From
Dr. Marc Levitt
Episode 19 - Interview with Dr Marc Levitt, Chief of Colorectal & Pelvic Reconstruction, Children‘s
With Dr. Marc Levitt · hosted by Dr. Greg Ryan
Part of
Anorectal Malformation 100 items
Chapter 1 of 13 · Fundamentals
Career origins
Introduction and Career Origins in Pediatric Colorectal Surgery
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
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 multidisciplinary approach with multiple disciplines represented to help complicated ARM patients was conceived during Levitt's medical school elective with Alberto Pena.
The first ever colorectal center was launched in Cincinnati in 2005 by Levitt and Pena.
Training surgeons in ARM specialty provides greater impact than individual patient care because trained surgeons help hundreds or thousands more patients.
The bowel management program with focused nursing attention for 4-5 days plus long-term follow-up is a major advance in ARM care.
Integration of urology and bladder management has revolutionized ARM care, with kidney transplant now exceedingly rare compared to previously being not uncommon.
Better urologic care has dramatically reduced renal disease in ARM patients.
The standard PSARP incision has gotten smaller and understanding of anatomy has improved since 2005.
Laparoscopy has been added to many kinds of ARM cases as a technical innovation.
Transition programs for ARM patients moving to adult care are the most behind aspect of the field compared to other areas like congenital heart disease and cystic fibrosis.
There are only 3 surgeons in the entire world trained in both pediatric and adult colorectal surgery: Ali Gisher in Columbus Ohio, Erin Teeple in Wilmington Delaware, and a surgeon named Mark in Munich Germany.
Paris at Necker Children's Hospital has done an amazing job with formal transition to adult programs, with teenagers meeting pediatric and adult providers together before transitioning to adult facility visits.
No parent has ever known anything about ARM when their baby is born, creating shock when a colorectal problem is announced.
ARM surgery typically requires 3 surgeries within the first year of life: colostomy, reconstructive operation, and colostomy closure.
ARM surgery requires months to years of tinkering and may require lifelong adjustments, unlike typical surgery where the problem is immediately solved.
Parents care more about functional results than anatomic reconstruction, but surgeons are often very proud of their anatomic creations.
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.
If a proper colostomy is made, most families would agree they'd rather change a colostomy bag than a diaper.
If the anus is misaligned with sphincters due to surgical error, the problem won't be discovered until potty training fails 4 years later, making it difficult for surgeons to improve their technique.
Studies have shown cardiac surgery in adults gets better results with higher surgical volume.
In typical US pediatric surgery training, fellows do approximately 12 ARM cases over 2 years of training.
The average finished pediatric surgeon performs 1 ARM case per year.
Levitt advocates strongly for pull-through surgery and colostomy closure rather than permanent colostomy, stating he wants every kid to be typical and normal without a colostomy.
With proper bowel management and good nursing care, Levitt is very confident patients can be gotten clean mechanically.
The Malone appendicostomy is an advance that allows patients without innate anatomy or sphincters to be cleaned mechanically by emptying the colon once daily.
Most patients would prefer being cleaned through the Malone route than having a permanent stoma.
Permanent colostomy may be more practical for rare patients who don't ambulate.
The vast majority of ARM patients can be perfectly clean with stool flowing through the normal anal route via bowel management.
Many patients actually develop bowel control even if predicted they would never achieve it, with proper nursing care and medical regimen tinkering.
Levitt and Richard Wood conducted a randomized controlled trial comparing standard dilation protocol versus no dilation after primary PSARP.
The dilation study found that whether dilations were done or not, there was a similar 15% risk of developing a stricture.
Strictures can be treated straightforwardly with a minor Heineke-Mikulicz anoplasty to enlarge the stricture at the time of colostomy closure.
Levitt's center no longer performs routine dilations, allowing families to avoid daily dilation burden and accept the 10-15% stricture risk manageable at colostomy closure.
Doing a good anoplasty with no tension and good blood supply affects the likelihood of getting a stricture.
Skin irritation after colostomy closure is a short-term problem lasting about 2 weeks because the skin has never seen stool.
The distal unused bowel segment needs to learn to adapt and absorb water to thicken stool after colostomy closure.
Post-closure skin irritation is managed with good perineal creams, frequent diaper changes, and preventing stool from sitting on skin, typically resolving by 3 weeks.
At 3 weeks post-closure, the problem switches to constipation, which many surgeons fail to manage aggressively.
Unrecognized constipation causes colonic dilation over time, making the colon harder to empty by age 4 when potty training begins.
Almost all of Levitt's patients are on laxatives about 3-4 weeks after colostomy closure to keep them flowing.
Starting at about age 2.5 years, the goal is achieving a good bowel movement pattern of 1-2 well-formed stools per day.
Achieving good bowel pattern requires diet with bulk fiber, water-soluble fiber, and a laxative with senna or bisacodyl that provokes stool.
Stool softeners do not help ARM children and actually make them worse because they prevent sensation development needed for potty training.
ARM children have a surgically created anal canal without typical sensation and somewhat good or not-so-good sphincters, missing two key continence components.
ARM patients are dependent on feeling rectal stretch from stool filling to develop bowel control.
Loose stool from stool softeners prevents feeling stretch, preventing development of bowel control.
Bulky stool (not constipated but with enough bulk to feel stretch) allows most patients to translate into successful potty training with one stool per day.
If potty training doesn't succeed, bowel management should begin at age 3-4 to get children clean and in normal underwear.
Enemas should be introduced when the child should be in normal underwear according to family choice, which varies but should be by age 4-5 for all children.
Bowel management is nursing-run by nurse practitioners or advanced practice providers.
The first responsibility in bowel management is assessing patient anatomy, which should be fixed first if there are anatomic issues.
Bowel management with enemas can still be done even without perfect anatomy, with anatomic correction performed later.
Bowel management involves mechanical emptying of the colon with an enema containing saline plus an additive that provokes stool emptying.
The Malone procedure connects the appendix to the umbilicus for more comfortable and independent enema administration.
The goal of bowel management is to empty the colon with a flush, then have nothing pass for the next 24 hours, achieving a clean child in normal underwear for 23.5 hours.
Bowel management program typically lasts about a week, with 4-5 days of X-rays.
An early Cincinnati study claimed 95% bowel management success at one week, but this short-term result is misleading.
Levitt and Wood's follow-up study documented bowel management results at 1 year, showing over 80% success for ARM patients.
Among the 4 patient categories (ARM, Hirschsprung's, spinal disorders, functional constipation), Hirschsprung's patients are the hardest for bowel management because they don't have good functioning sphincters or their sphincters are sometimes too good.
A lot of tinkering is required during the year after bowel management initiation, with X-rays and flush adjustments when accidents occur.
About 75% of ARM patients should be able to develop their own bowel control and have voluntary bowel movements based on good operation, good quality sacrum, and good quality spine.