the interface between paediatric and adult coloproctology · the interface between paediatric and...

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