Pediatrician - Special Surgery Edition
October 9, 2015

A new clinic combines multispecialty medical and surgical services to achieve the best possible outcomes for patients with short gut.

Pediatric surgeon Sam Alaish recalls this decade-old case like it happened yesterday. The 2-year-old was in shock and being rushed to the OR for an emergency laparotomy. Opening the abdominal cavity, Alaish found one of the worst cases of intestinal malrotation with midgut volvulus he would ever see. In such cases, he knew, patients have only six to eight hours before the twisted intestine chokes off its own blood supply, and, by the sight of it, necrosis had already started spreading. He saved what he could but it was too little—the child would require complex, multispecialty care for most of his life.

“You take out what’s dead, leave in what’s borderline, and come back at a later time to see if it survived to give him his best chance to have the most intestine possible, but we knew he would need TPN (total parenteral nutrition) for a long, long time,” says Alaish. “These are kids with severe disease, who need a lot of follow up and multidisciplinary care to optimize their outcomes.”

Unfortunately, Alaish adds, there are too few multidisciplinary centers to treat children with short bowel and intestinal failure secondary to congenital conditions like Hirschsprung’s disease, gastroschisis, intestinal atresia and necrotizing enterocolitis (NEC), all of which can lead to disabling and even life-threatening complications. Mortality remains high at 7 to 28 percent, and children fortunate enough to survive continue to suffer greater morbidity from both infections and liver failure (J Surg Res 2011;170:27-31).

To improve such outcomes, Alaish and pediatric gastroenterologist Darla Shores have led development of a new clinic that brings multiple specialists together under one roof to treat such complex patients. “We do know that if you put these very challenging patients in a multi-disciplinary clinic they do better, but not every state has such a clinic for kids,” says Alaish.

“We’re taking all the bits and pieces that were happening randomly at different clinics and getting everyone in the same area to see patients in a more efficient manner,” adds Shores. “All of the specialists come together, agree on one course of action and present a uniform plan to the family, which should improve patient care and patients’ quality of life.”

In addition to pediatric surgeons, gastroenterologists, gastro-intestinal nurses and pediatric nurse practitioners, clinic staff include a nutritionist, occupational therapist, pharmacist, psychologist and speech pathologist. The strength of Hopkins' long-standing pediatric nutrition program is a value-added feature of the clinic, says Shores, citing the myriad nutritional complications and needs of patients with short bowel. Another value is having pediatric surgeons like Alaish and David Hackam, who specializes in treating patients with NEC. Also, all three physicians are aggressively pursuing research to improve existing treatment protocols and to develop new, more effective therapies for short bowel. In fact, to enhance the impact of research for these fragile patients they’ve created the Center for Intestinal Rehabilitation and Cure Using Science, or CIRCUS.

“The reason I came here,” says Alaish, “was to put some science behind our treatments, to measure our outcomes, to see how we’re doing and what can we do better.”

For more information or to schedule an appointment, call 410-614-4615.