Is Multi-disciplinary care the future of medicine?

Morning everyone, can you? And I know you can hear me in the auditorium, but can, uh, those on Zoom hear me? Yes, yeah. Great, great, so good. Thank you. Um, so good morning all. Um, it is my pleasure, uh, to introduce this grand round speaker, Doctor Mark Levitt. Um, he, Doctor Mark Levitt, came to us from a nationwide hospital, uh, about 4 years ago, just before, um, the pandemic. Uh, Doctor Levitt, uh, is the chief of colorectal and pelvic reconstruction surgery here at Children's, and he's a professor of surgery and pediatrics at the George Washington School of Medicine. Dr. Levitt has focused his clinical and academic career in helping patients with complex colorectal and pelvic problems. He's published over 300 peer-reviewed manuscripts, 90 book chapters, and 5 books. He's delivered over 500 national, international, regional presentations of his work and has been invited professor all over the world. He's trained clinical fellows, research fellows. Surgical residents, nurses, and students in his career, including more than 50 pediatric surgery and colorectal surgery fellows. He's directed numerous colorectal training courses attended by surgeons and surgical trainees from all over the world. He dedicates much of his free time to mission trips around the world, where he trains surgeons in complex colorectal techniques. As part of the organization colorectal team overseas this morning, he will bring to us some pearls about the collaboration, uh, and the importance of, of what we do in anesthesia and how we can, uh, contribute to the care of the colorectal surgery patients. So please join me in welcoming Doctor Levitt. Thank you, Sophie. Hi everybody, nice to see you in this uh venue, um, we. Love spending time with you. We are very dependent upon you, uh, for this collaboration. And, um. What I put together today has two parts. One is what is our colorectal center all about, what we're trying to achieve here at Children's National. Um, and the second part is very specific to what are the colorectal anesthesia collaborations. What are the challenges. What we, where are, where our lives paths cross. So who um has read this book? Or to their children or to their nieces and nephews. So this is a very important book. Huh? You know this book, right? So this is a very important book. It's a very important message. This is a physiologic process that everyone deals with and honestly everyone pretty much takes for granted. And many families, in fact, most families who have a baby that's born with an anorectal malformation, never heard that that was ever something that could happen. They're in a bit of shock and of course then they need surgery and it's a big psychological drama. Everyone's heard that you can have a heart defect or cystic fibrosis, but colorectal problems are not really spoken about. Well, we're very passionate about this book because we know that there's another book that we have to read as well, and that's this book. And this is the problem, right? This is the patients that we're trying to fix. The patients who can't empty their colon. Um, for a variety of congenital and acquired conditions, that's the field of pediatric colorectal. Amazingly, I would attribute the first reference to colorectal surgery to a 2000 year old reference in the Babylonian Talmud that states that if an infant whose anus is not visible, is born, they should be rubbed with oil and stood in the sun, and where it shows transparent, should be torn crosswise with a barley grain. So this is really the description of an annoplasty. Right, the anus is there. It's hiding below the surface. We need to find it and make it. Functional. Um, amazing. 2000 years ago, babies like this were born and babies like this, as long as the rectum was very low, survived. Because if someone came along and found the opening and where they, I think they're probably talking about where they could see meconium, that baby could potentially survive. Really the modern techniques of how to actually do a reconstruction that not just conveys survival, but also conveys function. It's very recent in the world of pediatric surgery. The first PSARP was in 1980. Most congenital surgeries that we deal with, esophageal atresia, diaphragmatic hernia are in the 1950s. Surgery is of course, being done. But the anus was just being rescued but not functional, and many of those patients suffered from constipation and fecal incontinence and terrible problems. The issue is they all survived. Esophageal atresia before a good repair, those patients did not survive. These patients survived and we see the implications of poor surgery throughout the world. We see it here. You guys know that we do a lot of reoperative surgery. The patients are surviving, but they are certainly suffering. Our goal is not only to do a good anatomic reconstruction, but it's also to create a functional anus that the patient can go to normal school and have wear normal underwear and all of those things that everyone else takes for granted. So, um, you have seen this image many, many times. Think for a moment what went into this project. How was this designed? What happened? I predict a group of very intelligent people got together in a room and said, Where should, where should the bricks go? When does the steel get laid? What's the height of the water? What's the height of the bridge? All of the things that go into a plan to make this beautiful engineering project. Well, if you think about something parallel in our lives like a cloacal reconstruction. Most of the world doesn't function in the way these individuals function to plan this bridge. Because what happens is maybe the pediatric surgeon deals with the rectum and doesn't think too much about the urologic system. Doesn't even consider that there might be gynecologic implications of what they're doing. Not a well found, not not a well thought through project. My mission was to try to make the care of a complex patient organized in a way that we see in other parts of our world. Like this that we pass every day. I suspect people in this room on this call passed this view this morning. You probably didn't think about what it took to get this project completed. And that's what the concept of collaborative care is all about. Well, I was a medical student. In 1992. And I was somewhat randomly assigned to an elective with Alberto Pena, who is the father of pediatric colorectal surgery, who is the person that did the first PSARC in 1980 that I already mentioned. And I watched what he was doing. And in those days, he had, um, uh, written about the PSAC. It was only 12 years old at that point. And still, he was already quite well known and patients were coming from all over, but he was a lone wolf in the care of these patients. And he used to joke that if someone would call the office and say, can I speak to the colorectal surgeon, he would say, you got him. That's me. All right, can you patch me through now to the urologist? He would say I do the urology as well. Do you have a gynecologist on your staff? I got that covered. Psychology, social work, I handle it all. And I watched this as a medical student and I was actually quite intimidated by the possibility that there's no way I could possibly provide that level of complexity of care, particularly with the way medicine was moving. And that's really what got me thinking about the collaborative model. So this is a rare photo. Does anyone recognize anyone in this photo? Believe it or not, that's me. That's 191992 as a young medical student with Alberto Pena learning about colorectal surgery. So take a quick look at this um artwork. A kindergarten class was asked to draw what they thought their mother did for work. OK, so one little kindergartner drew this beautiful picture. And um the teacher probably was a little bit perplexed and was wondering what was going on in this picture. I'm not sure what you all were thinking, but the true story is that the mother worked for Home Depot. And she was telling the daughter a story about a snowy day when they, everyone wanted a shovel, and she had the last shovel to be sold. What what were you guys thinking was the story? So the point of this image is perspective. So I had a unique perspective as a medical student without a lot of knowledge, wondering about the complexity of medicine. Seeing complex care being administered by one person. Recognizing that I would never be able to do that. Recognizing how important it is to have collaborators. Which I think launched the concept of the collaborative care model in colorectal. It's something we do routinely in many fields, but it had not been done in colorectal. So I sort of mentioned this. This is the shock and awe moment where a baby is born in the NICU. Almost always there is no prenatal, um, expectation of something being wrong. Babies are full term. They're healthy. They pop out. Someone does an exam and notices that obviously there's something missing. And then the drama begins with we need to do a colostomy or we might do a primary repair. Anesthesia comes by, all of these things start happening to this family, and I can assure you none of them, Even knew this was a possibility, number one. And as soon as they figure out that there's a problem with the anus, I can assure you also, they don't care much about how elegant is our technique to perform an anoplasty. Their question is, will my child be normal when they're age 4 and are supposed to be potty training. That is their question. So as surgeons, our, our job. Is to do an anatomic reconstruction with a good functional result. Because a good anatomic reconstruction without a good functional result. Think about any of the surgeries you do. It's all about correcting the anatomy or getting a good functional result. Correct the scoliosis and the child can't walk, you haven't accomplished very much. Right? So very, very true in what we do. As proud as we are of our surgical technique, we always need to remember that our mission is what happens in 4 years when the child gets to use the anatomy we just created. And the anatomy is very intertwined. I mean, here you have bladder, gynecologic system, and rectum all filling the pelvis. How could colorectal urology and gynecology not collaborate? It makes very little sense for us not to work closely together. We have a cloacal reconstruction today. But, you know, as many of you know, this is the World Center for Cloacal Care. I think today's is the 32nd Cloaca in the last 4 years. Most centers see one Cloaca every 5 years. We have one today, and all 3 teams will be represented in the care of this child. And there are many specialties, of course, that are routinely involved colorectal gynecology, urology, but a lot of orthopedics, cardiology, neurosurgery patients have tethered cord, cardiac defects. Um, these all need to be thought through. These are thought through from an anesthetic point of view. Obviously, we need to understand what is the respiratory and cardiac implications of the patient if they're undergoing anesthesia. And I like this photo a lot because what most people think it takes to do colorectal care is represented in the photo on the left. My good friend Todd Ponsky, who trained here by the way, some of you may recognize that person, but it actually is a heavy lift, and this is my dad with his, um, most dramatic, uh, redfish catch. It's a heavy lift. It takes an incredible amount of work and a lot of collaborative effort. Um, so some things that we think through, um, you may or may not involve, be involved at the prenatal stage from an anesthesia point of view, but occasionally we get a prenatal diagnosis, particularly a cloaca might be prenatally diagnosed. They sometimes have a large pelvic mass identified on ultrasound. They may have hydronephrosis, a missing kidney. Some things, these things can be noticed prenatally. The baby is born. This is a baby, newborn, one day old, with a large pelvic mass. What is that mass? That actually is the hydroculpus. That is a vagina filled with urine. The urine did not successfully exit because of the anatomy. Of the common channel of the cloaca and instead the urine flowed but backwards into the vagina, which has incredible implications. It can, uh, depress respiration. It can make the kidneys fail. It can make hydronephrosis. So this is something that may need to be dealt with in the newborn. So patients like this, I think are best served by being delivered in a NICU like ours that can be, can handle all of these things. It's important to remember that there are associated neurologic problems, as you well know. Our patients often may have a single kidney or have some degree of CKD. Which has anesthesia implications. The gynecologic system can be abnormal. In this case, you see a duplicated Mullerian system. The um sacrum and spine are important and in fact, we use them to predict continence so we can have a pretty educated conversation with the family, even on the first day of life about their child. How is their sacrum? How is their spine. These have implications on where do you put the caudal, where do you put the epidural, right? Can you do an epidural? Well, these are also relevant for continence prediction. So if a patient has a favorable malformation, a good quality sacrum and a normal spine, I can tell the family very confidently your child will have continence in 4 years after the reconstruction. If they are born with a myelomeningocele, I will tell them they will not be continent in 4 years, but we will have bowel management programs. We have a very robust nursing program for those patients. Again, our mission is not just the anatomic reconstruction, but to get them to be functionally doing what all other kids are doing. We do a lot of laparoscopy in care of the colorectal patient and we do some robotic surgery in the care of colorectal patients which obviously have anesthetic implications on their own. Um, this is just a very cool image of a cloacogram. You can see that the gray is the rectum entering the back of the, um, um, vagina, and then the red on the back is the bladder. So all three systems all form one confluence, and cloaca actually is from the French word. We have some French speakers here, I believe, which means sewer. And for those of you who ever had a bird poop on your car, you would know that they combine the poop and the pee together because they all have cloacas. Because there's a confluence of the structures. The urinary system, the fecal system and the gynecologic system are one. And there's a single exit. Obviously we want to make three openings for that child. Sadly, there's a lot of complications in colorectal surgery. We want to avoid these complications, but here we show several examples, rectal prolapse, a posterior urethral diverticulum, a misplaced anus. A lot of what we do, as I said, are re-operations. All right, well, the devil is in the details. So you have to make sure you get everything right, everything perfect, right? This is a slight typographical error. Everyone see the mistake? No. OK, so, um, we treat a lot of patients with fecal incontinence, as I mentioned, the bowel management program, which has, um, needs for surgery, such as a Malone. We do a lot of Malones, probably do 100 malones a year. Very cool operation where we take the appendix, connect it to the belly button, and through the appendix, the patient can be flushed. Their colon can be flushed once a day. They don't poop for the next 24 hours. Very reliable system. You don't need continence. You don't need sphincters. As long as the poop comes out at a specific time and no poop comes anymore for the next 24 hours, you have a clean child that can wear normal underwear. Um, sometimes we take out parts of the colon. This is just some imagery of showing the dilations of these colons that come over time and they need to be removed. This is part of our collaboration with GI where they do anorectal manometry, colonic manometry to make assessments of the colon. And here are some pictures of that malone. Here's, uh, the appendix. It's wrapped with the cecum, and the picture on the right, if the patient doesn't have an appendix, we can actually make one. It looks quite nice. So, um, these are ways, accesses to the colon, the beginning of the colon, obviously, flushing the colon through with a solution. Poop comes out, no poop for 24 hours until the next flush. We have a clean patient. All right, we do a lot of urinary reconstruction. This was a gift I gave when I was in Columbus to our graduating fellow. Um, like representative of the Cloaca. I just want you to think about the fact that, I, I don't know if you want this, but you can order a bowling ball online. It's, uh, uh, made very personalized like I did. But they don't send them with the holes. You have to go to a bowling alley and have those drills for your specific fingers. I just want you to think about the fact that I was at a bowling alley. Having a conversation about a cloaca. With the gentleman who was asked to drill only one hole. OK, think about that moment for me. By the way, he only charged me 1/3 of the typical price, which is very nice. Um, and here I am with some of my colleagues from, um, from Columbus, and, um, Rama has a, has a, um, jacket which says liquid Waste Management, and he got this for Richard and I which says solid Waste Management. So this is what, this is what we do. All right, so I'm thinking about the collaborative model. How would you handle a six year old with myelomeningocele, urinary and fecal incontinence, before and after the collaborative concept? Well, I can tell you urology might have done a full reconstruction and not thought about the colon. Or the system, or the continents of the colon. Nowadays we would do this together here. These are the all day cases where there is a potentially a bladder augmentation. The bladder needs to be made bigger for urologic reasons. Bonus, we take the piece of colon and use that as the augment. So now we have a pedicolized segment of colon that makes the bladder bigger. And simultaneously we've made that colon a little shorter and easier to empty, so we're solving both the fecal and urinary problems in one operation which require the collaborative approach to get that patient to an operating room with both teams working together. Another example, here is an appendix that we are splitting some for the Malone, some for the metrofenil, and you'll see many of these cases on the OR schedule. This is really cool. You take a piece, take an appendix and you share it, um, only possible if you have the collaborative model in place. All right, well, just to give you a brief overview, there are 600 newborns with ARM per year born in the United States. There are pediatric surgery fellows. We have those training right here. They do about 14 cases in 2 years, and a pediatric surgeon does about one case per year. How are they possibly supposed to have enough experience and expertise to get it right? And unfortunately I believe this is one of the reasons why we see so many redos, which is why I've been a big advocate for regional centers, patients that come to a center that can do all aspects of colorectal care. And this is something not new. In, for example, in the UK, biliary atresia and bladder atrophy are specifically focused at certain centers. They are not able to be operated on in other centers because the country recognized the expertise that was available by having the collaborative model in one or two locations. So truly we can achieve 1 + 1 equals 3, and this is the design of the program which I mentioned. Um, because our job is to provide care for this 20 week fetus. The picture on the left is the cloaca, all the way until she grows up and has a baby herself. And as you may know, we now have launched a transition program in colorectal with our new recruit, Erin Tel, who will allow us in collaboration with MedStar to take care of these patients as they become adults. So we're very excited about that. The scope of the problem is really important. There are many aspects that I've mentioned and how do we tell people that we're here? Marketing, not so easy for colorectal, right? This is a. Ad for the University of Michigan. They're very proud of their heart program. We can't put a similar ad in the New York Times Magazine for our PSARP incision. So we need to do it slightly differently. But I can tell you there are many patients that need us. We need to get the message out. And we have, uh, that, uh, that they can come here for care. I'm gonna skip a couple of these things. Um, I can tell you 15 years ago there was one center in Cincinnati, and now here we have the colorectal center spread throughout the world. It's really amazing emphasis on collaboration and a lot of centers have taken on this mission. And as you, some of you know, I travel, as Sophie mentioned, to, uh, parts of the world that don't even know where Washington DC is. Those patients need care too. Um, and, um, we hope to collaborate. In fact, uh, Julian and Sophie were supposed to be on a trip that got ultimately got canceled. But we're gonna re up now that COVID seems to be gone, but maybe it's back. We're not sure. Um, but to go on some of these trips and to collaborate with you guys on some of these trips to bring colorectal care to the rest of the world. All right, now