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When bowel disorders are present in childhood, young patients may eventually need an adult surgeon. Anthony DeRoss, MD, and Jeremy Lipman, MD, discuss their multidisciplinary approach to lifelong diseases that ensures patients receive the best care from diagnosis through adulthood.

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Care For A Lifetime: Cleveland Clinic’s Pediatric & Adult Colorectal Surgery Clinic

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Welcome to another episode of Butts & Guts, I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. We're very pleased to have to return guests here on Butts & Guts. We're going to talk a little bit about the Cleveland Clinic's Pediatric and Adult Colorectal Surgery Clinic, kind of a transition clinic here. And so we're joined here today by Dr. Anthony DeRoss, who's a pediatric surgeon here in Cleveland Clinic Children's, as well as Jeremy Lipman, who's a colorectal surgeon within the Digestive Disease & Surgery Institute. Jeremy's also the Program Director for General Surgery here. So they are our co-directors of Cleveland Clinic's Pediatric and Adult Colorectal Surgery Clinic. Gentlemen, welcome back to Butts & Guts.

Jeremy Lipman: Thank you for having us.

Anthony DeRoss: Thank you.

Scott Steele: I know it's hard to believe, but a lot of our listeners out there may not go back to all of the old ones. So for those people out there that are first time listeners, Anthony, let's start with you. Give us a little bit about yourself, where you're from, where'd you train and how did it come to the point that you're ped surgery here at the Clinic.

Anthony DeRoss: Sure. Thanks. And thanks for having us. I've been at the Clinic now for about six years and have been in Cleveland for about 10. Trained in Pittsburgh and Vermont and then ended up in Cleveland for a bunch of different reasons, but have found that to be a great place to work and live and practice.

Scott Steele: Yeah, we're glad to having you here. Jeremy, a little bit about you. Obviously, you're within the greatest department in the world in colorectal surgery.

Jeremy Lipman: I grew up in Pittsburgh and came to Cleveland about 15 years ago to do residency and I've been here ever since. I joined the department three years ago and it's been a fantastic.

Scott Steele: Well, that's great. And again, very, very glad to have you here. Today we're here to talk about Cleveland Clinic's Pediatric and Adult Colorectal Surgery Clinic. So let's just go real big. Jeremy, we'll start with you. Give us the 10,000 foot view of what exactly that means.

Jeremy Lipman: A lot of patients, young patients, unfortunately have to deal with adult diseases. And when kids have to deal with those diseases, it can really span a couple of different areas of clinical work. What Tony and I have done is we work together to take care of these complicated patients who are very young. So Tony's expertise in pediatric surgery and my experience in colorectal surgery comes together to provide care for these people.

Scott Steele: Tony, what gave you guys the idea and give us a little bit of background about how this was created and how it evolved over the time?

Anthony DeRoss: Sure. It was actually started by a couple of different surgeons even before both of us were here, but over that period of time we've grown it and have tried to publicize it and worked closely with the gastroenterologists, particularly the pediatric gastroenterologists who end up seeking out surgical care for their patients after they have exhausted their medical options. And it's grown into quite a robust clinic with a number of different disease processes, mostly centered currently in inflammatory bowel disease, but it spans the realm of pediatric colorectal disorders from Hirschsprung's disease, to rectal prolapse, to chronic constipation that sometimes requires surgical intervention. And we're trying to grow it into something even bigger as we continue to accumulate patients.

Scott Steele: Let's start there. Let's just narrow it down for me. So when we talk about pediatric age patients transition clinic early adulthood, what are these age ranges are these patients? And how early does some of these disease process manifest themselves?

Anthony DeRoss: Absolutely. Well, I'll just talk about inflammatory bowel disease to start with because that is the disease process that we see the most. So the age range can be as young as four or five years old. Fortunately not usually too much younger than that and it can range up to 21, but between 18 and 21 we start to think about transitioning these patients to the adult colorectal surgery realm. And that's a process that we try to facilitate for these patients to make it easier for them to navigate the different care areas that that transition requires.

Scott Steele: Jeremy, walk us through a little bit. What's the journey that these patients take kind of to get into this path? Let's start there actually. How do they get to see you guys from there? And then what's a typical visit like?

Jeremy Lipman: Yeah, if you're a mom or a dad and dealing with this in your family, the easiest thing is you can just call and schedule an appointment to come in and see us. A lot of times you'll go and see your pediatrician or your gastroenterologist and they'll recommend that you come and see us because they feel like it's time to start thinking about surgical options or just want to introduce you to the idea of what surgery is like. Have that conversation now before it's even needed, maybe even in the hopes that you won't need it.

And then once you get an appointment with us, you come in and you'll see Tony and I at the same time. We've reviewed the records that had been sent over, so we have a good understanding of what's happening. We meet with you and your child and do the exam, get all the information we need. And a lot of times it can just be about information gathering. We talk to you about what surgery would look like, what this could be. So we have a plan in place, so it's not a surprise if down the road it becomes necessary.

Scott Steele: It's apparent to me, obviously that I'm sitting here talking to two surgeons. Where do the medicine doctors come into play in terms of this type of thing? Have they already seen them and it's decided that surgery is a potential option for them? And then is there an opportunity to have some of the medicine doctors and specifically gastroenterologists, if we're sticking on the inflammatory bowel disease seen?

Anthony DeRoss: Oftentimes that's the way that it transpires where the patients will be working closely with our gastroenterologists. They've gotten close to the limits of what they can accomplish with medicines and nonsurgical management of their diseases. And that's when they end up coming to see us. But there are occasions where the gastroenterologist will just send them to us to talk about surgery as Jeremy pointed out so that they have an idea of what might be coming down the road. And that's really the optimal time to see these patients, not in the hospital when they're sick and they need an emergent surgery.

But really it's nice to have a chance to meet with them and talk to them when they're still doing relatively well but we think they might need surgery within the next month, two months. And occasionally we will have the gastroenterologists come actually to the clinic along with the patient. And so Jeremy and I and the gastroenterologist will see the patient together and have an opportunity for the parents and the patient to ask questions and talk about what the different options are.

Scott Steele: Jeremy, one of the things that strikes me is the fact that when we think about surgery, we think, "I met the surgeon once and somebody operated on me and years passed by and I kind of forget their name." But what we're really talking about here is a journey in some cases as a child. Can you talk a little bit about this? I mean, you have these disease processes that may occur when they're children and you may start to see them multiple times over the course of their lifetime.

Jeremy Lipman: Yeah. On the one hand, it's nice that we see these kids sometimes when they're a young and very sick and are able to make a difference and we're able to follow them and watch them grow and recover and do well. It's definitely different than a lot of the adult patients that we take care of.

Scott Steele: Talk to me a little bit about the handoff to ensure the tweener age or the teenage and then into early adulthood, especially those that may be even leaving home for the first time going off to college or traveling away for the job. How do they not get lost within a system like this?

Jeremy Lipman: A lot of times they are seen with their parents and sometimes not if they are a sort of at the beginning of adulthood and coming by themselves. But we have a team that we work with of nurses and support people that help us to keep track of what's going on. Tony and I are in constant communication with each other for sure, but also with the gastroenterology team and the nutrition team and the psychology team in making sure that everyone's getting all the resources they need for these complicated problems.

Scott Steele: If you're talking about education aspect of it, what role do you guys play in terms of educating these patients in terms of their disease as they do this transition type clinic into early adulthood where they may be moving off or doing these other things?

Anthony DeRoss: We do try to stress to them, especially in our older patients, the need for them to take ownership of their care, to keep appointments, to stay on their medications, to make sure that they have routine scheduled follow-up, for example, for patients who have had reconstructive surgery after a colectomy for ulcerative colitis and might have a J-pouch. That pouch needs to have surveillance pouchoscopy every one to two years depending, and we make it clear to that they need to return. Or we try to make some of these patients who are coming from distances, we try to make arrangements for them to have that done closer to home if that needs to be done. But optimally we like to have that done here and Jeremy will do those scopes.

Anthony DeRoss: And just in terms of education in general before surgery, fortunately, Dr. Lipman is an excellent artist and he'll oftentimes draw pictures of the surgeries and what is to transpire and then gives the patient that artistic drawing to take home with them.

Jeremy Lipman: They can leave and put that on the fridge or scrapbook, whatever.

Anthony DeRoss: It's a lot of fun.

Scott Steele: That's fantastic. Tony, I recognize the fact that we focused a little bit and you mentioned... Let's circle back to something you talked about. As we talked about the different aspects of the type of disease processes that occur, you mentioned inflammatory bowel disease, but can you go in a little bit more about those other disease processes that you are evolving this transition clinic into?

Anthony DeRoss: Sure. One of the things that I think is difficult for both pediatric surgeons and adult colorectal surgeons is for example, a patient with Hirschsprung's disease who has had a resection of their rectum and distal colon and a pull through procedure as a baby and maybe has had issues with constipation throughout their life, but it was manageable. And then suddenly, it gets to a point where it's not. And that patient then who is a older teenager, 18, 19 years old, comes to seeing adult colorectal surgeon and it's not something that the adult colorectal surgeons deal with on a routine basis. It's hard to decipher exactly what was done in the operative notes and those sorts of things.

That's where I think that having the combined clinic has another important role, where the different areas of expertise can come together to give those patients the best care. We can work to figure out exactly what was done, what the issue is, and then if something reconstructive needs to be done further to help these patients, then we can put our heads together and come up with the best operative strategy.

Scott Steele: Jeremy, one of the probably most scary things that's out there, especially for a child is to, "I'm going to go to the doctor." And especially if you throw into it that, "I'm going to go see a surgeon." Walk me through what a patient or a parent can expect. What's a typical visit like?

Jeremy Lipman: Yeah, it is scary for a parent and for the kid for sure. So they come in and there'll be in the room, they'll meet our nursing team first, who asks a few general questions about health just to make sure their health record is up to date and make sure we have all the information together. And then Tony and I will come in together and meet the family, get to know them a little bit, and then get the story about. Make sure we understand everything about how their disease has progressed, what exactly has gone on now, find out what their goals for care are. What do they want out of this? Some people just want information. Some people are really ready for surgery and want to get that scheduled as soon as possible, and we try to meet them where they are. We're both really funny and really nice and so that makes it pretty easy.

Scott Steele: Yeah, I can echo that last comment. And so Anthony, you had mentioned some other things like tests and scopes and things like that. Is that a part of that particular visit? When does that occur in all of this?

Anthony DeRoss: Sometimes. For follow-up scopes, it's interesting. A lot of the pediatric patients are used to having a general anesthesia to have their endoscopy's and when we see our older teenage patients, especially for pouchoscopies, Dr. Lipman's been able to do those in the office, which has been fantastic. So it occasionally is a part of the visit and we've also had some patients preoperatively who have needed endoscopic evaluations occasionally that we've then scheduled for the operating room. So yeah, it depends.

Scott Steele: What's next on the horizon for this type of transition clinic? Do you see it branching out to other multidisciplinary specialties or is there anything new that you're working towards that it's going to continue to improve our patient's quality of life and the care that they received? Jeremy, we'll start with you.

Jeremy Lipman: I mean, we have a number of gastroenterologists who are already doing this informally and we're trying to get them all pulled in. We'd really like to make it much more convenient for the patients so that they can meet with the pediatric and adult gastroenterologists, the pediatric and adult surgeons all at the same time. Nutrition is definitely a huge part of inflammatory bowel disease as you know, as well as many of the other GI diseases. We're working to incorporate that. Psychology. This is a incredibly difficult thing for the parents, for the patients, for the families to go through. We have those resources available here, so pulling those people in as well. Really trying to expand the clinic to be a holistic and complete service for people.

Scott Steele: Anthony?

Anthony DeRoss: The other amazing resource we have here at the Cleveland Clinic that's I think different from any other place that certainly I'm familiar with is our outstanding enterostomal therapy team. These folks are a resource that you just can't put a value on for our patients. They have worked closely with all of our pediatric patients, both preoperatively with marking for a stoma, if patients need to have that done, as well as dealing with the management of ostomies as they heal. They will correspond with patients from home if they live a distance away over the phone and give them options for their appliances when they need it. Those folks have just been... I can't tell you how much I appreciate it and the patients appreciate everything they've done for our patients.

Scott Steele: Final take-home messages for our listeners.

Jeremy Lipman: These are scary diseases, these are big diseases, but we have the resources to help people to navigate the system that can be very complicated and make it as easy as possible.

Anthony DeRoss: I'll echo that and we really try to focus on decreasing the anxiety about the whole process as much as we can for both patients and families.

Scott Steele: For the listeners out there, they know I like to always wind up soon with some quick hitters, but since we got some repeat guests, I got some new questions for you first. Number one, do you listen to music in the operating room and if so, what is it?

Anthony DeRoss: I try to use my phone and I have a mix of different things, but I love the Beatles so I usually try to have a little of that going.

Scott Steele: Jeremy?

Jeremy Lipman: I do listen to music. If the patient doesn't have a preference for what they want, then I let the nurses keeps the room happy.

Scott Steele: And I'll go right back to you for number two. What was the first car that you ever had?

Jeremy Lipman: A Volvo station wagon.

Scott Steele: What year? Do you remember?

Jeremy Lipman: What year was the car?

Scott Steele: Yeah.

Jeremy Lipman: Somewhere in the '80s let's say.

Anthony DeRoss: I had a Subaru Justy. It was three cylinders and it was something in the '80s probably too. I don't remember. '90s maybe.

Scott Steele: Yeah. I don't even remember what that is.

Anthony DeRoss: You don't want to.

Scott Steele: A particular food that you just will not eat.

Jeremy Lipman: I don't like kale.

Anthony DeRoss: That's such a hard question. I like kale and I'll eat just about anything. Kale's like a toothbrush for your colon. Don't you think? It just moves right through.

Jeremy Lipman: Yeah, I'll find another one.

Scott Steele: And then the last question is, if you could go back in time and tell yourself this is what you're going to be most proud of on your journey in medicine, what would it be?

Anthony DeRoss: Oh boy. I think probably, I'll just say that the thing that is most gratifying for me is just when a patient says thank you and I see them leave the hospital in better shape than when they came in.

Jeremy Lipman: Yeah. Seeing the patients back, doing well. That's incredibly gratifying.

Scott Steele: Well, gentlemen, that is absolutely great stuff. So to schedule an appointment within the Pediatric and Adult Colorectal Surgery Clinic, please call (216) 444-8555. That's (216) 444-8555. And for more information on specific colorectal disorders, please visit Cleveland Clinic's health library at clevelandclinic.org/health. That's clevelandclinic.org/health. Gentlemen, once again, thank you for joining us on Butts & Guts.

Jeremy Lipman: Thank you.

Anthony DeRoss: Thanks for having us.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.

Butts & Guts
Butts & Guts

Butts & Guts

A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. You’ll learn how to have the best digestive health possible from your gall bladder to your liver and more from our host, Colorectal Surgery Chairman Scott Steele, MD.
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