Dr Marc Levitt speaks about The Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s Hospital

I would like to con­grat­u­late Dr. Marc Levitt on his new mul­ti-dis­ci­pli­nary sur­gi­cal pro­gram at Nation­wide Children’s Hos­pi­tal and offer him this oppor­tu­ni­ty to talk about his plans and his phi­los­o­phy about bow­el management. 
Fred Daum, MD

“I was very hap­py to be asked to con­tribute Dr. Daum’s web­site with the occa­sion­al blog post. 

Dr Daum and I go way back to the days when he was an attend­ing at North Shore Uni­ver­si­ty Hos­pi­tal, Man­has­set, New York and I a young med­ical stu­dent.  Dr. Daum has focused his career on car­ing for chil­dren with enco­pre­sis and with­hold­ing and I am ecsta­t­ic about the promise of our con­tin­ued collaboration. 

As many of you know, I am a pedi­atric sur­geon total­ly focused on the care of chil­dren with colon relat­ed sur­gi­cal prob­lems, and Dr. Daum has focused his long career in Pedi­atric Gas­troen­terol­o­gy on the med­ical treat­ment of chil­dren with bow­el and oth­er GI disorders.

I recent­ly moved to a won­der­ful hos­pi­tal, Nation­wide Children’s Hos­pi­tal in Colum­bus Ohio because they were very inter­est­ed in bring­ing a dream of mine into real­i­ty – the cre­ation of a col­orec­tal pro­gram that inte­grates col­orec­tal surgery, urol­o­gy, gyne­col­o­gy, and GI/motility into one well-func­tion­ing team.  This bold endeav­or will be the first of its kind in the world in which all four of these teams are ful­ly inte­grat­ed.  Imag­ine that a patient with prob­lems in any or all of these areas can call one phone num­ber, and make one vis­it, to have their col­orec­tal, motil­i­ty, or pelvic recon­struc­tion prob­lem solved, with the team of doc­tors and nurs­es assem­bled around that child and com­plete­ly focused on them.  The new pro­gram is called the Cen­ter for Col­orec­tal and Pelvic Recon­struc­tion (www.nationwidechildrens.org/ccpr)

Here is a brief intro­duc­tion to the types of patients Dr. Daum and I try to help:

Soil­ing, Enco­pre­sis and Fecal Incontinence
Fecal soil­ing in chil­dren is sur­pris­ing­ly com­mon, and can pre­vent a child from becom­ing social­ly accept­ed.  It can affect those born with sur­gi­cal con­di­tions such as anorec­tal mal­for­ma­tions (ARMs)/imperforate anus and Hirschsprung dis­ease (HD), and those who have spinal cord prob­lems, such as spina bifi­da.  Soil­ing can also occur in patients suf­fer­ing from severe con­sti­pa­tion. This is often called enco­pre­sis.  In addi­tion to soil­ing, patients can also suf­fer from abdom­i­nal pain, bloat­ing, and poor appetite. 

The key ques­tion to ask is whether the child has true fecal incon­ti­nence – mean­ing they do not have the nor­mal mech­a­nisms of con­ti­nence.  These include some patients with anorec­tal malformations/imperforate anus, Hirschsprung dis­ease and those with spinal prob­lems. Or does the patient have “over­flow pseudoin­con­ti­nence”, which means they have all the poten­tial to be con­ti­nent but because of con­sti­pa­tion and impaction, they soil.

True Fecal Incon­ti­nence — Who are the patients and how are they treated?
Of the sur­gi­cal patients (those with anorec­tal malformations/imperforate anus, Hirschsprung dis­ease, and those with spinal prob­lems) approx­i­mate­ly ¹⁄₄ oper­at­ed on for anorec­tal mal­for­ma­tions have enough of an abnor­mal­i­ty in their con­ti­nence mech­a­nism that they are unable to have a vol­un­tary bow­el move­ment.  Many oth­ers are able to be con­ti­nent but often require some med­ical treat­ment, usu­al­ly lax­a­tives to treat con­sti­pa­tion, but some­times they need treat­ments to slow down the stool if their colon moves too fast.  A small num­ber (less than 5%) of Hirschsprung patients have fecal incon­ti­nence after their sur­gi­cal pull-through. This is usu­al­ly relat­ed to how intact is their anal canal and/or sphinc­ters.  Patients with spinal prob­lems, such as spina bifi­da, or spinal injuries can have a lim­it­ed capac­i­ty for vol­un­tary bow­el movements.

Patients with true fecal incon­ti­nence need an arti­fi­cial (mechan­i­cal) mech­a­nism to keep them clean and in nor­mal under­wear.  An ene­ma pro­gram designed specif­i­cal­ly for the patient’s type of colon works to emp­ty the colon once a day, and they remain clean for the rest of the day.  For these patients, lax­a­tives and oth­er med­i­cines do not work well, and can make the sit­u­a­tion worse, as the lax­a­tives or stool soft­en­ers pro­voke more acci­dents.  The ene­ma can be giv­en via the rec­tum, or a sur­gi­cal pro­ce­dure can be done to allow the ene­ma to be giv­en from the top of the colon down, with an open­ing cre­at­ed in the appen­dix or cecum (Terms used for this pro­ce­dure include an appen­di­cos­to­my, Mal­one pro­ce­dure, or cecos­to­my).  In this group of patients, enhance­ments of their sphinc­ter con­trol by tech­niques such as sacral nerve stim­u­la­tion (SNS) may give them just enough con­trol to gain continence.

Pseudoin­con­ti­nence or Enco­pre­sis – Who are the patients and how are they treated?
These patients may not have had any surgery at all, yet have severe con­sti­pa­tion and soil because they are impact­ed and have over­flow soil­ing.  Some patients who have had col­orec­tal surgery may have good poten­tial for bow­el con­trol but also soil due to con­sti­pa­tion, and behave in much the same way.  The rare patient in this group has very severe con­sti­pa­tion and needs a focused motil­i­ty eval­u­a­tion, includ­ing colonic and anorec­tal manom­e­try evaluation.

For these patients, ade­quate treat­ment of their con­sti­pa­tion usu­al­ly solves the prob­lem. This can be best accom­plished through a pre­scribed pro­gram, reg­u­lat­ing the colon, with lax­a­tives and diet, and care­ful­ly check­ing results so accu­mu­la­tion of stool does not recur.  For the most severe patients, advanced tech­niques to manip­u­late the colonic motil­i­ty med­ical­ly are required, and some­times sur­gi­cal inter­ven­tions includ­ing removal of non-work­ing parts of the colon are needed.”
 
Marc A. Levitt, M.D.
Sur­gi­cal Direc­tor, Cen­ter for Col­orec­tal and Pelvic Reconstruction
Pedi­atric Surgery, Nation­wide Children’s Hospital
http://www.nationwidechildrens.org/colorectal-pelvic-reconstruction-center