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April 19, 2019
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Why Wrestling Through the Logistical Challenges of a Multidisciplinary Colorectal Center Matters

Consider the complex case of a girl born with rectal, vaginal and urinary tracts fused into a common channel – a cloacal malformation.

The child needs reconstructive procedures across three different organ systems and three different surgical specialties. It could take months or years to manage the surgeries needed for the colorectal portion, then the gynecological portion, then the urological portion. Multiple anesthetic inductions, intubations, inpatient stints and recovery periods.

The definitive surgical repair could also take just eight hours in a single day, if those different specialties operated in the same room together. But in most institutions, they almost never do because it’s a logistical nightmare to plan, schedule, bill and share resources between divisions.

Or consider the case of a boy with severe functional constipation, referred for surgery after failure of medical management. A gastroenterologist, working closely with a colorectal surgeon, could conduct motility testing to help guide treatment. The motility testing may actually suggest that surgery isn’t the best option, that a Botox injection, or even behavioral health interventions, make more sense.

But most often, a GI doctor does one thing, a colorectal surgeon does another. Maybe they talk and maybe they don’t.

“Intuitively, it’s better for the child if the surgeon and I plan and carry out the best course of action together,” says Carlo Di Lorenzo, MD, chief of Gastroenterology at Nationwide Children’s Hospital. “It’s better for the patient if a colorectal surgeon, a gynecologist and a urologist collaborate on a complex case. But I always thought, if this were a model that worked, other institutions would already use it.”

That’s how Dr. Di Lorenzo described his attitude about an integrated center approach several years ago. This is Dr. Di Lorenzo describing it this year: “Now it would be really hard to do it any other way.”

In the spring of 2014, Marc Levitt, MD, a colorectal surgeon, created the Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s. Dr. Levitt and his collaborators across the hospital have spent the last five years showing how the model can, in fact, succeed.

The collaboration has not always been easy. For those who have participated, though, and those who are adopting some of the same methods outside of Nationwide Children’s, it’s worth it.

A “LEAP OF FAITH”

In the first full year of existence, the Center for Colorectal and Pelvic Reconstruction performed 132 combined procedures on 82 patients. A total of 87 procedures were urological, gynecological and colorectal, and the rest were either urological and colorectal or gynecological and colorectal.

Had the procedures been done independently instead of in combination, there would have been a total of 346 anesthetic inductions. There were actually 132. There would have been 101 endotracheal intubations. There were actually 50. Hospital length of stay was shorter and there were fewer post-operative clinic visits. Patients went home sooner. Families had to travel to the hospital less frequently.

Those were the benefits seen across 82 patients in 2015. In 2018, the center handled 1,000 cases.

When Dr. Levitt first proposed the center to Dr. Di Lorenzo and what would become the center’s other primary service line chiefs – Geri Hewitt, MD, of Gynecology, and V. Rama Jayanthi, MD, of Urology – he had none of these statistics. He just had an idea of what could happen if everyone came together.

“Dr. Di Lorenzo, Dr. Jayanthi and Dr. Hewitt did not know this would work,” says Dr. Levitt, who is himself chief of the Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s. “They knew the concept could help patients. It was a leap of faith in the beginning.”

Or, as Dr. Hewitt put it: “We understood why it would work. How it would work was the hard part.”

"We understood why it would work. How it would work was the hard part." – Geri Hewitt, MD

The primary solution Dr. Levitt proposed was making the center its own service line with its own faculty and staff members. The center would not be stealing resources from other divisions, or asking those divisions to contribute out of the goodness of their hearts; those divisions would themselves be receiving value from the cases the center brought in.

As a practical matter, 14 surgeons and gastroenterology physicians now divide their work between their home divisions and the center (two surgeons, including Dr. Levitt, are essentially full-time center faculty). For example, several urologists spend 25 percent of their time on collaborative cases, and the remainder of their time on pure urology cases. That has allowed Nationwide Children’s to hire additional urologists in the division.

“There are some inefficiencies – a urologist may have to block off an entire day for a single, complex center case, when the urological portion of that case may last only two hours,” says Dr. Jayanthi, the Urology chief. “We accept that, because we know it’s better for the patient.

We also know that some patients are coming to this hospital who wouldn’t have before, because they can get this comprehensive care. This is bigger than Urology alone. We recognize it, and the hospital recognizes it.”

Dr. Hewitt had to reorganize her entire practice routine, and request that her gynecological partners reorganize theirs, to make it work. Dr. Di Lorenzo says that in a weekly center meeting, there can be four surgeons, a handful of GI motilitists, plus behavioral health and social work talking about a single child for more than an hour.

The center published a study in 2018 explaining in detail how all of this works, from intake meetings for a very young child through the transition to adult care. Dr. Levitt believes other institutions can use this model to help their patients, or to use information from the center to create other multidisciplinary programs.

Some institutions are doing just that.

A DIFFERENT WAY

At Seattle Children’s Hospital, the system has grown gradually over time, as it became clear that a multidisciplinary approach could work there, says Jeffrey R. Avansino, MD, a general pediatric surgeon and founding member of Seattle Children’s Reconstructive Pelvic Medicine Program.

“I looked at it the same way I look at writing a grant,” says Dr. Avansino. “You have to do the experiments before you apply for a grant to provide proof the future experiments will be successful.”

The Reconstructive Pelvic Medicine Program did not have the same initial institutional investment of the center at Nationwide Children’s, but the program has ultimately been able to make a similar business argument, after the clinic was established.

“Of course it’s better for the patient, but it’s also true that some patients come for the program who never would have made it to Seattle otherwise.” says Dr. Avansino.

Patients with complex anorectal malformations often have other conditions that must be addressed, and those patients can be referred to an institution’s neurosurgeons or heart specialists. It becomes clear that while a gynecologist is perhaps not doing as many individual gynecological procedures, the entire hospital actually benefits from the multidisciplinary program, say both Dr. Levitt and Dr. Avansino.

“Most importantly, multidisciplinary care benefits the patients,” says Dr. Avansino. “You realize that if you need to examine the child under anesthesia, and a urologist also needs to scope the same child, it would be better if everyone worked together. If you do a complex repair together, perhaps you can share tissue, which ultimately creates the best outcome for the patient.”

But Seattle and Nationwide Children’s have significant resources and large potential patient volumes. What about other pediatric institutions that don’t?

"We want other centers to understand that this is worth doing. This is how we can give the best possible care to these patients across the country." – Marc Levitt, MD

Dr. Avansino credits Dr. Levitt and others with building an international network of like-minded providers who are engaged with that very issue. Some large pediatric colorectal programs have joined to create the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC.org), both to advance research and create common definitions for terms like “failure of medical management” in constipation. (The Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s runs a “Bowel Management Boot Camp,” which often finds that an intensive initial medical regimen allows children with severe constipation to avoid surgery.)

Those large centers can help develop knowledge and take care of the most complex cases. What they learn can be transmitted to smaller institutions, so they can better take care of less complex cases, or help with ongoing management after centers like Nationwide Children’s and Seattle Children’s have completed surgical repairs.

“We want other centers to understand this is worth doing,” says Dr. Levitt. “This is how we can give the best possible care to these patients across the country.”

THE FRUITS OF COLLABORATION

Consider, again, the complex case of a girl born with a cloaca. For decades, the length of the common rectal, vaginal and urinary channel was the main guide for surgical strategy. The Center for Colorectal and Pelvic Reconstruction has been referred a number of patients who have already undergone reconstruction elsewhere using the traditional strategy, and who have post-operative urinary complications.

The center’s urologists, colorectal surgeons and gynecologists together analyzed what they were seeing, and realized surgeons also needed to use urethral length to guide reconstruction. A short urethral length, or an especially long common channel length, suggests a technique that is not routine. They published a new algorithm for cloacal management in 2018, in the Journal of Pediatric Surgery, considering both common channel and urethral length. According to Dr. Levitt, this is the first change in cloacal surgery technique in more than two decades. So far, the outcomes have been excellent.

“The importance of collaboration with urology on the management of cloacal malformations cannot be over-emphasized, and this urethral issue is a great example,” wrote the authors, including Dr. Levitt, Dr. Hewitt, Dr. Jayanthi and many of their center partners.

This new algorithm is exactly the reason the Center for Colorectal and Pelvic Reconstruction exists. Maybe it was a leap of faith in the beginning. Maybe the logistics are difficult. But in the end, the patient gets better care.

“This works,” says Dr. Levitt.

 

Citations:

  1. Vilanova-Sánchez A, Reck CA, Wood RJ, Garcia Mauriño C, Gasior AC, Dyckes RE, McCracken K, Weaver L, Halleran DR, Diefenbach K, Minzler D, Rentea RM, Ching CB, Jayanthi VR, Fuchs M, Dajusta D, Hewitt GD, Levitt MA. Impact on Patient Care of a Multidisciplinary Center Specializing in Colorectal and Pelvic Reconstruction. Frontiers in Surgery. 2018 Nov 19; 5:68.
  2. Vilanova-Sanchez A, Halleran DR, Reck-Burneo CA, Gasior AC, Weaver L, Fisher M, Wagner A, Nash O, Booth K, Peters K, Williams C, Brown SM, Lu P, Fuchs M, Diefenbach K, Leonard JR, Hewitt G, McCracken K, Di Lorenzo C, Wood RJ, Levitt MA. A descriptive model for a multidisciplinary unit for colorectal and pelvic malformations. Journal of Pediatric Surgery. 2019 Mar; 54(3):479-485
  3. Reeder RW, Wood RJ, Avansino JR, Levitt MA, Durham MM, Sutcliffe J, Midrio P, Calkins CM, de Blaauw I, Dickie BH, Rollins MD; Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). The Pediatric Colorectal and Pelvic Learning Consortium (PCPLC): rationale, infrastructure, and initial steps. Techniques in Coloproctology. 2018 May; 22(5):395-399.
  4. Halleran DR, Thompson B, Fuchs M, Vilanova-Sanchez A, Rentea RM, Bates DG, McCracken K, Hewitt G, Ching C, DaJusta D, Levitt MA, Wood RJ. Urethral length in female infants and its relevance in the repair of cloaca. Journal of Pediatric Surgery. 2019 Feb;54(2):303-306.

Photo credit: Nationwide Children’s (pictured left to right: Dr. Hewitt, Dr. Levitt, Dr. Jayanthi, Dr. Di Lorenzo)