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Marc Levitt plays with a patient

Evidence to eliminate burdensome postop practice after imperforate anus repair

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Marc Levitt plays with a patient

The study was co-led by Marc Levitt, M.D., who launched the division of Pediatric Colorectal and Pelvic Reconstructive Surgery at Children’s National Hospital in late 2019.

A prospective randomized controlled trial has given pediatric colorectal specialists the first evidence to reconsider a standard postoperative care practice: Routine anal dilations following a primary posterior sagittal anorectoplasty (PSARP), an operation to reconstruct a child born with imperforate anus. This treatment has been the standard of care following PSARP for more than thirty years and was believed to help prevent strictures after surgery for anorectal malformations (imperforate anus). However, it requires parents and caregivers to perform this uncomfortable procedure on their child daily, which can have a significant psychological impact on the child. Prior to this trial, a quality of life assessment found that postoperative dilations were the most stressful part of these patients’ care for both patient and parents.

“The PSARP procedure, performed for the first time in 1980, improves the lives of children born with imperforate anus by providing a safe and effective reconstruction technique,” says Marc Levitt, M.D., who led the study with co-author Richard Wood, M.D., before joining Children’s National Hospital as chief of the division of Colorectal and Pelvic Reconstructive Surgery. “We are thrilled to have evidence that one of the top postoperative challenges for parents – a twice daily anal dilation for several months after the surgery is completed – can potentially be eliminated for most kids with no impact on their recovery.”

“We also found that if a stricture, or scar, develops, which occurs in only about 10 percent of cases, it can easily be managed with a minor operative procedure done at the same time as colostomy closure, which they already need. So, if a family had to choose between daily dilations for months or a one in 10 risk of needing a minor surgical procedure, they can now make that choice and avoid routine dilations.”

The prospective single institution randomized controlled trial was conducted between 2017 and 2019 and included 49 patients. The abstract of the results will be presented as part of the British Association of Paediatric Surgeons Annual International Congress, which is currently scheduled for July 2020.

“The clinical benefit of routine dilation had never been studied in a formal way, it had been accepted as surgical dogma. Our cohort gave us the ability to look at this practice in an evidence-based way,” Dr. Levitt says. “Revising this practice could be a real game-changer for parents and kids with anorectal malformations.”

Dr. Sean Tabaie at the Limb Deformity Course

Orthopaedic surgeon shares expertise at Baltimore Limb Deformity Course

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Dr. Sean Tabaie at the Limb Deformity Course

Dr. Tabaie oversees a hands-on lab session focused on teaching orthopaedic surgeons and other allied health professionals proper assessment and placement of corrective hardware for limb deformities.

Sean Tabaie served as a lab instructor to guide hands-on applications of the latest devices for treatment of limb deformities.

Earlier this year, Children’s National orthopaedic surgeon Sean Tabaie, M.D., served as a faculty member for one of the most highly regarded courses focused on limb deformities, the 29th Annual Baltimore Limb Deformity Course. The course is presented each year by the International Center for Limb Lengthening.

The event brings together nearly 400 orthpaedic physicians, podiatrists and allied health professionals from 36 countries and 33 states to learn from pre-eminent surgical experts in these conditions. The three-day meeting provides lecture content as well as hands-on opportunities to practice care and treatment of limb deformities in both adults and children.

Dr. Tabaie served as a lab instructor, sharing expertise and in-depth knowledge from the pediatric perspective about how to assess limb alignment and plan corrections for specific deformities. The faculty teams also outlined current best practices for correction of several specific deformities, including Blount’s deformity, using internal and external devices.

“It was an honor to be asked to serve as faculty alongside these pre-eminent leaders in the field of limb deformity,” he says. “It is workshops like these that give us the opportunity to share what we know and also learn from the experience of others. And ultimately, lending expertise to these courses helps everyone more effectively assess and treat limb deformities in children and adults around the world.”

Read more about the course’s esteemed history and its 2020 schedule.

child measuring his stomach

Cognitive function does not predict weight-loss outcome for adolescents

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child measuring his stomach

Though young people with intellectual disabilities or cognitive impairment have greater rates of obesity and other comorbidities that impact their health and well-being, primary care providers are often reluctant to discuss or refer these patients for weight-loss surgery due to concerns about their ability to assent to both the surgery and the ongoing diet and lifestyle changes after surgery.

However, a study in Pediatrics authored by psychologists at Children’s National Health System finds that these young people, including those with Down syndrome, have similar weight-loss trajectories to those with typical cognitive function after bariatric surgery. The study is the first to look at post-surgical outcomes for this subgroup of adolescent bariatric surgery patients.

“It’s challenging to ensure that an adolescent who is cognitively impaired understands what it means to undergo a surgical procedure like bariatric surgery, but we do find ways to ensure assent whenever possible, and make sure the patient also has a guardian capable of consent,” says Sarah Hornack, Ph.D., a clinical psychologist at Children’s National and the study’s first author. “A very important determinant of post-surgical success for any young candidate, however, is a support structure to help them with weight-loss surgery requirements. Often, we see that adolescents with lower cognitive function already have a well-established support system in place to assist them with other care needs, that can easily adapt to providing structure and follow through after weight-loss surgery, too.”

The study reviewed outcomes for 63 adolescents ranging in age from 13 to 24 years old with an average body mass index of 51.2, all of whom were part of the bariatric surgery program at Children’s National Health System. The participants were diagnosed with cognitive impairment or intellectual disability via standardized cognitive assessments as part of a preoperative psychological evaluation or through a previous diagnosis. This study adds to the body of research that is helping to create standard criteria for bariatric surgery in adolescents and teenagers.

Children’s National is one of only a few children’s hospitals with accreditation from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program of the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery to offer bariatric surgery for adolescents with severe obesity. The extraordinary diversity of the patient population in Washington, D.C., including high rates of young people with obesity, allows the team to collect more comprehensive information about successful interventions across subgroups, including cognitive impairment or developmental disabilities, than nearly every other center in the United States.

“We’re happy to contribute evidence that can help families and care providers make informed health decisions for young people with intellectual disabilities or cognitive impairments. So many families are hoping to make sure that their children, despite disabilities, can be as healthy as possible in the long term,” says Eleanor Mackey, Ph.D., who is also a clinical psychologist at Children’s National and served as the study’s senior author. “Though the sample size is small, it does give credence to the idea that for many adolescents and teenagers, weight loss surgery may be a really viable option regardless of pre-existing conditions such as intellectual ability or cognitive function.”

Jeffrey Lukish

Pediatric Surgeon receives ACS/APSA Health Policy Scholarship

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Jeffrey Lukish

Jeffrey Lukish, M.D., a pediatric surgeon at Children’s National Health System, has been named a 2019 American College of Surgeons (ACS) and American Pediatric Surgical Association (APSA) Health Policy Scholar for 2019.

The scholarship supports Dr. Lukish’s attendance at the Executive Leadership Program in Health Policy and Management at Brandeis University, which teaches knowledge and skills essential for participating in health care policy and equips health leaders with tools to create innovative and sustainable ways to improve health care service delivery. As a 2019 scholar, he will also provide health policy-related assistance to the ACS and the APSA as requested, and will have opportunities to build relationships with local, state and federal lawmakers.

Dr. Lukish is a nationally recognized expert in advanced minimally invasive surgery in infants and children, as well as pediatric surgical innovation. He has been voted a Baltimore Top Doctor by his peers for five of the last eight years. He holds academic appointments as a professor of surgery from the Uniformed Services University and associate professor of surgery at the George Washington University.

Dr. Lukish is a fellow of the American College of Surgeons and the American Academy of Pediatrics, and member of several prominent professional societies, including the American Pediatric Surgical Society, the Pediatric Cancer Oncology Group and the International Pediatric Endosurgery Group.  He has authored over 100 publications.

Adolescent brain scan from obesity study

Imaging captures obesity’s impact on the adolescent brain

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Adolescent brain scan from obesity study

For the first time, a team of researchers led by Chandan Vaidya, Ph.D., chair of the Department of Psychology at Georgetown University, has used functional magnetic resonance imaging (fMRI) to capture the brain function of a small population of adolescents with obesity, both before and after bariatric surgery.

Obesity affects the whole body, from more obvious physical impacts on bones and joints to more subtle, internal impacts on organs like the brain.

For the first time, a team of researchers has used functional magnetic resonance imaging (fMRI) to capture the brain function of a small population of adolescents with obesity, both before and after bariatric surgery. The goal is to better understand the neural changes that occur when an adolescent is obese, and determine the effectiveness of interventions, such as vertical sleeve gastrectomy, at improving brain function as weight is lost.

The study, published as the November Editors’ Choice in the journal Obesity, found that executive and reward-related brain functions of study participants with obesity improved following the surgical procedure and initial weight loss.

How bariatric surgery changes the teenage brain from Research Square on Vimeo.

“We’ve known for some time that severe obesity has negative consequences on some neurocognitive function areas for adults,” says Chandan Vaidya, Ph.D., chair of the Department of Psychology at Georgetown University and a senior author of the study. “But for the first time, we’ve captured fMRI evidence in young patients, and also shown that surgical intervention and the resulting weight loss can reverse some of those deficits.”

“For me, this early evidence makes a strong case that when kids are struggling with severe obesity, we need to consider surgical intervention as an option sooner in the process,” notes Evan Nadler, M.D., director of the Bariatric Surgery Program at Children’s National Health System, who also contributed to the study. “The question that remains is whether the neurocognitive function improves more if surgery, and thus weight loss, happens earlier – and is there a time factor that should help us determine when to perform a procedure that will maximize improvements?”

The preliminary study included 36 participants and was conducted using patients recruited from the Children’s National Bariatric Surgery program, one of the first children’s hospitals to achieve national accreditation by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

“We asked these questions because we know that in the kids we see, their behavioral, brain, and physical health are all very closely related to one another and have an impact on each other,” adds Eleanor Mackey, Ph.D., study senior author and co-principal investigator on the National Institute of Diabetes and Digestive and Kidney Diseases grant that funded the project. “We expected that as physical health improves, we might see corresponding improvements in brain and behavior such as cognitive and school performance.”

The study also pointed out some technical and practical challenges to studying this particular young population. Anyone with a BMI greater than 50 was not able to fit within the MR bore used in the study, preventing fMRI participation by those patients.

“In addition to future studies with a larger sample size, we’d like to see if there are neuroimaging markers of plasticity differences in a population with BMI greater than 50,” says Dr. Vaidya. “Does the severity of the obesity change how quickly the brain can adapt following surgery and weight loss?”

The abstract was selected by the journal’s editors as one that provides insights into preventing and treating obesity. It was featured at the Obesity Journal Symposium during Obesity Week 2017 in Washington, D.C., as part of the Obesity Week recognition, and a digital video abstract was also released about the findings.