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two doctors perform surgery

Can complex pediatric surgery interventions be standardized to facilitate telementoring?

two doctors perform surgery

The study’s authors write, “These discussions are particularly relevant to surgeons in small or rural practices who provide much-needed care to underserved populations and have decreased exposure to these index cases. Conversely, in some developing countries where prevalence of rare congenital surgical conditions is higher, there is a shortage of adequately trained pediatric surgeons. Each of these scenarios involves a mismatch in experience and exposure, which can result in poor patient outcomes and inadequate healthcare delivery.”

How does a surgeon-in-training get enough exposure to rare or complex cases to serve the patients who need them? How does a practicing surgeon perform enough cases each year to maintain proficiency at such index cases?

The authors of a study in the Journal of Pediatric Surgery, including Marc Levitt, M.D., chief of the Division of Colorectal and Pelvic Reconstruction at Children’s National Hospital, write that, “These discussions are particularly relevant to surgeons in small or rural practices who provide much-needed care to underserved populations and have decreased exposure to these index cases. Conversely, in some developing countries where prevalence of rare congenital surgical conditions is higher, there is a shortage of adequately trained pediatric surgeons. Each of these scenarios involves a mismatch in experience and exposure, which can result in poor patient outcomes and inadequate healthcare delivery.”

Telementoring is one strategy being explored by the American College of Surgeons’ Telementoring Task Force initiative. Pediatric anorectal malformations (ARM), pediatric colorectal surgical procedure, posterior sagittal anorectoplasty (PSARP) were the “index” areas for the pilot study. Once the expert established the areas of great need, they will test the feasibility of a curriculum and training program using telementoring in pediatric surgery. The ACS Task Force notes that these conditions are relatively rare and require a particular skill level to manage appropriately, making them good candidates for the study.

The Journal of Pediatric Surgery study presents a process for mapping out a standardized curriculum for these procedures. First, the authors sought expert consensus on three interoperative checklists that form a de facto curriculum for teaching, learning and performing ARM and PSARP procedures. Second, a multidisciplinary team of medical educators and pediatric surgery experts drafted the checklists. The authors then sought review and input from pediatric colorectal surgery experts at 10 institutions worldwide, who comprised the study’s colorectal pediatric surgery subject matter expert panel. To be considered “expert,” participants had to meet or exceed several strict inclusion criteria related to years in practice and experience with these case types.

Institutions of the colorectal pediatric surgery subject matter expert panel.

Institutions of the colorectal pediatric surgery subject matter expert panel.

The process led to a successful set of consensus documents. “To our knowledge, this is the first study to establish and standardize key intraoperative objectives using a modified-Delphi method in pediatric surgery,” the authors write. “Although this process can be quite time consuming, it provides an incredible opportunity to standardize intraoperative teaching and expectations of trainees. Future studies will expand these checklists into developing a competency assessment tool involving assessment for validity and reliability in a clinical setting to ultimately improve patient safety through standardization.”

Dr. Levitt says the overarching goal of this work is “to improve the surgical technique everywhere [to] thereby help as many kids as we can, even those we will never meet.”

Colorectal clinic with Marc Levitt, MD, and patient families

Early promise of sphincter reconstruction for Hirschsprung disease

Colorectal clinic with Marc Levitt, MD, and patient families

A team of surgeons, led by international pediatric colorectal expert Marc Levitt, M.D., has developed a new surgical approach to tighten, or reconstruct, the sphincters of Hirschsprung patients who have true fecal incontinence after a pull-through procedure.

A team of surgeons, led by international pediatric colorectal expert Marc Levitt, M.D., has developed a new surgical approach to tighten, or reconstruct, the sphincters of Hirschsprung patients who have true fecal incontinence after a pull-through procedure.

Early cases using this approach were outlined in a study published in the Journal of Pediatric Surgery. Though only performed in a handful of patients so far, the authors write, “We feel confident to offer this procedure to other patients with a similar anatomic concern.”

The people who care for Hirschsprung disease patients, including the team at the Pediatric Colorectal and Pelvic Reconstruction Division at Children’s National, continue to seek better approaches for these issues because soiling and fecal incontinence are rare but devastating complications that can occur after children have a pull-through procedure.

“In the presence of an intact continence mechanisms, the anal sphincters and the dentate line, patients with Hirschsprung disease should do well and have bowel control.  For some with soiling, this can be improved with treatment of constipation or hypermotility,” the authors write. “However, patients with a damaged anal canal and/or sphincter mechanism are unable to sense stool and distension of the neorectum or hold the stool in, which can lead to true fecal incontinence.”

Currently, there is no optimal treatment for the fecal incontinence that these patients experience. This repair procedure pioneered by surgeons at Children’s National offers a promising option to help get children with Hirschsprung disease one step closer to a happier, less stressful life.