2019 Chandler Lecture: Dr. Marc Levitt

In medicine, care is often uncoordinated: a colorectal surgeon may repair a colorectal problem without addressing a bladder issue, and six months later a urologist discovers the need for intervention after the patient has already had a laparotomy.

In the UK, biliary atresia and bladder exstrophy can only be treated at certain designated medical centers because experience improves outcomes.

Walmart sends employees anywhere in the United States to Cleveland Clinic for coronary surgery because they have designated it their go-to place for open heart surgery.

There are approximately 600 newborns with anorectal malformations born per year in the United States.

A pediatric surgery fellow does about 14 anorectal malformation cases in 2 years, and a graduate does about 1 case per year.

Complications of anorectal malformation surgery include fecal incontinence, urinary incontinence, renal dysfunction requiring renal transplant, sexual dysfunction, and infertility.

If a surgeon misplaces the anus outside the sphincters during surgery on a 6-month-old, the error will not be apparent until the child is 4 years old and attempting to potty train.

Surgeons are slow to admit they could have a complication until it happens to them personally.

Approximately 60% of Levitt's practice is reoperative surgery for anorectal malformations.

In a collaborative 10-hour operation requiring urology and gynecology, traditional siloed RVU models fail because they do not account for the fact that all participants are essential and cannot do other work during the case.

Patients with anorectal malformations often have associated Mullerian anomalies (e.g., hemisystems) that, if not identified and addressed during initial abdominal surgery at 6 months, will present as pelvic pain at age 13 due to obstructed menstrual blood.

Knowledge of associated sacral and spinal problems allows prediction of continence in the neonatal period, enabling clinicians to tell families either that the child will likely be continent with proper management or that continence is unlikely but the child can be kept clean with bowel management.

Rectourethral fistulas are classified as bladder neck (at the deltoid level), prostatic (at the tricep level), or bulbar (at the elbow level), and each has a different surgical approach and potential outcome.

Common technical errors in anorectal malformation surgery include placing the anus too far posterior (outside the sphincter center), creating a stricture, leaving a remnant of the original fistula, and causing rectal prolapse.

Reoperative surgery for misplaced anus and other technical errors can convert a significant number of patients to continence and improve quality of life.

The baseline surgical site infection rate after colostomy and ileostomy closure was 22.4%, which is standard in the literature.

Implementing a GI bundle (most importantly, changing instruments and gloves before closing the fascia) reduced the surgical site infection rate to 7.9%.

Organisms growing in surgical site infections after colostomy closure were resistant to the preoperative antibiotic (cefoxitin) given within an hour of incision.

Switching the preoperative antibiotic from cefoxitin to Unasyn (based on wound culture data and infectious disease consultation) reduced the surgical site infection rate to 2.2%.

In cloacal malformations, if the residual urethra after reconstruction will be shorter than 1.5 cm, the patient will be urinary incontinent ('wet'); leaving adequate urethral length preserves continence.

In a coordinated operation for a child with myelomeningocele and urinary and fecal incontinence, the sigmoid colon can be resected to improve bowel care but preserved on its mesentery and used for bladder augmentation, and the appendix can be divided to create both a Malone antegrade enema channel (proximal) and a Mitrofanoff catheterizable channel (distal).

The Pediatric Colorectal and Pelvic Learning Consortium has collected data on 22,200 patients across 15 centers over three years, allowing real-time queries such as the incidence of enterocolitis in Hirschsprung disease.

The Sir Dennis Browne medal from the British Association of Paediatric Surgeons states that 'the aim of pediatric surgery is to set a standard, not to seek a monopoly.'

In most departments of surgery, clinicians do not know their wound infection, death, or line infection rates in real time, unlike industries such as airlines, which track delay statistics daily.

Tissue engineering (e.g., engineered vaginal tissue) will revolutionize cloacal reconstruction by eliminating the need to use bowel.