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TheInterfacebetweenPaediatricandAdultColoproctology
Mr RichardEnglandConsultantPaediatricSurgeon
JennyLindChildren’sHospitalNorwich,UK
WheredoIfinishandyoubegin?AdultColorectalSurgerySpecialist
PaediatricSurgery
Controversy?
AdultSurgeons?Adolescents??Pregnancy??Implicationsforoffspring??
SpecialistPaediatricSurgeons?AdultCongenitalGISurgeons
Controversy??AdultColorectal
Surgeons?
PaediatricSurgeryCentresAberdeenEdinburghGlasgowNewcastleLiverpoolBelfastManchesterLeedsHullSheffieldNottingham
LeicesterBirminghamDublinCardiffBristolOxfordCambridgeNorwichLondon(x6centres)SouthamptonBrighton
27MajorCentresand~200Specialistsurgeonswitharound50havingamajorinterestin
paediatriccolorectalsurgery
HandholdingorTeamworking?• IBD
– Laparoscopiccolectomy– PouchSurgery– Perianaldisease– MDTreview
– Polyposis
• RectalProlapse– Delormes procedure– MeshRectopexy
• Haemorrhoidectomy
Operativecollaboration• Preceptorship forlaparoscopiccolectomy(2007-2010)
– 8SubtotalcolectomiesforUC– 4RightHemicolectomies forCrohns– 3SubtotalcolectomiesforCrohns– 4LaparoscopicpouchforUC
Operativecollaboration• Externalhaemorrhoidectomy• Rareinchildren• Laxativetherapysofarhasbeen
ineffective• Absenceofliverdisease
• 5patientsinclinicage3-12
• 2haveundergoneEndo-analUSandhaemorrhoidectomywithoneofmycolorectalcolleagues
Anorectalmalformations
Recto-vesical fistula Persistentcloaca
PeterPanPerineum?
LongtermissuesinARM
• Constipation• Faecal Incontinence– ACEwashouts– Peristeen
• ROOF– RemnantOfOriginalFistula
• Vaginalseptum• Obstetrictears
VACTERLassociation
VACTERLcomponent LongtermproblemsVertebralanomalies Scoliosis
Pelvicdysplasia
AnorectalMalformations ConstipationFaecal IncontinenceObstetric issues
Cardiac ArrhythmiasCardiacFailure
Tracheo – Esophageal Oesophageal atresia-• Stricture• Reflux• Barratts
Renal HypertensionChronicRenalFailureUrosepsis
Limb EmploymentlimitationsArthritis
Hirschsprungs disease
SwensonandSoave
DuhamelPull-through
LongtermproblemsinHirschsprungs
Specific
• Constipation– Spurresection– Transitionzonepullthrough– Botox
• Entercolitis
• Soiling/Frequency/Incontinence
• Perianalexcoriation
• Needforpermanentstoma
• Psychologicalissues
Syndromic associations
• RETgenemutations– MEN2Aassociation– FamilialMedullaryThyroidCa– Prophylacticthyroidectomy
• Down’sSyndrome– Cardiacanomalies– Immunologicaldeficiency– Neurodevelopmentaldelay– Morepronetoenterocolitis
• Mowat-WilsonSyndrome– Intellectualdisability– Cardiacdefects
• Congenitalcentralhypoventilationsyndrome– Longtermventilationrequiredwhenasleep
TransitiontoAdultServices• NICEguidancepublishedFeb2016
– Transitionofphysicalhealth/mentalhealthandsocialcarefragmented
– Confusionandchangeleadsto‘lostinthesystem’situationanddisengagementwithhealthprofessionals
– Earlyplanning(fromage14)– AnnualReview– Namedtransitioncoordinator– Buildconfidenceinmanagingtheirowncondition– Becomefamiliarwithadulthealthcareprofessionals
– PatientswithColorectaldisordersandassociatedanomalies/neurodevelopmentaldisorderswillbenefitfromamorecoordinatedtransitionpackage
ColorectalTransition• Adhoc Cases
– AdultSurgeonvisitspaediatricclinic– PaediatricSurgeonattendsadultclinic
• HighVolume:Dedicatedtransitionclinic
• Writtenhandover• Explanationofanatomyandsurgicalhistorytopatients
• Stablepatients?• Patientswithongoing problems?
• Needingsurgery• Non-operative
• Educationforcolorectalnursespecialists
• Lengthoffollow-up
CollaborationAfterTransition• Acuteevents
– Managementofcomplications– Understandingthesurgicalanatomy
• ElectiveSurgicalplanning– Reviewofprevioussurgicalanatomy– Retrievalofoldnotesifpossible
Longtermfollow-up• Follow-upletters
• Fewlongtermoutcomestudiesofcongenitalcolorectaldisorders– letscollaborate!
• OldestpatientundergoingthePSARPforARMis36
• LearningfromolderpatientswithARMorHirschsprungsdisease.
• Theroleofthepatientsupportgroup
Thank you