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"Transition of care in Paediatric Colorectal Surgery" by Dr Giulia Brisighelli, Paediatric Colorectal Surgeon, Johannesburg, South Africa - January 16, 2024



Join this enlightening academic Zoom meeting hosted by the Department of Pediatric Surgery in East London, South Africa. The special guest for this session is Dr. Julia Bri from Johannesburg who will be sharing her meticulous research and vast knowledge on transitioning in pediatric colorectal surgery. With a record of 43 published papers and a passion for documenting her medical findings for scientific research, Dr. Bri is a specialist with valuable expertise in the field. The session will dive into the intricacies of managing congenital colorectal diseases, patient communication via telemedicine, and the urgent need for better transitional care systems. This is an essential opportunity for medical professionals to gain fresh insights and exchange ideas around pediatric colorectal surgery, patient management, and effective transition of care.
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AI-generated summary of the talk:

Milind Chitnis welcomed attendees and introduced guest speaker Giulia Brisighelli from Johannesburg to discuss the transition of care challenges in pediatric colorectal surgery. Giulia's expertise from Italy, the US, and South Africa was highlighted.

Transition of care challenges and experiences @ 13:30

Giulia shared a patient message showing an urgent need for transition support. Surveys found a lack of long-term follow-up and risk assessment, though responsibility fell to pediatric surgeons. Adult providers were less understood.

Long-term outcomes of congenital conditions @ 25:05

Studies found that 17-37% of patients with anorectal malformations experienced long-term fecal incontinence, with constipation also common. Urinary issues including incontinence and dysfunction occurred in 16-36% and fertility was impacted. Quality of life was lower.

Johannesburg transition of care program @ 32:07

Giulia launched bi-monthly meetings in 2023. Record challenges, different medical languages, and a lack of dedicated specialists were discussed. Two to three complex cases are presented per meeting.

Lessons from meetings and the path forward @ 36:22

Humility and patience were emphasized. Progress was made in understanding through discussion. The need for transition was clear despite difficulties. Regional collaboration offered potential solutions.

Case studies and discussion @ 46:40

Eight cases were presented showing issues like delayed diagnosis, complications, and specialists unfamiliar with conditions. Prognosis involved tailored plans for social continence though true continence was challenging.

Closing remarks and future talks @ 59:00

Milind thanked Giulia and the attendees. Giulia's work built on BARA's legacy. The schedule for 2024 talks was announced, including Arua Obasi on “the role of Minimally invasive surgery for congenital malformations” in February.

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Learning objectives

1. Understand the challenges and importance of transition from pediatric to adult care in colorectal surgery 2. Identify the barriers perceived by patients and medical practitioners in transition of care 3. Learn about various colorectal diseases and the nomens surrounding it to better understand the transition in care 4. Understand the need and necessity of implementing a structured long term follow up for patients in transition 5. Learn how to evaluate and stratify patient's needs for effective transition planning.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Good afternoon. Good morning. Good evening. Um, greetings and welcome to the first uh Zoom academic meeting of the year 2024 the Zoom academic meetings of the Department of pediatric Surgery in East London, South Africa. And uh today, um we are really glad and fortunate that uh one of our young and very bright uh colleague, Doctor Julia Bri from Johannesburg has uh agreed to share her expertise and knowledge about transition of care in pediatric colorectal surgery. I know Julia for many years and I've seen her uh uh career progress um from, from a fellow to an actively uh participating specialist or a consultant in South Africa. She uh she um is originally from Italy and did her basic uh medical training in, in um in Italy. After that, she did a research fellowship in Collective Center Center in Cincinnati USA in 2012. Then she came back to Italy qualified as a pediatric surgeon and subsequently joined as a fellow in co pediatric colorectal surgery at the Krish Baragwanath Hospital in Johannesburg in 2017. Um Now, currently she is a consultant there and she runs the Johannesburg pediatric color Clinic at uh at the hospital in Johannesburg. She has published 43 papers in peer reviewed journals and this is what I like and admire about Julia that uh whatever she does she records properly and she tries to get scientific information out of that, which is not useful, not only for audit but is also useful for research purposes. Uh In addition to being a pediatric surgeon where she's very busy. Her hobbies are photography, traveling, embroidering, and watching her daughter grow. So Julia, thank you for, for giving a talk today and I'll stop share and you can start share and share your uh views with us. Thank you. OK. Good morning. Good afternoon. Good evening to everybody. Thank you for a very nice and kind presentation prof thus a pleasure to deal with the Eastern Cape. Um And um yeah, so I just, I think this is potentially a very, very boring presentation. Um but I actually have a lot of interest in this topic and um so I'll just start with it. So I think the best way of starting this presentation is actually show uh sharing with you a screenshot of one of the conversations with one of our patients. So um it's now three years that we started um a, a telemedicine program, meaning that we just have a colorectal phone that I am either myself or C Karina who uh works with me in Colorectal Clinic have and um all patients have the number and They're welcome to message us. And this patient messaged us recently and she said good afternoon, I have a bit of a problem I'm facing and we said, hello, how can we help you? She says I'm 31. I had an a operation now I'm 38 weeks pregnant. I've been attending Song which is a, a peripheral hospital here. Uh So now they told me that I cannot deliver here. I have to go to Joburg Jane since I have more than 15 operations. So we did ask her to please come see us and call her rectal clinic to try and give her some help. Um She never picked up um but um this is the type of messages we received and that's why um we started believing with our team that there was a desperate need for transition of care and that's why we started studying transition of care. So this is why because um congenital colorectal diseases are surrounded by so much nomen like Hydrocoral Mitro of a Malone mace bowel management. So Duhamel Stenson low anterior resection and sometimes it's very difficult to keep track of what we're talking about. And I was recently using Google translate. And because um when I talk to adult surgeons, adult colorectal surgeons, I never understand what they're trying to say. I believe there is a desperate need for a Google translate option to translate between pediatric surgeons and adult surgeons. Still up to date, I don't truly understand what a low anterior resection is. And II don't know if I will ever understand. So, um, my training in Italy, um and the training system in general in Europe does not, um, entail having to go through general surgery first before becoming a, before joining the pediatric surgery department. So we go straight into pediatric surgery. So maybe that's the issue. But I've noticed here as well that even if adult surgeons, um general surgeons uh join the department, I still do not um, fully understand and we still don't fully understand each other when it uh comes to pediatric colorectal surgery and colorectal surgery in general. So just to give some numbers um in uh at the Johannesburg pediatric colorectal clinic, which is based at Barguna Hospital, we currently have a database with 316 patients for which we have complete information and the vast majority of them are patients with any recal malformations. And which is also fairly interesting because if you look at the literature, you would see that the the prevalence reported of anorectal and hash's is the same basically. So one in 3000, 501 in 5000. Um but definitely we follow up way more anorectal malformations and hash's which means that they do more poorly later on. Whereas patients with Harr's usually do fine after a while, the majority of our patients are males and the mean age of our population. Currently, this is from two months ago is 6.3 years with a wide range though. So we go from nearest to 31 years old and this 31 years old is 102 kg. So does she really belong to Colorectal clinic, pediatric colorectal clinic at Paraguana Hospital. Uh Together with the unit that weighs 2 kg, I'm not sure. Um Then if you look at the age of our population, um I encircled in uh red. Um and you can see that. Um so 30 sorry, 11% which is 34 of them, 34 of patients are older than 13 years, which is considered teenagers. So is that a lot? Probably not, but in two years, that number will double. And the question is, are we ready for transition of care? Are we ready for these patients? Do we know what to do when they come to us? So the first time I heard the word transition of care for pediatric colorectal surgery um was 2016 when I actually saw this paper published in the journal of pediatric surgery. It was a survey and it was um uh basically they distributed a survey uh of 21 questions to delegates that were attending two large colorectal surgical meetings. Um So it it's very biased because only pediatric colorectal surgeon answered and the majority of them were consultant with also some trainees and some psychologists answered. So there were 21 questions about basically what is the setup of transitional care. So when respondents were asked, how was the MDT S organized? So you can see that um the vast majority of centers had a surgeon, a urologist, a continence nurse and a near surgeon in the teams. But if you look more closely than at the answers in the paper, some of them only had a pediatric surgeon as part of the team. Um that was doing a multidisciplinary approach to patients with anorectal malformation in their centers. So when the respondents, uh the participants were asked, uh what was the usual duration of the follow up for the patients with anorectal malformation? It was um uh actually quite worrying that 33% of patient of respondents follow up their patients for less than 10 years and it wasn't clear if it's post surgery or 10, 5 to 10 years of age. Um whereas 67% follow them up until they are 18 years of age. But what happens after that? We don't really know. So, um and then um nearly 40% of the participants um admitted that they believe that more than 30% of the teenager they follow up actually have ongoing medical and psychosocial problems. And amongst these problems, they listed that fecal incontinence, psychosocial issues, poor quality of life, urinary incontinence and poor sexual sexual function were the most experienced issues in their population of teenagers. So they also said that 89% of respondents recognize that the patient developed new problems when they approach teenage years. Um The majority of them also acknowledge that it is the responsibility of the pediatric surgeon to transition the patients properly and effectively to the adult services. But none of the participants had a scoring system to stratify teenager problems and that could help uh plan multidisciplinary meetings or transitional care. So uh this is a bit confusing just because they use an opposite grading. So with one being most common and seven being less common. So we need to look at one. But um what the respondents saw was mainly a lack of structure in the current transition program and a parental reluctance to transition. This is fairly interesting, I thought um because just if uh sorry, sorry, I'll, I'll go back to that now. But so basically the conclusion to the paper was that uh there was the extreme need for an international consensus on four main aspects. So one, they needed a structured long term follow up for patients with ectal malformation. Second, they needed an objective assessment and risk stratification scores for their patients to decide which ones need transitional care. And then there was the need for pathways of transition. And it was also the need for methods to prepare patients parents and other practitioners to transition of care. So I was saying that it was very interesting about um various perceived to transition of care because a very similar article was published. But it was the counterpart. Number one, it's the American group. And number two, they asked their parents and their patients what their perspective was, but it was a very similar paper. So basically, it was a survey. So um they asked a group of um parents uh of patients with anorectal malformations and HIRS disease this time around. Uh what were the barriers to transition of care and other patients? So, uh only a few people responded, meaning that only 28% of the people that the survey was sent to replied to the survey. So it is also quite biased. But in the majority of cases, it was the pediatric surgeon still doing the follow up of the patients and bear in mind that the mean age of the patients in this survey was 12.6 years. So nearly basically, nearly teenagers but still the pediatric surgeon was doing the uh follow up. So was being the current provider uh followed by the gi T doctor or the pediatrician. And then when um parents and families were asked, what were the barriers to transition? They were saying that they had a fear that they will not find a provider who understands their condition. That was the mostly reported issue followed by distrust and concerns for decreased sensitivities of adult providers compared to pediatric providers. So, um they concluded by saying that patients with anorectal malformation and hairs often experience ongoing symptoms, especially of bowel function. But uh very uh rarely engaged in conversations required regarding transitional care. And there is the desperate need to implement transition of care plans. They also seem to suggest um um like a timing for transition of care with um between 12 and 14 years of age. They suggest that that um there needs to be an initiation of transition. Um and identifying an adult surgeon for the patient at 14 years of age, they suggest to initiate annual self assessment survey. Uh Basically, it's a risk stratification. Uh At 16 General Health Knowledge Assessment. Between 18 and 21 they want uh integrated meeting between pediatric and out of colorectal surgeon. And by 21 years of age, they suggest that the transition of care should be um uh completed. So I do like surveys because they give you a perception of what's happening around you. But I also really like numbers. Um So I went to see what's actually if there is anything comprehensive in the literature about what are the long term outcomes and concerns when you follow up patients with congenital colorectal disease. So, this paper was published in 2016 on disease colorectum and it only um looks at patients with anorectal malformations and uh in terms of fecal incon, so it's basically a systematic review uh done very, very properly. And um it says that between 17 and 77% of patients with anorectal malformation will, will have long term issues with fecal incontinence. And this is strongly dependent on the type of anorectal malformation. Um difficult to say uh because some uh people included, still use uh all classifications but basically um poor prognosis and rectal malformations like about clinically. Hello. Right. Is there a question? Can I carry on? No, please carry on um like cloacas and rectal bladder, neck fistulas have poorer outcomes in terms of fecal incontinence. As we read from the books, the same applied to constipation with a wide variation. Uh between 22% and 87% of patients will have issues with uh constipation later on in life. And it also depends on the type of ectal malformation with rectoperineal and rectal fistulas being more affected by constipation for both fecal incontinence and constipation. They observed that there is slight improvement in adults compared to the transitional care group. So, teenagers do more poorly than adults because they can come up with coping mechanisms. Another paper also very nicely done in patients with anorectal malformation, looked at urinal urinary um issues um and gynecologicals as well. So, um 16% of patients with anorectal malformation will have long term issues with urinary incontinence. And again, it depends on the type of an rectal malformation more frequent for cloacas and rectal bladder neck fistulas. The same applies for uh um neurogenic bladder and uh lower unitary tract symptoms with 36% of patients suffering of these issues in the long run. And it also depends on the type of anorectal malformation. They also depend on the presence of spinal abnormalities, both in terms of birth rate. They reported that there was an incident, like 20% of the patients that they followed up had um managed to conceive 20%. However, this was very dependent on the type of anorectal malformation. And weird enough, cloe had more fertility compared to uh rectoperineal and rectovesicular fistulas. But it also very much depended on the length of the follow up and up until now, there aren't enough studies with a good length of follow up to actually discuss birth rate in these patients. In terms of females and sexual dysfunction, up to 50% of them were reporting issues with dyspareunia. So, uh pain at intercourse or with having abnormal orgasms. Um The co the male counterpart, 12% of them had issues with erectile dysfunction, and 16% of them had issues with ejaculatory dysfunctions. This was dependent on the type of anorectal malformation with rectal bladder neck fistula being um uh obviously having worse outcomes compared to rectoperineal fistula. This was also related to the presence of spinal abnormalities and in terms of ejaculatory dysfunction, we also know that it depends on the distance from the bladder neck to the very Montanum, which is shorter in patients with rectal bladder neck fistulas, for example. So another study also very nicely done a bit difficult to understand. But I think the graph on the right. Um If you spend uh five minutes on it. It does um make you understand what you're looking at basically. Um on the left you have um di divided patients according to no issues, mild issues, moderate issues or severe issues. And then they compare the control group on the right and the Hehman group on the left and they look at awareness, holding back, defecation, soil and, and accidents. So they looked at the uh at a very large number of patients. It was also a systematic review. Um 5% of the patients had a and 5% of them had permanent stomas, which is also important to mention. Um because obviously you can't really compare these patients with the ones that have um continuity of their bowel. Um And uh basically, for all of them, you can see from the graph that um they um Hirsch's group does worse compared to the uh control group, but it looks like that. Hi, the Hirsch's group does better with more a in adults compared to younger patients. Um And adults also do better compared to teenage patients. Uh in terms of urinary function, which I also looked at in this group of patients. They have seen that Hi's group have worse urine function compared to to controls. They also saw that the urinary function improves with age. And um they have linked so they found a association between urinary incontinence in adults with female gender and with constipation, constipation makes sense because obviously, if you're more constipated, there is less space in the bladder and therefore you do tend to have um more uh accidents. But with uh female gender, I uh struggle to understand the um like, so I also tried to look at quality of life. Um A lot of people are trying to concentrate on quality of life. I still find it very, very hard to understand what the issues are. Meaning that everybody in the literature reports that patients with anorectal malformations and Hirs disease do in the long run have a worse quality of life compared to control groups. But to me, this topic is too difficult to analyze in a 40 minutes presentation. So I decided to leave it out, but it doesn't mean that I don't think it's important. II think it's extremely important. I just think it shouldn't necessarily belong just to surgeons. But if you want to look at quality of life, you do need a good psychologist on board um to explain you the results. Um um yeah, so to go back to our experience. So we have started a transition of care program. Um here in Johannesburg, we have a meeting every second month. Um We um we meet for 1, 1.5 hour and we um at the first meeting, it was uh just myself uh adult colorectal surgeon and um sister Catarina who is the nurse that comes and volunteers with us on Wednesday. So it wasn't um it wasn't a happy experience, but as meetings went past, then there is more and more people on board and it's very, very nice to um discuss things. Um So we te we present 2 to 3 patients at every meeting and then we spend long time discussing um each one's perspectives and um each word basically that we are discussing. Um So what our struggles have been. So we have poor records. So it is good now that we started a database at Bara, we have um it's much easier to access information, but otherwise um relying on files, it is very difficult. Yeah, there is very little information about surgery that was done. There is basically no imaging available and the reports, histology reports, bloods, it, it's like difficult to find out. So you end up having to request the same thing for the same patient over and over again. There is also lack of dedicated pediatric surgeons and adult surgeons. So um you need to identify somebody that really wants to do this, like they need to have a drive otherwise it's pointless. Otherwise. Um uh uh there's no improvement. Um And then also there's a lot, lot of lack of interest in these conditions. So it's difficult to establish an MDT. So most of the times you will see that it's easy to find surgeons that um want to surge, but it's also very difficult to find people that are interested in followup. And that are interested in multidisciplinary followup. So it's very difficult to have a urologist that comes on board. It's difficult to have a neurosurgeon that comes on board uh or a gynecologist. Um And um yeah, and there is also no pathways um to, to find a better way of having people involved. Plus we have very poor social conditions around us. So what we know from the literature cannot be applied to our conditions. We work in a different environment. So what are what the challenges are in the USA and Europe? It's like it doesn't apply to what we see here. So it's a bit difficult to extrapolate from reading to our reality. And the last struggle is that there is the desperate need for transition of care and um dedicated surgeons for both private and state and private and state in South Africa don't frequently speak the same language or like to talk to each other. So uh last year we had um sorry, four meetings. Um And um we're gonna have another one soon. We have presented a total of eight cases um with a wide variety of ages. Most of them, as you can see, it's either in rema formations of hairs, which is what the literature says. And most of them have issues with incontinence and what we see in our series is also delayed diagnosis or obviously complications, post primary surgery. Um Yeah, and most patients as you can also see are adults which means that the adult surgeon uh end up with having to see these patients in the clinic and they actually don't really know what to do with them and that's why they consult pediatric surgery. Um um yeah, making it very interesting journey. So what we have learned so far from our five meetings was it's essential. It's absolutely needed. Um There is the need out there both in private and in state and we need to do something for it, but it's also very difficult, very difficult and very humbling. And I still don't understand what a low anterior resection is, but it is so nice because compared to the first couple of meetings, the last couple of meetings were very humbling and all of us were like, I don't understand what this word means. Can you draw it for me? And it made it very pleasant because you learn from these meetings. So you need to attend, attend the meeting with the purpose of learning and bringing something home. So if you do that, then it also becomes rewarding. So be humble, be patient and be persistent is our motto basically. Um And it also pays off because then um these are the messages that you get from your parents, which are extremely loyal and extremely thankful for what you do for them. And this is the go go of a teenager that was actually abandoned from the mother and has been incontinence for his entire life. But now he is completely um continent to stools actually clean to from stools and from urine because of a good collaboration between us and the urologist. So, yeah, um I just, I wanted to take the opportunity uh of this presentation to highlight once again the importance of transition of care and to um let everybody know about this conference we're organizing in Johannesburg um in October between the 17th and 19th. Um and uh plus minus a couple of days of surgery after that. And uh in rectal malformations, he's disease and functional constipation, what our management will be discussed. Thank you very much. Uh Thank you Julia. That was really uh it was simple, straightforward and honest presentation and, and uh it's very useful and, and uh uh very essential. And um I, I've got at least six colleagues from whom I would like to uh get comments just quickly. I will share our experience. Uh we uh will be completing 29 years of our department's existence in East London. And uh after you spend many years at a particular center, your patients uh become older, but they don't want to leave you. So even at 2627 years old patients with Hirschprung's disease, African degenerative myopathy complex ect malformations, they have problems. I think the first part of, of, of advice is, is uh me or one of my colleagues uh in our department. So, uh this is, this is really essential for us to work together with adult general or colorectal surgeons, urologist, uh maybe even physicians sometimes and, and, and hand over care very gradually uh to, to the adult uh practitioners and incidentally in our department, we, we had just started this discussion. So this talk was really very appropriate. Uh First senior colleague, I would like to ask, uh, comment is uh Doctor Julia's immediate boss, uh Doctor Derek Harrison, who is the acting HD of pediatric surgery at uh bar hospital. Derek. Your comments, please? Uh Hi me. Hi. Hi, hi. Um sorry, I'm on a, I'm on a call at the moment but um let me just so um that's an excellent initiative um that Julia started up, I mean, and as she said, it's been difficult to get it going but it's picking up momentum. Um And yeah, I think it's been a long time coming for, for something like this to happen. Um Yeah, and I think everyone should look forward to the, the conference that's happening later this year. Sorry, I need to go. No, thank, thank you, Derek. Thank you for your comments. Um I see Doctor Paul Stevens uh is here, Paul Stevens uh uh works in private sector in, in uh Pretoria. So Paul uh your, your comments, your experience. I I'm not sure you can hear me or not. I don't have my microphone on at the moment. No, we we can hear nice and clear. Um Yeah, me. It it, it is something that, that, that is actually quite late in the private uh sector. We, we, we, we find particularly the, the adult chaps aren't really interested in long term looking after our, um, uh, patients as they go into adulthood. We find a little bit more, um, a little bit more help more from the gastroenterologist as opposed from the surgical side. Um, urology tends to be a little bit easier because a lot of our uh urologists are actually adult trained urologists who do Children as well so that all of those kids up going into to adult with them. Um It is something uh sort of slightly different, but we're also looking at, at, at, at trying to get our intestinal failure, kids followed up into adult. Um Fortunately at the moment there, there, there, the unit starting up in joburg from an adult perspective that's helping from the intestinal failure side. But it is something that, that we haven't quite cracked in private just yet. Bye bye. So, um what I've been doing, um uh and I'm just making, I'm just commenting, I'm not really giving any advice because uh far from me, II don't think I can give. Um So II don't do private. Um I only work here at BA and, but a lot of patients also in the private sector do need um transitional care and do need a pediatric surgeon because most of them actually show up at the general surgeon who asks them um to a pediatric surgeon to see them. So I've been offering for them to come to bar uh for free. Obviously, they just need to open a file. And um yeah, we see them here. We just put together all the information that we need and then we discuss the patient together with the adult colorectal surgeon at the transitional care meeting, which helps in terms of other people on board. Like I really struggle to get um renal and urology on board. Um even the adults counterparts, um it's extremely difficult. So it's mainly pediatric surgeons that have expertise in urology that I need to uh ask for advice. Um And yeah, that's what I've been doing. Uh Thanks Julia. Here is a comment by Doctor Brendan Babington that I found a number of patients with periodic colorectal pathology lost for follow up for many years. Uh Yes, that that's, that's quite true because they probably don't find a sympathetic ear and maybe in, in, in the doctors, they, they seek uh advice and care from. Um I see doctor Andre Theron who is also a senior pediatric surgeon. He works between state and private sector in Johannesburg. So Andre your comments, your your experience. Um prof I don't think he can answer. Um I think he's listening but I think he's scribed. Oh ok. Where is uh uh Doctor Beton is actually uh I didn't know that he was attending the meeting but he is the adult colorectal surgeon that um that together with myself and sister Karina, who is his wife put together the transitional care uh initiative uh on every second month. Excellent, excellent. Thank you, Doctor Babington for attending and uh and, and contributing. Thank you. Uh There is uh uh uh there is a question, I don't know what the name I got question about presented eight cases. Can you tell us prognosis? So, so it's difficult to summarize the prognosis. So, OK, and let me just go back on the presentation. So, um the f the first question was actually very um she was a patient at 25 102 kg for 155 centimeters of height that came to us because um she had vaginal Andreia at birth and she had some surgery, but the vagina was not there and she only realized much later when she was uh wanted to have intercourse and she came with her mother that didn't really want her to have intercourse. Um So we had to, it was very stressful because I've never operated on such a big patient. And luckily we managed to do everything from the bottom. But if I had to go in an abdomen like this, I would have really struggled. Um So I had the gynecologist joining me in theater, but the gynecologist, the adult did not know how to do a vaginal pull through. So it was uh it was quite stressful. The other ones are mainly patients with anorectal malformations and he's disease that were completely lost to follow up. Um Also because the importance of a chronic followup was very underestimated a few years ago. So, um they would then showed up with longstanding histories of severe constipation with overflow uh at the general surgeons that obviously do not really know what is the difference between a hammer, a stent or a bladder neck and a perineal. So together we have to come up with prognosis in terms of bowel function, ability to be continent or incontinent and then with a tailored bowel management program uh which is also not easy because other surgeons don't do aces. Um and um they also don't do washouts. So it, it's been an interesting journey. So it's been a lot of translation and a lot of lost in translation, but we really learned from each other. So, uh prognosis is good, meaning that for all of them, for all of the patients that came, we came up with a plan that helped them to be uh socially continent. Uh but it doesn't mean that they are actually continent, they're clean, but it doesn't mean they're continent, but they're happier. Ok. Thank you, Julia. Now, there's a question from Doctor Mahmud. How is the public health care system organized in South Africa? Are there geographic based health boards which take ultimate responsibility for individual patient and the pediatric surgeons continue to look after their patients on adult side. I think Julia can answer that. Uh So I don't know how to answer the first question about other geographic based health boards. So, I mean, there's lots of geography so there are referral areas. But ultimately, if a patient needs transitional care, I don't think that anybody else can offer it. So they're welcome. I don't think they would be denied referral to Barra. Let's put it this way. Um In terms of can a pediatric surgery continue to look after the patients? I don't know, I don't know, in private, it's more difficult in state. We made a plan so we won't stop anybody from coming into clinic regardless of the age, the gender like the issue. Like if nobody else can help them, then they should come to us. Um I can also uh try to answer this question. So, Doctor Mammoth, uh the healthcare system in South Africa is uh two tier one is the the government or the state sector and about 90% of the patients are uh they take advantage or they take uh help from the state sector. Uh The about 10% of the population which has got medical insurance is looked after in the private sector. There is unfortunately not much cross pollination between the state and the private sector. Few uh um about, I would say 30% of the pediatric surgeons, they do some private practice. So they uh they know what happens in private sector as well. And uh in state sector on an average patients are referred within a particular province but for a special uh problem and follow up, um I think interprovincial referral is possible and uh it it is not complicated. So I think this probably answers your question. So next person I would like to ask advice, somebody from not our department, but our city is doctor who is a pediatric surgeon in private practice in East London. Currently, she trained in Johannesburg and worked at Red Cross Children's Hospital in Cape Town and has special interest in colorectal problems, constipation. So your comments, um I II do feel a bit in EPT to answer these questions or to give any comments. Thank you, Doctor Chips because I'm still at the beginning and I'm very excited about what Julia is doing because I think she's giving framework and um and direction to us who have like a small number of patients. You know, it would be good to go to a to be able to speak to someone at a high volume center for um for advice. And um but I also think that um in East London since I've been here, I've only been here six months, the the older patients, um the general surgeons here, the general adult surgeons have been exceptionally nearly like warm and welcoming and helpful and have given a lot of advi advice and and just been so generous with it. We've had like um a patient with a uh vascular anomaly that required discussion. Um There was a patient with that um looked like there was maybe a genetic um uh kind of hereditary pattern to the Hirschprung's disease and we were able to, to have great discourse. Um So I do think it's um people are hungry for it and ready for it. And I think also just in terms of the multidisciplinary way of doing things, I don't think it was really traditionally um something that was done in private, but I am finding like quite um like amazing openness to it in private practice here in East London. So it's all just very, very encouraging. Uh Thank you re uh in East London. Uh We are uh relatively fortunate. We have an adult colorectal surgeon who is predominantly in private practice, but also the sessions in the state hospitals. Unfortunately, he couldn't attend this meeting today. But uh but we uh what are a few patients I had uh previously in private sector once they became adolescents uh II handed over care to, to the uh adult colorectal surgeon and, and that was quite useful. Um I will ask uh comments from consultant in our department, Doctor Nkole Masha Knox, your comments, please. She trained in, in Johannesburg and uh she uh is currently working with us for almost two years as a specialist period surgeon Knox. Well, I think she left a meeting Uh at least it said uh II think it said she left the meeting. Yeah, sorry. Is Noxia? No, she left the meeting. Oh, she left the meeting. Oh, ok. Sorry. Uh Then I think uh final comment I will ask is a senior pediatric surgeon in our department. Doctor. Yy, your comments. All right. Thanks prof and thank you Julia. This was very important talk. I think something as pediatric surgeons, we um tend to forget uh the importance of this. And as prof has already mentioned, I think we, we do it on a case by case basis and we do discuss with the general surgeons. They are very helpful. Um And it is it, yeah, I think we have a good relationship with them. So it, it works. And if they have difficult patients with pediatric pathology, they usually they will contact us early. But you do highlight the need for something formal. Um you know, and as in the form of an MDT, which I think we'll find the same kind of problems here in trying to organize some uh formal meeting, but it's something to work towards. Um So that's uh yeah, thank you for that. And I think you identify some, it's a pervasive problem in pediatric surgery where we lack that long term follow up because once they turn 12, um like I said on a case by case basis, we'll, we'll see them, but generally we, we won't see over 12 years old in our clinic or admit them. Um So we do try to get the general surgeons involved in the patients that are still coming to us, but we need to pay more attention to that transition of care, not only for colorectal, but um most of the conditions we treat, um We don't know what happens to them. So, um yeah, thank you for the talk and um good luck with your initiative. Thanks. Yes, th thank you, soda. I think we have already initiated a multidisciplinary team for our intestinal failure patients. And uh we work closely with urologist. I think it is time for us to have informal form multidisciplinary teams at least identify uh adult colleagues with interest in these problems so that we can gradually hand over their take care of these patients to our adult colleagues. I think Julia final message from you take home message. Um take a message is it's ii believe transition of care is extremely important. But for colorectal patients, it's like crucial because like it doesn't end with the surgery. And I'm in a very, I'm a very abnormal surgeon and I'm gonna say this in front of 49 parti participants. If they had to ask me tomorrow, would you give up surgery or would you give up follow up? I know I would give up surgery. Um To me like we can make such a difference in these patients. We can actually give them a normal life if we just try a bit harder. And to me that's basically the reason why I'm here in South Africa and the reason why I fell in love with Barra and the pediatric Directive Clinic and it's, it's a, it's a gift. Um I'm, I'm extremely privileged and um and II really believe that this change needs to happen because they, they deserve a normal life. Thank you, Julia. Um If I can, if I can comment is is that uh there is a big legacy of uh pediatric colorectal care at Baragwanath Hospital and those who do not know we uh have exported to a very senior pediatric surgeons to the States. And Doctor Richard Wood is originally from South Africa and Doctor Chris Wear um also has immigrated to the States and both of them uh uh involved in the pediatric color clinic. But Julia has built on that foundation and she has shown us that something like this is possible in a low to middle income setting in an extremely busy hospital with inadequate resource. And we can still make a big difference uh to the quality of life of of these patients uh by keeping a good scientific record, uh studying those things, discussing with colleagues and and just being open to help these patients. So Julia, thank you very much and thank you and it was very, very interesting in a month's time on the second Tuesday of February, we will have an interesting talk about minimal invasive surgery for congenital abnormalities. And it is uh a young pediatric surgeon from Nigeria doctor a Obasi who will be giving this talk. And I'm just very glad and proud to say that the schedule for the entire 2024 is, is ready and we will have really exciting and um uh talks during the course of the year. So thank you again. Uh The recording of this uh talk will be available later today or early tomorrow on my youtube channel, uh which I will share on various platforms. So thank you. We'll see you in a month's time. Bye-bye.