A multi-specialty, collaborative approach to complex pelvic anomalies leads to a reduction in clinic visits, fewer anesthetic events and improved surgical planning.
Alejandra Vilanova-Sanchez, MD, Molly E. Fuchs, MD, Carlos A. Reck-Burneo, MD, Christina B. Ching, MD, Daniel G. DaJusta, MD, Richard J. Wood, MD, Kristina Booth, APN, Venkata R. Jayanthi, MD, Marc A. Levitt, MD.
Nationwide Children's Hospital, Columbus, OH, USA.
Background /Aim Many patients with complex colorectal malformations have associated urologic and gynecologic pathology that require surgical treatment. To improve the quality and efficiency of treatment, we developed a multidisciplinary center with pediatric surgery, urology and gynecology. The aim of this study is to evaluate the impact of this collaborative approach on the efficiency of delivering surgical care to these complex patients. We hypothesized that a multidisciplinary approach could improve clinic time utilization for the patient and consolidates operative procedures performed.Methods: We established a prospective database of patients seen in our multi-specialty clinic for complex colorectal and pelvic abnormalities. In this clinic, all patients were discussed in a collaborative meeting prior to their clinic visit which included all specialties involved: pediatric surgery, urology and gynecology. All providers then saw the patient in a single clinic encounter and all specialties involved formulated a unified surgical plan. We queried our database for patients who underwent a combined procedure performed by more than one surgical service between 1/2015 and 1/2016. Patients undergoing surgery by a single specialty were excluded. We recorded demographic data, details of the child's pelvic malformation, and procedures performed. We calculated the number of clinic visits, and anesthetic (surgical) events that were potentially avoided using the assumption that without a multidisciplinary approach, each patient would have required a separate visit with each specialty. Similarly, we assumed if these patients had not undergone a combined surgery, they would have undergone separate surgical procedures and thus anesthetic events by each specialty. Results A total of 53 patients (18 females), ( 33 anorectal malformations, 18 complex cloacas, 2 myelomeningoceles) underwent 55 combined procedures (image 1). The mean age at the time of the combined procedures was 5.2 years (range 0.4-17). Nine of these involved sharing of tissue between specialties such as split appendix for Mitrofanoff/Malone creation or bladder augmentation using resected colon deemed necessary for colorectal management. Eight patients underwent comprehensive reconstruction with by all three surgical specialties. The remaining 38 patients had procedures performed by multiple specialties because of a practical advantage while the child was under general anesthetic. Our cohort avoided 59 anesthetics (average saved per patient 1.1;range 1-2) during the study period. There were a total of 110 pre-operative and post-operative clinic visits in which multiple providers were seen. As a result of this collaboration, 126 clinic visits were saved with an average of 2.3 visits saved per patient (range 2-4).Conclusion Our multidisciplinary approach to managing children with complex colorectal and pelvic malformations reduces the number of anesthetic exposures and clinic visits. It also creates an opportunity for surgeons from different specialties to collaborate to perform multiple complex operations in one setting and potentially utilize shared tissue for reconstruction. We believe this is an important step in creating greater efficiency in health care utilization and may lead to better overall patient care.
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