestinal outcomes in CM patients, considering the length of common channel (CC) and presence of occult spinal dysraphism (OSD). METHODS Retrospective review of CM treated at our institution by a multidisciplinary team from 1999 to 2020. Patients with follow-up < 2.5 years were excluded. Length of CC, renal function, urinary and bowel outcomes, presence of associated anomalies (especially OSD) were evaluated. RESULTS Twenty patients were included, median age at follow-up: 8 years (4-15). A long CC > 3 cm was described in 11 (55%). Chronic kidney disease was found in 3 patients. Urinary continence was achieved in 8/20 patients, dryness (with intermittent catheterization) in 9/20. Fecal continence was obtained in 3/20, cleanliness in 14 (under bowel regimen). OSD was present in 10 patients (higher prevalence in long-CC, 73%). Among OSD, 1 patient reached fecal continence, 7 were clean; 2 achieved urinary continence, while 6 were dry. CONCLUSIONS Length of CC and OSD may affect urinary and fecal continence. An early counseling can improve outcome at long-term follow-up. Multidisciplinary management with patient centralization in high grade institutions is recommended to achieve better results.
Collapse
Affiliation(s)
- C Pellegrino
- Division of Neuro-Urology, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
| | - M Agamennone
- Division of Neuro-Urology, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
- Pediatric Surgery, University of Genoa, DINOGMI, Largo Paolo Daneo 3, 16132, Genoa, GE, Italy
| | - B D Iacobelli
- Neonatal Surgery Unit, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy.
| | - B Turchi
- Division of Neuro-Urology, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
- Urology Unit, Azienda Ospedaliera Sant'Andrea, 'Sapienza' University of Rome, Via di Grottarossa, 1035/1039, 00189, Rome, RM, Italy
| | - M L Capitanucci
- Division of Neuro-Urology, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
| | - F Beati
- Neonatal Surgery Unit, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
| | - V Forlini
- Division of Neuro-Urology, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
- Pediatric Surgery, University of Genoa, DINOGMI, Largo Paolo Daneo 3, 16132, Genoa, GE, Italy
| | - M L Sollini
- Division of Neuro-Urology, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
- Division of Physical Rehabilitation, University of Tor Vergata, Via Cracovia 50, 00133, Rome, RM, Italy
| | - C E Marras
- Neurosurgery Unit, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
| | - G Esposito
- Neurosurgery Unit, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
| | - P Palma
- Neurosurgery Unit, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
| | - G Della Bella
- Neurorehabilitation and Adapted Physical Activity Day Hospital, Bambino Gesù Children's Hospital IRCCS, 00165, Rome, Italy
| | - R D'Urzo
- Neurorehabilitation and Adapted Physical Activity Day Hospital, Bambino Gesù Children's Hospital IRCCS, 00165, Rome, Italy
| | - T Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza di Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - E Castelli
- Neurorehabilitation Unit, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - A Conforti
- Neonatal Surgery Unit, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
| | - P Bagolan
- Neonatal Surgery Unit, Area of Fetal, Neonatal and Cardiological Sciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - G Mosiello
- Division of Neuro-Urology, Bambino Gesu' Children's Hospital, IRCCS, Piazza di Sant'Onofrio 4, 00165, Rome, RM, Italy
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Jacobs SE, Tiusaba L, Bokova E, Al-Shamaileh T, Russell TL, Varda BK, Feng C, Badillo AT, Levitt MA. Where Is the Vagina? A Rectal Stricture after a Presumed Cloacal Repair Turns Out to be the Mobilized Vagina and a Missed High Rectovaginal Fistula. European J Pediatr Surg Rep 2022; 10:e145-e147. [PMID: 36225532 PMCID: PMC9550519 DOI: 10.1055/s-0042-1755538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/10/2022] [Indexed: 11/03/2022] Open
Abstract
We present a case of a rare complication in a 10-month-old female referred to our institution for an anal stricture after primary cloacal repair as an infant. Multimodal imaging, careful physical exam, and endoscopic evaluation revealed her vagina had been pulled through to the location of her anal sphincter muscle complex. We describe the correction of this problem, including identification of her rectum.
Collapse
Affiliation(s)
- Shimon E. Jacobs
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Laura Tiusaba
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Elizaveta Bokova
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Tamador Al-Shamaileh
- Department of General Surgery, Division of Pediatric Surgery, King Hussain Cancer Center, Amman, Jordan
| | - Teresa L. Russell
- Department of Urology, Children's National Hospital, Washington, District of Columbia, United States,Address for correspondence Marc A. Levitt, MD Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National HospitalWashington, DC 20010United States
| | - Briony K. Varda
- Department of Urology, Children's National Hospital, Washington, District of Columbia, United States
| | - Christina Feng
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Andrea T. Badillo
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| | - Marc A. Levitt
- Department of Surgery, Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, District of Columbia, United States
| |
Collapse
|
6
|
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.
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Ralls M, Thompson BP, Adler B, Ma G, Bates DG, Kraus S, Jarboe M. Radiology of anorectal malformations: What does the surgeon need to know? Semin Pediatr Surg 2020; 29:150997. [PMID: 33288131 DOI: 10.1016/j.sempedsurg.2020.150997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Imaging is extremely important throughout all phases of care provided to children with anorectal malformations (ARM). A preoperative determination of the patient specific malformation will help establish the operative plan. Moreover, the majority of ARM patients will have an associated anomaly that will require imaging workup for full understanding of those abnormalities prior to addressing the ARM. The complexity of ARM care will mandate continued imaging throughout the post-operative period even in those with straight forward malformations.
Collapse
Affiliation(s)
- Matthew Ralls
- Mott Children's Hospital, Ann Arbor, MI, United States.
| | | | - Brent Adler
- Nationwide Children's Hospital, Columbus, OH, United States
| | - Grace Ma
- Children's National Hospital, Washington, DC, United States
| | | | - Steve Kraus
- Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Marcus Jarboe
- Mott Children's Hospital, Ann Arbor, MI, United States
| |
Collapse
|
9
|
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]
|
10
|
Lane VA, Levitt MA. Clinical Quiz: Reconstructive Strategies in a 5-Month-Old Infant with a Cloaca. European J Pediatr Surg Rep 2020; 8:e45-e47. [PMID: 32793406 PMCID: PMC7354864 DOI: 10.1055/s-0040-1713136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/15/2020] [Indexed: 12/04/2022] Open
Abstract
Herein we present a case of 5-month-old female born with a cloaca. She underwent a colostomy at birth and then underwent endoscopy and cloacagram to plan for the definitive reconstruction. The case is presented with a focus on the reconstructive strategies, and questions for the readers are posed in a quiz format.
Collapse
Affiliation(s)
- Victoria A Lane
- Department of Paediatric Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Marc A Levitt
- Department of Surgery, Center for Colorectal and Pelvic Reconstructive Surgery, Children's National Hospital, District of Columbia, Washington, United States
| |
Collapse
|