2019 Chandler Lecture: Dr. Marc Levitt

In medicine, the colorectal surgeon may take care of a colorectal problem and not really worry about the bladder issue, and 6 months later the urologist meets the patient and realizes they have to do some intervention after the patient already had a laparotomy for their colon problem—completely uncoordinated care.

There are about 600 newborns with an anorectal malformation born per year in the United States.

A pediatric surgery fellow does about 14 anorectal malformation cases in 2 years, and a graduate does about 1 case per year.

Complications of anorectal malformations include fecal incontinence, urinary incontinence, renal dysfunction and the need for renal transplant, sexual dysfunction, and infertility.

In colorectal surgery, if you do an operation as a 6 month old and put the anus outside of the sphincters, the 6 month old won't know that until they are 4 years old and trying to potty train—the surgeon will never figure out they didn't do a great job and will keep doing the same mistake over and over again.

The speaker's current practice is about 60% reoperative surgery.

Patients with anorectal malformations many times have associated spinal problems, and if you don't collaborate upfront with neurosurgery, you may discover a neurologic problem 5 years later when the patient already has renal damage.

Patients with cloacal malformations many times have Mullerian anomalies and hemisystems—if you don't think about gynecology when they're 6 months old during cloacal reconstruction, you're setting yourself up for a very difficult problem 13 years down the road when they have pelvic pain because their Mullerian structure is not draining menstrual blood.

Knowing the associated sacral and spinal problems allows us to predict continence and have a conversation with a family in the neonatal unit about whether their child will very likely be continent with proper management, or whether there's not really a lot of chance for continence because of the associated spinal problem.

Rectourethral fistulas are classified as bladder neck fistula (at the deltoid level), prostatic fistula (at the tricep level), or bulbar fistula (at the elbow level)—each diagnosis has a different surgical approach and a different potential outcome.

Common technical errors in anorectal malformation repair include anus placed too far posterior (outside the sphincter), stricture, remnant of the original fistula left behind, and rectal prolapse—these are solvable with better technique.

Redoing patients with misplaced anus can dramatically improve their functional outcome and quality of life—we were able to convert a good number of these patients to continence by making them have better anatomy.

The surgeon's responsibility is to get good anatomy, but after achieving that goal there's a functional outcome that's relevant—you can do a perfectly good Nissen but it requires some tinkering over time to try to get the best possible result for that patient.

The colostomy and ileostomy closure surgical site infection rate was 22.4%, which is pretty standard in the literature.

Implementing a GI bundle—most importantly changing instruments and gloves before closing the fascia—reduced the wound infection rate to 7.9%.

The organism that ultimately grew in the wounds was resistant to the preoperative antibiotic (cefoxitin) given within an hour of incision in every circumstance.

Changing the preoperative antibiotic from cefoxitin to Unasyn (chosen with infectious disease collaboration based on wound culture data) reduced the wound infection rate to 2.2%.

In cloacal malformation repair, you have to measure both the common channel length and the urethral length and make a plan accordingly—if the urethra is going to ultimately be shorter than 1.5 centimeters, bringing the bladder neck down to the perineum makes a wet (incontinent) patient.

If you leave enough of the urethra behind at the end of cloacal reconstruction (>1.5 cm), you could have a dry patient 4 years hence.

In a 6 year old with myelomeningocele who has urinary and fecal incontinence, you can take out the sigmoid to improve bowel care but keep it on its mesentery and roll it over to use for bladder augmentation, and share the appendix between Malone (antegrade enema) and Mitrofanoff (catheterizable channel)—the only way to do that is with coordinated care between urology and colorectal surgery.

The proximal appendix becomes the antegrade access for enemas for patients that are fecally incontinent but can be made clean by a flush every single day, and the distal piece stays on its blood supply and can be implanted into the bladder for intermittent catheterization for urine—they can be rendered dry and clean for urine and stool in a single operation.

There are certain patients with severe functional constipation that need surgical solutions—in the adult world that's a subtotal colectomy ileorectal anastomosis, but in the pediatric world before the entire colon has dilated up we may be able to get away with just a segmental resection of the sigmoid.