# Colorectal / ARM & Hirschsprung — GCMD Library living collection

Also covered as: anorectal malformation · Hirschsprung disease · constipation · enterocolitis · fecal incontinence · cloaca · tethered cord · anorectal malformations

Experts: Dr. Marc Levitt, Dr. Jason Frischer, Dr. Todd Ponsky, Dr. Rod Gerardo

Updated: n/a · 252 episodes · 5788 cited statements

## Episodes
### Foundations
- [History of Hirschsprung Disease](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734) — video · 18:50 · [machine version](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734.md)
- [Hirschsprung Disease: History](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032) — video · 14:03 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032.md)
- [Anorectal Malformations: Introduction and Overview for bowel management](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071) — video · 26:08 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071.md)
- [ARMs in Neonates: Pediatric Colorectal Controversies 2014](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100) — video · 105:12 · [machine version](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100.md)
- [Hirschsprung's Disease](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187) — podcast · 20:48 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187.md)
- [The Colorectal Quiz Episode 21: The History of Hirschsprung Disease](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512) — podcast · 15:20 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512.md)
- [Intestinal rehabilitation: What is intestinal rehab? - Episode 1](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741) — video · 14:33 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741.md)
- [Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742) — podcast · 14:33 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742.md)
- [Hirschsprung Disease in Brief](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023) — video · 10:44 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023.md)
- [Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597) — podcast · 20:08 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597.md)
- [#115: Must Know Urology for The General Surgeon w/ Dr. Ponsky and Dr. Cherullo](https://library.globalcastmd.com/watch/115-must-know-urology-for-the-general-surgeon-w-dr-ponsky-and-dr-cherullo-13657) — podcast · [machine version](https://library.globalcastmd.com/watch/115-must-know-urology-for-the-general-surgeon-w-dr-ponsky-and-dr-cherullo-13657.md)
- [Integrated Care Concept in Pediatric Colorectal Surgery by Marc Levitt](https://library.globalcastmd.com/watch/integrated-care-concept-in-pediatric-colorectal-surgery-by-marc-levitt-13837) — video · [machine version](https://library.globalcastmd.com/watch/integrated-care-concept-in-pediatric-colorectal-surgery-by-marc-levitt-13837.md)
- [The History of International Colorectal Surgery Team Development](https://library.globalcastmd.com/watch/the-history-of-international-colorectal-surgery-team-development-13841) — video · [machine version](https://library.globalcastmd.com/watch/the-history-of-international-colorectal-surgery-team-development-13841.md)
- [The Colorectal Quiz Episode 21: The History of Hirschsprung Disease](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861) — podcast · 15:56 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861.md)

### Diagnosis & Workup
- [Evaluation & Management Of Hirschsprung's Disease](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626) — video · 44:35 · [machine version](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626.md)
- [Cloaca - Workup & Evaluation](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683) — video · 20:22 · [machine version](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683.md)
- [Cloaca - Prental Imaging & Diagnosis - Counseling](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682) — video · 36:15 · [machine version](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682.md)
- [Radiology and Image Diagnosis of Hirschsprung Disease](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733) — video · 44:35 · [machine version](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733.md)
- [CinciHirsch - Pathology of Hirschprung Disease](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737) — video · 44:06 · [machine version](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737.md)
- [Hirschsprung Disease: Radiology Aspect](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030) — video · 43:27 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030.md)
- [Prenatal Imaging and Counseling: Cloaca and Complex ARMs 2015](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021) — video · 31:23 · [machine version](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021.md)
- [Hirschsprung Disease: Pathology Aspect](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031) — video · 42:59 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031.md)
- [Contrast Enema for Hirschsprung Disease](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034) — video · 11:11 · [machine version](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034.md)
- [Panel Discussion and Case Presentation Part I: Pediatric Bowel Management 2013](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070) — video · 12:27 · [machine version](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070.md)
- [Anorectal Malformation Radiology: Pediatric Colorectal Controversies 2014](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097) — video · 61:48 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097.md)
- [Colorectal Quiz Episode 3: Hirschsprung Disease](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649) — podcast · 20:10 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649.md)
- [The Colorectal Quiz Episode 3.5: Proximal Hirschsprung Disease](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682) — podcast · 8:42 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682.md)
- [The Colorectal Quiz Episode 8: Motility Disorders Part 1](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824) — podcast · 14:04 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824.md)
- [The Colorectal Quiz Episode 9: Motility Disorders Part 2](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888) — podcast · 13:52 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888.md)
- [Colorectal Quiz Episode 12: Newborn ARM Part 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121) — podcast · 12:01 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121.md)
- [Colorectal Quiz Episode 13: Newborn ARM Part 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142) — podcast · 15:48 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142.md)
- [Colorectal Quiz Episode 14: ARM Newborn Part 3](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155) — podcast · 10:03 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155.md)
- [Colorectal Quiz Episode 17: Cloaca Part 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322) — podcast · 27:29 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322.md)
- [Colorectal Collaboration: Neurogastroenterology/Motility Disorders](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366) — video · 14:55 · [machine version](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366.md)
- [Hirschsprung Disease Workup](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411) — podcast · 10:44 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411.md)
- [Colorectal Quiz 25: Perineal Groove](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790) — podcast · 30:14 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790.md)
- [Colorectal Quiz Episode 30: Tethered Cord](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235) — podcast · 21:57 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235.md)
- [How is Hirschsprung's Disease diagnosed? An ERNICA animation for parents and families](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806) — video · 3:58 · [machine version](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806.md)
- [Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083) — video · 1:52 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083.md)
- [Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084) — video · 1:52 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084.md)

### Acute Management
- [Suspected Hirschsprung's-associated enterocolitis (HAEC) Treatment Guideline...](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540) — video · [machine version](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540.md)

### Medical Management
- [Bowel Management Updates & Innovations with Live Q&A: April 2018](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360) — video · 61:03 · [machine version](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360.md)
- [Fecal Incontinence Bowel Management: Pediatric Bowel Management 2013](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067) — video · 85:01 · [machine version](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067.md)
- [Intestinal Failure with Dr. Brad Warner](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296) — podcast · 52:46 · [machine version](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296.md)
- [Hirschsprung Disease Audience Q&A with Dr. Marc Levitt](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440) — podcast · 12:40 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440.md)
- [Update Course Rewind: 2020 Colorectal Part 2](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834) — podcast · 11:01 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834.md)
- [Colorectal Quiz Episode 15: Bowel Management in Spinal Patients - Need for a UrologistPart 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232) — podcast · 17:26 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232.md)

### Surgical Management
- [Pediatric Colorectal Contraversies Part I: Pediatric Colorectal Contraversies...](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417) — video · 25:43 · [machine version](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417.md)
- [Pediatric Colorectal Contraversies Part II: Pediatric Colorectal...](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416) — video · 31:29 · [machine version](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416.md)
- [Pediatric Colorectal Contraversies Part III: Pediatric Colorectal...](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415) — video · 19:24 · [machine version](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415.md)
- [Laparoscopic Surgery for Male Imperforate Anus and Rectourethral Fistula:...](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425) — video · 25:00 · [machine version](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425.md)
- [How I Do It Levitt PSARP](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532) — video · 7:02 · [machine version](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532.md)
- [Tricks - Imperforate Anus and Rectourethral Fistula](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631) — video · 45:32 · [machine version](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631.md)
- [Hirschsprung Disease - Imperforate Anus - Rectal Prolapse: Update Course 2015](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675) — video · 25:37 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675.md)
- [Cloaca - Long Common Channel](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686) — video · 14:55 · [machine version](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686.md)
- [Surgical Management Of Female Anorectal Malformation Patients Including...](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741) — video · 57:59 · [machine version](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741.md)
- [Surgical Procedures for Hirschsprung Disease](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736) — video · 128:56 · [machine version](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736.md)
- [Technique: Laparoscopic Assisted Pull-through for Hirschsprung's Disease](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756) — video · 10:47 · [machine version](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756.md)
- [Technique: Laparoscopic-Assisted Pull-through for Imperforate Anus](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759) — video · 15:14 · [machine version](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759.md)
- [Technique: Laparoscopic-Assisted Pull-through for Imperforate Anus](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762) — video · 15:14 · [machine version](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762.md)
- [Technique: Laparoscopic Assisted Pull-through for Hirschsprung's Disease](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760) — video · 10:48 · [machine version](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760.md)
- [Hirschsprung Disease Part I with Marc Levitt](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933) — podcast · 59:20 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933.md)
- [Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957) — podcast · 43:47 · [machine version](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957.md)
- [Hirschsprung Disease: Update Course 2015](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000) — video · 7:42 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000.md)
- [Hirschsprung Disease: Surgical Procedures](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029) — video · 128:56 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029.md)
- [Imperforate Anus & Rectourethral Fistula Technique & Discussion: Difficult Cases](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054) — video · 25:05 · [machine version](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054.md)
- [Bowel Management for Hirschsprung's Disease Patients: Pediatric Bowel...](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069) — video · 34:28 · [machine version](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069.md)
- [Panel Discussion and Case Presentation Part II: Pediatric Bowel Management 2013](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068) — video · 33:57 · [machine version](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068.md)
- [Bowel Management for Hirschsprung's Disease](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073) — video · 34:28 · [machine version](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073.md)
- [Posterior Sagittal Anorectaplasty-Female Part II: Pediatric Colorectal...](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093) — video · 30:03 · [machine version](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093.md)
- [Anorectal Malformation Management of Female Patients Part II: Pediatric...](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090) — video · 28:20 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090.md)
- [Urologic and Gynecologic Aspects in Anorectal Malformations: Pediatric...](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098) — video · 41:46 · [machine version](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098.md)
- [Posterior Sagittal Anorectaplasty-Female Part III: Pediatric Colorectal...](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092) — video · 30:12 · [machine version](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092.md)
- [Anorectal Malformation Management of Female Patients Part I: Pediatric...](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091) — video · 26:39 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091.md)
- [Posterior Sagittal Anorectaplasty-Female Part I: Pediatric Colorectal...](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094) — video · 28:08 · [machine version](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094.md)
- [Posterior Sagittal Anorectaplasty in a Female: Pediatric Colorectal...](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095) — video · 88:20 · [machine version](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095.md)
- [ARMs in Female Patients: Pediatric Colorectal Controversies 2014](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101) — video · 55:00 · [machine version](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101.md)
- [ARMs in Male Patients: Pediatric Colorectal Controversies 2014](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099) — video · 54:25 · [machine version](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099.md)
- [Hirschsprung Disease Part I with Marc Levitt](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311) — podcast · 59:20 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311.md)
- [Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299) — podcast · 43:47 · [machine version](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299.md)
- [Colorectal Quiz Episode 2: When to redo a PSARP](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580) — podcast · 18:15 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580.md)
- [The Colorectal Quiz Episode 4: Classic Hirschsprung disease - Surgical Technique](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704) — podcast · 19:28 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704.md)
- [The Colorectal Quiz Episode 5: Proximal Hirschsprung Disease Surgical Technique](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745) — podcast · 14:37 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745.md)
- [The Colorectal Quiz Episode 11: Total Colonic Hirschsprung's Part 2](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932) — podcast · 15:45 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932.md)
- [Descending Colostomy for Anorectal Malformations Dr. Tamer Ashraf Wafa](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002) — video · 5:09 · [machine version](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002.md)
- [Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304) — podcast · 14:18 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304.md)
- [Colorectal Quiz Episode 18: Cloaca Part 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336) — podcast · 23:10 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336.md)
- [Colorectal Quiz Episode 24: Cloaca Part 3](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055) — podcast · 45:10 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055.md)
- [Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115) — podcast · 19:59 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115.md)
- [Colorectal Quiz Episode 29: Female ARM-Post Op Management](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181) — podcast · 25:09 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181.md)
- [Sphincter Reconstruction for Patients with Soiling after a Pull-Through for Hirschsprung Disease](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096) — video · 5:04 · [machine version](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096.md)
- [ERN eUROGEN ARM Webinar Series: Management of Cloacal Malformations – what is new in 2021?](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228) — video · 48:03 · [machine version](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228.md)
- [Transanal Swenson like Technique for Hirschsprung's Disease (No audio)](https://library.globalcastmd.com/watch/transanal-swenson-like-technique-for-hirschsprung-s-disease-6464) — video · 6:59 · [machine version](https://library.globalcastmd.com/watch/transanal-swenson-like-technique-for-hirschsprung-s-disease-6464.md)
- [Surgical Treatment of Recto-Urethral Fistula (No audio)](https://library.globalcastmd.com/watch/surgical-treatment-of-recto-urethral-fistula-6483) — video · 18:29 · [machine version](https://library.globalcastmd.com/watch/surgical-treatment-of-recto-urethral-fistula-6483.md)
- [Transanal full thickness rectal mobilization with an ischiorectal fat pad to repair an H-Type rectovaginal fistula](https://library.globalcastmd.com/watch/transanal-full-thickness-rectal-mobilization-with-an-ischiorectal-fat-pad-to-repair-an-h-type-rectovaginal-fistula-7278) — video · [machine version](https://library.globalcastmd.com/watch/transanal-full-thickness-rectal-mobilization-with-an-ischiorectal-fat-pad-to-repair-an-h-type-rectovaginal-fistula-7278.md)
- [Colorectal Surgery: What does the anesthesia provider need to know?](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276) — video · 24:52 · [machine version](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276.md)
- [Surgical treatment for Hirschsprung’s Disease: An ERNICA animation for parents and families](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807) — video · 3:38 · [machine version](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807.md)
- [Update Course Rewind: Perineal Body Sparing PSARP 2023](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857) — video · 2:55 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857.md)
- [A Complex Urogenital Malformation: Urogenital Sinus with Normal Anus](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078) — video · 4:57 · [machine version](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078.md)
- [Cloacal Exstrophy: A Modification of the Newborn Operation - Leaving the Cecal Plate Untouched](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275) — video · 6:48 · [machine version](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275.md)
- [Laparoscopic Assisted Posterior Sagittal Anorectoplasty](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641) — video · 5:49 · [machine version](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641.md)
- [Posterior Sagittal Anorectoplasty](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130) — video · 6:24 · [machine version](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130.md)
- [Enhancing Urethral Meatus Creation in Cloacal Malformations: A New Technique](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865) — video · 4:41 · [machine version](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865.md)
- [Enhancing Urethral Meatus Creation in Cloacal Malformations: A New Technique](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864) — video · 4:41 · [machine version](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864.md)
- [Rectal Atresia - a Unique Anorectal Malformation](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105) — video · 4:58 · [machine version](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105.md)
- [Turnbull Stoma](https://library.globalcastmd.com/watch/turnbull-stoma-11526) — video · 4:56 · [machine version](https://library.globalcastmd.com/watch/turnbull-stoma-11526.md)
- [Total colonic Hirschsprung disease: Ileostomy take down and ileoanal pull-through](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713) — video · 9:25 · [machine version](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713.md)
- [Sphincter Reconstruction in a patient who suffered from Fournier’s gangrene](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714) — video · 5:47 · [machine version](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714.md)
- [Posterior Rectal Advancement Anoplasty (PRAA) in a male with an anorectal malformation and rectoperineal fistula](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715) — video · 9:36 · [machine version](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715.md)
- [Update Course Rewind 2025: Timing of PSARP: Early vs. Delayed—Does It Really Matter?](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860) — video · 3:45 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860.md)
- [Update Course Rewind 2025: Perineal Body–Preserving PSARP: The New Standard?](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867) — video · 2:13 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867.md)
- [Update Course Rewind 2025: Do We Still Need Routine Anal Dilations After PSARP?](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895) — video · 2:32 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895.md)
- [Update Course Rewind 2025: Hirschsprung’s Pull-Through: Why Family Training May Save Lives](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009) — video · 2:04 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009.md)
- [Update Course Rewind 2025: Botox for Hirschsprung’s: Where, When, and Why](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049) — video · 1:55 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049.md)
- [The Perineal Body Preserving PSARP (PPP)](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116) — video · 11:47 · [machine version](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116.md)
- [Validation of an anorectal malformation trainer - Can a high-fidelity model simulate real life?](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687) — video · 1:37 · [machine version](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687.md)

### Complications
- [Outcomes and Complications in Hirschsprung Disease](https://library.globalcastmd.com/watch/outcomes-and-complications-in-hirschsprung-disease-735) — video · 105:48 · [machine version](https://library.globalcastmd.com/watch/outcomes-and-complications-in-hirschsprung-disease-735.md)
- [Complications of Anorectal Malformations with Dr. Marc Levitt](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951) — podcast · 48:09 · [machine version](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951.md)
- [Hirschsprung Disease Rapid Fire: Update Course 2015](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985) — video · 12:14 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985.md)
- [Enterocolitis in Hirschsprung Disease: Update Course 2015](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001) — video · 5:02 · [machine version](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001.md)
- [Hirschsprung Disease: Cases and Complications](https://library.globalcastmd.com/watch/hirschsprung-disease-cases-and-complications-1028) — video · 103:35 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-cases-and-complications-1028.md)
- [Problematic Anorectal Malformation Cases: Pediatric Colorectal Controversies...](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096) — video · 13:17 · [machine version](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096.md)
- [Error Traps and Culture of Safety in Anorectal Malformations](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683) — video · 2:02 · [machine version](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683.md)
- [Error Traps and Culture of Safety in Hirschsprung Disease](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726) — video · [machine version](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726.md)
- [Colorectal - Clinical Practice Updates](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997) — video · 52:31 · [machine version](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997.md)
- [Hirschsprung Disease Part II with Dr. Marc Levitt](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310) — podcast · 44:38 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310.md)
- [Complications of Anorectal Malformations with Dr. Marc Levitt](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304) — podcast · 48:09 · [machine version](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304.md)
- [Update Course Rewind: 2020 Colorectal Part 1](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801) — podcast · 12:25 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801.md)
- [Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407) — podcast · 24:11 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407.md)
- [The Colorectal Quiz Episode 20: Hirschsprung Disease Obstruction Part 2](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461) — podcast · 21:29 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461.md)
- [The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616) — podcast · 19:45 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616.md)
- [The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient Part 2 -The Dentate Line and Motility](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739) — podcast · 26:46 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739.md)
- [Colorectal Quiz Episode 26: Perianal Crohn's Disease](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890) — podcast · 23:58 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890.md)
- [The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056) — podcast · 26:16 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056.md)
- [Hirschsprung-associated enterocolitis in children: An ERNICA animation for parents and families](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808) — video · 3:23 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808.md)
- [Update Course Rewind: Botox in Hirschsprung Disease 2023](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941) — video · 5:55 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941.md)
- [Rectal Prolapse Repair Following a Posterior Sagittal Anorectoplasty](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723) — video · 4:55 · [machine version](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723.md)
- [Morbidity of Rectal Prolapse Repair After Surgery for Anorectal Malformation](https://library.globalcastmd.com/watch/morbidity-of-rectal-prolapse-repair-after-surgery-for-anorectal-malformation-10942) — video · 0:39 · [machine version](https://library.globalcastmd.com/watch/morbidity-of-rectal-prolapse-repair-after-surgery-for-anorectal-malformation-10942.md)
- [Safety and utility of long-acting steroid injection for management of post-operative stricture...](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169) — video · 1:39 · [machine version](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169.md)
- [Complications and Long-Term Outcomes of Patients With Cloacal Malformation After Bowel Neovagina...](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170) — video · 1:05 · [machine version](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170.md)
- [Anorectal Malformations Complications](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872) — podcast · 48:08 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872.md)
- [Anorectal Malformations Complications](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873) — podcast · 48:08 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873.md)
- [Anorectal Malformations Complications](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874) — podcast · 48:08 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874.md)
- [Hirschsprung Disease Part 2](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875) — podcast · 44:44 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875.md)
- [Hirschsprung Disease Part 2](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876) — podcast · 44:44 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876.md)

### Evidence & Research
- [Challenging Dogma: Does Colostomy Type Matter?](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-325) — video · 1:29 · [machine version](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-325.md)
- [Challenging Dogma: Does Colostomy Type Matter?](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-398) — video · 1:29 · [machine version](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-398.md)
- [The Extent of the Transition Zone in Hirschsprungs Disease](https://library.globalcastmd.com/watch/the-extent-of-the-transition-zone-in-hirschsprungs-disease-2625) — video · 0:34 · [machine version](https://library.globalcastmd.com/watch/the-extent-of-the-transition-zone-in-hirschsprungs-disease-2625.md)
- [Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308) — podcast · 44:19 · [machine version](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308.md)
- [Journal of Pediatric Surgery Article Review: October 2021](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661) — podcast · 19:10 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661.md)
- [Update Course Rewind: Pediatric Colorectal Consortium 2021](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357) — podcast · 14:55 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357.md)
- [Update Course 2021: PEDS COLORECTAL CONSORTIUM CONCLUSIONS](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413) — video · 36:32 · [machine version](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413.md)
- [CAPS - Educational Outcomes in School Age Children with a History of Hirschsprung’s Disease - Michael Cowap](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420) — video · [machine version](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420.md)
- [Journal of Pediatric Surgery Article Review: May 2022, CAPS Issue](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787) — podcast · 16:37 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787.md)
- [Update Course 2022 - APSA PDC UPDATES - Mary Edwards, Paul Jeziorczak, Craig Lillehei, and Charles Snyder,](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820) — video · 64:30 · [machine version](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820.md)
- [Best of the Best Gen Surg - Development of postoperative local tumors and distant metastases in diet, genetics and microbiome-dependent in a mouse model of colorectal cancer recurrence - Dr. Morgan](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861) — video · 12:40 · [machine version](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861.md)
- [Standardized perioperative care reduces colorectal surgical site infection in children](https://library.globalcastmd.com/watch/standardized-perioperative-care-reduces-colorectal-surgical-site-infection-in-children-6578) — video · 1:02 · [machine version](https://library.globalcastmd.com/watch/standardized-perioperative-care-reduces-colorectal-surgical-site-infection-in-children-6578.md)
- [Journal of Pediatric Surgery Article Review: February 2023, BAPS issue](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580) — podcast · 12:32 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580.md)
- [Routine contrast enema prior to stoma reversal seems only required following treatment for necrotizing enterocolitis: An evaluation of the diagnostic accuracy of the contrast enema](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603) — video · 0:56 · [machine version](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603.md)
- [Quick Literature Updates Episode 7](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686) — video · [machine version](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686.md)
- [Enfermedad Inflamatoria intestinal asociada a Hirschsprung](https://library.globalcastmd.com/watch/enfermedad-inflamatoria-intestinal-asociada-a-hirschsprung-6708) — video · 0:58 · [machine version](https://library.globalcastmd.com/watch/enfermedad-inflamatoria-intestinal-asociada-a-hirschsprung-6708.md)
- [Quick Literature Updates Episode 10](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801) — video · [machine version](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801.md)
- [Journal of Pediatric Surgery Article Review:  May 2023, CAPS Issue](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077) — podcast · 11:17 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077.md)
- [Meta-Analysis of Enhanced Recovery After Surgery Protocols for the Perioperative Management of Pediatric Colorectal Surgery](https://library.globalcastmd.com/watch/meta-analysis-of-enhanced-recovery-after-surgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7597) — video · 0:45 · [machine version](https://library.globalcastmd.com/watch/meta-analysis-of-enhanced-recovery-after-surgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7597.md)
- [Quick Literature Updates Episode 14](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776) — video · 4:46 · [machine version](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776.md)
- [Meta-Analysis of Enhaced Recovery After Ssurgery Protocols for the Perioperative Management of Pediatric Colorectal Surgery](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881) — video · 0:53 · [machine version](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881.md)
- [Quick Literature Updates Episode 15](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927) — video · 4:12 · [machine version](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927.md)
- [Journal of Pediatric Surgery Article Review: September 2023](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057) — podcast · 13:31 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057.md)
- [Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154) — podcast · 17:03 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154.md)
- [Does Delayed Diagnosis of Hirschsprung Disease Impact Post-operative and Functional Outcomes? A Multi-Center Review From the Pediatric Colorectal and Pelvic Learning Consortium](https://library.globalcastmd.com/watch/does-delayed-diagnosis-of-hirschsprung-disease-impact-post-operative-and-functional-outcomes-a-multi-center-review-from-the-pediatric-colorectal-and-pelvic-learning-consortium-9263) — video · 1:09 · [machine version](https://library.globalcastmd.com/watch/does-delayed-diagnosis-of-hirschsprung-disease-impact-post-operative-and-functional-outcomes-a-multi-center-review-from-the-pediatric-colorectal-and-pelvic-learning-consortium-9263.md)
- [Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308) — podcast · 19:28 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308.md)
- [The use of postoperative calibrations in Hirschsprung disease](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460) — video · 0:59 · [machine version](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460.md)
- [Quick Literature Updates Episode 17](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803) — video · 4:28 · [machine version](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803.md)
- [Finnish Pediatric Surgery Hub - From Centralization to Collective Learning and Sharing of Expertise](https://library.globalcastmd.com/watch/finnish-pediatric-surgery-hub-from-centralization-to-collective-learning-and-sharing-of-expertise-9951) — video · 0:48 · [machine version](https://library.globalcastmd.com/watch/finnish-pediatric-surgery-hub-from-centralization-to-collective-learning-and-sharing-of-expertise-9951.md)
- [Quick Literature Updates Episode 18](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064) — video · 4:21 · [machine version](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064.md)
- [Comparing Loop and Divided Colostomy for Anorectal Malformation: A Systematic Review and Meta-Analysis](https://library.globalcastmd.com/watch/comparing-loop-and-divided-colostomy-for-anorectal-malformation-a-systematic-review-and-meta-analysis-10428) — video · 0:43 · [machine version](https://library.globalcastmd.com/watch/comparing-loop-and-divided-colostomy-for-anorectal-malformation-a-systematic-review-and-meta-analysis-10428.md)
- [Post Operative Anal Dilatations for the Prevention of Anal Strictures in Children With Anorectal Malformation: A Systematic Review](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-children-with-anorectal-malformation-a-systematic-review-11031) — video · 0:48 · [machine version](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-children-with-anorectal-malformation-a-systematic-review-11031.md)
- [Quick Literature Updates Ep 22](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118) — video · 4:23 · [machine version](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118.md)
- [Quick Literature Updates Ep 23](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174) — video · 4:20 · [machine version](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174.md)
- [Sacrococcygeal Teratomas in Currarino Syndrome: A Multicenter Review of Tumor Characteristics, Surgical Outcomes, and Recurrence](https://library.globalcastmd.com/watch/sacrococcygeal-teratomas-in-currarino-syndrome-a-multicenter-review-of-tumor-characteristics-surgical-outcomes-and-recurrence-11278) — video · 0:56 · [machine version](https://library.globalcastmd.com/watch/sacrococcygeal-teratomas-in-currarino-syndrome-a-multicenter-review-of-tumor-characteristics-surgical-outcomes-and-recurrence-11278.md)
- [Patient-reported outcomes of Children with an Anorectal Malformation](https://library.globalcastmd.com/watch/patient-reported-outcomes-of-children-with-an-anorectal-malformation-11390) — video · 0:59 · [machine version](https://library.globalcastmd.com/watch/patient-reported-outcomes-of-children-with-an-anorectal-malformation-11390.md)
- [Quick Literature Updates Ep 26](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413) — video · 4:40 · [machine version](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413.md)
- [Laparoscopic modified percutaneous internal ring suturing - a mesh-free alternative for indirect inguinal hernia repair in adults. a pilot prospective cohort study](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894) — video · 0:43 · [machine version](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894.md)
- [Association Between Social Determinants of Health and Choice of Urinary Reconstruction in Children](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168) — video · 1:22 · [machine version](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168.md)

### Case-Based Learning
- [Ultra-Short Segment Hirschsprung Disease: Difficult Cases](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550) — video · 17:44 · [machine version](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550.md)
- [Tricks - Total Colonic Aganglionosis Associated with Malrotation & Multiple...](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645) — video · 15:41 · [machine version](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645.md)
- [Tricks - Ultrashort Segment Hirschsprungs - Kristine Thayer](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652) — video · 17:50 · [machine version](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652.md)
- [Imperforate Anus Rapid Fire: Update Course 2015](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984) — video · 6:54 · [machine version](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984.md)
- [Total Colonic Hirschsprung Disease with Malrotation: Difficult Cases](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052) — video · 13:15 · [machine version](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052.md)
- [Hirschsprung Disease: Update Course 2013](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056) — video · 38:06 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056.md)
- [Hirschsprung Disease: Update Course 2013](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061) — video · 38:50 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061.md)
- [Neuroblastoma](https://library.globalcastmd.com/watch/neuroblastoma-1620) — podcast · 56:19 · [machine version](https://library.globalcastmd.com/watch/neuroblastoma-1620.md)
- [The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527) — podcast · 15:45 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527.md)
- [The Colorectal Quiz Episode 10: Total Colonic Hirschsprung Disease Part 1](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893) — podcast · 12:24 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893.md)
- [Laparoscopic Segmental Colectomy for Functional Constipation](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504) — video · 4:52 · [machine version](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504.md)
- [Colorectal Quiz: Episode 42 - HD Constipation](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506) — podcast · 14:48 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506.md)
- [Colorectal Quiz: Episode 49 - Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845) — podcast · 40:45 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845.md)
- [Colorectal Quiz: Episode 47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846) — podcast · 22:19 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846.md)
- [Colorectal Quiz: Episode 47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847) — podcast · 22:19 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847.md)
- [Colorectal Quiz: Episode 46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848) — podcast · 29:59 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848.md)
- [Colorectal Quiz: Episode 46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849) — podcast · 29:59 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849.md)
- [Colorectal Quiz: Episode 43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850) — podcast · 23:29 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850.md)
- [Colorectal Quiz: Episode 43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851) — podcast · 23:29 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851.md)
- [Colorectal Quiz: Episode 40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852) — podcast · 18:43 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852.md)
- [Colorectal Quiz: Episode 40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853) — podcast · 18:43 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853.md)
- [Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856) — podcast · 16:18 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856.md)
- [Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857) — podcast · 16:18 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857.md)
- [Colorectal Quiz Episode 29: Female ARM](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858) — podcast · 25:08 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858.md)
- [Colorectal Quiz Episode 29: Female ARM](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859) — podcast · 25:08 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859.md)
- [Colorectal Quiz Episode 18: Cloaca Part 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862) — podcast · 23:10 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862.md)
- [Colorectal Quiz Episode 17: Cloaca Part 1](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863) — podcast · 27:32 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863.md)
- [The Colorectal Quiz Episode 4](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864) — podcast · 19:28 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864.md)
- [Colorectal Quiz: Episode 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865) — podcast · 18:15 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865.md)
- [The Colorectal Quiz Episode 4](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866) — podcast · 19:28 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866.md)
- [Colorectal Quiz: Episode 2](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867) — podcast · 18:15 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867.md)
- [The Colorectal Quiz: Episode 1](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868) — podcast · 15:45 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868.md)
- [The Colorectal Quiz: Episode 1](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869) — podcast · 15:45 · [machine version](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869.md)

### In-Depth Reviews
- [Collaborative work: Complex Pediatric Anorectal Malformations 2017](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924) — video · 23:45 · [machine version](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924.md)
- [Anorectal Malformations with Dr. Andrea Bischoff](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937) — podcast · 47:46 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937.md)
- [Top Themes From The Stay Current App](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999) — video · [machine version](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999.md)
- [Cloacal Exstrophy with Dr. Alberto Peña](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309) — podcast · 53:06 · [machine version](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309.md)
- [Anorectal Malformations with Dr. Andrea Bischoff](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315) — podcast · 47:46 · [machine version](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315.md)
- [DrBeen Medical Lectures: Dr. Marc Levitt, MD Discusses Hirschsprung Disease](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227) — video · 53:42 · [machine version](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227.md)
- [Update Course 2023 - Updates in Colorectal Pathology](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268) — video · 27:42 · [machine version](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268.md)
- [2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899) — video · 30:29 · [machine version](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899.md)
- [Colorectal Quiz: Episode 50 - 16th Annual European Pediatric Colorectal and Pelvic Reconstruction Conference, Stockholm, Sweden, October 2025 - What did we learn?](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653) — podcast · 24:17 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653.md)
- [Colorectal Cancer](https://library.globalcastmd.com/watch/colorectal-cancer-13749) — podcast · 26:42 · [machine version](https://library.globalcastmd.com/watch/colorectal-cancer-13749.md)
- [Colorectal Cancer](https://library.globalcastmd.com/watch/colorectal-cancer-13750) — podcast · 26:42 · [machine version](https://library.globalcastmd.com/watch/colorectal-cancer-13750.md)
- [Colorectal Cancer](https://library.globalcastmd.com/watch/colorectal-cancer-13754) — podcast · 26:42 · [machine version](https://library.globalcastmd.com/watch/colorectal-cancer-13754.md)
- [Keynote Address on Pediatric Colorectal Surgery by Dr. Marc Levitt](https://library.globalcastmd.com/watch/keynote-address-on-pediatric-colorectal-surgery-by-dr-marc-levitt-13836) — video · [machine version](https://library.globalcastmd.com/watch/keynote-address-on-pediatric-colorectal-surgery-by-dr-marc-levitt-13836.md)
- [Episode 19 - Interview with Dr Marc Levitt, Chief of Colorectal & Pelvic Reconstruction, Children‘s National Hospital, Washington DC USA | The Rare and Resilient](https://library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstruction-children-s-national-hospital-washington-dc-usa-the-rare-and-resilient-13860) — podcast · [machine version](https://library.globalcastmd.com/watch/episode-19-interview-with-dr-marc-levitt-chief-of-colorectal-pelvic-reconstruction-children-s-national-hospital-washington-dc-usa-the-rare-and-resilient-13860.md)
- [Hirschsprung](https://library.globalcastmd.com/watch/hirschsprung-13870) — podcast · 22:45 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-13870.md)
- [Hirschsprung's Disease with Dr. Marc Levitt](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871) — podcast · 22:45 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871.md)
- [Hirschsprung Disease – PediaCast 287](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877) — podcast · 38:55 · [machine version](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877.md)

### Emerging & Future Directions
- [Colorectal Quiz: Episode 49 – Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649) — podcast · 40:41 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649.md)

### Patient & Family Education
- [How to Make Saline](https://library.globalcastmd.com/watch/how-to-make-saline-6743) — video · 2:56 · [machine version](https://library.globalcastmd.com/watch/how-to-make-saline-6743.md)
- [How to Administer a Rectal Irrigation at Home](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744) — video · 5:36 · [machine version](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744.md)
- [How to Change Your Child’s MiniACE Balloon Device](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746) — video · 3:29 · [machine version](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746.md)
- [What is Hirschsprung's Disease? An ERNICA animation for parents and families](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805) — video · 4:50 · [machine version](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805.md)
- [Introducing Dr. Marc Levitt: Pediatric Colorectal Surgeon Profile](https://library.globalcastmd.com/watch/introducing-dr-marc-levitt-pediatric-colorectal-surgeon-profile-13831) — video · [machine version](https://library.globalcastmd.com/watch/introducing-dr-marc-levitt-pediatric-colorectal-surgeon-profile-13831.md)
- [Andrea Kesar Discusses Marc Levitt's Contributions to Pediatric Colorectal Surgery](https://library.globalcastmd.com/watch/andrea-kesar-discusses-marc-levitt-s-contributions-to-pediatric-colorectal-surgery-13832) — video · [machine version](https://library.globalcastmd.com/watch/andrea-kesar-discusses-marc-levitt-s-contributions-to-pediatric-colorectal-surgery-13832.md)
- [Dr. Marc Levitt on the CTO Mission in Pediatric Colorectal Surgery](https://library.globalcastmd.com/watch/dr-marc-levitt-on-the-cto-mission-in-pediatric-colorectal-surgery-13834) — video · [machine version](https://library.globalcastmd.com/watch/dr-marc-levitt-on-the-cto-mission-in-pediatric-colorectal-surgery-13834.md)
- [Addressing Ministers of Health: Pediatric Colorectal Surgery Advocacy and Global Healthcare Priorities](https://library.globalcastmd.com/watch/addressing-ministers-of-health-pediatric-colorectal-surgery-advocacy-and-global-healthcare-priorities-13838) — video · [machine version](https://library.globalcastmd.com/watch/addressing-ministers-of-health-pediatric-colorectal-surgery-advocacy-and-global-healthcare-priorities-13838.md)
- [Patient Outreach and Communication in Pediatric Colorectal Surgery](https://library.globalcastmd.com/watch/patient-outreach-and-communication-in-pediatric-colorectal-surgery-13839) — video · [machine version](https://library.globalcastmd.com/watch/patient-outreach-and-communication-in-pediatric-colorectal-surgery-13839.md)
- [How the Colorectal and Pelvic Reconstruction Center Uses Donor Support](https://library.globalcastmd.com/watch/how-the-colorectal-and-pelvic-reconstruction-center-uses-donor-support-13842) — video · [machine version](https://library.globalcastmd.com/watch/how-the-colorectal-and-pelvic-reconstruction-center-uses-donor-support-13842.md)
- [Introduction to Dr. Marc Levitt's Pediatric Colorectal Surgery Practice](https://library.globalcastmd.com/watch/introduction-to-dr-marc-levitt-s-pediatric-colorectal-surgery-practice-13843) — video · [machine version](https://library.globalcastmd.com/watch/introduction-to-dr-marc-levitt-s-pediatric-colorectal-surgery-practice-13843.md)
- [The value and weakness of Medical Mission Work in ARM](https://library.globalcastmd.com/watch/the-value-and-weakness-of-medical-mission-work-in-arm-13844) — video · [machine version](https://library.globalcastmd.com/watch/the-value-and-weakness-of-medical-mission-work-in-arm-13844.md)

### Long-Term Care
- [Adult Outcomes: Hirschsprung Disease](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033) — video · 20:17 · [machine version](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033.md)
- [Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049) — video · 25:39 · [machine version](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049.md)
- [Transitional Care in Anorectal Malformation and Hirschsprung's Disease](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940) — video · 1:05 · [machine version](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940.md)
- [Cuidado de transición en malformación anorrectal y enfermedad de Hirschsprung](https://library.globalcastmd.com/watch/cuidado-de-transici-n-en-malformaci-n-anorrectal-y-enfermedad-de-hirschsprung-8946) — video · 1:09 · [machine version](https://library.globalcastmd.com/watch/cuidado-de-transici-n-en-malformaci-n-anorrectal-y-enfermedad-de-hirschsprung-8946.md)
- [Transition From Pediatric to Adult Healthcare for Colorectal Conditions: A Systematic Review](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114) — video · 0:58 · [machine version](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114.md)

## Chapters
- [0:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=4) Introduction and Program Context (Ep 113)
- [1:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=106) Defining Intestinal Failure (Ep 113)
- [4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=290) Three Categories of Intestinal Failure (Ep 113)
- [8:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=499) Timing of Diagnosis and Referral (Ep 113)
- [10:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=604) Multidisciplinary Team Approach (Ep 113)
- [12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=754) Outcomes and Future Challenges (Ep 113)
- [0:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=0) Introduction and Program Expansion (Ep 112)
- [1:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=106) Defining Intestinal Failure (Ep 112)
- [4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=290) Three Categories of Intestinal Failure (Ep 112)
- [8:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=499) Timing of Diagnosis and Referral (Ep 112)
- [10:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=604) Team Approach and Long-term Outcomes (Ep 112)
- [13:14](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=794) Series Goals and Closing (Ep 112)
- [0:00](https://library.globalcastmd.com/watch/patient-reported-outcomes-of-children-with-an-anorectal-malformation-11390?t=0) Sacral Ratio and Quality of Life in Anorectal Malformation (Ep 187)
- [0:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=0) Introduction and Definition of Intestinal Failure (Ep 75)
- [1:42](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=102) Prognostic Factors and Bowel Length Criteria (Ep 75)
- [7:07](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=427) Medical Management and TPN Strategy (Ep 75)
- [12:55](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=775) Lipid Formulations and Cholestasis Management (Ep 75)
- [17:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1071) Enteral Feeding Strategy and Adaptation (Ep 75)
- [26:01](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1561) Surgical Interventions: Lengthening Procedures (Ep 75)
- [38:10](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2290) Bacterial Overgrowth and Microbiome (Ep 75)
- [43:35](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2615) Growth Factors and Future Therapies (Ep 75)
- [46:32](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2792) Intestinal Transplantation and Multidisciplinary Care (Ep 75)
- [0:00](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=0) Introduction and Podcast Context (Ep 83)
- [2:38](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=158) Prenatal Evaluation and Diagnosis (Ep 83)
- [5:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=315) Newborn Physical Examination (Ep 83)
- [10:03](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=603) Initial Workup and Colostomy Creation (Ep 83)
- [18:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1097) Hydrocolpos Pathophysiology and Management (Ep 83)
- [22:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1337) Urogenital Sinus Management (Ep 83)
- [24:46](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1486) Imaging: Endoscopy and Cloacogram (Ep 83)
- [30:04](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1804) Surgical Planning and Urogenital Mobilization (Ep 83)
- [37:37](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2257) Vaginal Replacement Techniques (Ep 83)
- [40:22](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2422) Common Redo Scenarios and Closing (Ep 83)
- [0:00](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=0) Introduction and Appendicitis Treatment Study (Ep 188)
- [1:51](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=111) VACTERL Screening in Anorectal Malformations (Ep 188)
- [3:01](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=181) Pediatric Sepsis Consensus Definitions (Ep 188)
- [0:00](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=0) Introduction and Anatomical Considerations (Ep 189)
- [1:26](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=86) Mesenteric Preservation Rationale (Ep 189)
- [1:58](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=118) Surgical Technique Demonstration (Ep 189)
- [0:01](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=1) Case presentation and initial management (Ep 191)
- [0:54](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=54) Transanal prone rectal dissection (Ep 191)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Intestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth" — Paul Wales (clinical) [Ep 113 · 2:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=125)
- "For a patient to be defined as having intestinal failure, they must have inadequate intestinal function necessitating parenteral support for at least 60 days" — Rod Gerardo (guideline) [Ep 113 · 2:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=144)
- "An intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and associated needs" — Paul Wales (clinical) [Ep 113 · 3:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=183)
- "Short bowel syndrome is by far the most common category of intestinal failure in pediatric patients" — Paul Wales (epidemiological) [Ep 113 · 4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=290)
- "Causes of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease" — Paul Wales (clinical) [Ep 113 · 5:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=306)
- "Acquired diseases of the newborn such as necrotizing enterocolitis can cause short bowel syndrome" — Paul Wales (clinical) [Ep 113 · 5:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=318)
- "Motility disorders occur when the bowel is unable to push contents through in a coordinated way due to abnormalities of the muscle itself or the nerves that control that muscle" — Paul Wales (clinical) [Ep 113 · 5:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=345)
- "Congenital enteropathies are conditions where the patient has all of their bowel but the mucosa does not work, leading to hypersecretion and profuse fluid losses" — Paul Wales (clinical) [Ep 113 · 6:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=377)
- "Some patients will have elements of two or three categories of intestinal failure in the way they present" — Paul Wales (clinical) [Ep 113 · 7:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=431)
- "A child with gastroschisis could have short bowel because it was not all viable, inflammation affecting absorption, and motility issues" — Ellen Encisco (clinical) [Ep 113 · 7:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=442)
- "Older pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease where they have lost gut as a result of complications" — Paul Wales (clinical) [Ep 113 · 7:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=476)
- "Trauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics" — Paul Wales (epidemiological) [Ep 113 · 8:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=484)
- "There are three time points where families reach intestinal rehabilitation programs: prenatal diagnosis, postnatal acquired problems, and later presentations after discharge" — Michael Helmrath (clinical) [Ep 113 · 8:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=533)
- "Prenatal diagnoses that lead to intestinal rehabilitation typically include atresia with cystic fibrosis and gastroschisis" — Michael Helmrath (clinical) [Ep 113 · 9:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=555)
- "Postnatal acquired problems leading to intestinal rehabilitation include volvulus and necrotizing enterocolitis" — Ellen Encisco (clinical) [Ep 113 · 9:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=569)
- "Dietitians play a key role in understanding the nutritional needs of children in intestinal rehabilitation" — Michael Helmrath (opinion) [Ep 113 · 11:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=712)
- "Social work is a key component of the intestinal rehabilitation team" — Michael Helmrath (opinion) [Ep 113 · 12:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=721)
- "The survival overall in big intestinal rehabilitation programs is usually over 90% long-term survival" — Rod Gerardo (epidemiological) [Ep 113 · 12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=754)
- "Children with intestinal failure who survive long-term now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues" — Paul Wales (clinical) [Ep 113 · 12:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=766)
- "Earlier recognition and taking advantage of the biology of the gut to adapt are time dependent" — Michael Helmrath (clinical) [Ep 113 · 2:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=160)
- "Intestinal rehabilitation streamlines care and improves communication with families and between care providers and team members" — Paul Wales (opinion) [Ep 113 · 3:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=235)
- "Intestinal rehabilitation comes down to key factors that drive the process: nutrition in the gut, nutrition in the body, and healing" — Michael Helmrath (clinical) [Ep 113 · 4:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=247)
- "Pattern recognition from multiple eyes on a baby who have seen them over time is important in intestinal rehabilitation" — Michael Helmrath (opinion) [Ep 113 · 4:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=259)
- "Intestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth" — Paul Wales (clinical) [Ep 112 · 2:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=125)
- "New guidelines define intestinal failure as requiring parental support for at least 60 days" — Rod Gerardo (guideline) [Ep 112 · 2:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=144)
- "An intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm providing coordinated care for children with intestinal failure through comprehensive management of specialized nutrition and associated needs" — Paul Wales (clinical) [Ep 112 · 3:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=183)
- "Short bowel syndrome is by far the most common category of intestinal failure in pediatric patients" — Paul Wales (epidemiological) [Ep 112 · 4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=290)
- "Causes of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease" — Paul Wales (clinical) [Ep 112 · 5:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=306)
- "Acquired diseases of the newborn such as necrotizing enterocolitis cause short bowel syndrome" — Paul Wales (clinical) [Ep 112 · 5:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=318)
- "Motility disorders occur when abnormalities of the intestinal muscle itself or the nerves that control that muscle prevent coordinated movement of food and stool" — Paul Wales (clinical) [Ep 112 · 5:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=345)
- "Children with motility disorders are dependent on intravenous support" — Paul Wales (clinical) [Ep 112 · 6:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=370)
- "Enteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work" — Paul Wales (clinical) [Ep 112 · 6:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=377)
- "Mucosal defects lead to hypersecretion and profuse fluid losses such that the bowel is unable to tolerate or absorb nutrients" — Ellen (clinical) [Ep 112 · 6:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=390)
- "Some patients will have elements of one, two, or all three categories of intestinal failure" — Paul Wales (clinical) [Ep 112 · 7:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=431)
- "A child with gastroschisis could have short bowel because it was not all viable, inflammation affecting absorption, and motility issues" — Ellen (clinical) [Ep 112 · 7:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=442)
- "Most intestinal failure patients are infants or babies, but some older kids develop intestinal failure" — Paul Wales (epidemiological) [Ep 112 · 7:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=465)
- "Inflammatory bowel disease or Crohn's disease can lead to gut loss and intestinal failure in older patients" — Paul Wales (clinical) [Ep 112 · 7:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=476)
- "Trauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics" — Paul Wales (epidemiological) [Ep 112 · 8:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=484)
- "There are three time points when families reach intestinal rehab programs: prenatal diagnosis, postnatal acquired problems, and later diagnosis after discharge" — Rod Gerardo (clinical) [Ep 112 · 8:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=531)
- "Prenatal diagnoses that lead to intestinal rehab referral include atresia with cystic fibrosis and gastroschisis" — Michael Helmrath (clinical) [Ep 112 · 9:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=555)
- "Postnatal acquired problems leading to intestinal rehab referral include volvulus and necrotizing enterocolitis" — Ellen (clinical) [Ep 112 · 9:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=569)
- "The intestinal rehab team includes surgeons, GI doctors, neonatologists, dietitians, social work, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology" — Michael Helmrath (clinical) [Ep 112 · 11:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=703)
- "Survival overall in big intestinal rehab programs is usually over 90% long-term survival" — Rod Gerardo (epidemiological) [Ep 112 · 12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=754)
- "Long-term survivors now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues" — Paul Wales (clinical) [Ep 112 · 12:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=766)
- "Earlier recognition and taking advantage of the gut's biology to adapt are time dependent" — Michael Helmrath (opinion) [Ep 112 · 2:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=160)
- "Intestinal rehabilitation comes down to key factors: nutrition in the gut, nutrition in the body, and healing" — Michael Helmrath (clinical) [Ep 112 · 4:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=247)
- "Pattern recognition from multiple experienced providers seeing patients over time is essential in intestinal rehabilitation" — Michael Helmrath (opinion) [Ep 112 · 4:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=259)
- "Families living within the region can benefit from understanding that delivery at an intestinal rehab center from the beginning is probably beneficial" — Michael Helmrath (opinion) [Ep 112 · 8:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=510)
- "Access and availability to an intestinal rehab program is still very rare" — Rod Gerardo (epidemiological) [Ep 112 · 8:41](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=521)
- "Innovation comes from multiple approaches to the problem and different visions, with more expertise bringing better outcomes" — Michael Helmrath (opinion) [Ep 112 · 10:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=625)
- "Transitioning older children with intestinal failure into their late teen years and later is a major obstacle that needs to be addressed" — Michael Helmrath (clinical) [Ep 112 · 10:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=651)
- "A 2024 survey by Witt et al. at Nationwide Children's was published in the Annals of Surgery examining patients with anorectal malformation" — Jill Knepprath (clinical) [Ep 187 · 0:10](https://library.globalcastmd.com/watch/patient-reported-outcomes-of-children-with-an-anorectal-malformation-11390?t=10)
- "The survey looked at over 900 patients with anorectal malformation" — Jill Knepprath (epidemiological) [Ep 187 · 0:11](https://library.globalcastmd.com/watch/patient-reported-outcomes-of-children-with-an-anorectal-malformation-11390?t=11)
- "There was no difference in continence for patients based on sacral ratio alone in regards to quality of life" — Jill Knepprath (clinical) [Ep 187 · 0:21](https://library.globalcastmd.com/watch/patient-reported-outcomes-of-children-with-an-anorectal-malformation-11390?t=21)
- "Patients who are incontinent had a 20-point lower quality of life compared to patients who were continent or clean on enemas" — Jill Knepprath (clinical) [Ep 187 · 0:29](https://library.globalcastmd.com/watch/patient-reported-outcomes-of-children-with-an-anorectal-malformation-11390?t=29)
- "The sacral ratio may not be as strong a predictor of continence as patients age" — Jill Knepprath (opinion) [Ep 187 · 0:38](https://library.globalcastmd.com/watch/patient-reported-outcomes-of-children-with-an-anorectal-malformation-11390?t=38)
- "Bowel management may actually matter more than sacral ratio in predicting continence outcomes" — Jill Knepprath (opinion) [Ep 187 · 0:38](https://library.globalcastmd.com/watch/patient-reported-outcomes-of-children-with-an-anorectal-malformation-11390?t=38)
- "Quality of life is significantly lower for patients with incontinence compared to those clean on enemas" — Jill Knepprath (clinical) [Ep 187 · 0:51](https://library.globalcastmd.com/watch/patient-reported-outcomes-of-children-with-an-anorectal-malformation-11390?t=51)
- "Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding" — Brad Warner (clinical) [Ep 75 · 1:42](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=102)
- "The intestine of a newborn or fetus doubles in length in the last trimester of gestation" — Brad Warner (clinical) [Ep 75 · 3:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=183)
- "For a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for salvageability" — Brad Warner (clinical) [Ep 75 · 4:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=243)
- "Without the colon and ileocecal valve, at least 15 to 20 centimeters would be a ballpark figure for salvageability" — Brad Warner (clinical) [Ep 75 · 4:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=277)
- "In adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years" — Brad Warner (epidemiological) [Ep 75 · 4:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=291)
- "For a patient with 15 centimeters of bowel and ileocecal valve, long term 50% should be able to wean from TPN, 25% would require transplant, and 25% would die" — Brad Warner (epidemiological) [Ep 75 · 5:56](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=356)
- "Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection" — Brad Warner (clinical) [Ep 75 · 7:49](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=469)
- "Stool outputs of up to 40 ccs per kilo per day are acceptable when advancing enteral feeding" — Brad Warner (guideline) [Ep 75 · 8:30](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=510)
- "For TPN, shoot for about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein" — Brad Warner (guideline) [Ep 75 · 10:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=622)
- "Generally shoot for about 2 to 3 g of protein per kilo per day and about 2 to 3 g of fat per kilo per day in TPN" — Brad Warner (guideline) [Ep 75 · 10:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=645)
- "A baby should gain about 20 to 30 g a day, which approximates in utero progression for a newborn" — Brad Warner (clinical) [Ep 75 · 12:05](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=725)
- "Lipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered daily down to about 1 g per kilo per day delivered twice or 3 times a week to reduce cholestasis" — Brad Warner (guideline) [Ep 75 · 12:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=773)
- "Omegaven is a fish oil-based fat primarily containing omega 3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega 6 fatty acids that are pro-inflammatory" — Brad Warner (clinical) [Ep 75 · 14:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=843)
- "SMOF lipid contains soybean (essential fatty acids), medium chain triglycerides (easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada" — Brad Warner (clinical) [Ep 75 · 15:08](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=908)
- "Breast milk is the best choice for neonates because it contains growth factors like EGF and IGF, milk oligosaccharides that enhance adaptation, and other beneficial components" — Brad Warner (opinion) [Ep 75 · 18:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1091)
- "Complex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent" — Brad Warner (clinical) [Ep 75 · 19:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1166)
- "There is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is unknown" — Brad Warner (clinical) [Ep 75 · 21:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1279)
- "Time to consider surgical intervention is when patient hits a plateau enterally and starts backing away, or if going backward rather than forward in enteral tolerance" — Brad Warner (guideline) [Ep 75 · 22:33](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1353)
- "Multiple episodes of sepsis along with abdominal distention and dilated bowel loops is an indication for surgical intervention" — Brad Warner (guideline) [Ep 75 · 23:01](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1381)
- "If child is starting to get jaundiced, there is a role to evaluate the gut for subclinical portal bacteremia arising from dilated bowel loops" — Brad Warner (clinical) [Ep 75 · 23:18](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1398)
- "Dilated bowel loops cause bacterial overgrowth leading to secretory diarrhea that is not related to digestion-absorption capacity but to enzyme dysfunction" — Brad Warner (clinical) [Ep 75 · 23:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1433)
- "More than 4 to 5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention" — Brad Warner (guideline) [Ep 75 · 25:43](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1543)
- "In a child who is completely stable after 3 years but not progressing, would interrogate bowel and if dilated would proceed with lengthening" — Brad Warner (opinion) [Ep 75 · 26:07](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1567)
- "If a child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem" — Brad Warner (clinical) [Ep 75 · 27:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1673)
- "With less than 50 centimeters of intestine and bowel at least 4 to 5 centimeters dilated, there is an option for either Bianchi or STEP procedure" — Brad Warner (guideline) [Ep 75 · 28:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1717)
- "The STEP procedure has emerged to be the most commonly performed lengthening operation because it is easier to do with less risk of injuring mesenteric blood supply" — Brad Warner (clinical) [Ep 75 · 29:31](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1771)
- "STEP procedures can redilate requiring redo procedures, and outcomes are not as good if a redo STEP is needed compared to never needing a redo" — Brad Warner (clinical) [Ep 75 · 32:54](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1974)
- "You can do a Bianchi and then later do a STEP on top of it, but you cannot do a Bianchi once a STEP has been done" — Brad Warner (clinical) [Ep 75 · 33:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2006)
- "STEP procedures can cause dysmotility acting as a brake on intestinal transit" — Brad Warner (clinical) [Ep 75 · 35:04](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2104)
- "Would taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length rather than performing a lengthening procedure" — Brad Warner (opinion) [Ep 75 · 38:21](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2301)
- "Chenodeoxycholic acid bile salts can be used to improve bile flow in TPN cholestasis" — Brad Warner (clinical) [Ep 75 · 39:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2340)
- "Cholecystokinin administration to promote bile flow and mitigate TPN cholestasis did not work in clinical trials" — Brad Warner (clinical) [Ep 75 · 39:23](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2363)
- "Gut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome" — Brad Warner (clinical) [Ep 75 · 41:54](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2514)
- "In mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection" — Brad Warner (clinical) [Ep 75 · 42:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2539)
- "Teduglutide, a GLP-2 analog, has been demonstrated in randomized trials to reduce TPN requirements by about 1-2 liters per week in adults with short gut syndrome" — Brad Warner (clinical) [Ep 75 · 43:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2625)
- "Teduglutide is not yet approved for children in the United States due to concerns about malignancy risk from promoting proliferation" — Brad Warner (clinical) [Ep 75 · 44:34](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2674)
- "Growth hormone and glutamine combinations have shown primarily mixed results and have not been a huge advance in TPN weaning" — Brad Warner (clinical) [Ep 75 · 45:40](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2740)
- "Survival for small bowel transplant is about 50 to 60% at 5 years, with one year survivals now above 70 to 80%" — Brad Warner (epidemiological) [Ep 75 · 46:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2811)
- "The intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft versus host response requiring industrial strength immunosuppression" — Brad Warner (clinical) [Ep 75 · 47:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2831)
- "Ethanol locks for central lines have reduced significantly the number of sepsis episodes in patients with short gut syndrome" — Brad Warner (clinical) [Ep 75 · 49:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2962)
- "Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID, radiology, and interventional radiology improve survival of intestinal failure patients" — Brad Warner (clinical) [Ep 75 · 51:16](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=3076)
- "The most common prenatal ultrasound finding in cloaca is a pelvic mass, often initially thought to be the bladder but actually representing a dilated vagina (hydrocolpos)" — Marc Levitt (clinical) [Ep 83 · 2:38](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=158)
- "Associated anomalies that increase suspicion for cloaca include missing radius, absent sacrum, single kidney, or hydronephrosis, particularly in a female fetus" — Marc Levitt (clinical) [Ep 83 · 3:35](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=215)
- "Fetal intervention for cloaca is unlikely to be necessary, with the only indication being massive hydronephrosis with impending renal loss" — Marc Levitt (clinical) [Ep 83 · 3:56](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=236)
- "At least one case report from Japan describes prenatal drainage of hydrocolpos for severe hydronephrosis, similar to bladder drainage for urethral valves" — Marc Levitt (epidemiological) [Ep 83 · 5:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=317)
- "In cloaca, there is one perineal hole below the clitoris with no anus; if there is a normal anus present with one hole, it is a urogenital sinus, not a cloaca" — Marc Levitt (clinical) [Ep 83 · 6:35](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=395)
- "Urogenital sinus with virilizing component (hypertrophied clitoris) requires evaluation for adrenal hyperplasia to rule out urgent electrolyte abnormality" — Marc Levitt (clinical) [Ep 83 · 7:02](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=422)
- "Cloaca is not ambiguous genitalia; the patient is a normal female with two normal ovaries and will be hormonally normal with no adrenal problem" — Marc Levitt (clinical) [Ep 83 · 7:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=447)
- "The most common anorectal malformation in females is three holes (normal urethra, normal vagina, and third hole in wrong place - vestibular or perineal fistula)" — Marc Levitt (epidemiological) [Ep 83 · 8:06](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=486)
- "Proper perineal examination requires very good lighting and lifting the labia up and out to accentuate visualization of the single hole in cloaca" — Marc Levitt (clinical) [Ep 83 · 8:36](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=516)
- "Many patients have been misdiagnosed as cloaca when better examination would reveal three distinct holes indicating vestibular fistula" — Marc Levitt (clinical) [Ep 83 · 9:03](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=543)
- "Initial workup for cloaca includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, cardiac auscultation, and spine X-ray to assess sacrum quality" — Marc Levitt (guideline) [Ep 83 · 9:59](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=599)
- "Intermittent catheterization of the common channel may decompress hydrocolpos but is unreliable because the catheter may enter urethra, right vagina, left vagina, or rectum" — Marc Levitt (clinical) [Ep 83 · 11:14](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=674)
- "If intermittent catheterization of common channel is attempted, ultrasound confirmation is needed to verify actual decompression of the hydrocolpos" — Marc Levitt (clinical) [Ep 83 · 12:09](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=729)
- "Hydrocolpos should be drained at the time of colostomy creation if intermittent catheterization is not successful" — Marc Levitt (guideline) [Ep 83 · 12:33](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=753)
- "For bilateral hydrocolpos, the septum between vaginas must be removed so one tube can drain both sides" — Marc Levitt (clinical) [Ep 83 · 13:28](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=808)
- "An 8 French or 10 French pigtail catheter from interventional radiology is preferred for vaginostomy because curled catheters do not fall out as hydrocolpos recedes, unlike straight catheters" — Marc Levitt (clinical) [Ep 83 · 14:21](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=861)
- "Vesicostomy does not relieve hydronephrosis in cloaca because the problem is hydrocolpos compressing the distal ureters at the trigone, not bladder outlet obstruction" — Marc Levitt (clinical) [Ep 83 · 15:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=915)
- "Draining the hydrocolpos relieves pressure on the ureteral orifices, allowing ureters to drain into the bladder, which then drains through the common channel or vaginostomy tube" — Marc Levitt (clinical) [Ep 83 · 15:46](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=946)
- "Vesicostomy or suprapubic tube is only needed in the rare circumstance when hydrocolpos is drained but bladder still does not decompress, typically with very long narrow common channel or absent urethra" — Marc Levitt (clinical) [Ep 83 · 16:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=975)
- "Hydronephrosis in cloaca is often a prenatal finding and will not resolve immediately; it should be monitored to ensure it is stable and not worsening, with resolution expected over several days to two weeks" — Marc Levitt (clinical) [Ep 83 · 16:56](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1016)
- "Massive bilateral ureteral reflux is an exception where vesicostomy may be needed to decompress the system until later in life" — Marc Levitt (clinical) [Ep 83 · 17:54](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1074)
- "Hydrocolpos develops because urine preferentially fills the vagina through the fistula rather than exiting the common channel, combined with vaginal mucus and maternal estrogen effect" — Marc Levitt (clinical) [Ep 83 · 18:24](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1104)
- "Some centers report hydrocolpos resolution with intermittent catheterization after maternal estrogen effect wanes at a couple weeks of age" — Marc Levitt (clinical) [Ep 83 · 18:48](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1128)
- "Hydrocolpos fluid is typically clear turbid fluid (combination of mucus and urine), though blood has been seen related to estrogen effect" — Marc Levitt (clinical) [Ep 83 · 19:03](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1143)
- "Urine does not drain easily from hydrocolpos because the urethra is far from the perineum and requires a steep turn upward into the bladder, while the vaginal fistula acts as a pop-off valve" — Marc Levitt (clinical) [Ep 83 · 19:31](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1171)
- "Cystoscopy is not performed in the newborn period because the required scope is tiny with poor visualization, the perineum is swollen, and minimizing OR time in newborns is important" — Marc Levitt (opinion) [Ep 83 · 20:29](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1229)
- "Laparoscopic approach for colostomy and hydrocolpos drainage, as described by the Michigan group, provides excellent visualization" — Marc Levitt (clinical) [Ep 83 · 20:49](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1249)
- "For massive hydrocolpos extending above the umbilicus, a lower midline incision is preferred over left lower quadrant oblique incision to access the dome of the hydrocolpos" — Marc Levitt (clinical) [Ep 83 · 21:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1277)
- "For very large hydrocolpos, a tubeless vaginostomy can be created by suturing the vagina to the abdominal wall like a G-tube, avoiding need for indwelling tube" — Marc Levitt (clinical) [Ep 83 · 21:47](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1307)
- "Urogenital sinus without anorectal malformation requires workup for adrenal problems causing virilization and may need hydrocolpos drainage if present" — Marc Levitt (clinical) [Ep 83 · 22:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1347)
- "Most urogenital sinus cases can be managed with perineal urogenital mobilization without touching the rectum; high UG sinus may require transrectal (Astra) approach" — Marc Levitt (clinical) [Ep 83 · 23:08](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1388)
- "Endoscopy with cystoscopy and vaginoscopy is performed at 2-3 months of age, with definitive cloaca repair typically within one year, ideally before 6 months if managing from birth" — Marc Levitt (guideline) [Ep 83 · 23:57](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1437)
- "Common channel length (traditionally 3cm cutoff) has been the standard measure for cloaca complexity, but urethral length from urethral takeoff to bladder neck is equally important for surgical planning" — Marc Levitt (clinical) [Ep 83 · 25:10](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1510)
- "Endoscopy alone can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum high in the abdomen; contrast study is needed to determine this" — Marc Levitt (clinical) [Ep 83 · 26:21](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1581)
- "Cloacogram is performed by injecting distal colostomy, vaginostomy (if present), and common channel, with catheters left in place during fluoroscopy or 3D reconstruction in interventional radiology" — Marc Levitt (clinical) [Ep 83 · 26:44](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1604)
- "Lateral fluoroscopic image is the most important view to assess rectal position, vaginal reachability, and urethral location" — Marc Levitt (clinical) [Ep 83 · 27:55](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1675)
- "A study comparing 2D cloacogram, 3D reconstruction, 3D printed model, and virtual reality found that more complex modalities yielded more correct anatomic descriptions by experienced surgeons" — Marc Levitt (epidemiological) [Ep 83 · 28:34](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1714)
- "3D imaging is definitively better than 2D for cloacogram interpretation, and 3D printed models may be better than 3D reconstruction alone" — Marc Levitt (opinion) [Ep 83 · 29:03](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1743)
- "Cloaca patients benefit from collaborative multidisciplinary approach including pediatric surgery, urology, and gynecology" — Marc Levitt (opinion) [Ep 83 · 30:29](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1829)
- "The days of a single surgeon handling cloaca complexity are over" — Marc Levitt (opinion) [Ep 83 · 30:44](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1844)
- "Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate of prior techniques" — Marc Levitt (clinical) [Ep 83 · 32:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1935)
- "Urogenital mobilization is appropriate when common channel is 3cm or less AND urethral length above the takeoff is at least 1.5-2cm" — Marc Levitt (clinical) [Ep 83 · 33:39](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2019)
- "Well-trained general pediatric surgeons can perform urogenital mobilization for appropriate cases (adequate urethral length), though it is more technically demanding for those who do it infrequently" — Marc Levitt (opinion) [Ep 83 · 34:06](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2046)
- "When urethral length is inadequate, the common channel must be preserved as the urethra by separating the vagina from it, which is technically demanding" — Marc Levitt (clinical) [Ep 83 · 34:34](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2074)
- "After vaginal separation, the common channel repair should be reinforced with anorectal fat pad and possibly SIS to ensure healing and avoid urethral-vaginal fistula" — Marc Levitt (clinical) [Ep 83 · 34:56](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2096)
- "If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery of the urogenital complex, which often fails and can result in devascularized urethral loss requiring Mitrofanoff" — Marc Levitt (clinical) [Ep 83 · 35:09](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2109)
- "Performing urogenital mobilization with inadequate urethral length leaves the patient with urinary leakage that cannot be controlled without tightening or closing the bladder neck" — Marc Levitt (clinical) [Ep 83 · 35:52](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2152)
- "Preserving the common channel as the entire urethra provides approximately 4cm urethral length, allowing intermittent catheterization and continence" — Marc Levitt (clinical) [Ep 83 · 36:05](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2165)
- "Type 1 cloaca has common channel of 1cm with adequate urethral length; only vaginal mobilization is needed, and a slightly hypospadiac urethra is acceptable if the patient will void and not require catheterization" — Marc Levitt (clinical) [Ep 83 · 36:40](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2200)
- "Patients with neurogenic bladder component (whether from tethered cord or not) require a visible urethral orifice that is easily catheterized" — Marc Levitt (clinical) [Ep 83 · 37:11](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2231)
- "When native vagina does not reach after full mobilization including abdominal approach, options include vaginal switch (disconnecting one side while preserving ovarian blood supply) or vaginal replacement" — Marc Levitt (clinical) [Ep 83 · 37:42](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2262)
- "For vaginal replacement, colon (particularly left colon or sigmoid depending on arcade) is the preferred conduit over rectum or small bowel" — Marc Levitt (opinion) [Ep 83 · 38:46](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2326)
- "Tissue engineering of vaginas using patient stem cells is on the horizon, with work already done at Wake Forest and in Mexico, which could revolutionize cloaca care by eliminating need for vaginal replacement" — Marc Levitt (clinical) [Ep 83 · 39:10](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2350)
- "Complex cloaca cases requiring expertise include common channel greater than 3cm or urethral length less than 1.5cm from takeoff to bladder neck" — Marc Levitt (clinical) [Ep 83 · 39:48](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2388)
- "The most common problem in redo cloaca cases is that the surgeon never realized they were dealing with a cloaca and only repaired the rectum, leaving the urogenital sinus untouched" — Marc Levitt (epidemiological) [Ep 83 · 40:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2427)
- "The second most common redo scenario is inadequate mobilization of structures resulting in stenosed or lost vagina" — Marc Levitt (epidemiological) [Ep 83 · 40:56](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2456)
- "Recent literature has been supporting treating appendicitis with antibiotics rather than surgery" — Lizzie Lee (opinion) [Ep 188 · 1:07](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=67)
- "The appendicitis study was a multi-center randomized trial conducted in Canada, the US, Finland, Sweden, and Singapore" — Lizzie Lee (clinical) [Ep 188 · 1:12](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=72)
- "34% of children treated with antibiotics for appendicitis eventually required surgery within a year" — Lizzie Lee (clinical) [Ep 188 · 1:24](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=84)
- "Only 7% in the appendectomy group required additional surgery within a year" — Lizzie Lee (clinical) [Ep 188 · 1:24](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=84)
- "There were no deaths in either the antibiotic or surgery group for appendicitis treatment" — Lizzie Lee (clinical) [Ep 188 · 1:32](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=92)
- "Children in the antibiotic group had a higher risk of mild to moderate adverse events compared to surgery group" — Lizzie Lee (clinical) [Ep 188 · 1:32](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=92)
- "Antibiotics were not as effective as surgery for treating non-perforated appendicitis in children and did not meet the threshold for non-inferiority" — Lizzie Lee (clinical) [Ep 188 · 1:39](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=99)
- "The ARM study used the PHIS database and included all ARM patients between 2016 and 2022" — Alex Halpern (clinical) [Ep 188 · 2:16](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=136)
- "In ARM patients, vertebral-spinal anomalies were diagnosed in 45.4% across all hospital encounters" — Alex Halpern (epidemiological) [Ep 188 · 2:25](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=145)
- "In ARM patients, cardiac anomalies were diagnosed in 77.4% across all hospital encounters" — Alex Halpern (epidemiological) [Ep 188 · 2:25](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=145)
- "In ARM patients, TEF was diagnosed in 10.2% across all hospital encounters" — Alex Halpern (epidemiological) [Ep 188 · 2:25](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=145)
- "In ARM patients, renal anomalies were diagnosed in 39.9% across all hospital encounters" — Alex Halpern (epidemiological) [Ep 188 · 2:25](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=145)
- "In ARM patients, limb anomalies were diagnosed in 15.7% across all hospital encounters" — Alex Halpern (epidemiological) [Ep 188 · 2:25](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=145)
- "25.8% of female ARM patients had a congenital gynecologic malformation diagnosed" — Alex Halpern (epidemiological) [Ep 188 · 2:40](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=160)
- "The most common anomalies associated with ARMs are cardiac, vertebrospinal, renal, and gynecologic" — Alex Halpern (clinical) [Ep 188 · 2:45](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=165)
- "The authors suggest changing the VACTERL acronym to VACTERL-GS to include gynecologic and spinal conditions" — Alex Halpern (guideline) [Ep 188 · 2:53](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=173)
- "The sepsis study was a worldwide study with a Delphi consensus process that aimed to update the definitions of sepsis and septic shock" — Cecilia Gigena (clinical) [Ep 188 · 3:20](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=200)
- "The Phoenix sepsis score includes variables in cardiovascular function, respiratory function, coagulation, and neurological function" — Cecilia Gigena (clinical) [Ep 188 · 3:29](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=209)
- "The Phoenix sepsis score correlates the definition with actual mortality rate" — Cecilia Gigena (clinical) [Ep 188 · 3:42](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=222)
- "Sepsis is defined as suspected infection plus 2 points in the Phoenix sepsis score" — Cecilia Gigena (guideline) [Ep 188 · 3:48](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=228)
- "Septic shock is defined as sepsis plus cardiovascular dysfunction seen when there is 1 point in the cardiovascular variable of the Phoenix sepsis score" — Cecilia Gigena (guideline) [Ep 188 · 3:48](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=228)
- "Sepsis has a mortality rate of 7.1%" — Cecilia Gigena (epidemiological) [Ep 188 · 4:06](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=246)
- "Septic shock has a mortality rate of 10.8 to 33.5% according to the research settings" — Cecilia Gigena (epidemiological) [Ep 188 · 4:06](https://library.globalcastmd.com/watch/quick-literature-updates-ep-26-11413?t=246)
- "The speaker now performs laparoscopy to identify the bowel segment for stoma creation rather than the traditional left lower quadrant incision approach" (clinical) [Ep 189 · 0:20](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=20)
- "The technique has recently changed from double barrel to loop stoma" (clinical) [Ep 189 · 0:29](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=29)
- "The stoma should be matured on the flat portion of the left lower quadrant between the ribs, anterior superior iliac crest, and pubic bone" (clinical) [Ep 189 · 0:36](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=36)
- "The proximal sigmoid should be chosen for stoma creation to preserve the distal sigmoid and rectum for ultimate pull through" (clinical) [Ep 189 · 0:51](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=51)
- "The Turnbull loop stoma appears to the world like an end stoma but has a tiny, flat mucous fistula" (clinical) [Ep 189 · 1:08](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=68)
- "During double barrel stoma creation, key collateral vessels to the distal segment can be easily ligated when taking mesentery" (clinical) [Ep 189 · 1:33](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=93)
- "The Turnbull stoma prevents mesenteric vessel injury because no mesentery is taken" (clinical) [Ep 189 · 1:50](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=110)
- "The Turnbull stoma is a loop that functions like an end stoma" (clinical) [Ep 189 · 1:58](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=118)
- "The key technical feature is creating a loop with the proximal side brooked and the distal side flat" (clinical) [Ep 189 · 2:06](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=126)
- "The stoma site should be on a flat part of the left lower quadrant at some distance from the incision" (clinical) [Ep 189 · 2:33](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=153)
- "The bowel is opened on the anti-mesenteric side" (clinical) [Ep 189 · 3:21](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=201)
- "The separation between proximal and distal limbs is 90 to 10" (clinical) [Ep 189 · 3:30](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=210)
- "The seromuscular layer is tacked to the fascia and the two corners are tacked to the dermis" (clinical) [Ep 189 · 3:43](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=223)
- "The main complication related to a loop stoma is prolapse" (clinical) [Ep 189 · 3:50](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=230)
- "The proximal limb is turned inside out using a retractor to create the appearance of an end stoma" (clinical) [Ep 189 · 4:22](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=262)
- "Patient presented with neonatal obstruction" (clinical) [Ep 191 · 0:15](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=15)
- "Contrast enema was typical of total colonic Hirschsprung disease" (clinical) [Ep 191 · 0:15](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=15)
- "All rectal and colonic biopsies showed no ganglion cells" (clinical) [Ep 191 · 0:27](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=27)
- "Good ganglion cells were present at the ileum where the stoma was opened" (clinical) [Ep 191 · 0:33](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=33)
- "Patient thrived and needed no enteral or parenteral nutrition supplementation" (clinical) [Ep 191 · 0:38](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=38)
- "At age 1, stool was noted to be thick in the ileostomy, prompting pull-through" (clinical) [Ep 191 · 0:46](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=46)
- "The distal ileostomy limb had about 25 centimeters of ganglionic ileum" (clinical) [Ep 191 · 0:57](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=57)
- "All redo Hirschsprung cases are best handled prone" (opinion) [Ep 191 · 1:15](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=75)
- "Transanal prone rectal dissection in untouched rectum helps understand anatomy of previously operated rectums" (opinion) [Ep 191 · 1:21](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=81)
- "Dentate line should be preserved and hidden under retraction pins" (clinical) [Ep 191 · 1:39](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=99)
- "Marking 0.5 centimeters from anal verge preserves the anal canal" (clinical) [Ep 191 · 1:53](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=113)
- "There is a typical areolar plane in the full-thickness Swenson dissection" (clinical) [Ep 191 · 2:39](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=159)
- "Tying off the distal rectum prevents spillage when entering the abdomen" (clinical) [Ep 191 · 4:40](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=280)
- "Elliptical incision around stomas makes transverse incision easier to close" (clinical) [Ep 191 · 5:18](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=318)
- "Downstream small bowel is very small in caliber after prolonged diversion" (clinical) [Ep 191 · 5:32](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=332)
- "Best orientation for pull-through is with small bowel limb coming down the right pelvis" (opinion) [Ep 191 · 6:31](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=391)
- "Marking 4 centimeters below superior aspect of pubic bone confirms pull-through segment will comfortably reach perineum" (clinical) [Ep 191 · 6:37](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=397)
- "Intact vascular arcade supplies the distal ileal segment" (clinical) [Ep 191 · 7:02](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=422)
- "Martini glass technique preserves V-shaped vessels and ligates the stem" (clinical) [Ep 191 · 7:08](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=428)
- "Pull-through segment must be under no tension" (clinical) [Ep 191 · 7:51](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=471)
- "Anastomosis uses seromuscular stitches from bowel to sphincters in 4 positions" (clinical) [Ep 191 · 7:59](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=479)
- "Second anastomotic layer is mucosa of ileum to mucosa proximal to preserved anal canal" (clinical) [Ep 191 · 8:10](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-ileostomy-take-down-and-ileoanal-pull-through-11713?t=490)
- "Patient was previously healthy but at age 3 suffered from Fournier's gangrene complicated by extensive sphincter and perineal muscle injury" (clinical) [Ep 192 · 0:00](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=0)
- "Initial management consisted of successive surgical debridements and creation of a diverting colostomy" (clinical) [Ep 192 · 0:15](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=15)
- "Patient healed but was left with a patulous anus and no dentate line and presumed to be fecally incontinent because of scarring" (clinical) [Ep 192 · 0:22](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=22)
- "Initial electrical stimulation showed very minimal sphincteric contractions" (clinical) [Ep 192 · 0:35](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=35)
- "Patient had a skin level anal stricture" (clinical) [Ep 192 · 0:51](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=51)
- "In the deeper layers, excellent muscle contraction was observed" (clinical) [Ep 192 · 1:47](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=107)
- "The muscle complex consists of parasagittal fibers and the levators" (clinical) [Ep 192 · 1:56](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=116)
- "The surgical technique is analogous to the conclusion of a PSARP for an anorectal malformation, tacking the muscle complex to the rectum" (clinical) [Ep 192 · 2:15](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=135)
- "When the reconstructed muscles contract, the rectum will be pulled in and closed" (clinical) [Ep 192 · 2:25](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=145)
- "It is very important that the muscle-tacking sutures not narrow the rectal lumen" (clinical) [Ep 192 · 2:32](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=152)
- "After reconstruction, the anoplasty is no longer patulous because the muscles are now holding it in" (clinical) [Ep 192 · 3:48](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=228)
- "Post-reconstruction electrical stimulation demonstrated the anus being closed by the sphincteric muscles" (clinical) [Ep 192 · 5:03](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=303)
- "Patient went on to have their colostomy closed and now has bowel control" (clinical) [Ep 192 · 5:42](https://library.globalcastmd.com/watch/sphincter-reconstruction-in-a-patient-who-suffered-from-fournier-s-gangrene-11714?t=342)
- "Many centers are starting irrigation competency even with an ostomy in place, particularly for total colonic Hirschsprung patients who may have delayed takedown" — Lindsay Clark (clinical) [Ep 190 · 1:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=77)
- "Enterocolitis remains a risk for Hirschsprung patients even after pull-through at about a rate of 20% of all patients" (epidemiological) [Ep 190 · 2:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=133)
- "Regular irrigations minimize enterocolitis risk" (clinical) [Ep 190 · 2:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=141)
- "Total colonic Hirschsprung patients represent the highest risk group for enterocolitis" — Marc Levitt (clinical) [Ep 190 · 2:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=165)
- "Most centers still do some kind of crusting, putting stool on the bottom first while patients have a stoma for small periods of time to help get their bottom used to it" — Megan Misa (clinical) [Ep 190 · 3:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=215)
- "Betel leaf was used for peristomal skin protection in Bangladesh with pristine skin results" — Megan Misa (clinical) [Ep 190 · 4:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=251)
- "Diet and nutrition management is not one size fits all; families must identify individual food triggers through pattern recognition" — Lindsay Clark (clinical) [Ep 190 · 4:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=288)
- "There have been advances in robotic-assisted repair for Hirschsprung disease and use of ICG to check blood supply of pull-throughs" — Felipe Gli (clinical) [Ep 190 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=323)
- "ICG fluorescence imaging can reduce the risk of leaks and ischemia during pull-throughs" (clinical) [Ep 190 · 5:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=336)
- "High frequency ultrasound measurement of muscle internal thickness can help determine the segment of aganglionic bowel" — Felipe Gli (clinical) [Ep 190 · 5:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=349)
- "More surgeons are able to perform robotic surgery on children less than 10 kg because equipment is improving" — Marc Levitt (clinical) [Ep 190 · 6:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=404)
- "Robotic surgery expenses have become almost equivalent to other techniques" — Felipe Gli (clinical) [Ep 190 · 6:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=411)
- "Goblet cells increase from proximal to distal bowel, producing more mucus distally which has a protective role" — Marc Levitt (clinical) [Ep 190 · 7:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=460)
- "The more proximal bowel that needs to be resected, the more at risk the patient is for future enterocolitis because proximal segments don't make as much protective mucus" — Marc Levitt (clinical) [Ep 190 · 7:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=476)
- "Mechanical stress and distension on the bowel wall leads to increased gut microbial dysbiosis and breakdown in mucosal lining and barrier function" — Marc Levitt (clinical) [Ep 190 · 8:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=517)
- "Bowel wall stress shows upregulation of pro-inflammatory factors affecting immune response, contributing to enterocolitis" — Marc Levitt (clinical) [Ep 190 · 9:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=544)
- "Most pull-through decompensation occurs despite originally good pathology, due to inadequate post-operative management" — Marc Levitt (clinical) [Ep 190 · 9:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=579)
- "Aggressive management with laxatives when needed and Botox when needed prevents pull-through decompensation" — Marc Levitt (clinical) [Ep 190 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=592)
- "The perineal-preserving PSARP avoids perineal body dissection altogether and avoids dehiscence possibility" — Marc Levitt (clinical) [Ep 190 · 16:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=985)
- "Perineal-preserving PSARP could potentially avoid colostomies and colostomy closures in many patients" — Marc Levitt (opinion) [Ep 190 · 16:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=996)
- "PRAA (posterectal advancement anoplasty) involves mobilization of posterior rectal wall only in males with perineal fistula and some females with perineal fistula when the fistula is in the anteriormost extent of the sphincteric ellipse" — Marc Levitt (clinical) [Ep 190 · 16:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1017)
- "In vestibular fistula repair, surgeons do not need to dissect all the way to the areolar plane separating anterior rectum from posterior vagina; they only need to ensure no tension on the rectum during anoplasty" — Marc Levitt (clinical) [Ep 190 · 17:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1038)
- "Delaying vaginal reconstruction in cloaca may allow for other surgical options with less conflict and avoid bowel vaginoplasty" — Felipe Gli (clinical) [Ep 190 · 18:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1087)
- "A vaginal replacement can hold the spot in the perineum and be resected later when the patient is older" — Felipe Gli (clinical) [Ep 190 · 18:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1107)
- "Cloaca patients need long-term follow-up especially during puberty to avoid menstrual obstruction, incapacity for egress, and risk of endometriosis and damage to uterus and fallopian tubes" — Felipe Gli (clinical) [Ep 190 · 18:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1124)
- "Structures that look atretic may actually grow into real useful structures, supporting a strategy of waiting on Mullerian structures" — Marc Levitt (clinical) [Ep 190 · 19:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1164)
- "A bowel neovagina can bridge the gap when native vagina does not reach, and may be removable in the future when native vagina can be pulled through after puberty" — Marc Levitt (clinical) [Ep 190 · 19:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1190)
- "Removal of the skin tag in chronic anal fissure can lead to better long-term healing" — Felipe Gli (clinical) [Ep 190 · 21:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1262)
- "Injection of 20 to 50 units of Botox can improve healing in chronic anal fissure" — Felipe Gli (clinical) [Ep 190 · 21:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1262)
- "There is a higher incidence of perianal disease in children with Crohn's disease, and sometimes perianal disease can be the first hint that the patient will develop Crohn's disease" — Marc Levitt (clinical) [Ep 190 · 21:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1295)
- "Enteral nutrition is as effective as steroids in treating transmural inflammation or stenosis of small bowel in Crohn's disease" — Marc Levitt (clinical) [Ep 190 · 21:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-50-16th-annual-european-pediatric-colorectal-and-pelvic-reconstruction-conference-stockholm-sweden-october-2025-what-did-we-learn-11653?t=1313)
- "In males with rectoperineal fistula, the good rectal lumen is only millimeters below the anal skin where the anoplasty needs to be" (clinical) [Ep 193 · 0:38](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=38)
- "The fistula opening in males is always located at the anteriormost part of the sphincteric ellipse, within the ellipse not outside of it" (clinical) [Ep 193 · 3:07](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=187)
- "Urethral injury is a complication that is surprisingly easy to do during operations for rectoperineal fistula" (clinical) [Ep 193 · 1:29](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=89)
- "The urethra is very close to the rectal wall in males with rectoperineal fistula" (clinical) [Ep 193 · 1:44](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=104)
- "Traditional posterior sagittal anorectoplasty (PSARP) with full thickness circumferential mobilization of the rectum can lead to urethral injury" (clinical) [Ep 193 · 1:52](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=112)
- "With PRAA, no dissection at all is done for the anterior rectal wall" (clinical) [Ep 193 · 2:10](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=130)
- "The fistula runs in a subepithelial plane into the scrotal raphae in some males" (clinical) [Ep 193 · 3:22](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=202)
- "The rectal lumen lies right below the surface at the anteriormost part of the sphincter" (clinical) [Ep 193 · 3:34](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=214)
- "The midline incision should not go any farther posterior than the intended anoplasty to avoid having any posterior sagittal incision to close or heal" (clinical) [Ep 193 · 3:57](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=237)
- "Muscle fibers below the skin triangles should be preserved during dissection" (clinical) [Ep 193 · 4:15](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=255)
- "The anterior rectal wall is not touched during PRAA" (clinical) [Ep 193 · 4:56](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=296)
- "The Lone Star retractor is very helpful to set up this case" (opinion) [Ep 193 · 5:38](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=338)
- "Lateral dissection is kept full thickness along the rectal wall with the rectal wall remaining intact" (clinical) [Ep 193 · 6:07](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=367)
- "Mobilization adequacy is checked by determining if healthy mucosa can easily reach the skin for anoplasty with no tension" (clinical) [Ep 193 · 7:00](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=420)
- "Not touching the anterior wall prevents any potential injury to the urethra, previously the most feared complication of this operation" (clinical) [Ep 193 · 7:29](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=449)
- "1 to 2 millimeters of fistulous tissue is trimmed on the lateral sides" (clinical) [Ep 193 · 8:28](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=508)
- "The PRAA technique preserves the dentate line in the anal canal" (clinical) [Ep 193 · 8:40](https://library.globalcastmd.com/watch/posterior-rectal-advancement-anoplasty-in-a-male-with-an-anorectal-malformation-and-rectoperineal-fistula-11715?t=520)
- "Full-term newborn baby girl with rectal vestibular fistula weighs 3 kg with completely negative VACTERL workup" — Jamie Harris (clinical) [Ep 194 · 0:37](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=37)
- "Dilations alone is probably not the correct management for rectal vestibular fistula" — Jamie Harris (opinion) [Ep 194 · 0:59](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=59)
- "Recommend only dilating to a 7 Hagar to decrease the potential scarring along the track for future PARPs" — Jamie Harris (clinical) [Ep 194 · 1:06](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=66)
- "If keeping the fistula open, only need to keep it open enough for soft mustardy poop to pass through" — Nelson (clinical) [Ep 194 · 1:12](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=72)
- "One surgeon prefers doing PSARP at one month of age so the baby could grow a little bit bigger" (opinion) [Ep 194 · 1:31](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=91)
- "One surgeon likes getting babies a little bit older and letting them go home before PSARP" (opinion) [Ep 194 · 1:36](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=96)
- "One surgeon likes to get PSARP done on the neonatal admission, not necessarily the next day" — Nelson (opinion) [Ep 194 · 1:45](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=105)
- "It's safe to perform the PSARP either early before discharge or later around 1 to 3 months of age" — Jill Knepprath (clinical) [Ep 194 · 1:49](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=109)
- "Two important studies on PSARP timing both came out in 2021" — Jamie Harris (epidemiological) [Ep 194 · 1:56](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=116)
- "NSQIP study defined early repair as 7 days and delayed repair as between 6 weeks and 8 months" — Jill Knepprath (epidemiological) [Ep 194 · 2:00](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=120)
- "NSQIP study found no difference in overall outcomes including re-operations and readmissions between early and delayed PSARP" — Jill Knepprath (epidemiological) [Ep 194 · 2:07](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=127)
- "Second 2021 study looked at 30-day outcomes comparing neonatal versus delayed anoplasty through PCQLC multi-institutional retrospective study" — Jamie Harris (epidemiological) [Ep 194 · 2:12](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=132)
- "PCQLC study defined early repair as 14 days versus late after 14 days" — Jamie Harris (epidemiological) [Ep 194 · 2:22](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=142)
- "Wound breakdown and dehiscence was the most common complication for both early and delayed repair groups" — Jill Knepprath (epidemiological) [Ep 194 · 2:26](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=146)
- "No significant difference in postoperative complications between early and delayed PSARP groups" — Jill Knepprath (epidemiological) [Ep 194 · 2:33](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=153)
- "There is discrepancy in the literature regarding timing of delayed repair, ranging from a couple of months to multiple months of age" — Jamie Harris (epidemiological) [Ep 194 · 2:40](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=160)
- "Theoretical fibrosis of the fistula tract can make dissection more difficult during PSARP" — Jamie Harris (clinical) [Ep 194 · 2:55](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=175)
- "If not completely decompressing the fistula, the rectum can get distended and make PSARP technically more difficult" — Jamie Harris (clinical) [Ep 194 · 3:00](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=180)
- "Early repair during newborn period avoids an additional admission for the surgery" — Jill Knepprath (clinical) [Ep 194 · 3:07](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=187)
- "Social determinants of health affect families' ability to make multiple trips for care; long distance travel can be expensive" — Jamie Harris (epidemiological) [Ep 194 · 3:14](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=194)
- "Both early and delayed PSARP repairs are safe for patients with rectal vestibular fistulas" — Jill Knepprath (clinical) [Ep 194 · 3:23](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=203)
- "What matters most for timing is the circumstances, family access to care, patient size, and surgeon comfort and experience" — Jill Knepprath (opinion) [Ep 194 · 3:29](https://library.globalcastmd.com/watch/update-course-rewind-2025-timing-of-psarp-early-vs-delayed-does-it-really-matter-11860?t=209)
- "High ligation hernia repair is traditionally a pediatric technique" — Jill Knepprath (clinical) [Ep 196 · 0:00](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=0)
- "The study was published in the International Journal of Surgery" — Jill Knepprath (clinical) [Ep 196 · 0:08](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=8)
- "The study used modified percutaneous internal ring suturing technique for laparoscopic non-mesh repair of indirect inguinal hernias in adults" — Jill Knepprath (clinical) [Ep 196 · 0:12](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=12)
- "The study included 20 patients" — Jill Knepprath (epidemiological) [Ep 196 · 0:23](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=23)
- "The majority of patients were male" — Jill Knepprath (epidemiological) [Ep 196 · 0:25](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=25)
- "No patients had hernia recurrence on follow-up" — Jill Knepprath (clinical) [Ep 196 · 0:26](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=26)
- "Median follow-up duration was 79 months" — Jill Knepprath (epidemiological) [Ep 196 · 0:26](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=26)
- "Patients reported a decrease in pain postoperatively" — Jill Knepprath (clinical) [Ep 196 · 0:31](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=31)
- "Patients reported improved activity postoperatively" — Jill Knepprath (clinical) [Ep 196 · 0:31](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=31)
- "This is a small single-center study" — Jill Knepprath (opinion) [Ep 196 · 0:35](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=35)
- "The study shows success with this technique in adults" — Jill Knepprath (opinion) [Ep 196 · 0:35](https://library.globalcastmd.com/watch/laparoscopic-modified-percutaneous-internal-ring-suturing-a-mesh-free-alternative-for-indirect-inguinal-hernia-repair-in-adults-a-pilot-prospective-cohort-study-11894?t=35)
- "First publications on perineal body-preserving PSARP appeared in 2023" (epidemiological) [Ep 195 · 0:46](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=46)
- "At one year follow-up, perineal body-preserving PSARP demonstrated no dehiscence" (clinical) [Ep 195 · 0:46](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=46)
- "At one year follow-up, perineal body-preserving PSARP demonstrated no prolapse" (clinical) [Ep 195 · 0:46](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=46)
- "Only 13% of patients required revision of anal stricture after perineal body-preserving PSARP" (clinical) [Ep 195 · 0:55](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=55)
- "Two-thirds of patients went home on postoperative day one after perineal body-preserving PSARP" — Jill Knepprath (clinical) [Ep 195 · 1:01](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=61)
- "Perineal body-preserving PSARP technique is the same as what one would do in a bulbar fistula but applied to a vestibular fistula" — Nelson (clinical) [Ep 195 · 1:13](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=73)
- "The technique involves cleaning up the lateral planes before coming around the front" — Nelson (clinical) [Ep 195 · 1:22](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=82)
- "Perineal body-preserving PSARP allows patients to go home earlier postoperatively" (clinical) [Ep 195 · 1:32](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=92)
- "With perineal body-preserving PSARP, surgeons do not need to worry about breakdown in the perineal body" (clinical) [Ep 195 · 1:32](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=92)
- "Perineal body-preserving PSARP is harder than opening it all the way anteriorly" (opinion) [Ep 195 · 1:36](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=96)
- "Conversion to standard PSARP is appropriate if uncertain about location of anterior wall or vagina" (guideline) [Ep 195 · 1:36](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=96)
- "Perineal body-preserving PSARP can be a trickier approach than standard PSARP" — Jill Knepprath (opinion) [Ep 195 · 1:51](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=111)
- "Conversion to standard approach is a valid pivot when in doubt about anatomy" — Jill Knepprath (guideline) [Ep 195 · 2:00](https://library.globalcastmd.com/watch/update-course-rewind-2025-perineal-body-preserving-psarp-the-new-standard-11867?t=120)
- "For decades, every child received anal dilations after PSARP" — Jill Knepprath (clinical) [Ep 197 · 0:21](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=21)
- "Data support parental anxiety associated with anal dilations" (epidemiological) [Ep 197 · 0:30](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=30)
- "PTSD occurs for both patients and caregivers related to anal dilations" (clinical) [Ep 197 · 0:33](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=33)
- "Families are worried that they're going to hurt their babies and hurt the repair" (clinical) [Ep 197 · 0:37](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=37)
- "Spanish study followed historical dilation protocol starting two weeks after PSARP" — Jill Knepprath (clinical) [Ep 197 · 0:40](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=40)
- "Spanish protocol involved dilations twice daily with Hagar size increased by 1 millimeter each week until optimal size reached" — Jill Knepprath (clinical) [Ep 197 · 0:45](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=45)
- "Single institution review in children under 2 years showed half received dilations and half did not" (clinical) [Ep 197 · 0:53](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=53)
- "Two children in each group (dilations vs no dilations) required reoperation for neoanal stricture" (clinical) [Ep 197 · 1:02](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=62)
- "Approximately 15% of children required Heineke-Mikulicz anoplasty" (epidemiological) [Ep 197 · 1:02](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=62)
- "Heineke-Mikulicz anoplasty is a procedure for skin-level strictures in PSARP patients" — Jill Knepprath (clinical) [Ep 197 · 1:12](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=72)
- "HMA is performed by making incisions at 12, 3, 6, and 9 o'clock positions creating a rhomboid shape that opens the strictured area" — Jill Knepprath (clinical) [Ep 197 · 1:20](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=80)
- "HMA does not require flaps or mobilization of the rectum" — Jill Knepprath (clinical) [Ep 197 · 1:30](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=90)
- "HMA is safe, effective, and minimally invasive" — Jill Knepprath (clinical) [Ep 197 · 1:34](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=94)
- "HMA can be done outpatient as an alternative to long-term dilations after PSARP" — Jill Knepprath (clinical) [Ep 197 · 1:38](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=98)
- "Neonates typically receive dilations in one surgeon's practice" (opinion) [Ep 197 · 1:46](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=106)
- "Older children, redo cases, and ambulatory patients may not receive dilations due to trauma concerns" (opinion) [Ep 197 · 1:49](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=109)
- "Neonatal cases usually receive dilations in Canadian practice" (opinion) [Ep 197 · 1:57](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=117)
- "Limited access to schedule elective cases in Canada influences preference to dilate all cases up front" (opinion) [Ep 197 · 2:00](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=120)
- "There isn't strong evidence to support mandatory anal dilation after PSARP" — Jill Knepprath (clinical) [Ep 197 · 2:09](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=129)
- "Anal dilations can cause stress for families" — Jill Knepprath (clinical) [Ep 197 · 2:09](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=129)
- "Age of patient and access to returning for outpatient procedure are considerations when deciding on dilations" — Jill Knepprath (opinion) [Ep 197 · 2:17](https://library.globalcastmd.com/watch/update-course-rewind-2025-do-we-still-need-routine-anal-dilations-after-psarp-11895?t=137)
- "The average American pediatric surgery fellow performs just 15 posterior sagittal anorectoplasties during their entire training" — Paul McClure (epidemiological) [Ep 206 · 0:09](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=9)
- "Recertifying surgeons are averaging only 2 PSARPs per year" — Paul McClure (epidemiological) [Ep 206 · 0:16](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=16)
- "Nearly 30% of recertifying surgeons are doing no PSARPs at all" — Paul McClure (epidemiological) [Ep 206 · 0:16](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=16)
- "Technical precision in PSARP directly impacts continence outcomes" — Paul McClure (clinical) [Ep 206 · 0:23](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=23)
- "The PSARP simulator was developed by a team of researchers at Boston Children's, Cincinnati Children's, and Nationwide Children's Hospitals" — Paul McClure (clinical) [Ep 206 · 0:30](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=30)
- "The simulator validation study was published in the Journal of Pediatric Surgery" — Paul McClure (clinical) [Ep 206 · 0:30](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=30)
- "The simulator replicates the full anatomy of a recto vestibular and ectal malformation, including a fistula, the sphincter complex, vagina, and rectum, with realistic haptics" — Paul McClure (clinical) [Ep 206 · 0:42](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=42)
- "27 surgeons (11 experts and 16 novices) performed a complete PSARP on the model at an international surgery meeting" — Paul McClure (clinical) [Ep 206 · 0:51](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=51)
- "Sessions were independently scored by 3 blinded colorectal surgeons" — Paul McClure (clinical) [Ep 206 · 0:51](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=51)
- "The model demonstrated face, content and discriminate construct validity" — Paul McClure (clinical) [Ep 206 · 1:03](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=63)
- "Participants rated the anatomy and haptics as highly realistic" — Paul McClure (clinical) [Ep 206 · 1:07](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=67)
- "Experienced colorectal surgeons confirmed the simulator's value as a teaching tool" — Paul McClure (opinion) [Ep 206 · 1:11](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=71)
- "The simulator reliably differentiated experts from novices on every single step of the procedure" — Paul McClure (clinical) [Ep 206 · 1:11](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=71)
- "Boston Children's Hospital has integrated the simulator into their fellowship curriculum" — Paul McClure (clinical) [Ep 206 · 1:27](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=87)
- "A male rectal urethral fistula version of the simulator is in development" — Paul McClure (clinical) [Ep 206 · 1:31](https://library.globalcastmd.com/watch/validation-of-an-anorectal-malformation-trainer-can-a-high-fidelity-model-simulate-real-life-12687?t=91)
- "The patient is a newborn weighing 3.2 kg" (clinical) [Ep 27 · 0:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=32)
- "A full-thickness biopsy was obtained approximately 5 centimeters above the transition zone between the distal sigmoid and rectum" (clinical) [Ep 27 · 1:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=65)
- "The key to mesenteric dissection is staying exactly adjacent to the colon wall to prevent injury to surrounding structures" (clinical) [Ep 27 · 1:21](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=81)
- "All heat and energy remains between the jaws of the sealer, preventing danger of injuring surrounding structures" (clinical) [Ep 27 · 1:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=92)
- "There is no risk of pass pointing with the 3 millimeter sealer as with a 3 millimeter hook, which used to be the preferred mode of dissection" (opinion) [Ep 27 · 2:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=165)
- "There is no need to perform instrument changes with the right hand throughout the case when using the sealer" (clinical) [Ep 27 · 2:55](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=175)
- "Carrying dissection down to the pelvic floor limits the amount of transanal dissection necessary and decreases the risk of injury to the external sphincter" (clinical) [Ep 27 · 3:24](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=204)
- "Because there is no energy spread from the tips of the instrument, it is safe for the instrument to be adjacent to the bladder, vagina, prostate, and other surrounding structures" (clinical) [Ep 27 · 3:51](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=231)
- "Energy only between the jaws of the instrument diminishes the risk of injury to the ureters and other vital structures such as the vas deferens" (clinical) [Ep 27 · 4:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=245)
- "When diagnosed, the preference is to perform this operation in the newborn period" (opinion) [Ep 27 · 4:35](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=275)
- "It is acceptable if the child tolerates rectal irrigations to let them grow" (opinion) [Ep 27 · 4:40](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=280)
- "With current technology, the operation is extremely safe in the newborn period, and the preference is to do the pull-through prior to discharge to home" (opinion) [Ep 27 · 4:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=285)
- "The mucosal incision is made 2 to 3 millimeters proximal to the dentate line" (clinical) [Ep 27 · 6:06](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=366)
- "The key to the transanal portion is that it should all take place externally to the anus" (clinical) [Ep 27 · 6:28](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=388)
- "The laparoscopic dissection down to the pelvic floor allows the dissection to be carried out outside of the anus so no retractors are ever placed within the external sphincter which may cause these muscles to be damaged" (clinical) [Ep 27 · 6:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=396)
- "Performing dissection external to the anus protects the external sphincter muscles and improves the chance of good continence" (clinical) [Ep 27 · 7:40](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=460)
- "The biopsy site is 5 to 6 centimeters above the obvious transition zone" (clinical) [Ep 27 · 8:19](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=499)
- "The colon is divided 5 to 6 centimeters above the biopsy site, which is 5 centimeters above the obvious transition zone" (clinical) [Ep 27 · 9:00](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=540)
- "In general, 3 to 4 additional sutures are placed in each quadrant for a total of 12 to 16 sutures forming the new coloanal anastomosis" (clinical) [Ep 27 · 9:30](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=570)
- "This operation took 70 minutes" (clinical) [Ep 27 · 9:57](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=597)
- "The child was left without a nasogastric tube and started stooling the morning following surgery" (clinical) [Ep 27 · 10:00](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=600)
- "The patient was started on feeds that afternoon, less than 24 hours after the procedure" (clinical) [Ep 27 · 10:07](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=607)
- "The anastomosis is calibrated with a 12 Hegar dilator at the end of the procedure" (clinical) [Ep 27 · 10:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=636)
- "A gauze packing is placed in the anus at the end of the procedure" (clinical) [Ep 27 · 10:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=645)
- "The baby is placed transversely on the table with the surgeon standing at the head" (clinical) [Ep 26 · 0:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=5)
- "Three trocars are used: one umbilical for the scope, one 3mm and one 5mm placed in right and left mid-quadrants just below the umbilicus" (clinical) [Ep 26 · 0:10](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=10)
- "The technique uses fine dissection just on the serosa of the bowel wall with individual vessel isolation and sealing" (clinical) [Ep 26 · 0:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=32)
- "This vessel sealing technique is safer than using electrocautery which could spread to surrounding structures causing injury to vas deferens, bladder, ureter, and other structures" (clinical) [Ep 26 · 0:57](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=57)
- "Electrocautery could damage surrounding nerves" (clinical) [Ep 26 · 1:10](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=70)
- "The 3mm sealer allows fine dissection with very limited heat spread" (clinical) [Ep 26 · 1:13](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=73)
- "Using the sealer in the right hand allows the surgeon to dissect with both hands, providing traction with the left and fine dissection with the right" (clinical) [Ep 26 · 1:25](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=85)
- "In this case, the fistula is a high fistula at the level of the bladder neck" (clinical) [Ep 26 · 2:04](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=124)
- "There is no bleeding because each vessel is sealed before being torn" (clinical) [Ep 26 · 2:26](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=146)
- "The most difficult portion of the dissection is always anteriorly where the fistula comes up into the bladder" (clinical) [Ep 26 · 2:49](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=169)
- "In the anterior area, one needs to be very careful to prevent injury to the prostate, seminal vesicles, or vas deferens" (clinical) [Ep 26 · 2:56](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=176)
- "A hitch stitch is placed through the anterior abdominal wall down to the peritoneal reflection to retract the bladder up and expose the anterior rectum" (clinical) [Ep 26 · 3:12](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=192)
- "The anterior dissection can be difficult as tissue planes can be very dense and difficult to differentiate between rectum and surrounding structures" (clinical) [Ep 26 · 3:26](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=206)
- "The colon tapers relatively quickly as it enters down into the bladder neck" (clinical) [Ep 26 · 4:06](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=246)
- "Most fistulas dealt with in this procedure are closer to the level of the prostate rather than at the bladder neck" (clinical) [Ep 26 · 4:19](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=259)
- "The fistula is taken using a 5mm stapler, with the best angle achieved by placing it through the left hand port in this case" (clinical) [Ep 26 · 5:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=305)
- "Whether the left or right hand port is upsized to 5mm for the stapler depends on the particular anatomy of the child" (clinical) [Ep 26 · 5:22](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=322)
- "The fistula is taken almost completely flush with the bladder neck to prevent any residual fistula and eliminate chance of diverticulum" (clinical) [Ep 26 · 5:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=332)
- "In most cases it is not necessary to mobilize the rectosigmoid much above the pelvic reflection" (clinical) [Ep 26 · 6:09](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=369)
- "Staying relatively close to the bowel wall prevents devascularization of the colon and injury to surrounding structures" (clinical) [Ep 26 · 6:26](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=386)
- "The sealing and tearing technique prevents the need for changing to scissors to cut tissue" (clinical) [Ep 26 · 7:00](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=420)
- "The technique prevents the heat spread seen with monopolar hook cautery" (clinical) [Ep 26 · 7:10](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=430)
- "The baby's feet and legs are prepped at the beginning of the procedure and retracted up toward the head to expose the external sphincter area" (clinical) [Ep 26 · 7:29](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=449)
- "The nerve stimulator is used to identify the center of the sphincter, which is marked at just over 1 centimeter" (clinical) [Ep 26 · 7:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=465)
- "The stimulator is used throughout the perineal dissection to ensure staying in the center and not wandering to right or left" (clinical) [Ep 26 · 8:19](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=499)
- "After dissecting through skin and subcutaneous tissue to the sphincter level, blunt dissection is performed in the center of the sphincter to preserve circular fibers" (clinical) [Ep 26 · 8:34](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=514)
- "A Veress needle is inserted through the center of the external sphincter into the center of the pelvic floor under direct visualization" (clinical) [Ep 26 · 8:53](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=533)
- "The tip of the needle should come out from the center of the levator complex well away from the bladder neck" (clinical) [Ep 26 · 9:07](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=547)
- "It is important to visualize the needle tip as it is possible to injure the urethra or bladder if not careful" (clinical) [Ep 26 · 9:14](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=554)
- "A sheath is inserted over the Veress needle and a series of radially expandable trocars are used to go from 5mm up to 10mm to create the anal canal" (clinical) [Ep 26 · 9:24](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=564)
- "A Babcock clamp is passed through the 10mm trocar to grasp the rectum, with no spillage due to the staple line" (clinical) [Ep 26 · 9:51](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=591)
- "Care should be taken to ensure correct orientation of the bowel and that it does not get twisted or the mesentery kinked" (clinical) [Ep 26 · 10:10](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=610)
- "Occasionally there is too much tension and more mobilization needs to be done, which can be achieved relatively easily" (clinical) [Ep 26 · 10:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=645)
- "A series of 4-0 interrupted absorbable sutures are used to create the neo-anus going full thickness through the colon and then through the skin" (clinical) [Ep 26 · 11:35](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=695)
- "Because the patient has a diverting colostomy, it is only necessary to place about 12 to 16 sutures as the anastomosis does not need to be airtight and should not be made ischemic" (clinical) [Ep 26 · 11:53](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=713)
- "Calibration and anal dilations are started at approximately 2 weeks of age and are often only necessary for a few weeks" (clinical) [Ep 26 · 12:57](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=777)
- "Two to three stitches are placed in each quadrant after the four corners are placed" (clinical) [Ep 26 · 13:22](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=802)
- "Once the anastomosis is complete, the anus already retracts somewhat creating a more normal skin line" (clinical) [Ep 26 · 13:59](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=839)
- "Hitch stitches are placed in the colon attaching the distal or mid rectum to the presacral fascia to help prevent prolapse later on" (clinical) [Ep 26 · 14:17](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=857)
- "Usually two stitches, one on each side, is sufficient for presacral fixation" (clinical) [Ep 26 · 14:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-762?t=876)
- "The Hirschsprung-associated IBD study was retrospective, looked at data from 2000 to 2021 at 17 institutions" — Cecilia Gigena (clinical) [Ep 144 · 1:33](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=93)
- "55 patients were included in the Hirschsprung study, 50% had long segment disease" — Cecilia Gigena (clinical) [Ep 144 · 2:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=125)
- "Enterocolitis was reported in 68% of Hirschsprung patients after pull-through" — Cecilia Gigena (clinical) [Ep 144 · 2:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=125)
- "The most common presentation was colonic or small bowel inflammation resembling IBD" — Cecilia Gigena (clinical) [Ep 144 · 2:17](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=137)
- "Three risk factors for Hirschsprung-associated IBD: trisomy 21, history of enterocolitis following surgery, and long segment disease" — Jacob Langer (clinical) [Ep 144 · 2:24](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=144)
- "Biologic therapy is powerful and most likely to be effective for Hirschsprung-associated IBD" — Sonia Butterworth (clinical) [Ep 144 · 2:33](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=153)
- "Hirschsprung-associated IBD is very poorly defined and presents in a number of different ways" — Jacob Langer (clinical) [Ep 144 · 3:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=185)
- "Hirschsprung enterocolitis that persists past age 5 or is unresponsive to typical treatment under age 5 should prompt consideration of this diagnosis" — Sonia Butterworth (clinical) [Ep 144 · 3:18](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=198)
- "The COVID-19 study assessed patients from February 2018 to June 2019 as pre-pandemic control and mid-February 2020 to June 2021 as COVID period" — Em Tombash (epidemiological) [Ep 144 · 4:32](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=272)
- "1100 patients total: 44% in pre-pandemic group, 56% in COVID-19 group" — Em Tombash (epidemiological) [Ep 144 · 4:55](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=295)
- "A larger proportion of complicated appendicitis occurred during COVID-19 compared to pre-pandemic period" — Em Tombash (epidemiological) [Ep 144 · 4:55](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=295)
- "Complicated appendicitis was defined as: perforated appendicitis, clear purulent peritonitis, or small bowel obstruction from appendicitis" — Greta Bercher (clinical) [Ep 144 · 5:18](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=318)
- "Symptom duration at presentation and length of stay were not significantly different between pre-pandemic and COVID groups" — Em Tombash (epidemiological) [Ep 144 · 5:28](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=328)
- "Median symptom duration was 1 day pre-COVID and 2 days during pandemic, though not statistically significant" — Sonia Butterworth (epidemiological) [Ep 144 · 5:55](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=355)
- "There was a clinically significant difference in symptom duration despite lack of statistical significance" — Sonia Butterworth (opinion) [Ep 144 · 6:18](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=378)
- "Increased rate of perforation occurred during pandemic versus pre-pandemic" — Sonia Butterworth (epidemiological) [Ep 144 · 6:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=416)
- "Patients during pandemic stayed in hospital longer and had increased risks of complications" — Sonia Butterworth (epidemiological) [Ep 144 · 7:03](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=423)
- "Ontario government made it mandatory that all patients below 18 years of age had to be treated at a pediatric hospital during pandemic" — Greta Bercher (guideline) [Ep 144 · 7:08](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=428)
- "The button battery study evaluated if implementation of a clinical algorithm shortened time from diagnosis to removal" — Cecilia Gigena (clinical) [Ep 144 · 7:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=474)
- "The algorithm was based on the national database algorithm and implemented in October 2019" — Cecilia Gigena (clinical) [Ep 144 · 8:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=489)
- "The institution already had a CART (critical airway response team) that activated all stakeholders except gastroenterology" — Katerina Dukleska (clinical) [Ep 144 · 8:20](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=500)
- "Time from chest X-ray to button battery removal was shortened from 73 to 35 minutes after implementing the protocol" — Cecilia Gigena (clinical) [Ep 144 · 8:45](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=525)
- "Even 73 minutes was a very impressive target before protocol implementation" — Sonia Butterworth (opinion) [Ep 144 · 9:10](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=550)
- "Button battery ingestions are not common events" — Katerina Dukleska (epidemiological) [Ep 144 · 9:45](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=585)
- "Anticipated decrease in major complications for button battery patients with faster removal times" — Katerina Dukleska (opinion) [Ep 144 · 9:45](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=585)
- "A 2021 prospective randomized controlled trial from Nationwide Children's Hospital compared dilated vs non-dilated groups after primary PSARP in patients under 2 years old with 12-month follow-up" — Caitlin Smith (clinical) [Ep 145 · 3:17](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=197)
- "Stricture rates were 3/25 in the dilated group and 8/25 in the non-dilated group, but only 3 patients in the non-dilated group required a separate anesthetic for strictureplasty" — Caitlin Smith (clinical) [Ep 145 · 4:20](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=260)
- "Strictureplasty is appropriate only for skin-level strictures, not for longer or deeper strictures which require redo operations" — Caitlin Smith (clinical) [Ep 145 · 5:31](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=331)
- "Strictureplasty for skin-level stricture takes approximately 20 minutes, patients can usually go home same day, and no dilations are performed after the procedure" — Julia Groski (clinical) [Ep 145 · 6:29](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=389)
- "Babies under 6 months generally tolerate dilations well, but patients over 6-12 months often have unsuccessful dilations and may develop strictures anyway" — Caitlin Smith (clinical) [Ep 145 · 7:02](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=422)
- "A prospective observational trial through the Pediatric Colorectal and Pelvic Learning Consortium will begin in the next few months to follow patients and describe findings regarding dilation practices" — Caitlin Smith (guideline) [Ep 145 · 8:23](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=503)
- "Strictures can develop in both dilated and non-dilated groups due to tension, ischemia, or reaction between epidermis and mucosa creating a band at the suture anastomosis" — Caitlin Smith (clinical) [Ep 145 · 10:44](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=644)
- "Keith Jorgeson taught that if you don't dilate at 2 weeks in the office, you're going to be hosed for a stricture" — Julia Groski (opinion) [Ep 145 · 12:10](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=730)
- "In resource-limited settings where patients cannot afford to return for additional surgery, routine dilations may be more appropriate to prevent strictures requiring reoperation" (opinion) [Ep 145 · 12:38](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=758)
- "The standard Botox technique is 100 units in 1 mL saline, injected in 3-4 aliquots at the dentate line, avoiding anterior injection to protect the genitourinary tract" — Julia Groski (clinical) [Ep 145 · 16:42](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1002)
- "Many pharmacies will indicate that 100 units of Botox is above weight-based dosing for pediatric patients, but this dose has been shown to be safe" — Caitlin Smith (clinical) [Ep 145 · 17:29](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1049)
- "Every baby with Hirschsprung disease has a poorly functioning sphincter by nature of the disease" — Julia Groski (clinical) [Ep 145 · 19:18](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1158)
- "Babies with Hirschsprung disease generally outgrow enterocolitis as their external sphincter matures and overcomes the internal sphincter, assuming no mechanical obstruction and complete resection of aganglionic bowel" — Julia Groski (clinical) [Ep 145 · 19:27](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1167)
- "All Hirschsprung physiology sets up the colon to act like a pond with poor emptying and motility issues, allowing bacterial overgrowth if the colon is not cleared diligently" — Caitlin Smith (clinical) [Ep 145 · 20:11](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1211)
- "There is a significantly higher rate of enterocolitis in total colon Hirschsprung disease after pull-through compared to shorter segment disease" — Julia Groski (epidemiological) [Ep 145 · 21:09](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1269)
- "Children with trisomy 21 have a much higher rate of enterocolitis after Hirschsprung pull-through without a well-understood explanation" — Julia Groski (epidemiological) [Ep 145 · 21:26](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1286)
- "Enterocolitis in a diverted colon is theoretically possible with a tight stoma that doesn't empty well, though rarely seen in practice" — Julia Groski (clinical) [Ep 145 · 22:33](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1353)
- "There is discussion of whether colectomy should be performed at the time of total colon Hirschsprung diagnosis due to enterocolitis risk, but waiting for final pathology is recommended to avoid unnecessary colectomy" — Julia Groski (opinion) [Ep 145 · 22:55](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1375)
- "Prophylactic Botox has not been shown to decrease the risk of enterocolitis in Hirschsprung patients" — Julia Groski (clinical) [Ep 145 · 24:01](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1441)
- "Botox has been shown to decrease length of stay in patients admitted for enterocolitis and potentially decrease hospitalizations in patients with recurrent obstruction or enterocolitis" — Julia Groski (clinical) [Ep 145 · 24:25](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1465)
- "Two variations of perineal body-sparing PSARP have been published in the last 6 months, one from Boston and one from DC, with slightly different techniques" — Caitlin Smith (clinical) [Ep 145 · 25:48](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1548)
- "The perineal body is important for sexual function and obstetric outcomes in female patients" — Caitlin Smith (clinical) [Ep 145 · 26:22](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1582)
- "Perineal body-sparing techniques reduce the risk of postoperative infection in patients undergoing dilations who are not diverted, as the perineal body seeing stool immediately is a setup for infection" — Julia Groski (clinical) [Ep 145 · 27:12](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1632)
- "The environment in which a surgeon operates, not the individual surgeon, is the determining factor of patient outcome in complex anorectal malformations" (opinion) [Ep 28 · 0:15](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=15)
- "Most hospitals do not have collaborative teams for complex pediatric cases" (opinion) [Ep 28 · 0:31](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=31)
- "Effective collaborative teams start with 2-3 completely dedicated practitioners and build resources incrementally" — Jason (opinion) [Ep 28 · 0:53](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=53)
- "The team coordinates Wednesdays at 9 a.m. for one hour to discuss patients" — Jason (clinical) [Ep 28 · 1:58](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=118)
- "The program added a physical therapist and behavioral medicine team in the current year" — Jason (clinical) [Ep 28 · 3:18](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=198)
- "International adoption records are not always specific and sometimes not truthful" — Ramesky (opinion) [Ep 28 · 4:20](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=260)
- "The diagnostic approach for cloaca is: if there's a hole, put a catheter or camera in it and fill it with contrast" — Ramesky (clinical) [Ep 28 · 5:31](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=331)
- "In this case, the common channel measured 2.3 centimeters by cloacogram study" — Ramesky (clinical) [Ep 28 · 6:49](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=409)
- "The patient had two vaginas and two cervices identified during vaginoscopy" — Ramesky (clinical) [Ep 28 · 6:57](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=417)
- "Vaginal length was approximately 4 centimeters after subtracting the common channel" — Ramesky (clinical) [Ep 28 · 7:02](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=422)
- "Hydrocolpos was not expected at this age in a patient in good health with a relatively short common channel" — Ramesky (clinical) [Ep 28 · 7:22](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=442)
- "When the vagina is filled with fluid/urine, it can prohibit urine emptying and put pressure on the ureters" — Leslie (clinical) [Ep 28 · 8:35](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=515)
- "Draining the vagina is primarily for kidney health and enabling urine release, not for the vagina's sake" — Leslie (clinical) [Ep 28 · 8:41](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=521)
- "Children with cloaca often have two hemivaginas, so it is important to drain both adequately" — Leslie (clinical) [Ep 28 · 9:53](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=593)
- "Creating a vesicostomy will impair any surgery down the road and must be taken down to facilitate tension-free mobilization of pelvic organs" — Reddy (clinical) [Ep 28 · 11:39](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=699)
- "After any drainage procedure, clinicians must verify the system is working by checking with ultrasound that the intended structure is being drained" — Jason (clinical) [Ep 28 · 12:00](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=720)
- "Ultrasound is a powerful tool with no radiation, widely available, and easily applicable to pelvis, bladder, vagina, and kidneys" — Reddy (clinical) [Ep 28 · 12:54](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=774)
- "75% of the audience would approach a 2.5-centimeter common channel cloaca with posterior sagittal and total urogenital mobilization" — Ramesky (epidemiological) [Ep 28 · 13:06](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=786)
- "Sometimes the distal rectal segment left on the mucous fistula side is too short and the mucous fistula must be closed to complete the pull-through" — Ramesky (clinical) [Ep 28 · 13:55](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=835)
- "At case completion, number 8 Hegar dilator fit the vagina and number 14 Hegar fit the rectum" — Ramesky (clinical) [Ep 28 · 14:08](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=848)
- "Most of the vaginal septum was resected, leaving a small amount close to the two cervices" — Ramesky (clinical) [Ep 28 · 15:32](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=932)
- "At Cincinnati Children's, test menstruation is performed to ensure both sides of a duplicated system are patent" — Leslie (clinical) [Ep 28 · 15:56](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=956)
- "Serial ultrasounds are used until about 6 months after onset of periods to monitor for obstruction" — Leslie (clinical) [Ep 28 · 16:16](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=976)
- "At 6 months post-op, the patient had no stricture, colostomy was closed, and she was starting potty training" — Ramesky (clinical) [Ep 28 · 16:27](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=987)
- "The patient has a normal sacrum, no tethered cord, and a relatively short common channel, making stool continence likely" — Ramesky (clinical) [Ep 28 · 17:04](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1024)
- "Native vagina is always preferred when possible because it is hormonally responsive and has proven durability" — Leslie (clinical) [Ep 28 · 18:23](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1103)
- "Rectum is considered for vaginal replacement in cases with poor prognosis for bowel control: tethered cord, poor sacrum, or multiple surgeries" — Leslie (clinical) [Ep 28 · 18:46](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1126)
- "Colon is the tissue of choice for vaginal replacement at this center and has been durable for future vaginal use" — Leslie (clinical) [Ep 28 · 19:18](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1158)
- "Any patient with vaginal replacement requires cesarean section for delivery" — Leslie (clinical) [Ep 28 · 19:27](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1167)
- "Small bowel has blood supply and pedicle limitations for reaching the pelvis but is used when all colon must be preserved" — Leslie (clinical) [Ep 28 · 19:44](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1184)
- "Buccal mucosa graft acts more like vagina than colon segments and is being used more commonly" — Leslie (clinical) [Ep 28 · 20:02](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1202)
- "Buccal graft patients are typically pubertal, hospitalized for about one week with minimal mobilization, and have a vaginal stent while the graft takes" — Leslie (clinical) [Ep 28 · 20:13](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1213)
- "Buccal grafts have been used for augmentation vaginoplasty in patients with strictures" — Leslie (clinical) [Ep 28 · 20:27](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1227)
- "Short common channel with normal spinal cord can typically be managed with urethral catheter, with family taught intermittent catheterization if needed" — Reddy (clinical) [Ep 28 · 21:29](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1289)
- "Longer common channels warrant suprapubic catheter to allow urethral stenting, catheter removal, and SP tube clamping trials to assess emptying" — Reddy (clinical) [Ep 28 · 22:40](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1360)
- "Incomplete bladder emptying causes muscle overstretching where cross-bridges no longer connect and the bladder cannot contract" — Reddy (clinical) [Ep 28 · 22:56](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1376)
- "In overtly neurogenic bladder where safe voiding is impossible, temporary vesicostomy protects upper tracts and prevents blind catheterization attempts into the reconstructed urethra" — Reddy (clinical) [Ep 28 · 23:22](https://library.globalcastmd.com/watch/collaborative-work-complex-pediatric-anorectal-malformations-2017-924?t=1402)
- "The most common prenatal ultrasound finding in cloaca is a pelvic mass, often initially thought to be the bladder but actually representing a dilated vagina (hydrocolpos)" — Marc Levitt (clinical) [Ep 32 · 2:38](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=158)
- "Fetal intervention for cloaca is unlikely to be necessary; there is almost never a situation requiring fetal intervention" — Marc Levitt (clinical) [Ep 32 · 3:56](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=236)
- "In cloaca, there is one perineal hole in the area just below the clitoris and no anus" — Marc Levitt (clinical) [Ep 32 · 6:35](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=395)
- "A single hole underneath the clitoris with a completely normal anus is not a cloaca but a urogenital sinus" — Marc Levitt (clinical) [Ep 32 · 6:57](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=417)
- "Cloaca is not ambiguous genitalia, not adrenal hyperplasia, and the baby is a normal female with two normal ovaries who will be hormonally normal" — Marc Levitt (clinical) [Ep 32 · 7:25](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=445)
- "Many patients considered cloacas actually have three holes (vestibular fistula) when examined properly with good lighting and labial retraction" — Marc Levitt (clinical) [Ep 32 · 9:03](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=543)
- "The hydronephrosis in cloaca is usually caused by the hydrocolpos pressing forward on the trigone and compressing the distal ureters, not by bladder obstruction" — Marc Levitt (clinical) [Ep 32 · 15:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=915)
- "Draining the hydrocolpos relieves pressure on the ureteral orifices, allowing them to drain into the bladder; vesicostomy does not resolve the hydronephrosis" — Marc Levitt (clinical) [Ep 32 · 15:40](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=940)
- "Vesicostomy is only indicated if the bladder still does not drain after successful hydrocolpos drainage, which is exceedingly rare" — Marc Levitt (clinical) [Ep 32 · 16:15](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=975)
- "The exception for vesicostomy is massive bilateral ureteral reflux, where vesicostomy is a safe way to decompress the system" — Marc Levitt (clinical) [Ep 32 · 17:54](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1074)
- "Hydrocolpos forms because the bladder preferentially fills the vagina through the fistula rather than exiting the common channel, combined with vaginal mucus and maternal estrogen effect" — Marc Levitt (clinical) [Ep 32 · 18:24](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1104)
- "Cystoscopy in the newborn period is not advantageous; the scope is tiny, visualization is poor, and the perineum is swollen" — Marc Levitt (opinion) [Ep 32 · 20:29](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1229)
- "For massive hydrocolpos above the umbilicus, a tubeless vaginostomy can be created by suturing the vagina to the abdominal wall like a G-tube" — Marc Levitt (clinical) [Ep 32 · 21:22](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1282)
- "Urogenital sinus patients need workup for adrenal problems and electrolyte abnormalities if there is virilization" — Marc Levitt (clinical) [Ep 32 · 22:28](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1348)
- "Cloaca repair timing: colostomy at birth, endoscopy and cloacagram at 2-3 months, definitive repair within one year, ideally by 6 months" — Marc Levitt (guideline) [Ep 32 · 23:57](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1437)
- "The length of the urethra (from urethral takeoff to bladder neck) is a critical measurement not mentioned in traditional papers but determines which operation to perform" — Marc Levitt (clinical) [Ep 32 · 25:41](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1541)
- "Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with the healthy rectum in the abdomen; contrast study is needed" — Marc Levitt (clinical) [Ep 32 · 26:21](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1581)
- "3D cloacagram reconstruction is better than 2D, and printed 3D models where you can hold the anatomy in your hand may be even more valuable" — Marc Levitt (clinical) [Ep 32 · 28:34](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1714)
- "Cloaca patients benefit from collaborative approach with urology and gynecology; the days of a single surgeon handling this complexity are over" — Marc Levitt (opinion) [Ep 32 · 30:29](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1829)
- "Urogenital mobilization is appropriate when common channel is ≤3 cm and urethra above the takeoff is at least 1.5-2 cm" — Marc Levitt (clinical) [Ep 32 · 33:39](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2019)
- "If urethral length is inadequate, the common channel should be left alone to become the urethra, and the vagina must be separated from it" — Marc Levitt (clinical) [Ep 32 · 34:34](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2074)
- "If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery, which often fails and can result in urethral loss from devascularization" — Marc Levitt (clinical) [Ep 32 · 35:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2117)
- "Leaving a patient with inadequate urethral length after urogenital mobilization results in leakage that cannot be controlled without tightening or closing the bladder neck" — Marc Levitt (clinical) [Ep 32 · 35:52](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2152)
- "For type 1 cloaca (1 cm common channel with adequate urethral length), only vaginal mobilization is needed and a slightly hypospadiac urethra is acceptable if the patient will void" — Marc Levitt (clinical) [Ep 32 · 36:33](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2193)
- "When native vagina does not reach after full mobilization, options include vaginal switch or vaginal replacement with colon (preferred), rectum, or small bowel" — Marc Levitt (clinical) [Ep 32 · 38:00](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2280)
- "Tissue engineering of vaginas using patient stem cells is on the horizon and would revolutionize cloaca care by eliminating the need for vaginal replacement" — Marc Levitt (opinion) [Ep 32 · 39:17](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2357)
- "The most common problem in redo cloaca is that the surgeon never realized they were dealing with a cloaca and only fixed the rectum, leaving the urogenital sinus untouched" — Marc Levitt (clinical) [Ep 32 · 40:27](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2427)
- "The second most common redo problem is inadequate mobilization of structures leaving the patient with a stenosed or lost vagina" — Marc Levitt (clinical) [Ep 32 · 40:56](https://library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2456)
- "A systematic review was conducted in the UK to establish and categorize challenges and solutions related to transitional care in colorectal patients" — Cecilia Gigena (epidemiological) [Ep 161 · 0:10](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940?t=10)
- "The systematic review included 234 studies" — Cecilia Gigena (epidemiological) [Ep 161 · 0:23](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940?t=23)
- "The first challenge identified was patients' lack of understanding of their own pathology" — Cecilia Gigena (clinical) [Ep 161 · 0:28](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940?t=28)
- "The second challenge was the lack of education and awareness of adult surgeons about pediatric colorectal pathologies" — Cecilia Gigena (clinical) [Ep 161 · 0:34](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940?t=34)
- "The third challenge was the lack of an instructional transitional care program" — Cecilia Gigena (clinical) [Ep 161 · 0:44](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940?t=44)
- "The first proposed solution was to foster young adult patients' autonomy" — Cecilia Gigena (guideline) [Ep 161 · 0:46](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940?t=46)
- "The second proposed solution was to conduct joint pediatric adult transitional clinics" — Cecilia Gigena (guideline) [Ep 161 · 0:46](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940?t=46)
- "The third proposed solution was to create a structured and coordinated transition program" — Cecilia Gigena (guideline) [Ep 161 · 0:46](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940?t=46)
- "There are systematic barriers to establishing transition care for patients with anorectal malformations and Hirschsprung disease" (clinical) [Ep 162 · 0:06](https://library.globalcastmd.com/watch/cuidado-de-transici-n-en-malformaci-n-anorrectal-y-enfermedad-de-hirschsprung-8946?t=6)
- "Patients and families lack education and knowledge about colorectal conditions" (clinical) [Ep 162 · 0:30](https://library.globalcastmd.com/watch/cuidado-de-transici-n-en-malformaci-n-anorrectal-y-enfermedad-de-hirschsprung-8946?t=30)
- "There is a lack of transition protocols between pediatric and adult care services" (clinical) [Ep 162 · 0:30](https://library.globalcastmd.com/watch/cuidado-de-transici-n-en-malformaci-n-anorrectal-y-enfermedad-de-hirschsprung-8946?t=30)
- "There is a shortage of adult colorectal clinicians trained to manage transition care for patients with congenital colorectal conditions" (clinical) [Ep 162 · 0:47](https://library.globalcastmd.com/watch/cuidado-de-transici-n-en-malformaci-n-anorrectal-y-enfermedad-de-hirschsprung-8946?t=47)
- "Five error traps have been identified in the management of anorectal malformations" — Andrea Bischoff (clinical) [Ep 68 · 0:31](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=31)
- "The first error trap is creation of a colostomy too distal in the sigmoid colon" — Andrea Bischoff (clinical) [Ep 68 · 0:34](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=34)
- "The recommendation is for a colostomy at the descending colon" — Andrea Bischoff (guideline) [Ep 68 · 0:40](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=40)
- "The second error trap is having an inaccurate distal colostogram" — Andrea Bischoff (clinical) [Ep 68 · 0:45](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=45)
- "A correctly done distal colostogram should show the site of the mucous fistula" — Andrea Bischoff (guideline) [Ep 68 · 0:51](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=51)
- "A correctly done distal colostogram should show the amount of bowel length available for the pull-through" — Andrea Bischoff (guideline) [Ep 68 · 0:51](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=51)
- "A correctly done distal colostogram should show the end of the rectum or the connection to the urinary tract" — Andrea Bischoff (guideline) [Ep 68 · 0:51](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=51)
- "A correctly done distal colostogram should show, whenever possible, the bladder and the urethra" — Andrea Bischoff (guideline) [Ep 68 · 1:07](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=67)
- "A correctly done distal colostogram should show the tip of the sacrum and the anal marker" — Andrea Bischoff (guideline) [Ep 68 · 1:07](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=67)
- "The third error trap is operating on a male patient without a Foley catheter" — Andrea Bischoff (clinical) [Ep 68 · 1:16](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=76)
- "The third error trap includes ignoring the hazards of the separation between the anterior rectal wall and the genitourinary tract" — Andrea Bischoff (clinical) [Ep 68 · 1:16](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=76)
- "The fourth error trap is attempting to dilate a true rectal stricture" — Andrea Bischoff (clinical) [Ep 68 · 1:32](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=92)
- "Anal dilations are not for real strictures" — Andrea Bischoff (guideline) [Ep 68 · 1:39](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=99)
- "The fifth error trap is not offering long-term follow-up to these patients" — Andrea Bischoff (clinical) [Ep 68 · 1:39](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=99)
- "Patients with anorectal malformations need long-term follow-up in colorectal, urology, and gynecology" — Andrea Bischoff (guideline) [Ep 68 · 1:49](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=109)
- "By avoiding these common error traps, patients will receive better care" — Andrea Bischoff (opinion) [Ep 68 · 1:56](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-anorectal-malformations-1683?t=116)
- "85% of Hirschsprung disease patients in the study were diagnosed at less than 1 year of age" — Em Gootee (epidemiological) [Ep 167 · 3:20](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=200)
- "Kids with shorter segment Hirschsprung disease (rectosigmoid or small portion of aganglionic bowel) were more likely to be diagnosed at a later age" — Em Gootee (clinical) [Ep 167 · 3:45](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=225)
- "Children with long segment Hirschsprung disease typically presented at birth with classic symptoms such as failure to pass meconium" — Em Gootee (clinical) [Ep 167 · 3:57](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=237)
- "Delayed diagnosis of Hirschsprung disease does not impact postoperative outcomes nor the need for revision surgery of the pull-through" — Colin Martin (clinical) [Ep 167 · 4:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=252)
- "Delayed diagnosis is associated with increased need for fecal diversion after pull-through" — Colin Martin (clinical) [Ep 167 · 4:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=252)
- "Approximately one-third of neonates and 50% of infants, toddlers, and children had diverting ostomies performed prior to pull-through" — Em Gootee (epidemiological) [Ep 167 · 4:26](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=266)
- "There was no difference in overall rates of redo pull-throughs across age groups" — Em Gootee (clinical) [Ep 167 · 5:01](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=301)
- "Older children were more likely to need a redo pull-through due to an anastomotic leak" — Em Gootee (clinical) [Ep 167 · 5:07](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=307)
- "Higher rates of diverting ostomy post pull-through were likely a treatment for a post pull-through leak or anastomotic leak" — Em Gootee (clinical) [Ep 167 · 5:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=313)
- "The only functional outcome that was different was nighttime soiling or incontinence in the older patient population" — Em Gootee (clinical) [Ep 167 · 5:24](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=324)
- "Neonates with gastroschisis consume a disproportionate amount of resources compared to other children in the NICU" — Mark Slidell (epidemiological) [Ep 167 · 7:43](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=463)
- "The gastroschisis systematic review included 28 high quality manuscripts" — Em Gootee (clinical) [Ep 167 · 8:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=489)
- "Two randomized controlled trials on gastroschisis had been started but both ended prematurely and were underpowered" — Em Gootee (clinical) [Ep 167 · 8:15](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=495)
- "There is no evidence to suggest that earlier delivery prior to 37 weeks for gastroschisis is justified" — Casey Culkins (clinical) [Ep 167 · 9:39](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=579)
- "Planned delivery before 37 weeks gestational age for gastroschisis is probably not beneficial and may in fact be harmful" — Mark Slidell (clinical) [Ep 167 · 9:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=596)
- "Early delivery may promote some of the complications of prematurity" — Mark Slidell (clinical) [Ep 167 · 10:04](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=604)
- "Delivery of infants with gastroschisis after 37 weeks post-conception seems to be preferable" — Mark Slidell (clinical) [Ep 167 · 10:04](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=604)
- "Skin organisms are most commonly identified in infections among infants with gastroschisis" — Em Gootee (clinical) [Ep 167 · 10:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=637)
- "Gastroschisis infants have a fairly high rate of wound infection" — Em Gootee (epidemiological) [Ep 167 · 10:44](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=644)
- "Silo closures have a higher rate of infection than other closure methods" — Em Gootee (clinical) [Ep 167 · 10:50](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=650)
- "Sutureless closure has the lowest rate of infection in gastroschisis" — Em Gootee (clinical) [Ep 167 · 10:50](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=650)
- "Recommendation is to provide antibiotic coverage for skin flora until the gastroschisis defect is closed and potentially for an additional 24 hours thereafter" — Em Gootee (guideline) [Ep 167 · 10:57](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=657)
- "Once the gastroschisis defect is closed, antibiotics can be safely stopped unless there is some other reason to continue" — Casey Culkins (guideline) [Ep 167 · 11:11](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=671)
- "Stable gastroschisis infants with sufficient abdominal capacity for sutureless closure tend to have the best outcomes" — Em Gootee (clinical) [Ep 167 · 12:22](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=742)
- "Minimizing fluids and paralytics in gastroschisis infants improves their results" — Em Gootee (clinical) [Ep 167 · 12:29](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=749)
- "Sutureless repair for gastroschisis is associated with a clear decrease in the need for mechanical ventilation" — Casey Culkins (clinical) [Ep 167 · 13:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=785)
- "The literature on gastroschisis suffers from a lack of level 1 randomized controlled trials or high level comparative studies" — Mark Slidell (opinion) [Ep 167 · 13:17](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=797)
- "The Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification" — Whit Holcomb (clinical) [Ep 167 · 16:39](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=999)
- "The Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification" — Whit Holcomb (clinical) [Ep 167 · 16:53](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=1013)
- "43% of pediatric surgeons preferred the Clavien-Madadi classification compared to 12% for the Clavien-Dindo classification" — Em Gootee (epidemiological) [Ep 167 · 17:04](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=1024)
- "Advantages of the Clavien-Madadi classification were affirmed by nearly 82% of the surgeons" — Em Gootee (epidemiological) [Ep 167 · 17:16](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=1036)
- "The study was prospective and took place from 2021 to 2023" — Lizzie Lee (clinical) [Ep 168 · 0:13](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=13)
- "The study included 33 patients under six months old who underwent endorectal pull-through surgeries" — Lizzie Lee (clinical) [Ep 168 · 0:13](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=13)
- "Patients were assigned to either a new non-dilation protocol group or a traditional dilation group" — Lizzie Lee (clinical) [Ep 168 · 0:24](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=24)
- "The primary outcomes measured were anastomotic complications, enterocolitis, and constipation" — Lizzie Lee (clinical) [Ep 168 · 0:30](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=30)
- "There was no significant difference in anastomotic complications between the two groups" — Lizzie Lee (clinical) [Ep 168 · 0:37](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=37)
- "The non-dilation group had less enterocolitis compared to the traditional dilation group" — Lizzie Lee (clinical) [Ep 168 · 0:37](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=37)
- "The non-dilation group had less constipation compared to the traditional dilation group" — Lizzie Lee (clinical) [Ep 168 · 0:37](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=37)
- "Choosing not to do postoperative anal dilations may be a good alternative with benefits like lower constipation and enterocolitis" — Lizzie Lee (opinion) [Ep 168 · 0:46](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=46)
- "Approximately one-third of Hirschsprung patients are constipated post-operatively and need proactive, aggressive management to avoid trouble" — Marc Levitt (epidemiological) [Ep 169 · 1:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=107)
- "Hirschsprung disease is a very anatomically fixable problem and with a good operation you should get a good result" — Marc Levitt (clinical) [Ep 169 · 1:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=98)
- "Surgeons might leave behind the dilated segment right above the aganglionic segment as an anatomic reason for decompensation" — Marc Levitt (clinical) [Ep 169 · 2:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=131)
- "The most relevant reason for decompensation is that the patient never figured out how to successfully empty their sphincters and the pull-through decompensates" — Marc Levitt (clinical) [Ep 169 · 2:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=142)
- "Calretinin hangs out with ganglion cells, so normal calretinin staining provides double evidence of good ganglion cells" — Marc Levitt (clinical) [Ep 169 · 3:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=194)
- "In younger children age less than 3 or so, hypertrophic nerves are defined as greater than 40 microns in diameter" — Jason Frischer (clinical) [Ep 169 · 3:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=227)
- "The definition of hypertrophic nerve is more gray in older patients and in patients who have chronic constipation issues" — Jason Frischer (clinical) [Ep 169 · 4:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=241)
- "If there are no ganglion cells and no calretinin staining, that is a retained Hirschsprung and the patient needs a redo to a higher level" — Marc Levitt (clinical) [Ep 169 · 4:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=267)
- "Nerve hypertrophy with good ganglion cells could represent transition zone or could represent that the bowel has decompensated over time because it hasn't emptied and gotten dilated" — Marc Levitt (clinical) [Ep 169 · 4:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=278)
- "An absent rectal anal inhibitory reflex means the internal anal sphincter doesn't relax when the rectum is distended, which can contribute to constipation" — Felipe Glu (clinical) [Ep 169 · 6:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=395)
- "Many patients are going to have an abnormal anorectal manometry but they're OK" — Marc Levitt (clinical) [Ep 169 · 6:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=407)
- "Botox helps patients learn to overcome non-relaxing sphincters by other maneuvers like pushing on their abdominal wall" — Marc Levitt (clinical) [Ep 169 · 6:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=416)
- "Many patients are completely asymptomatic doing great with Hirschsprung's that have residual absent rectal anal inhibitory reflex" — Marc Levitt (clinical) [Ep 169 · 7:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=431)
- "In Hirschsprung patients with constipation, the colon is not the problem; the problem usually is the sphincters or the pelvic floor" — Marc Levitt (clinical) [Ep 169 · 7:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=459)
- "If you get an awake anorectal manometry in a cooperative patient with a normal rectal anal inhibitory reflex and can detect the resting pressure, the evaluation is complete without anesthesia or procedure" — Marc Levitt (clinical) [Ep 169 · 8:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=494)
- "If the rectal anal inhibitory reflex is absent, you're obligated to do a biopsy and give Botox" — Marc Levitt (guideline) [Ep 169 · 8:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=509)
- "Botox is given if the resting pressure of the external sphincter is also high" — Marc Levitt (clinical) [Ep 169 · 8:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=516)
- "Pelvic floor dysynergia can be detected on anorectal manometry and is a good indication that pelvic floor physical therapy will help the patient" — Marc Levitt (clinical) [Ep 169 · 8:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=521)
- "Colonic manometry should not be done in Hirschsprung patients with obstructive symptoms because it's not the colon but the distal pull-through that's the problem" — Marc Levitt (guideline) [Ep 169 · 9:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=595)
- "Anatomic and pathologic causes must be ruled out before any colonic manometry is considered" — Marc Levitt (guideline) [Ep 169 · 10:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=611)
- "Colonic manometry in a patient with a distal obstruction is the wrong test" — Marc Levitt (guideline) [Ep 169 · 10:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=618)
- "Once distal obstruction is ruled out or fixed and the colon is still not working, then you have a problem warranting colonic manometry" — Jason Frischer (clinical) [Ep 169 · 10:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=627)
- "If there's a segment less than 30 centimeters of inadequate high amplitude propagating contractions, the approach is not super aggressive; over 30 centimeters is definitely more of a red flag" — Jason Frischer (clinical) [Ep 169 · 11:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=661)
- "High amplitude propagating contractions aid in the transfer of colonic contents over long distance and often precede emptying" — Felipe Glu (clinical) [Ep 169 · 11:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=677)
- "In a PCPLC Consortium study of close to 100 patients with functional constipation and segmental dysmotility of the sigmoid, 97% successfully responded to Malone only without needing resection" — Marc Levitt (epidemiological) [Ep 169 · 11:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=714)
- "Five years ago, surgeons were taking sigmoids out of patients with segmental dysmotility, but this practice has changed based on new data" — Marc Levitt (clinical) [Ep 169 · 12:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=748)
- "A Malone procedure is a route for medical treatment, providing antegrade access to the colon for gastroenterologists to give better medical treatment" — Marc Levitt (clinical) [Ep 169 · 13:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=804)
- "While surgery can correct the underlying anatomical problem in Hirschsprung disease, many other factors can contribute to constipation including motility disorders, pelvic floor dysfunction, and behavioral issues" — Felipe Glu (clinical) [Ep 169 · 14:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=855)
- "Patients with anorectal malformations and Hirschsprung's disease need transfer from pediatric to adult providers to manage their colorectal conditions" — Alex Halpern (clinical) [Ep 163 · 0:00](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114?t=0)
- "A team from Melbourne, Australia performed a systematic review and meta-analysis on transition of care for these conditions" — Alex Halpern (epidemiological) [Ep 163 · 0:22](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114?t=22)
- "Eight studies were found on the topic of transition care for anorectal malformations and Hirschsprung's disease" — Alex Halpern (epidemiological) [Ep 163 · 0:28](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114?t=28)
- "Studies agreed that transitional care should start early in adolescence" — Alex Halpern (guideline) [Ep 163 · 0:30](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114?t=30)
- "Little evidence exists that transfer from pediatric to adult care is happening in a coordinated or timely fashion" — Alex Halpern (epidemiological) [Ep 163 · 0:30](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114?t=30)
- "No models of transition care were identified in the systematic review" — Alex Halpern (epidemiological) [Ep 163 · 0:40](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114?t=40)
- "More work is needed to ensure children with anorectal malformations and Hirschsprung's disease continue to receive optimal care as they grow older" — Alex Halpern (opinion) [Ep 163 · 0:43](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114?t=43)
- "MMP-7 (matrix metalloproteinase 7) are proteolytic peptidases that break down peptide bonds for amino acids and are part of tissue remodeling processes" — Em Gootee (clinical) [Ep 164 · 1:25](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=85)
- "MMP-7 plays an important role in tissue repair, arthritis, metastasis, and cirrhosis" — Em Gootee (clinical) [Ep 164 · 1:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=97)
- "Higher levels of MMP-7 are associated with the diagnosis of biliary atresia" — Em Gootee (clinical) [Ep 164 · 1:43](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=103)
- "Out of 329 biliary atresia cases from July 2020 to December 2022, 40 were classified as low MMP-7" — Em Gootee (epidemiological) [Ep 164 · 1:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=116)
- "Low levels of MMP-7 in biliary atresia patients are associated with low levels of preoperative GGT and direct bilirubin" — Em Gootee (clinical) [Ep 164 · 2:36](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=156)
- "GGT (gamma glutamyl transpeptidase) is an enzyme found in high levels in liver, kidney, pancreas, heart, and brain" — Em Gootee (clinical) [Ep 164 · 3:02](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=182)
- "GGT blood test levels are used to detect diseases of the liver and bile ducts" — Em Gootee (clinical) [Ep 164 · 3:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=192)
- "Biliary atresia patients can have dramatically different outcomes even when they anatomically look like they should behave in a similar fashion" — Em Gootee (clinical) [Ep 164 · 3:27](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=207)
- "Lower MMP-7 levels within the cohort of biliary atresia patients are associated with worse outcomes" — Em Gootee (clinical) [Ep 164 · 4:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=249)
- "The reason why low MMP-7 levels equal the worst prognosis in biliary atresia is unknown" — Em Gootee (clinical) [Ep 164 · 4:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=281)
- "The gastroschisis study included 411 infants treated at CAPSNET centers from 2014 to 2022, with 144 excluded, leaving 267 participants" — Em Gootee (epidemiological) [Ep 164 · 7:02](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=422)
- "78% of gastroschisis patients received exclusive breast milk in the first 28 days of life, and 22% received supplemental or exclusive formula" — Em Gootee (epidemiological) [Ep 164 · 7:43](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=463)
- "Patients with gastroschisis who had some exposure to formula in the first 28 days of life did not have increased risk of necrotizing enterocolitis or major differences in reaching full enteral feeds" — Mike Livingston (clinical) [Ep 164 · 8:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=492)
- "There were no significant differences between breast milk and formula groups in time to reach full enteral feeds, duration of parenteral nutrition, or length of stay" — Em Gootee (clinical) [Ep 164 · 8:27](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=507)
- "Gastroschisis patients exposed to formula seemed to have a slightly faster time getting to full feeds, likely related to timing of closure rather than feeding" — Mike Livingston (clinical) [Ep 164 · 8:34](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=514)
- "Gastroschisis patients who received exclusive breast milk in first 28 days were far more likely to transition to exclusive breastfeeding: 73% compared to 11% in those with formula exposure" — Mike Livingston (clinical) [Ep 164 · 8:53](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=533)
- "The transition systematic review found 8 studies that included patient and parent responses and clinician perspectives" — Whit Holcomb (epidemiological) [Ep 164 · 12:46](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=766)
- "The transition research included patients between ages 10 to 30 years with anorectal malformation or Hirschsprung disease" — Em Gootee (epidemiological) [Ep 164 · 12:55](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=775)
- "There is a group of colorectal patients discharged from care in late childhood around age 10 years, and another group that remains in pediatric care way beyond the normal age of transfer (around 25 years)" — Em Gootee (clinical) [Ep 164 · 13:16](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=796)
- "The life course progression of anorectal malformation and Hirschsprung disease is not well understood" — Em Gootee (clinical) [Ep 164 · 13:30](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=810)
- "Barriers and enablers of successful transition for surgical patients showed agreement with those for medical patients that guidelines were based on" — Sebastian King (clinical) [Ep 164 · 13:42](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=822)
- "Patients felt clinicians did not always understand the need for transitioning their child's care from pediatric to adult settings, including the reasons, processes, and how to make processes smooth" — Sebastian King (opinion) [Ep 164 · 13:42](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=822)
- "There was little evidence that transfer of colorectal patients happened in a timely or coordinated manner" — Whit Holcomb (clinical) [Ep 164 · 14:22](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=862)
- "Patients felt clinicians did not always understand the significance of transfer to an adult service" — Whit Holcomb (opinion) [Ep 164 · 14:31](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=871)
- "No models of transfer of care for colorectal conditions were identified" — Whit Holcomb (clinical) [Ep 164 · 14:38](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=878)
- "The Pediatric Colorectal and Pelvic Learning Consortium conducted a multi-center retrospective review from 2017 to 2023 examining the relationship between delayed diagnosis of Hirschsprung disease and postoperative/functional outcomes." — Alex Halpern (clinical) [Ep 165 · 0:12](https://library.globalcastmd.com/watch/does-delayed-diagnosis-of-hirschsprung-disease-impact-post-operative-and-functional-outcomes-a-multi-center-review-from-the-pediatric-colorectal-and-pelvic-learning-consortium-9263?t=12)
- "The study included 679 patients with Hirschsprung disease from 14 different sites." — Alex Halpern (epidemiological) [Ep 165 · 0:23](https://library.globalcastmd.com/watch/does-delayed-diagnosis-of-hirschsprung-disease-impact-post-operative-and-functional-outcomes-a-multi-center-review-from-the-pediatric-colorectal-and-pelvic-learning-consortium-9263?t=23)
- "Increased age at diagnosis was associated with a greater likelihood of undergoing fecal diversion after initial pull-through procedure." — Alex Halpern (clinical) [Ep 165 · 0:29](https://library.globalcastmd.com/watch/does-delayed-diagnosis-of-hirschsprung-disease-impact-post-operative-and-functional-outcomes-a-multi-center-review-from-the-pediatric-colorectal-and-pelvic-learning-consortium-9263?t=29)
- "Increased age at diagnosis was associated with an increased risk of constipation or incontinence requiring intervention postoperatively." — Alex Halpern (clinical) [Ep 165 · 0:39](https://library.globalcastmd.com/watch/does-delayed-diagnosis-of-hirschsprung-disease-impact-post-operative-and-functional-outcomes-a-multi-center-review-from-the-pediatric-colorectal-and-pelvic-learning-consortium-9263?t=39)
- "No association was found between age at diagnosis and 30-day complication rate after initial pull-through." — Alex Halpern (clinical) [Ep 165 · 0:49](https://library.globalcastmd.com/watch/does-delayed-diagnosis-of-hirschsprung-disease-impact-post-operative-and-functional-outcomes-a-multi-center-review-from-the-pediatric-colorectal-and-pelvic-learning-consortium-9263?t=49)
- "No association was found between age at diagnosis and need for pull-through revision." — Alex Halpern (clinical) [Ep 165 · 0:49](https://library.globalcastmd.com/watch/does-delayed-diagnosis-of-hirschsprung-disease-impact-post-operative-and-functional-outcomes-a-multi-center-review-from-the-pediatric-colorectal-and-pelvic-learning-consortium-9263?t=49)
- "Delayed diagnosis of Hirschsprung disease affects certain postoperative and functional outcomes in patients." — Alex Halpern (clinical) [Ep 165 · 0:58](https://library.globalcastmd.com/watch/does-delayed-diagnosis-of-hirschsprung-disease-impact-post-operative-and-functional-outcomes-a-multi-center-review-from-the-pediatric-colorectal-and-pelvic-learning-consortium-9263?t=58)
- "Cloacal exstrophy is the most complex of all anatomic problems faced by the pediatric reconstructive surgeon" (opinion) [Ep 166 · 0:00](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=0)
- "In cloacal exstrophy, the distal ileum and appendix are often intussuscepted" (clinical) [Ep 166 · 0:20](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=20)
- "The traditional newborn operation separates the cecal plate from within the two hemibladders, tubularizes it, and adds it to the fecal stream" (clinical) [Ep 166 · 0:24](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=24)
- "The rationale for tubularizing the cecum was to maximize the amount of colon the patient had and to avoid resorption of urine by bowel mucosa" (clinical) [Ep 166 · 0:35](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=35)
- "The tubularized cecum led to stasis and bacterial overgrowth" (clinical) [Ep 166 · 0:46](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=46)
- "Urinary absorption by bowel did not lead to the clinical concern of acidosis that had been expected" (clinical) [Ep 166 · 0:56](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=56)
- "Leaving the cecal plate untouched avoids the technically challenging separation of the cecal plate from between the two hemibladders" (clinical) [Ep 166 · 1:43](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=103)
- "Leaving the cecal plate untouched allows for an auto augmentation of the bladder" (clinical) [Ep 166 · 1:55](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=115)
- "The ileum to hindgut connection is a 1 to 1 size differential" (clinical) [Ep 166 · 1:59](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=119)
- "Leaving the cecal plate untouched avoids the tubularized cecum which leads to problems related to dysmotility" (clinical) [Ep 166 · 2:06](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=126)
- "In this case the hindgut was about 12 centimeters, a good length" (clinical) [Ep 166 · 3:31](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=211)
- "The hindgut ended blindly as a colonic atresia" (clinical) [Ep 166 · 3:35](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=215)
- "In this case, essentially this is just the right colon" (clinical) [Ep 166 · 3:39](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=219)
- "A Cheatle maneuver on the hindgut was needed to set up a better aligned ileum to hindgut anastomosis" (clinical) [Ep 166 · 5:10](https://library.globalcastmd.com/watch/cloacal-exstrophy-a-modification-of-the-newborn-operation-leaving-the-cecal-plate-untouched-9275?t=310)
- "A fistula entering the deltoid or shoulder region of the urethra is a bladder neck fistula" (clinical) [Ep 170 · 0:50](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=50)
- "A fistula entering the triceps or humerus area of the urethra is a prostatic fistula" (clinical) [Ep 170 · 0:57](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=57)
- "A fistula entering at the elbow of the urethra is a bulbar fistula" (clinical) [Ep 170 · 1:03](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=63)
- "The laparoscopic view alone does not help the surgeon know where the distal rectum enters the urinary tract" (clinical) [Ep 170 · 1:17](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=77)
- "A properly done distal colostogram is required to determine where the distal rectum enters the urinary tract" (clinical) [Ep 170 · 1:25](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=85)
- "A high rectum with fistula to lower prostatic level where the rectum is above the pubococcygeal or PC line is amenable to a laparoscopic approach" (clinical) [Ep 170 · 1:30](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=90)
- "A lower rectum with fistula to the bulbar urethra is ideal for a posterior sagittal approach" (clinical) [Ep 170 · 1:47](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=107)
- "The laparoscopic setup uses a 5 millimeter port at the umbilicus for the camera, which is then moved to the right upper quadrant for best visualization of the pelvis" (clinical) [Ep 170 · 1:58](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=118)
- "The sphincter is marked with silk sutures after defining its extent using an electrical stimulator" (clinical) [Ep 170 · 2:30](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=150)
- "Muscle relaxant is provided by the anesthesiologist once the sphincter has been marked" (clinical) [Ep 170 · 2:38](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=158)
- "The laparoscopic dissection stays intimately attached to the rectal wall, preserving the IMA in its arcade" (clinical) [Ep 170 · 2:55](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=175)
- "The intramural blood supply profuses the rectal wall" (clinical) [Ep 170 · 3:01](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=181)
- "Redundancy in the sigmoid indicates the colostomy was correctly opened in the proximal sigmoid, leaving the distal aspect for the pull through" (clinical) [Ep 170 · 3:06](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=186)
- "Dissection continues until the rectum tapers into a narrow fistula" (clinical) [Ep 170 · 3:34](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=214)
- "The goal is to have the tapered fistula area be the size of a 3 millimeter Maryland grasper" (clinical) [Ep 170 · 3:39](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=219)
- "Dissection up to the stoma frees the rectum so the pull through will not be under any tension" (clinical) [Ep 170 · 3:59](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=239)
- "Before ligating the fistula, the perineum is opened at the intended location of the anoplasty" (clinical) [Ep 170 · 4:20](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=260)
- "Blunt, gentle dissection finds the path into the pelvis which will be the trajectory of the pull through" (clinical) [Ep 170 · 4:28](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=268)
- "The fistula is ligated by preloading the Maryland grasper over an endo loop" (clinical) [Ep 170 · 4:40](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=280)
- "The distal rectum is cut with sharp scissors and the urinary tract is closed with the endo loop" (clinical) [Ep 170 · 4:47](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=287)
- "The anoplasty is created with tacking of the posterior rectal wall to the edge of the muscle complex" (clinical) [Ep 170 · 5:42](https://library.globalcastmd.com/watch/laparoscopic-assisted-posterior-sagittal-anorectoplasty-9641?t=342)
- "Rectal prolapse is a very common problem following repair of an anorectal malformation" (clinical) [Ep 171 · 0:11](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=11)
- "Rectal prolapse can cause mucous production and bleeding" (clinical) [Ep 171 · 0:19](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=19)
- "Rectal prolapse can interfere with the patient's ability to close the anus and thereby affect bowel control" (clinical) [Ep 171 · 0:19](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=19)
- "The anoplasty location should be checked with an electrical stimulator to confirm well-located positioning with circumferential contractions" (clinical) [Ep 171 · 0:44](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=44)
- "Full thickness rectum is incised off the skin edge while preserving the sphincter muscle" (clinical) [Ep 171 · 1:27](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=87)
- "Leaving the right side of the anoplasty untouched reduces the risk of postoperative stricture" (clinical) [Ep 171 · 1:35](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=95)
- "The rectum is mobilized out until there is slight tension and the intended cut line will comfortably reach the anal skin" (clinical) [Ep 171 · 1:47](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=107)
- "Extra stitches placed into the redundancy help straighten out the rectal tissue prior to incising it" (clinical) [Ep 171 · 2:13](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=133)
- "The Lone Star retractor is very helpful to set up the anoplasty" (opinion) [Ep 171 · 2:28](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=148)
- "The anoplasty technique involves taking a bite of anal skin to full thickness rectal wall" (clinical) [Ep 171 · 2:47](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=167)
- "Dividing the upper and lower quadrants of the left-sided prolapse creates two triangles" (clinical) [Ep 171 · 3:28](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=208)
- "All sutures are tied under slight tension so that once cut, the anoplasty retracts back nicely" (clinical) [Ep 171 · 4:48](https://library.globalcastmd.com/watch/rectal-prolapse-repair-following-a-posterior-sagittal-anorectoplasty-9723?t=288)
- "The Finnish Pediatric Surgery Hub was established in 2021 by pediatric surgeons from Finland's five neonatal surgery centers." — Lizzie Lee (clinical) [Ep 173 · 0:10](https://library.globalcastmd.com/watch/finnish-pediatric-surgery-hub-from-centralization-to-collective-learning-and-sharing-of-expertise-9951?t=10)
- "The hub performed 34 elective and 6 urgent cases total." — Lizzie Lee (epidemiological) [Ep 173 · 0:18](https://library.globalcastmd.com/watch/finnish-pediatric-surgery-hub-from-centralization-to-collective-learning-and-sharing-of-expertise-9951?t=18)
- "The most frequent diagnoses included anorectal malformations, esophageal atresia, and Hirschsprung disease." — Lizzie Lee (epidemiological) [Ep 173 · 0:18](https://library.globalcastmd.com/watch/finnish-pediatric-surgery-hub-from-centralization-to-collective-learning-and-sharing-of-expertise-9951?t=18)
- "The hub held regular monthly virtual meetings to present new patients, discuss complex cases, and follow up on patients after surgery." — Lizzie Lee (clinical) [Ep 173 · 0:28](https://library.globalcastmd.com/watch/finnish-pediatric-surgery-hub-from-centralization-to-collective-learning-and-sharing-of-expertise-9951?t=28)
- "Findings suggest that the Finnish Pediatric Surgery hub fosters an effective and safe place for sharing surgical expertise and learning." — Lizzie Lee (opinion) [Ep 173 · 0:36](https://library.globalcastmd.com/watch/finnish-pediatric-surgery-hub-from-centralization-to-collective-learning-and-sharing-of-expertise-9951?t=36)
- "The study by Zeng et al. is a retrospective multi-center study done in China comparing robotic repair versus thoracoscopic repair for esophageal atresia" — Cecilia Gigena (clinical) [Ep 172 · 0:58](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=58)
- "After propensity score matching, the study included 126 patients with 63 in each group" — Cecilia Gigena (clinical) [Ep 172 · 1:07](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=67)
- "Robotic surgery had longer operative time but shorter anastomotic time compared to thoracoscopic repair" — Cecilia Gigena (clinical) [Ep 172 · 1:15](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=75)
- "The robotic group had lower anastomotic strictures compared to thoracoscopic repair" — Cecilia Gigena (clinical) [Ep 172 · 1:22](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=82)
- "The robotic group had lower readmissions within 2 years post-op compared to thoracoscopic repair" — Cecilia Gigena (clinical) [Ep 172 · 1:28](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=88)
- "Robotic surgery is a good answer for esophageal atresia repair" — Cecilia Gigena (opinion) [Ep 172 · 1:32](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=92)
- "The Pediatric Colorectal and Pelvic Learning Consortium study included 679 patients with Hirschsprung disease from 14 different sites between 2017 and 2023" — Alex Halpern (clinical) [Ep 172 · 2:05](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=125)
- "Increased age at diagnosis of Hirschsprung disease was associated with a greater likelihood of undergoing fecal diversion after initial pull-through procedure" — Alex Halpern (clinical) [Ep 172 · 2:22](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=142)
- "Increasing age at diagnosis of Hirschsprung disease was associated with an increased risk of constipation or incontinence requiring intervention postoperatively" — Alex Halpern (clinical) [Ep 172 · 2:32](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=152)
- "No association was found between age at diagnosis of Hirschsprung disease and 30-day complication rate after initial pull-through" — Alex Halpern (clinical) [Ep 172 · 2:42](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=162)
- "No association was found between age at diagnosis of Hirschsprung disease and need for pull-through revision" — Alex Halpern (clinical) [Ep 172 · 2:48](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=168)
- "Delayed diagnosis of Hirschsprung disease does affect certain outcomes in these patients" — Alex Halpern (opinion) [Ep 172 · 2:51](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=171)
- "The Children's Hospital in Pakistan conducted a randomized control trial including 124 patients in 2021 to 2022 who needed stoma reversal" — Lizzie Lee (clinical) [Ep 172 · 3:25](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=205)
- "The study aimed to compare surgical site infections and cosmetic outcomes of scars in patients receiving purse-string or linear skin closure techniques for stoma reversal" — Lizzie Lee (clinical) [Ep 172 · 3:35](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=215)
- "The purse-string closure group had way fewer surgical site infections compared to the linear closure group" — Lizzie Lee (clinical) [Ep 172 · 3:44](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=224)
- "The purse-string closure group had much better scar quality compared to the linear closure group" — Lizzie Lee (clinical) [Ep 172 · 3:49](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=229)
- "When reversing a stoma, purse-string closure technique is the best way to do it" — Lizzie Lee (opinion) [Ep 172 · 3:52](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=232)
- "Post-Hirschsprung patients can develop outlet obstruction as the anastomotic area narrows during healing, typically presenting after the initial post-operative period rather than immediately" — Megan (clinical) [Ep 71 · 2:10](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=130)
- "Liquid stool in infants does not help maintain the anastomosis that may be narrowing during normal healing" — Megan (clinical) [Ep 71 · 2:27](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=147)
- "Early post-operative anal dilation carries risk of disrupting the healing anastomosis" — Eunice (clinical) [Ep 71 · 3:29](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=209)
- "Some Hirschsprung patients do well without intervention while others require frequent follow-up despite identical surgical technique" — Eunice (clinical) [Ep 71 · 4:00](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=240)
- "Treatment for Hirschsprung complications should be tailored to the individual patient rather than applying a standard protocol" — Eunice (opinion) [Ep 71 · 4:13](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=253)
- "Standard enterocolitis management includes IV fluids, rectal irrigations (10 cc/kg normal saline every 8 hours for first 24-48 hours), and IV Flagyl" — Megan (clinical) [Ep 71 · 7:17](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=437)
- "Probiotics are used more for chronic management than acute treatment of Hirschsprung enterocolitis" — Eunice (opinion) [Ep 71 · 9:54](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=594)
- "No standardized probiotic formulations exist, adding variability to treatment even when probiotics are used" — Megan (clinical) [Ep 71 · 10:42](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=642)
- "Anorectal manometry results may be unreliable in patients with actively dilated colon that is not adequately decompressed" — Megan (clinical) [Ep 71 · 10:59](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=659)
- "Teaching parents to perform rectal irrigations at home improves quality of life by allowing them to manage early symptoms without emergency room visits" — Eunice (clinical) [Ep 71 · 12:19](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=739)
- "Standardized nursing education on rectal irrigations is necessary because this is not a common procedure and skill levels vary" — Megan (clinical) [Ep 71 · 13:24](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=804)
- "There is no strong evidence base for most Hirschsprung enterocolitis management strategies" — Megan (epidemiological) [Ep 71 · 14:38](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=878)
- "Defining enterocolitis consistently is necessary before outcomes data can be meaningfully compared across studies" — Eunice (epidemiological) [Ep 71 · 15:20](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=920)
- "Botox injection can help overcome intense anal sphincter contraction in post-Hirschsprung patients with outlet obstruction" — Megan (clinical) [Ep 71 · 16:58](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1018)
- "Antegrade continence enema (ACE) procedures are more difficult in Hirschsprung patients than anorectal malformation patients due to intact sphincter causing outlet obstruction" — Megan (clinical) [Ep 71 · 17:56](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1076)
- "Fecal incontinence in Hirschsprung patients often presents later than obstructive symptoms because soiling in diapers may be missed until school age" — Megan (clinical) [Ep 71 · 18:36](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1116)
- "High-amplitude propagating contractions (HAPC) reaching 400 mmHg cannot be controlled voluntarily at the anal sphincter" — Megan (clinical) [Ep 71 · 21:05](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1265)
- "Removal of the rectum in Hirschsprung surgery eliminates the capacitance organ, leaving patients vulnerable to high-pressure colonic contractions" — Megan (clinical) [Ep 71 · 21:22](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1282)
- "Most pediatric rectal prolapse occurs during potty training age due to weak pelvic floor and low rectal position in children" — Eunice (clinical) [Ep 71 · 25:14](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1514)
- "Cystic fibrosis should be considered in the differential diagnosis of pediatric rectal prolapse" — Eunice (guideline) [Ep 71 · 25:45](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1545)
- "Teaching proper toilet positioning (upright with step stool, limited time on toilet) can resolve many cases of rectal prolapse" — Eunice (clinical) [Ep 71 · 26:08](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1568)
- "Sclerotherapy for rectal prolapse uses 5 cc of sclerosing agent injected in 4 quadrants" — Sean (clinical) [Ep 71 · 27:52](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1672)
- "Systematic review of 27 publications on pediatric rectal prolapse included 900 patients: 300 received sclerotherapy, 600 underwent operative management with 17 different procedures" — Eunice (epidemiological) [Ep 71 · 31:11](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1871)
- "Transabdominal procedures for rectal prolapse have high success rates according to published data" — Eunice (epidemiological) [Ep 71 · 31:48](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1908)
- "95% alcohol is the most commonly used sclerosing agent for rectal prolapse, with high success rate and minimal complications" — Eunice (clinical) [Ep 71 · 33:17](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1997)
- "Initial sclerotherapy success rate is high; cumulative success reaches 80% after up to three attempts" — Eunice (epidemiological) [Ep 71 · 33:17](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=1997)
- "After three failed sclerotherapy attempts, laparoscopic rectopexy is reasonable next step" — Eunice (guideline) [Ep 71 · 33:38](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2018)
- "Complications from sclerotherapy are mostly acute and negligible with minimal long-term risk" — Eunice (epidemiological) [Ep 71 · 34:10](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2050)
- "Laparoscopic rectopexy has highest success rate with lowest complication risk among operative options for rectal prolapse" — Eunice (epidemiological) [Ep 71 · 35:10](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2110)
- "Approximately half of children over 3 years old with rectal prolapse have comorbid psychiatric diagnoses such as OCD, anxiety, or depression" — Eunice (epidemiological) [Ep 71 · 37:18](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2238)
- "Pelvic floor rehabilitation combined with psychiatric management and surgical intervention is effective for rectal prolapse in patients with anxiety or depression" — Eunice (clinical) [Ep 71 · 37:36](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2256)
- "Gastrographin protocol for bowel obstruction is standard of care in adult surgery" — Beth (clinical) [Ep 71 · 47:27](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2847)
- "Limited pediatric data on gastrographin for bowel obstruction parallels adult data in safety and efficacy" — Beth (epidemiological) [Ep 71 · 47:52](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2872)
- "Gastrographin protocol requires no signs of strangulation or peritonitis and is only for adhesive bowel obstruction in patients with prior abdominal surgery" — Beth (guideline) [Ep 71 · 48:28](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2908)
- "If contrast reaches or passes the cecum by 8-10 hours, bowel obstruction is ruled out and NG tube can be removed" — Beth (clinical) [Ep 71 · 49:13](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2953)
- "If contrast has not reached cecum by 24 hours, patient can move more rapidly to operating room than with traditional conservative management" — Beth (clinical) [Ep 71 · 49:31](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2971)
- "Attending surgeon must examine patient and review X-rays before gastrographin protocol is initiated" — Beth (guideline) [Ep 71 · 45:55](https://library.globalcastmd.com/watch/colorectal-clinical-practice-updates-2997?t=2755)
- "Five to ten years ago, the recommendation for total colonic Hirschsprung was to wait until the child was potty trained for urine and could sit on a potty before performing pull-through" — Marc Levitt (clinical) [Ep 95 · 2:23](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=143)
- "Studies showed no significant difference in skin excoriation between younger and older patients undergoing pull-through" — Rod Gerardo (clinical) [Ep 95 · 2:46](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=166)
- "Two patients who waited until older age for pull-through developed proctalgia (anal sphincter spasm unresponsive to Botox) requiring ileostomy recreation" — Marc Levitt (clinical) [Ep 95 · 2:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=178)
- "Current routine is to perform pull-through somewhere between 6 and 18 months of age" — Marc Levitt (clinical) [Ep 95 · 3:23](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=203)
- "Timing of pull-through should wait until child has good growth and more solid stool consistency from solid diet" — Jason Frischer (clinical) [Ep 95 · 3:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=210)
- "High ileostomy output can be managed with pectin or Imodium to thicken stools" — Amanda Jensen (clinical) [Ep 95 · 3:59](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=239)
- "Skin training technique involves taking stool from ostomy bag and placing in diaper for 15-20 minutes to expose virgin buttock skin to stool before pull-through" — Jason Frischer (clinical) [Ep 95 · 4:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=252)
- "These ileostomies can remain in place for 6, 12, or 24 months" — Marc Levitt (clinical) [Ep 95 · 4:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=297)
- "Urine sodium (total body sodium) is a key component for growth in patients with long-standing ileostomies, not just blood sodium" — Jason Frischer (clinical) [Ep 95 · 5:19](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=319)
- "Urine sodium should be checked a few weeks after ileostomy creation, prior to discharge, and a month or two later" — Jason Frischer (clinical) [Ep 95 · 5:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=334)
- "Low total body sodium can be treated with salt tablets or salt addition" — Jason Frischer (clinical) [Ep 95 · 5:49](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=349)
- "For patients with high ileostomy output and failure to thrive, if urine sodium is less than 20, oral sodium supplementation is needed" — Hira Ahmad (clinical) [Ep 95 · 5:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=357)
- "Oral sodium supplementation protocol: add 3 mEq/kg/day using recipe of 1 tablespoon salt plus 40 mL water (gives 2.5 mEq sodium per mL), continue 1-2 months then recheck urine sodium" — Rod Gerardo (clinical) [Ep 95 · 6:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=386)
- "Oral salt intake improves glucose absorption in the GI tract, leading to better nutrition" — Marc Levitt (clinical) [Ep 95 · 6:49](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=409)
- "Sodium is actively absorbed in the ileum but passively absorbed in the jejunum" — Amanda Jensen (clinical) [Ep 95 · 7:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=428)
- "Urine sodium should be greater than 20 millimoles per liter; if less, the baby is retaining sodium and likely sodium-depleted despite normal serum sodium" — Marc Levitt (clinical) [Ep 95 · 7:37](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=457)
- "For total colonic Hirschsprung, typical approach is ileoanal anastomosis (straight pull-through)" — Jason Frischer (clinical) [Ep 95 · 8:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=480)
- "Duhamel procedure leads to stasis, which is problematic" — Marc Levitt (opinion) [Ep 95 · 8:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=506)
- "The Martin procedure (ultimate Duhamel using entire sigmoid and left colon) has been abandoned due to excessive stasis" — Marc Levitt (clinical) [Ep 95 · 8:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=506)
- "The Kamura procedure involves right colon connected to ileum in form of ileostomy" — Marc Levitt (clinical) [Ep 95 · 8:50](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=530)
- "An ileoduhamel with a very short pouch is a very nice operation for total colonic Hirschsprung and many patients do well" — Marc Levitt (opinion) [Ep 95 · 9:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=541)
- "The issue with Duhamel failures is not the Duhamel itself but the ganglionic bowel, as not all ganglionated bowel is created equally" — Marc Levitt (opinion) [Ep 95 · 9:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=566)
- "Ganglionated bowel can decompensate when there is slowing of stool in the Duhamel pouch" — Rod Gerardo (clinical) [Ep 95 · 9:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=578)
- "Decision to redivert after ileoanal pull-through is made intraoperatively based on anastomosis quality, blood supply, tension, and nutritional optimization" — Jason Frischer (clinical) [Ep 95 · 9:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=597)
- "In theory, an ileoanal anastomosis should not require diversion" — Marc Levitt (opinion) [Ep 95 · 10:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=626)
- "Diverting more proximally may make the patient short gut with inadequate intestinal length for absorption, resulting in higher output ileostomy" — Marc Levitt (clinical) [Ep 95 · 10:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=630)
- "Family comfort with rectal irrigations is an important consideration in surgical planning" — Jason Frischer (clinical) [Ep 95 · 10:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=657)
- "Patients with total colonic Hirschsprung disease are more susceptible to severe enterocolitis compared to traditional rectosigmoid Hirschsprung patients" — Rod Gerardo (clinical) [Ep 95 · 11:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=664)
- "First-line medical management is diet modification, which can be started before pull-through" — Rod Gerardo (clinical) [Ep 95 · 11:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=676)
- "First-line medication treatment is loperamide" — Jason Frischer (clinical) [Ep 95 · 11:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=686)
- "Liquid loperamide contains glucose and sugar which can cause hypermotility; crushing pills in applesauce is preferred" — Jason Frischer (clinical) [Ep 95 · 11:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=690)
- "Dietary recommendations include avoiding sugar (berries particularly offensive), avoiding fats and oily foods, and bulking the stool" — Marc Levitt (clinical) [Ep 95 · 11:42](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=702)
- "Levsin is used successfully as an added medicine to slow down stool" — Marc Levitt (clinical) [Ep 95 · 11:56](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=716)
- "Lomotil (atropine-diphenoxylate) is a controlled substance in the United States" — Jason Frischer (clinical) [Ep 95 · 12:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=727)
- "Botox is given immediately when intestinal continuity is established" — Jason Frischer (clinical) [Ep 95 · 12:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=744)
- "First post-operative visit is at 2 weeks for routine check of eating, growth, and rash assessment" — Jason Frischer (clinical) [Ep 95 · 12:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=754)
- "Anastomosis check is performed at 4 weeks post-operatively in clinic using Hagar dilators sized appropriately for child's age" — Jason Frischer (clinical) [Ep 95 · 12:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=758)
- "Anastomotic sizing starts with 7 or 8 Hagar dilator and gently sizes up to resistance, not to stretch but to check size" — Jason Frischer (clinical) [Ep 95 · 13:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=785)
- "For a child undergoing pull-through at around 10 months of age, proper anastomotic size should be 13 or 14 Hagar dilator" — Jason Frischer (clinical) [Ep 95 · 13:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-11-total-colonic-hirschsprung-s-part-2-3932?t=795)
- "The ERAS Society used a modified Delphi technique with a multidisciplinary group of experts to reach more than 70% consensus" — Lizzie Lee (guideline) [Ep 174 · 1:10](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=70)
- "The ERAS Society agreed on 16 recommendations covering 11 topics including team communication, pre-surgery fasting, temperature control, and antibiotic use" — Lizzie Lee (guideline) [Ep 174 · 1:34](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=94)
- "The ERAS Society did not have enough data to make recommendations about nasogastric tubes and central lines" — Lizzie Lee (guideline) [Ep 174 · 1:43](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=103)
- "Eight studies were found examining transition from pediatric to adult healthcare for colorectal conditions" — Alex Halpern (epidemiological) [Ep 174 · 2:21](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=141)
- "Studies agreed that transitional care should start early in adolescence" — Alex Halpern (guideline) [Ep 174 · 2:24](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=144)
- "Little evidence exists that transfer from pediatric to adult care is happening in a coordinated or timely fashion" — Alex Halpern (epidemiological) [Ep 174 · 2:24](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=144)
- "No models of transition care were identified for patients with anorectal malformations and Hirschsprung's disease" — Alex Halpern (epidemiological) [Ep 174 · 2:33](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=153)
- "The CPAM study included 110 patients" — Cecilia Gigena (epidemiological) [Ep 174 · 3:21](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=201)
- "Patients who underwent surgery before becoming symptomatic had shorter length of stay" — Cecilia Gigena (clinical) [Ep 174 · 3:21](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=201)
- "Patients who underwent surgery before becoming symptomatic had shorter mechanical ventilation after surgery" — Cecilia Gigena (clinical) [Ep 174 · 3:21](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=201)
- "Patients who underwent surgery before becoming symptomatic had shorter operating times" — Cecilia Gigena (clinical) [Ep 174 · 3:21](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=201)
- "There was no significant difference in conversion or post-operative complications between symptomatic and asymptomatic CPAM patients undergoing surgery" — Cecilia Gigena (clinical) [Ep 174 · 3:31](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=211)
- "It appears safer to operate on CPAM patients before they become symptomatic" — Cecilia Gigena (opinion) [Ep 174 · 3:44](https://library.globalcastmd.com/watch/quick-literature-updates-episode-18-10064?t=224)
- "The Hirschsprung study was prospective and took place 2021 to 2023, including 33 patients under six months old who underwent endorectal pull-through surgeries" — Lizzie Lee (clinical) [Ep 184 · 1:03](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=63)
- "Primary outcomes examined were anastomotic complications, enterocolitis, and constipation" — Lizzie Lee (clinical) [Ep 184 · 1:20](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=80)
- "There was no significant difference in anastomotic complications between dilation and non-dilation groups" — Lizzie Lee (clinical) [Ep 184 · 1:27](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=87)
- "The non-dilation group had less enterocolitis and less constipation compared to traditional dilation group" — Lizzie Lee (clinical) [Ep 184 · 1:27](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=87)
- "Choosing not to do postoperative anal dilations may be a good alternative with benefits like lower constipation and enterocolitis" — Lizzie Lee (opinion) [Ep 184 · 1:36](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=96)
- "For gastroschisis, delivery after 37 weeks is optimal" — Alex Halpern (guideline) [Ep 184 · 2:18](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=138)
- "Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until closure in gastroschisis" — Alex Halpern (guideline) [Ep 184 · 2:21](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=141)
- "Studies support primary fascial repair for gastroschisis as long as hemodynamics and abdominal domain permit" — Alex Halpern (guideline) [Ep 184 · 2:28](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=148)
- "Sutureless repair for gastroschisis is safe, effective, and does not delay feeding or increase length of stay" — Alex Halpern (clinical) [Ep 184 · 2:28](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=148)
- "There is a need for high quality randomized controlled trials to help provide evidence-based care for gastroschisis infants" — Alex Halpern (opinion) [Ep 184 · 2:42](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=162)
- "The CDH study was retrospective, done in Texas using a state hospital database" — Cecilia Gigena (clinical) [Ep 184 · 3:16](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=196)
- "The CDH study identified 1,314 patients: 728 from high volume centers, 9 from mid-volume centers, and 79 from low volume centers" — Cecilia Gigena (epidemiological) [Ep 184 · 3:32](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=212)
- "High volume centers had significantly lower mortality rates for CDH despite having significantly sicker patients" — Cecilia Gigena (clinical) [Ep 184 · 3:46](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=226)
- "High volume centers had significantly shorter length of stay for CDH patients" — Cecilia Gigena (clinical) [Ep 184 · 3:46](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=226)
- "High volume centers had better outcomes for patients with CDH" — Cecilia Gigena (opinion) [Ep 184 · 4:00](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=240)
- "APSA published best practices for locum tenens surgeons, hospitals and agencies" — Lizzie Lee (guideline) [Ep 185 · 1:02](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=62)
- "APSA guidelines stress the importance of patient safety and support for surgeons" — Lizzie Lee (guideline) [Ep 185 · 1:12](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=72)
- "Locum tenens can help prevent burnout by offering flexible work options for a better work-life balance" — Lizzie Lee (opinion) [Ep 185 · 1:17](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=77)
- "Hospitals should avoid relying solely on locum tenens pediatric surgeons without any full-time surgeons because this may cause patients to slip through handoffs" — Lizzie Lee (guideline) [Ep 185 · 1:23](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=83)
- "Locum tenens agencies should sponsor CME and conduct formal exit interviews" — Lizzie Lee (guideline) [Ep 185 · 1:32](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=92)
- "A working group of pediatric surgeons from Europe created 19 case scenarios with unexpected events to validate the Clavien-Madadi classification" — Alex Halpern (clinical) [Ep 185 · 2:01](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=121)
- "Scenarios were circulated within the European Reference Network of inherited and congenital anomalies" — Alex Halpern (clinical) [Ep 185 · 2:10](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=130)
- "Surgeons rated scenarios based on either Clavien-Dindo classification or Clavien-Madadi classification" — Alex Halpern (clinical) [Ep 185 · 2:10](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=130)
- "59 surgeons completed the questionnaire" — Alex Halpern (epidemiological) [Ep 185 · 2:23](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=143)
- "The Clavien-Madadi classification showed significantly better agreement rates than Clavien-Dindo" — Alex Halpern (clinical) [Ep 185 · 2:27](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=147)
- "The Clavien-Madadi classification was less frequently considered inaccurate" — Alex Halpern (clinical) [Ep 185 · 2:27](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=147)
- "More pediatric surgeons preferred using the Clavien-Madadi classification" — Alex Halpern (opinion) [Ep 185 · 2:34](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=154)
- "The Clavien-Madadi classification is both an accurate and useful tool in grading unexpected events in pediatric surgery" — Alex Halpern (clinical) [Ep 185 · 2:38](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=158)
- "The systematic review was done in the UK and aimed to establish and categorize challenges and solutions related to transitional care in colorectal patients" — Cecilia Gigena (clinical) [Ep 185 · 3:10](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=190)
- "The systematic review included 234 studies" — Cecilia Gigena (epidemiological) [Ep 185 · 3:23](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=203)
- "First challenge identified was patients' lack of understanding of their own pathology" — Cecilia Gigena (clinical) [Ep 185 · 3:29](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=209)
- "Second challenge was the lack of education and awareness of adult surgeons about pediatric colorectal pathologies" — Cecilia Gigena (clinical) [Ep 185 · 3:34](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=214)
- "Third challenge was the lack of a structured transitional care program" — Cecilia Gigena (clinical) [Ep 185 · 3:42](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=222)
- "First proposed solution is to foster young adult patients' autonomy" — Cecilia Gigena (guideline) [Ep 185 · 3:46](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=226)
- "Second proposed solution is to conduct joint pediatric-adult transitional clinics" — Cecilia Gigena (guideline) [Ep 185 · 3:46](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=226)
- "Third proposed solution is to create a structured and coordinated transition program" — Cecilia Gigena (guideline) [Ep 185 · 3:46](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=226)
- "A multicenter review examined over 200 sacrococcygeal teratoma cases comparing children with Currarino syndrome to those without it." — Lizzie Lee (epidemiological) [Ep 186 · 0:10](https://library.globalcastmd.com/watch/sacrococcygeal-teratomas-in-currarino-syndrome-a-multicenter-review-of-tumor-characteristics-surgical-outcomes-and-recurrence-11278?t=10)
- "Currarino patients were almost always diagnosed after birth." — Lizzie Lee (clinical) [Ep 186 · 0:19](https://library.globalcastmd.com/watch/sacrococcygeal-teratomas-in-currarino-syndrome-a-multicenter-review-of-tumor-characteristics-surgical-outcomes-and-recurrence-11278?t=19)
- "Tumors in Currarino patients are almost exclusively Altman type 4, buried deep in the pelvis." — Lizzie Lee (clinical) [Ep 186 · 0:19](https://library.globalcastmd.com/watch/sacrococcygeal-teratomas-in-currarino-syndrome-a-multicenter-review-of-tumor-characteristics-surgical-outcomes-and-recurrence-11278?t=19)
- "Every tumor in the Currarino group was a mature one with no immature or malignant components at all." — Lizzie Lee (clinical) [Ep 186 · 0:27](https://library.globalcastmd.com/watch/sacrococcygeal-teratomas-in-currarino-syndrome-a-multicenter-review-of-tumor-characteristics-surgical-outcomes-and-recurrence-11278?t=27)
- "Currarino-associated tumors were much smaller, around 3 centimeters instead of 8 centimeters." — Lizzie Lee (clinical) [Ep 186 · 0:33](https://library.globalcastmd.com/watch/sacrococcygeal-teratomas-in-currarino-syndrome-a-multicenter-review-of-tumor-characteristics-surgical-outcomes-and-recurrence-11278?t=33)
- "Recurrence was almost nonexistent in Currarino cases and not significantly different from non-Currarino cases." — Lizzie Lee (clinical) [Ep 186 · 0:36](https://library.globalcastmd.com/watch/sacrococcygeal-teratomas-in-currarino-syndrome-a-multicenter-review-of-tumor-characteristics-surgical-outcomes-and-recurrence-11278?t=36)
- "Currarino-associated sacrococcygeal teratomas behave incredibly well oncologically, suggesting potential for less aggressive long-term follow-up." — Lizzie Lee (opinion) [Ep 186 · 0:41](https://library.globalcastmd.com/watch/sacrococcygeal-teratomas-in-currarino-syndrome-a-multicenter-review-of-tumor-characteristics-surgical-outcomes-and-recurrence-11278?t=41)
- "Cross-table lateral film (also called crossfire film) is obtained by placing baby prone in NICU" — Levitt (clinical) [Ep 99 · 1:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=76)
- "Cross-table lateral is the modern version of the old-fashioned invertogram" — Levitt (clinical) [Ep 99 · 1:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=83)
- "Cross-table lateral films should be obtained around 24 hours after birth when no fistula is evident on exam" — Fisher (clinical) [Ep 99 · 1:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=109)
- "When air column stops at about the 4th sacral vertebral body with large distance to sphincter marker, colostomy with distal colostogram is indicated" — Fisher (clinical) [Ep 99 · 2:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=126)
- "When air column is very close to anticipated anal opening location, primary anoplasty can be considered" — Fisher (clinical) [Ep 99 · 2:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=169)
- "Image showing air column far from sphincter is almost definitely a rectal urethral fistula worthy of colostomy" — Levitt (clinical) [Ep 99 · 3:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=210)
- "Image showing air column close to sphincter is probably a perineal fistula or no fistula, potentially suitable for primary repair, but must be careful of low bulbar fistula" — Levitt (clinical) [Ep 99 · 3:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=219)
- "VACTERL acronym stands for: Vertebral, Anorectal, Cardiac, Tracheoesophageal fistula, Renal, and Limb" — Amanda Jensen (clinical) [Ep 99 · 4:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=264)
- "For every ARM patient, must know: type of malformation, quality of sacrum, and quality of spine" — Levitt (clinical) [Ep 99 · 4:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=286)
- "High malformation, poor sacrum, poor spine predicts poor continence potential" — Levitt (clinical) [Ep 99 · 4:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=286)
- "Low malformation, normal sacrum, normal spine predicts good potential for bowel control" — Levitt (clinical) [Ep 99 · 4:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=286)
- "PCPLC consortium is collecting data across 15 centers to predict continence outcomes based on malformation type, sacral ratio, and spine status" — Levitt (epidemiological) [Ep 99 · 5:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=312)
- "Decision for primary anoplasty versus colostomy depends on surgeon comfort level and institutional post-operative care capabilities" — Fisher (opinion) [Ep 99 · 6:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=373)
- "When fistula opening is in the northernmost part of sphincteric ellipse in males, posterior rectal wall only mobilization should be performed" — Levitt (clinical) [Ep 99 · 6:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=395)
- "Avoiding anterior wall mobilization removes the major complication risk of urethral injury" — Levitt (clinical) [Ep 99 · 6:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=417)
- "Posterior-only mobilization technique applies only when fistula dot is within the sphincteric ellipse" — Rod Gerardo (clinical) [Ep 99 · 7:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=429)
- "The common wall between rectum and urethra is closer and longer than many people anticipate" — Fisher (clinical) [Ep 99 · 7:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=436)
- "For fistula in sphincter but in most anterior portion, anterior rectal wall does not need to be touched during dissection" — Levitt (clinical) [Ep 99 · 7:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=449)
- "When no obvious fistula is present at 24 hours and cross-table lateral does not show distal air column, colostomy is needed" — Fisher (clinical) [Ep 99 · 7:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-14-arm-newborn-part-3-4155?t=461)
- "About 5% of colorectal work is surgical and the rest is bowel management." — Rebecca Rentia (opinion) [Ep 100 · 1:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=108)
- "MiraLax softens stool but does not push it out; patients need a 'kick' from Senna or bisacodyl." — Christine Warner (clinical) [Ep 100 · 6:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=376)
- "MiraLax is problematic for patients with anorectal malformations who need fullness to detect stool, because it makes soft stool that 'mushes out'." — Marc Levitt (clinical) [Ep 100 · 7:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=435)
- "Senna rash is thought to be a chemical burn rather than a true allergy, presenting as blistering." — Jason Frischer (clinical) [Ep 100 · 5:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=330)
- "Senna rash is treated with silver sulfadiazine and resolves with time; some patients tolerate Senna upon reintroduction." — Jason Frischer (clinical) [Ep 100 · 5:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=338)
- "Timing Senna dose in the early morning so stool passes during the day (when diapers are changed frequently) reduces the risk of Senna rash from prolonged overnight stool contact." — Jason Frischer (clinical) [Ep 100 · 5:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=353)
- "Bisacodyl and Senna are the two medications that provide a motility 'kick'; everything else is a stool softener." — Marc Levitt (clinical) [Ep 100 · 6:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=419)
- "Small-volume enemas (150 mL saline + 9 mL castile soap) via balloon Foley catheter resulted in 1–2 stool diapers per day and resolution of diaper rash." — Wendy Lewis (clinical) [Ep 100 · 8:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=522)
- "Glycerin is more tolerated than castile soap in pediatric enemas; castile causes more cramping and discomfort." — Wendy Lewis (clinical) [Ep 100 · 9:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=550)
- "Children with spinal differences may need bladder access later in life, and the appendix is the preferred conduit for that (Mitrofanoff)." — Rebecca Rentia (clinical) [Ep 100 · 9:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=589)
- "Care coordination with urology from the beginning is essential in spina bifida patients to avoid committing the appendix to colorectal use when it may be needed for urologic reconstruction." — Jason Frischer (clinical) [Ep 100 · 10:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=608)
- "A cecostomy tube is a direct access to the cecum (analogous to a G-tube for the colon) that can be placed laparoscopically or by interventional radiology and preserves the appendix." — Rebecca Rentia (clinical) [Ep 100 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=713)
- "A non-plicated, non-trimmed Malone (tip of appendix sewn to right lower quadrant with a tube, without plication) preserves the appendix for future urologic use or splitting." — Marc Levitt (clinical) [Ep 100 · 12:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=742)
- "Urologists require an appendix of at least 5 cm length for a Mitrofanoff; shorter appendices are not useful for urology and may be used for Malone." — Marc Levitt (clinical) [Ep 100 · 13:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=816)
- "An appendix of 7 cm or longer may be splittable (e.g., 2 cm for Malone + 5 cm for Mitrofanoff)." — Marc Levitt (clinical) [Ep 100 · 13:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=839)
- "Urologists prefer the appendix for Mitrofanoff over a Monti channel made from small bowel because it has better long-term outcomes." — Marc Levitt (clinical) [Ep 100 · 14:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=847)
- "A neo-Malone can be created from a flap of colon if the appendix is used for urologic reconstruction." — Marc Levitt (clinical) [Ep 100 · 14:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=858)
- "The scenario requiring a temporizing conduit (cecostomy or non-plicated Malone) is rare: a child not tolerating rectal enemas, needing antegrade access, whose bladder reconstruction plan (augment, bladder neck sling) is not yet defined." — Marc Levitt (clinical) [Ep 100 · 15:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=910)
- "Taking down a cecostomy tube is relatively easy and leaves the appendix free for future use." — Marc Levitt (clinical) [Ep 100 · 15:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urologistpart-1-4232?t=938)
- "When urologists and colorectal surgeons split an appendix, the division is typically 70/30 in favor of urology, not equal sharing" — Marc Levitt (opinion) [Ep 101 · 1:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=98)
- "The colorectal team benefits from using the portion of appendix closer to the cecum because it has a stronger blood supply" — Jason Frischer (clinical) [Ep 101 · 1:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=115)
- "A 1-2 centimeter appendiceal stump can be extended 2-3 more centimeters by suturing or using a non-cutting laparoscopic stapler along the cecal wall" — Jason Frischer (clinical) [Ep 101 · 2:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=131)
- "One of the main problems with Malone appendicostomy is leakage" — Jason Frischer (clinical) [Ep 101 · 2:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=154)
- "The longer the Malone channel, the less likely it is to leak" — Jason Frischer (clinical) [Ep 101 · 2:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=167)
- "Extending the channel 2-3 centimeters by suturing or stapling can be extremely helpful in preventing leakage" — Jason Frischer (clinical) [Ep 101 · 2:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=175)
- "Children in rural locations or with behavioral issues who pull at tubes are good candidates for unplicated Malones" (clinical) [Ep 101 · 3:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=187)
- "Rectal irrigation devices made by companies like Coloplast can be used by patients with hand difficulties to self-administer enemas" — Jason Frischer (clinical) [Ep 101 · 4:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=240)
- "Spina bifida patients with absent coccyx have difficulty retaining enema fluid even for the short time needed to transfer to toilet" — Wendy (clinical) [Ep 101 · 4:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=297)
- "Most spinal patients prefer not to have a bag and would prefer transferring to a commode and doing an antegrade flush" — Marc Levitt (opinion) [Ep 101 · 5:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=353)
- "If a colon is very difficult to empty (requiring voluminous or concentrated enemas) and the urologist needs to do an augment, the sigmoid can be removed from colonic transit to make bowel management easier and used for bladder augmentation" — Marc Levitt (clinical) [Ep 101 · 6:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=408)
- "If a patient has an easy-to-empty colon and needs bladder augmentation, the urologist can use small bowel instead" — Marc Levitt (clinical) [Ep 101 · 7:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=444)
- "A careful assessment of existing bowel management (sit time, ingredients, flush volume) must be done before the next surgical intervention" (clinical) [Ep 101 · 7:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=459)
- "A good bowel management plan can influence the urologic plan; patients who are empty regularly for stool may have improved bladder function" — Marc Levitt (clinical) [Ep 101 · 7:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=472)
- "Vesicoureteral reflux might resolve with successful bowel management, potentially saving a patient from ureteral reimplantation" — Marc Levitt (clinical) [Ep 101 · 8:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=487)
- "Fecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux" — Jason Frischer (clinical) [Ep 101 · 8:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=525)
- "In Kansas City, the Mitrofanoff goes at the umbilicus and the MACE or appendicostomy goes in the right lower quadrant" (clinical) [Ep 101 · 9:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=559)
- "Anatomically, the bladder is a midline structure and access through the umbilicus makes sense; the cecum is right lower quadrant and placement there makes sense" — Marc Levitt (clinical) [Ep 101 · 9:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=569)
- "At Cincinnati, 99% of Malones are placed in the umbilicus and almost all Mitrofanoffs are in the right lower quadrant with a tunnel channel through the rectus to prevent leakage" — Jason Frischer (clinical) [Ep 101 · 9:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=584)
- "Blood supply is the ultimate driving factor for orifice placement; Malones not in the umbilicus are typically due to blood supply issues" — Jason Frischer (clinical) [Ep 101 · 10:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=621)
- "Orifices should not be matured until everyone has a plan in the OR to avoid one team pulling on the other's mesentery" — Marc Levitt (clinical) [Ep 101 · 10:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=642)
- "The last steps of combined procedures should be: mature the Mitrofanoff, mature the Malone, then close the abdomen" — Jason Frischer (clinical) [Ep 101 · 10:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=651)
- "The laxity of pelvic floor and anal canal in spinal patients makes them different, especially when doing retrograde enemas" — Jason Frischer (clinical) [Ep 101 · 11:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=669)
- "Adding bisacodyl to the flush has shown good success in spina bifida patients" — Wendy (clinical) [Ep 101 · 11:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=691)
- "Spina bifida patients sometimes do better with smaller enema volumes because their colons empty at different rates" — Wendy (clinical) [Ep 101 · 11:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=695)
- "Having patients stand up at the end of their flush, move around, and sit back down can help evacuate more stool because things move through their colon differently" — Wendy (clinical) [Ep 101 · 11:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=714)
- "Putting additional water volume into the enema balloon helps hold it in place so fluid doesn't go around it in patients who cannot hold like other children" (clinical) [Ep 101 · 12:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=736)
- "Using MiraLax helps with stool on the right side of the colon to aid complete evacuation in spinal patients" — Amanda Jensen (clinical) [Ep 101 · 12:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-16-bowel-management-in-spinal-patients-need-for-a-urologist-part-2-4304?t=778)
- "Definitive diagnostic workup for cloaca is typically performed at 5 to 6 months of age" — Richard Wood (clinical) [Ep 103 · 1:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=113)
- "The workup includes cystovaginoscopy, examination under anesthesia, preoperative urodynamics, and 3D cloacogram" — Richard Wood (clinical) [Ep 103 · 2:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=126)
- "During cystoscopy of the common channel, the easiest structure to enter is the vagina or vaginas; entering the urethra and bladder is challenging because it requires pointing very far up" — Richard Wood (clinical) [Ep 103 · 2:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=170)
- "If a septum is present, the rectal fistula is very often seen in the bottom of the septum on the rectal side" — Richard Wood (clinical) [Ep 103 · 3:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=204)
- "Cystoscopy significantly undermeasures structures compared to 3D reconstruction in the same patient, because a straight scope cannot measure the turn behind the pubis" — Richard Wood (clinical) [Ep 103 · 6:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=396)
- "Endoscopy has value in helping general pediatric surgeons differentiate straightforward from complex cloacas and determine whether referral to a specialized center is needed" — Marc Levitt (opinion) [Ep 103 · 7:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=461)
- "Lower confluence cloacas, if the surgeon knows the technique, represent a beautiful, elegant operation" — Marc Levitt (opinion) [Ep 103 · 8:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=532)
- "Higher confluence cloacas requiring vaginal replacement, high vaginas, and management of ectopic ureters should be done by specialized centers" — Marc Levitt (opinion) [Ep 103 · 8:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=537)
- "A common channel less than 1 centimeter long is classified as a type 1 cloaca, essentially a hypospadic urethra with a rectovaginal fistula" — Richard Wood (clinical) [Ep 103 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=628)
- "For type 1 cloaca (common channel <1 cm), the hypospadic urethral orifice is not touched; the plan is vaginoplasty, anorectoplasty, and PSARP" — Richard Wood (clinical) [Ep 103 · 10:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=657)
- "Even in type 1 cloaca with short common channel, the true rectum can still be high, so imaging is important to determine rectal height" — Richard Wood (clinical) [Ep 103 · 11:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=677)
- "A normal urethra should be at least 1.5 centimeters in length" — Richard Wood (clinical) [Ep 103 · 11:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=704)
- "For common channel 1-3 cm with urethral length >1.5 cm, total urogenital mobilization (TUM) and PSARP is the appropriate approach" — Richard Wood (clinical) [Ep 103 · 11:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=709)
- "If urethral length is <1.5 cm, urogenital separation is advocated because performing TUM on a 1 cm urethra would place the bladder neck near the perineum and could render the patient incontinent" — Richard Wood (clinical) [Ep 103 · 12:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=727)
- "The majority of cloacas with 1-3 cm common channel have normal urethral length and are amenable to TUM" — Richard Wood (epidemiological) [Ep 103 · 12:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=749)
- "For common channel >3 cm, patients often have urethral length <1.5 cm; in either case, urogenital separation is advocated with repair of the common channel left as the urethra" — Richard Wood (clinical) [Ep 103 · 12:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=764)
- "If the vagina or vaginas cannot reach the perineum, the patient may need vaginal replacement to bridge the gap" — Richard Wood (clinical) [Ep 103 · 13:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=798)
- "If the rectum is high, an abdominal or laparoscopic-assisted PSARP approach may be needed to mobilize adequate rectal length" — Richard Wood (clinical) [Ep 103 · 13:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=814)
- "Hardy Hendren was the father of cloacal management in the late 1960s and 1970s, with specific focus on urology and urethral reconstruction" — Marc Levitt (clinical) [Ep 103 · 14:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=851)
- "Alberto Pena made a major advance in 1996 with development of total urogenital mobilization (TUM); prior to that, all patients had urogenital separation" — Marc Levitt (clinical) [Ep 103 · 14:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=876)
- "The next major change in cloaca protocol came 21 years after TUM, in 2017, with the algorithm incorporating urethral length measurement" — Marc Levitt (clinical) [Ep 103 · 15:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=905)
- "The 2017 algorithm has been validated in 116 consecutive patients without once needing to change the surgical plan" — Richard Wood (epidemiological) [Ep 103 · 17:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1073)
- "The major change in the 2017 algorithm was ensuring measurement of urethral length, whereas previously the decision was based only on common channel length (less than or greater than 3 cm)" — Marc Levitt (clinical) [Ep 103 · 18:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1104)
- "Urethral length is measured from where the common channel splits (where urethra leaves the common channel) to where it enters the bladder, not from the single perineal orifice to the bladder neck" — Richard Wood (clinical) [Ep 103 · 19:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1149)
- "The goal is to position the bladder neck above the urogenital diaphragm where the sphincter complex lies, so intraabdominal pressure does not compromise continence" — Richard Wood (clinical) [Ep 103 · 19:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1180)
- "The most accurate urethral measurement comes from 3D imaging rather than cystoscopy, because imaging does not straighten structures and falsely measure them" — Richard Wood (clinical) [Ep 103 · 19:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-4336?t=1199)
- "Manometry is a catheter-based study of pressure changes within the lumen of the gut, involving visual pattern recognition of tracings to identify deviations from normal." — Ajay Hall (clinical) [Ep 104 · 1:24](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=84)
- "Colonic motility has four key components: diameter of the colon, tone, compliance of the colonic wall, and contraction pressures (how strong the contractions are), plus the length of the colon." — Ajay Hall (clinical) [Ep 104 · 1:34](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=94)
- "In megacolon, tone and compliance are usually abnormal, but colonic manometry may still show normal high-amplitude propagated contractions and transit may be normal." — Ajay Hall (clinical) [Ep 104 · 1:58](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=118)
- "There are three types of constipation: normal transit constipation, slow transit constipation (a problem with the neuromuscular integrity of the colonic wall), and outlet obstruction or withholding." — Ajay Hall (clinical) [Ep 104 · 2:35](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=155)
- "Outlet obstruction or withholding is the most common type of constipation in the pediatric population, including children with anorectal malformations." — Ajay Hall (epidemiological) [Ep 104 · 2:55](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=175)
- "In a Sitz marker study, a patient ingests radio-opaque markers and an X-ray is obtained after about 5 days; normally all markers should be evacuated, but remaining markers indicate abnormal transit." — Ajay Hall (clinical) [Ep 104 · 3:19](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=199)
- "When Sitz markers are collected in the dilated rectum at 5 days, this is indicative of outlet obstruction or withholding." — Ajay Hall (clinical) [Ep 104 · 3:48](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=228)
- "When Sitz markers are scattered all over the colon at 5 days, this is indicative of slow transit constipation." — Ajay Hall (clinical) [Ep 104 · 4:06](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=246)
- "Scintigraphy studies colonic transit by tracking the geometric center of an ingested radioisotope and can identify specific colonic locations with transit issues." — Ajay Hall (clinical) [Ep 104 · 4:15](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=255)
- "The smart pill is a large capsule that measures pH, temperature, and pressure; it is suitable for children around 10 or 12 years old and measures transit time from mouth to anus." — Ajay Hall (clinical) [Ep 104 · 4:51](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=291)
- "Colonic contractions include phasic (brief) or tonic (sustained) contractions, segmental non-propagated contractions (most common), and propagated contractions." — Ajay Hall (clinical) [Ep 104 · 6:05](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=365)
- "High-amplitude propagated contractions (HAPCs) move stool along the length of the colon and correspond to what radiologists see on contrast enema as mass movement." — Ajay Hall (clinical) [Ep 104 · 6:26](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=386)
- "The orthocolonic reflex (stimulus to colonic motility upon waking) and the gastrocolonic reflex (stimulus upon eating) affect colonic contractions." — Ajay Hall (clinical) [Ep 104 · 6:45](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=405)
- "Sennosides or bisacodyl can be used to induce high-amplitude propagated contractions." — Rod Gerardo (clinical) [Ep 104 · 6:54](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=414)
- "The majority of HAPCs originate in the proximal colon, most do not propagate beyond the midcolon, and fewer than 5% reach the rectum." — Ajay Hall (clinical) [Ep 104 · 7:05](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=425)
- "When an HAPC occurs, the internal anal sphincter should relax (choloanal reflex) to allow stool evacuation." — Rod Gerardo (clinical) [Ep 104 · 7:15](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=435)
- "Manometry catheters are typically placed during endoscopy, which allows evaluation of the colonic mucosa, though interventional radiologists can also place them under fluoroscopy." — Ajay Hall (clinical) [Ep 104 · 7:48](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=468)
- "The rectal motor complex appears as multiple small spikes on manometry tracings at the level of the rectum." — Ajay Hall (clinical) [Ep 104 · 8:33](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=513)
- "If more than 40 to 50 centimeters of colon does not have HAPCs, that segment is considered dysfunctional colon." — Ajay Hall (clinical) [Ep 104 · 10:16](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=616)
- "Management at Cincinnati Children's prioritizes maximizing medical therapy and understanding anatomic and functional issues before resorting to surgical resection." — Jason Frischer (guideline) [Ep 104 · 10:31](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=631)
- "The first step in management is to maximize stimulant laxatives to ensure evacuation; if that fails, irrigation or enemas are tried, and only then are other surgical interventions discussed." — Ajay Hall (guideline) [Ep 104 · 10:48](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=648)
- "Resection should not be performed immediately based on one abnormal finding; multiple factors must be considered." — Jason Frischer (opinion) [Ep 104 · 11:04](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=664)
- "The first step in evaluating a patient with suspected motility disorder is to ensure normal anatomy, which can be assessed with contrast studies." — Jason Frischer (guideline) [Ep 104 · 12:13](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=733)
- "In a child with gastroparesis, the stomach may appear enlarged on upper GI study." — Ajay Hall (clinical) [Ep 104 · 12:52](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=772)
- "Duodenal and colonic manometry can rule out more widespread dysmotility, which is invaluable information in a patient with an anorectal malformation." — Rod Gerardo (opinion) [Ep 104 · 14:03](https://library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=843)
- "Hirschsprung enterocolitis can occur before surgery, after surgery, and even after successful surgery when patients do not relax their sphincters and hold stool efficiently" — Marc Levitt (clinical) [Ep 105 · 11:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=666)
- "In Hirschsprung enterocolitis, the colon fills with liquid stool with severe bacterial overgrowth, causing fluid loss into the bowel lumen, hypovolemia, and bacterial translocation leading to bacteremia, all with no passage of stool" — Marc Levitt (clinical) [Ep 105 · 10:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=610)
- "Post-pull-through enterocolitis within the first 3 months occurs in about 20% of cases" — Marc Levitt (epidemiological) [Ep 105 · 14:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=848)
- "Any type of pull-through can have a stricture or a twist regardless of the initial type" — Hira Ahmad (clinical) [Ep 105 · 6:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=405)
- "Specific to Soave pull-through, one must consider Soave cuff as a cause of obstruction" — Hira Ahmad (clinical) [Ep 105 · 6:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=419)
- "Specific to Duhamel pull-through, one must consider Duhamel spur or a large distended segment that is not functioning" — Hira Ahmad (clinical) [Ep 105 · 7:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=426)
- "With Swenson pull-through, one could potentially have a stricture and a twist" — Hira Ahmad (clinical) [Ep 105 · 7:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=435)
- "Rehbein procedure can present with a non-functional segment that does not empty" — Hira Ahmad (clinical) [Ep 105 · 7:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=442)
- "The anatomy of the original pull-through could explain the patient's obstructive symptoms and whether there is a fixable problem" — Marc Levitt (clinical) [Ep 105 · 3:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=199)
- "A contrast study is helpful for inferring the original surgery type based on findings when the operative note is unavailable" — Marc Levitt (clinical) [Ep 105 · 7:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=468)
- "In a very ill child, a contrast study would not be the best initial option; resuscitation takes priority" — Rebecca Rentia (clinical) [Ep 105 · 8:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=505)
- "If sedation in the ER does not work for a severely ill patient, one should go to the OR under general anesthesia to irrigate until the child feels better" — Marc Levitt (clinical) [Ep 105 · 16:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1000)
- "In rare circumstances, an ileostomy may be needed to get the child out of trouble, with workup of the pull-through problem deferred" — Marc Levitt (clinical) [Ep 105 · 16:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1010)
- "If a patient with past Hirschsprung diagnosis comes in sick, one must assume Hirschsprung-associated enterocolitis; treatment with rectal irrigations, IV fluids, and antibiotics will not cause harm even if the diagnosis turns out to be different" — Jason Frischer (clinical) [Ep 105 · 12:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=726)
- "Families should not undergo Hirschsprung pull-through surgery until they can demonstrate ability to perform irrigations" — Jason Frischer (opinion) [Ep 105 · 14:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=898)
- "Families should be discharged with supplies (Foley catheter, saline, syringe, bucket) to perform irrigations at home, as this could be life-saving" — Jason Frischer (clinical) [Ep 105 · 15:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=924)
- "Irrigation is the CPR of the colon for Hirschsprung patients" — Rebecca Rentia (opinion) [Ep 105 · 15:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=950)
- "When performing initial rectal exam on a distended Hirschsprung patient, the examiner should step to the side to avoid an explosive release of stool" — Jason Frischer (clinical) [Ep 105 · 4:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=291)
- "The presacral space (space between the hollow of the sacrum and the pull-through) is an important observation on contrast studies" — Marc Levitt (clinical) [Ep 105 · 19:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1154)
- "A lateral view of the rectum on contrast study provides important information and should be obtained" — Jason Frischer (clinical) [Ep 105 · 19:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1186)
- "On contrast enema, if the catheter balloon is over-inflated or inserted too high, distal pathology cannot be easily ascertained" — Rebecca Rentia (clinical) [Ep 105 · 20:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1248)
- "Widened presacral space on contrast study suggests a Soave pull-through" — Jason Frischer (clinical) [Ep 105 · 21:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1300)
- "A dilated colon narrowing over the distal 6 cm with widened presacral space suggests either retained aganglionosis or a long Soave cuff constricting the distal neorectum" — Jason Frischer (clinical) [Ep 105 · 21:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-19-hirschsprung-disease-the-obstructed-patient-part-1-4407?t=1317)
- "Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period" — Marc Levitt (clinical) [Ep 82 · 2:57](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=177)
- "Male babies with perineal fistula may pass meconium and no one notices anything wrong with their anorectal anatomy, typically presenting in the first year of life with severe constipation" — Marc Levitt (clinical) [Ep 82 · 3:06](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=186)
- "A newborn should accept a size 12 Hagar dilator and a 1 year old should accept a size 15" — Marc Levitt (clinical) [Ep 82 · 6:16](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=376)
- "Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation" — Marc Levitt (clinical) [Ep 82 · 4:54](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=294)
- "Patients with uncorrected perineal fistula will soil with loose stool or athletic activity because they cannot completely close the hole when squeezing sphincters" — Marc Levitt (clinical) [Ep 82 · 5:38](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=338)
- "Female perineal fistula diagnosis requires assessment of three criteria: hole size, adequate perineal body, and hole centered in sphincter" — Marc Levitt (clinical) [Ep 82 · 8:02](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=482)
- "If the hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, the patient does not need surgery and the perineal body will lengthen with growth" — Marc Levitt (clinical) [Ep 82 · 8:47](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=527)
- "The standard now is to not check rectal temperature but check temperature on forehead or ear, making it easier to miss anorectal malformations" — Marc Levitt (clinical) [Ep 82 · 4:25](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=265)
- "Rectourethral fistula patients should not be approached primarily because you cannot know where the rectum is (bladder neck, prostatic, or bulbar level)" — Marc Levitt (clinical) [Ep 82 · 12:45](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=765)
- "All rectourethral fistula patients should be managed with colostomy and distal colostogram, except exceedingly rare cases with very low rectum on cross table lateral at 20 hours" — Marc Levitt (clinical) [Ep 82 · 13:20](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=800)
- "Colostomy opened too distal in the sigmoid restricts the ultimate pull-through by location of colostomy or mucous fistula" — Marc Levitt (clinical) [Ep 82 · 17:18](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1038)
- "Incompletely diverting loop colostomies allow stool to spill across and contaminate distal segment, leading to urinary tract infections" — Marc Levitt (clinical) [Ep 82 · 17:45](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1065)
- "Transverse colostomies can prolapse and if there is a large rectourethral fistula, the left colon absorbs all the urine causing acidosis" — Marc Levitt (clinical) [Ep 82 · 18:38](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1118)
- "Proximal sigmoid colostomy leaves entire sigmoid loop for pull-through and only the distal segment can prolapse because left colon is fixed to retroperitoneum" — Marc Levitt (clinical) [Ep 82 · 19:14](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1154)
- "Prolapse is related to mobility of colon proximal or distal to the stoma; ileostomies prolapse frequently because they are free floating unless tacked to anterior abdominal wall" — Marc Levitt (clinical) [Ep 82 · 20:04](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1204)
- "Mark the anoplasty location on skin surface before making incision to avoid getting lost when looking at jumping muscles from stimulator" — Marc Levitt (clinical) [Ep 82 · 21:30](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1290)
- "Really good surgeons have put anuses in wrong places because they do not have sense of center once everything is disrupted and open" — Marc Levitt (clinical) [Ep 82 · 23:04](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1384)
- "Common distal colostogram mistake is not giving enough contrast or pressure, creating false impression that rectum is high with no fistula" — Marc Levitt (clinical) [Ep 82 · 24:11](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1451)
- "If you see flattening of rectum corresponding to pubococcygeal line, the radiologist did not give enough contrast or pressure to overcome the sphincters" — Marc Levitt (clinical) [Ep 82 · 24:26](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1466)
- "Fistula location can be determined by viewing urethra as reverse C or elbow: at or below elbow is bulbar, above elbow is prostatic, at bladder neck is bladder neck fistula" — Marc Levitt (clinical) [Ep 82 · 25:23](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1523)
- "Bulbous rectum might be reachable posterior sagittally and hard laparoscopically; tapered rectum is better approached laparoscopically" — Marc Levitt (clinical) [Ep 82 · 25:58](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1558)
- "Opening posterior sagittally without knowing where rectum is will lead to finding whitish shiny structures that are urinary tract (bladder neck) rather than rectum" — Marc Levitt (clinical) [Ep 82 · 27:00](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1620)
- "Bulbar and low prostatic rectums with bulge are more easily approached posterior sagittally; high prostatic tapered rectums and bladder neck fistulas are best served by laparoscopy" — Marc Levitt (clinical) [Ep 82 · 30:09](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1809)
- "Attempting laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level risks leaving behind remnant of original fistula (roof)" — Marc Levitt (clinical) [Ep 82 · 30:43](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1843)
- "Laparoscopy replaces laparotomy, not PSARP; should do mini-PSARP with laparoscopy to safely enter pelvis and tack rectum to posterior muscle complex to avoid prolapse" — Marc Levitt (clinical) [Ep 82 · 31:48](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1908)
- "Prolapse occurs in about 3% of cases, particularly in those without great muscles" — Marc Levitt (epidemiological) [Ep 82 · 33:35](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2015)
- "Rectal prolapse causes bleeding, mucus, and can inhibit bowel control in patients with good potential because they cannot close opening with prolapsed tissue through it" — Marc Levitt (clinical) [Ep 82 · 33:58](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2038)
- "Prolapse more than 3 millimeters should be treated; ideal time is when patient still has colostomy" — Marc Levitt (clinical) [Ep 82 · 34:25](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2065)
- "Circumferential prolapse can be trimmed in two stages (half circumference each) in ambulatory settings, avoiding hospitalization and not requiring dilation because half circumference is untouched" — Marc Levitt (clinical) [Ep 82 · 34:48](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2088)
- "Key to preventing perineal body dehiscence is mobilizing rectum well to get anterior rectal wall completely separated from posterior vaginal wall to areolar plane, avoiding tension on anoplasty" — Marc Levitt (clinical) [Ep 82 · 35:41](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2141)
- "Perineal body dehiscence is the most common cause of reoperation in female ARM repairs" — Marc Levitt (epidemiological) [Ep 82 · 36:03](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2163)
- "Traditional management is NPO for 7 days on 10% dextrose; recently trialing clear liquids only for a week because major problem is hard stool, not stool volume" — Marc Levitt (clinical) [Ep 82 · 36:35](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2195)
- "If perineal body dehiscence is detected on days 5-8, can salvage by taking patient back to OR to re-suture; by 3-4 weeks later, entire perineal body is dehisced and nothing can be done" — Marc Levitt (clinical) [Ep 82 · 37:48](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2268)
- "High rectums, particularly bladder neck fistulas, require preservation of IMA because colostomy may have disrupted collaterals down left colic, making rectum completely dependent on IMA" — Marc Levitt (clinical) [Ep 82 · 39:20](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2360)
- "Rectum has excellent intramural blood supply from IMA; taking IMA or branches too close to aorta will cause rectal necrosis without left colic collateralization" — Marc Levitt (clinical) [Ep 82 · 39:47](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2387)
- "ARM continence potential is determined by three factors: original malformation type, quality of sacrum with calculated sacral ratio, and quality of spine" — Marc Levitt (clinical) [Ep 82 · 42:14](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2534)
- "Bulbar fistula with good sacrum (sacral ratio of 1) and normal spine should absolutely have bowel control" — Marc Levitt (clinical) [Ep 82 · 43:19](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2599)
- "Bladder neck fistula with poor sacrum (sacral ratio 0.4) and tethered cord or myelomeningocele has no chance of good bowel control" — Marc Levitt (clinical) [Ep 82 · 43:29](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2609)
- "First step for soiling 4-year-old is to get them clean mechanically with bowel management using enemas; for those with continence potential, try switching to laxatives when older and more mature" — Marc Levitt (clinical) [Ep 82 · 43:54](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2634)
- "Indications for redo procedure include improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum) in patients with any continence potential" — Marc Levitt (clinical) [Ep 82 · 44:39](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2679)
- "Traditional teaching advocates divided colostomy for anorectal malformations to prevent stool flow that could cause urinary tract infections" — Todd Ponsky (guideline) [Ep 1 · 0:08](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-325?t=8)
- "Meta-analysis of multiple studies found no statistical difference in UTI incidence between divided colostomy and loop colostomy" — Todd Ponsky (clinical) [Ep 1 · 0:27](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-325?t=27)
- "Some individual studies showed a difference in UTI rates, but overall meta-analysis showed no statistical difference" — Todd Ponsky (clinical) [Ep 1 · 0:39](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-325?t=39)
- "Loop colostomies had a significantly higher stoma prolapse rate compared to divided colostomies" — Todd Ponsky (clinical) [Ep 1 · 0:51](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-325?t=51)
- "No statistical difference was found between loop and divided colostomy for skin excoriation, stoma retraction, peristomal hernia, wound infection, and stoma stricture" — Todd Ponsky (clinical) [Ep 1 · 1:05](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-325?t=65)
- "Patients with anorectal malformation with good prognosis for bowel control will have well-formed buttocks with good midline groove and good anal dimple; patients with bad prognosis will have flat bottom and no clear delineation of anal dimple" — Andrea Bischoff (clinical) [Ep 81 · 1:52](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=112)
- "In a newborn baby one should be able to accommodate a number 12 Hegar dilator for a normal caliber anus" — Andrea Bischoff (clinical) [Ep 81 · 2:31](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=151)
- "8% of patients with anorectal malformation will have esophageal atresia" — Andrea Bischoff (epidemiological) [Ep 81 · 5:01](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=301)
- "30% of patients with anorectal malformation will have cardiac anomalies, but in only 10% of them these anomalies are hemodynamically significant" — Andrea Bischoff (epidemiological) [Ep 81 · 5:27](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=327)
- "50% of patients with anorectal malformation have associated urological defects" — Andrea Bischoff (epidemiological) [Ep 81 · 5:54](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=354)
- "25% of patients with anorectal malformation have tethered cord" — Andrea Bischoff (epidemiological) [Ep 81 · 6:02](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=362)
- "Cross-table lateral film should never be done before 24 hours of life because it will give false impression of high malformation due to muscle tone" — Andrea Bischoff (clinical) [Ep 81 · 7:17](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=437)
- "Spinal ultrasound is adequate until 3 months of age; after that MRI is needed due to ossification process to correctly see tethered cord" — Andrea Bischoff (clinical) [Ep 81 · 8:22](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=502)
- "Tethered cord has more influence on urinary tract rather than gastrointestinal tract in terms of prognosis" — Andrea Bischoff (clinical) [Ep 81 · 8:47](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=527)
- "Presacral masses are most commonly found in malformations with good prognosis such as rectal perineal fistula, rectal vestibular fistula, and rectal atresia, but when present the prognosis changes" — Andrea Bischoff (clinical) [Ep 81 · 9:53](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=593)
- "Advantage of primary newborn repair is that bowel preparation is not required since meconium is considered sterile" — Andrea Bischoff (clinical) [Ep 81 · 11:55](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=715)
- "It is better to open a colostomy and have a perfect operation than to do a primary repair, have a complication such as dehiscence retraction that requires re-operation" — Andrea Bischoff (opinion) [Ep 81 · 12:20](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=740)
- "Patients with anorectal malformation have one chance to have the right operation; secondary operations or re-operations usually change the prognosis for bowel control" — Andrea Bischoff (clinical) [Ep 81 · 12:33](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=753)
- "Vestibular fistula is the most common type of anorectal malformation anomaly" — Andrea Bischoff (epidemiological) [Ep 81 · 13:36](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=816)
- "Cloaca patients have never been seen with disorder of sexual differentiation; they are all females with normal ovaries" — Andrea Bischoff (clinical) [Ep 81 · 25:23](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1523)
- "Cloacas with common channel less than 3 centimeters can be repaired posterior sagittally with total urogenital mobilization" — Andrea Bischoff (clinical) [Ep 81 · 26:56](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1616)
- "Rectal perineal fistula patients with normal sacrum and no tethered cord have 100% chance of bowel control" — Andrea Bischoff (clinical) [Ep 81 · 28:08](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1688)
- "Malformations with better prognosis for bowel control will suffer from more constipation" — Andrea Bischoff (clinical) [Ep 81 · 28:18](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1698)
- "Rectal vestibular fistula patients with normal sacrum and no tethered cord have 95% chance of bowel control" — Andrea Bischoff (clinical) [Ep 81 · 28:40](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1720)
- "Rectal urethral bulbar fistula patients have 85% chance of bowel control" — Andrea Bischoff (clinical) [Ep 81 · 28:57](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1737)
- "Anorectal malformation without fistula patients have 80% chance of bowel control" — Andrea Bischoff (clinical) [Ep 81 · 29:02](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1742)
- "Rectal urethral prostatic fistula patients have 60% chance of bowel control" — Andrea Bischoff (clinical) [Ep 81 · 29:08](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1748)
- "Rectal bladder neck fistula patients have 20% chance of bowel control" — Andrea Bischoff (clinical) [Ep 81 · 29:14](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1754)
- "Cloaca with common channel less than 3 centimeters and normal sacrum have generally about 70% chance of bowel control" — Andrea Bischoff (clinical) [Ep 81 · 29:24](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1764)
- "The only indication to keep a colostomy would be incapacity to form solid stool" — Andrea Bischoff (guideline) [Ep 81 · 29:57](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1797)
- "Patients prefer the quality of life of a pull through with bowel management rather than with a colostomy" — Andrea Bischoff (opinion) [Ep 81 · 30:20](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1820)
- "All children with anorectal malformations should be out of diapers at the same age that other children are normally out of diapers, usually at 3 years of age in the United States" — Andrea Bischoff (guideline) [Ep 81 · 30:43](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1843)
- "The bowel management for children with bad prognosis consists in finding the enema that completely cleans the colon and allows for the child to be clean of stool in the underwear for 24 hours" — Andrea Bischoff (clinical) [Ep 81 · 31:41](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=1901)
- "Appendicostomy (Malone procedure) is not the treatment for fecal incontinence; the treatment is finding the enema that works for the child. Appendicostomy just gives more independence" — Andrea Bischoff (clinical) [Ep 81 · 40:32](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2432)
- "Disimpaction protocol consists of 3 enemas per day for 3 days; most children are disimpacted after day 3" — Andrea Bischoff (clinical) [Ep 81 · 42:35](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-315?t=2555)
- "Irrigations are probably the best treatment for Hirschsprung disease and it is very rare that Hirschsprung disease is a surgical emergency, but without irrigation it will become an emergency" — Marc Levitt (clinical) [Ep 77 · 8:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=530)
- "Proper irrigation technique requires a large bore tube (20 French Foley), instilling 10-20 cc aliquots of warm saline at a time, moving the tube to and fro, and allowing fluid mixed with stool to drip back" — Marc Levitt (clinical) [Ep 77 · 9:13](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=553)
- "The biggest mistake with irrigations is using too small of a tube and just putting fluid in and letting it sit (an enema), when babies with Hirschsprung disease have no ability to expel enema fluid" — Marc Levitt (clinical) [Ep 77 · 10:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=651)
- "Rectal biopsies must be taken at least 1 centimeter in from the dentate line because everyone has an aganglionic segment at the dentate line and biopsying too close can give a false positive diagnosis" — Marc Levitt (clinical) [Ep 77 · 12:38](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=758)
- "The pathologist must confirm both the absence of ganglion cells AND the presence of hypertrophic nerves; absence of ganglion cells alone is not Hirschsprung disease as that could be a biopsy taken too low" — Marc Levitt (clinical) [Ep 77 · 13:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=803)
- "Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia due to an immune component that makes the bowel mucosa more susceptible to translocation" — Marc Levitt (clinical) [Ep 77 · 14:35](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=875)
- "When irrigations fail and the baby is ill, diversion should be done at the ileum rather than a leveling colostomy, especially without reliable frozen section pathology" — Marc Levitt (clinical) [Ep 77 · 15:42](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=942)
- "Frozen section results can be inaccurate, particularly for transition zones higher in the colon, making permanent section more reliable for determining resection level" — Marc Levitt (clinical) [Ep 77 · 16:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1000)
- "The Swenson operation was done incorrectly historically with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence" — Marc Levitt (clinical) [Ep 77 · 18:17](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1097)
- "The Soave procedure involves a mucosal dissection inside the outer rectal wall to avoid injuring pelvic nerves, which was quite brilliant" — Marc Levitt (clinical) [Ep 77 · 19:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1159)
- "Of the four classic procedures (Swenson, Soave, Duhamel, Rebein), only the Swenson actually leaves behind virtually no Hirschsprung tissue" — Marc Levitt (clinical) [Ep 77 · 21:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1278)
- "Many patients with residual aganglionic bowel (from Soave, Duhamel, or Rebein) did perfectly well because ganglionic bowel, if it's good, can overcome a lot" — Marc Levitt (clinical) [Ep 77 · 21:43](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1303)
- "The transanal Swenson is the preferred approach because it is the purest operation, leaving behind no Hirschsprung except at the very bottom just above the dentate line" — Marc Levitt (opinion) [Ep 77 · 25:34](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1534)
- "If you find the right plane for transanal Swenson it's elegant and bloodless, but if you find the wrong plane you can really injure the patient by dissecting too wide" — Marc Levitt (clinical) [Ep 77 · 26:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1570)
- "Overly aggressive transanal-only approach trying to reach the transition zone without laparoscopy has resulted in significant morbidity" — Marc Levitt (clinical) [Ep 77 · 28:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1730)
- "Transanal-only approach is appropriate when there is a very reachable transition zone comfortably at mid-sigmoid and the transition zone is obvious" — Marc Levitt (clinical) [Ep 77 · 29:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1758)
- "Prone positioning for transanal approach is preferred because the tough anterior dissection becomes easier when looking down on it rather than up at it" — Marc Levitt (opinion) [Ep 77 · 29:52](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1792)
- "Total colonic Hirschsprung patients present differently: diagnosis isn't made right away, contrast study is not typical, and irrigations don't go well" — Marc Levitt (clinical) [Ep 77 · 31:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1878)
- "The biggest problem in technique is surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or they overstretch the sphincters with aggressive exposure" — Marc Levitt (clinical) [Ep 77 · 33:55](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2035)
- "The dissection must start 1 centimeter proximal to the dentate line, which by definition leaves behind 1 centimeter of aganglionic columnar epithelium and the internal sphincter, but ganglionic bowel can overcome this" — Marc Levitt (clinical) [Ep 77 · 35:42](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2142)
- "Sequential stitches placed at the 6 o'clock position (in prone) as the bowel is pulled out helps maintain alignment and prevents twisting of the pull-through" — Marc Levitt (clinical) [Ep 77 · 48:34](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2914)
- "Seromuscular laparoscopic biopsies can show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa, potentially leading to a transition zone pull-through" — Marc Levitt (clinical) [Ep 77 · 40:48](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2448)
- "Normal nerve size is 40 microns or less; anything bigger than 40 microns indicates transition zone bowel requiring higher resection" — Marc Levitt (clinical) [Ep 77 · 44:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2645)
- "The concept of going 5 centimeters above the transition zone is inaccurate because transition zone is a spectrum ranging from 3 to 10 centimeters" — Marc Levitt (clinical) [Ep 77 · 44:14](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2654)
- "Taking the IMA and preserving the marginal arcade makes the left colon and sigmoid straight down into the perineum, creating an easy-to-irrigate configuration" — Marc Levitt (clinical) [Ep 77 · 45:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2751)
- "Many patients have not had enough of a pull-through when the entire sigmoid loop is still present, requiring redo surgery to remove more bowel" — Marc Levitt (clinical) [Ep 77 · 46:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2765)
- "For transition zones proximal to the splenic flexure, colonic biopsies and ileostomy should be performed rather than relying on frozen section, which is notoriously fraught with errors in these cases" — Marc Levitt (clinical) [Ep 77 · 46:46](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2806)
- "Postoperative feeding should be delayed until the abdomen is absolutely soft and flat with bowel function, usually 3-4 days, to prevent enterocolitis readmission" — Marc Levitt (clinical) [Ep 77 · 53:06](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3186)
- "Abdominal distention can be subclinical, so an X-ray should be obtained before feeding to confirm the bowel is decompressed" — Marc Levitt (clinical) [Ep 77 · 53:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3203)
- "Families must be taught irrigation technique preoperatively and made paranoid about distention so they will seek care immediately if it develops" — Marc Levitt (clinical) [Ep 77 · 54:02](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3242)
- "Anal calibration (not true dilation) should be performed at one month using Hegar dilators, as the stimulation helps the baby more successfully empty" — Marc Levitt (clinical) [Ep 77 · 54:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3268)
- "For hepatic flexure transition zones, the entire right colon must be taken down, the ileocolic vessel preserved, and the colon de-rotated so the cecum is at the hepatic liver bed to achieve adequate length" — Marc Levitt (clinical) [Ep 77 · 57:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3425)
- "When bringing de-rotated colon down the left side of the abdomen, the ligament of Treitz must be mobilized to prevent the mesenteric vessel from draping across the third portion of the duodenum and causing obstruction" — Marc Levitt (clinical) [Ep 77 · 57:57](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3477)
- "The vast majority of patients with Hirschsprung's disease do extremely well after pull-through with no emptying problems and normal bowel control" — Marc Levitt (clinical) [Ep 79 · 3:29](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=209)
- "Problem patients divide into two types: obstruction patients who do not empty, and soiling patients" — Marc Levitt (clinical) [Ep 79 · 3:37](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=217)
- "Babies have very tight sphincters capable of keeping sphincters tight for many hours, leading to enterocolitis even after perfectly done pull-through" — Marc Levitt (clinical) [Ep 79 · 4:25](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=265)
- "After about age one, patients should learn to empty and relax sphincters with more normal bowel movement pattern" — Marc Levitt (clinical) [Ep 79 · 4:59](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=299)
- "Evaluation of obstructed post-pull-through patient involves contrast study of colon and examination under anesthesia" — Marc Levitt (clinical) [Ep 79 · 5:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=320)
- "Anatomic causes of obstruction include distal stricture, obstructing cuff, atonic Duhamel pouch, twisted pull-through, and dilated segment" — Marc Levitt (clinical) [Ep 79 · 5:38](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=338)
- "Soave cuff has been getting shorter as most surgeons do Soave pull-throughs" — Marc Levitt (epidemiological) [Ep 79 · 5:56](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=356)
- "Aganglionic outer rectal wall (cuff) that is not properly split, fused, or scarred can cause obstruction" — Marc Levitt (clinical) [Ep 79 · 6:08](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=368)
- "Pull-through can be twisted up to 360 degrees leading to obstruction" — Marc Levitt (clinical) [Ep 79 · 6:41](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=401)
- "Pathologic cause of obstruction is pull-through not done to ganglionated bowel with normal sized nerves" — Marc Levitt (clinical) [Ep 79 · 7:14](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=434)
- "Nerve roots should be no bigger than 40 microns; anything larger is transition zone bowel that might not function" — Marc Levitt (clinical) [Ep 79 · 7:52](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=472)
- "Treatment for enterocolitis includes hydration, intravenous metronidazole (Flagyl), and aggressive irrigations 2-3 times daily" — Marc Levitt (clinical) [Ep 79 · 8:45](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=525)
- "Irrigation volume is 10-20 ccs per cycle using size 20-22 Foley catheter, moving tube to wash inside of colon" — Marc Levitt (clinical) [Ep 79 · 9:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=563)
- "Metronidazole has same efficacy IV or PO because in both cases it is excreted in bile" — Marc Levitt (clinical) [Ep 79 · 11:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=681)
- "In diverted colon with ileostomy, Flagyl will not work for C. difficile colitis because drug does not reach colon; vancomycin enemas needed instead" — Marc Levitt (clinical) [Ep 79 · 11:32](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=692)
- "Approximately 15-20% of patients can have enterocolitis episode within first year after pull-through" — Marc Levitt (epidemiological) [Ep 79 · 12:13](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=733)
- "After one year post-pull-through, patients should not be having enterocolitis; if they are, seek anatomic or pathologic explanation" — Marc Levitt (clinical) [Ep 79 · 12:26](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=746)
- "On contrast study, pull-through should hug the sacrum; diversion forward suggests space-occupying mass which may be a cuff" — Marc Levitt (clinical) [Ep 79 · 13:09](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=789)
- "Obstructing cuff can be felt on digital rectal exam as rubbery thick rubber band structure around pull-through outside the lumen, along hollow of sacrum" — Marc Levitt (clinical) [Ep 79 · 16:34](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=994)
- "Cuff is outside the pull-through and cannot be detected intraluminally with scopes" — Marc Levitt (clinical) [Ep 79 · 17:02](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1022)
- "Biopsy should be taken 1 cm above dentate line and sent for permanent section to assess ganglion cell quality and nerve size" — Marc Levitt (clinical) [Ep 79 · 17:22](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1042)
- "Transition zone pull-through with hypertrophic nerves requires redo pull-through" — Marc Levitt (clinical) [Ep 79 · 18:17](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1097)
- "Redo pull-through approach is prone and supine transanal dissection with preservation of anal canal and dentate line, full thickness dissection of pull-through, and removal of cuff" — Marc Levitt (clinical) [Ep 79 · 18:27](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1107)
- "For obstructing cuff, dissect between bowel and cuff, then make second plane outside cuff in Swenson plane to remove muscular tissue" — Marc Levitt (clinical) [Ep 79 · 20:31](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1231)
- "Do not need to remove entire cuff circumferentially; breaking the ring posteriorly and laterally solves the problem while avoiding anterior structures" — Marc Levitt (clinical) [Ep 79 · 21:22](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1282)
- "Successful myectomies may have been cutting Soave cuff rather than internal sphincter, though surgeons thought they were cutting sphincter" — Marc Levitt (opinion) [Ep 79 · 21:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1311)
- "Myectomies performed by 10 different surgeons would all look different because of varying concepts of what is being cut" — Marc Levitt (opinion) [Ep 79 · 22:09](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1329)
- "Myectomies can hurt skeletal muscle and leave patient incontinent" — Marc Levitt (clinical) [Ep 79 · 22:43](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1363)
- "Number of Hirschsprung patients have tight sphincters with powerful internal sphincter that fails to relax, confirmed by anorectal manometry" — Marc Levitt (clinical) [Ep 79 · 24:16](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1456)
- "Post pull-through sphincter problems are relatively rare compared to anatomic problems" — Marc Levitt (opinion) [Ep 79 · 24:34](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1474)
- "Sphincter-mediated obstruction is relatively rare in children over one year of age" — Marc Levitt (clinical) [Ep 79 · 25:22](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1522)
- "Botox acts as temporary myectomy and is preferred over permanent myectomy because it wears off as child learns sphincter coordination" — Marc Levitt (clinical) [Ep 79 · 25:35](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1535)
- "Botox at 4-8 weeks combined with aggressive laxatives helps children learn appropriate bowel movement pattern" — Marc Levitt (clinical) [Ep 79 · 26:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1579)
- "Botox provides temporary improvement for cuff problems but patients will recur because cuff must be removed for long-term fix" — Marc Levitt (clinical) [Ep 79 · 26:45](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1605)
- "Anorectal manometry can distinguish sphincter dysfunction (1 cm high tone) from sphincter plus cuff obstruction (3-4 cm high tone)" — Marc Levitt (clinical) [Ep 79 · 27:17](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1637)
- "Twisted pull-through requires dissection in Swenson plane around pull-through up to peritoneal reflection, often requiring laparotomy for mobilization" — Marc Levitt (clinical) [Ep 79 · 28:01](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1681)
- "Redo Duhamel is probably the hardest operation in Hirschsprung disease due to pelvic fibrosis from stapled connection" — Marc Levitt (opinion) [Ep 79 · 30:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1818)
- "Redo Duhamel requires combined transanal and deep pelvic dissection using St. Mark's lighted retractor, removing pouch and doing Swenson-format redo" — Marc Levitt (clinical) [Ep 79 · 31:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1860)
- "All patients with Hirschsprung disease should be able to empty spontaneously and should be clean" — Marc Levitt (opinion) [Ep 79 · 33:15](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=1995)
- "Concept that Hirschsprung patients will eventually get better as teenagers is wrong; must address emptying and cleanliness issues earlier" — Marc Levitt (opinion) [Ep 79 · 33:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2003)
- "Patients with Hirschsprung disease are born with normal anal canal and normal sphincters; if anything, sphincters are too good" — Marc Levitt (clinical) [Ep 79 · 33:48](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2028)
- "No Hirschsprung patient is born with missing anal canal or weak sphincter" — Marc Levitt (clinical) [Ep 79 · 33:59](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2039)
- "Soiling Hirschsprung patients with destroyed anal canal or weak sphincter have iatrogenic injury from transanal dissection started too low, invading dentate line" — Marc Levitt (clinical) [Ep 79 · 34:08](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2048)
- "Overstretching during surgery can destroy sphincter, causing patient to sit with open anus even when awake" — Marc Levitt (clinical) [Ep 79 · 34:57](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2097)
- "Laparoscopy avoids deep transanal work and reduces risk of sphincter injury compared to aggressive transanal dissection" — Marc Levitt (opinion) [Ep 79 · 35:04](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2104)
- "Capacity for bowel control in Hirschsprung patients is determined by whether sphincters and anal canal are intact" — Marc Levitt (clinical) [Ep 79 · 41:35](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2495)
- "Patients with intact sphincters and anal canal have every reason to expect normal bowel control" — Marc Levitt (clinical) [Ep 79 · 41:42](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2502)
- "Soiling patients with capacity for bowel control can usually be treated with medicines; those without capacity need enema programs" — Marc Levitt (clinical) [Ep 79 · 41:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2511)
- "Enema volume (low vs high) is based on caliber of colon on contrast study" — Marc Levitt (clinical) [Ep 79 · 42:03](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2523)
- "Surgical management for patients without bowel control capacity is Malone appendicostomy or cecostomy" — Marc Levitt (clinical) [Ep 79 · 42:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-ii-with-dr-marc-levitt-310?t=2550)
- "Traditional teaching advocates divided colostomy for anorectal malformations to prevent stool flow that could cause urinary tract infections" — Todd Ponsky (guideline) [Ep 3 · 0:08](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-398?t=8)
- "Meta-analysis of multiple studies found no statistical difference in UTI incidence between divided colostomy and loop colostomy" — Todd Ponsky (clinical) [Ep 3 · 0:27](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-398?t=27)
- "Some individual studies showed a difference in UTI rates, but overall meta-analysis showed no statistical difference" — Todd Ponsky (clinical) [Ep 3 · 0:39](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-398?t=39)
- "Loop colostomies had a significantly higher stoma prolapse rate compared to divided colostomies" — Todd Ponsky (clinical) [Ep 3 · 0:51](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-398?t=51)
- "No statistical difference was found between loop and divided colostomy for skin excoriation, stoma retraction, peristomal hernia, wound infection, and stoma stricture" — Todd Ponsky (clinical) [Ep 3 · 1:05](https://library.globalcastmd.com/watch/challenging-dogma-does-colostomy-type-matter-398?t=65)
- "Primary repair for vestibular fistula is preferred around 5-7 days of life" (clinical) [Ep 5 · 0:34](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=34)
- "Primary repair can be performed up to 3-4 months of age in vestibular fistula cases" — Marcella (clinical) [Ep 5 · 1:30](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=90)
- "Patients repaired with classical 3-stage operations have beautiful perineum and perfect function in teenage follow-up" — Marcella (clinical) [Ep 5 · 2:28](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=148)
- "Primary repairs performed 7-8 years ago show more stenosis and adhesions due to feces passing through during healing" — Marcella (clinical) [Ep 5 · 2:57](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=177)
- "Vestibular fistula patients with normal sacrum and no cord have excellent prognosis with good operation" (clinical) [Ep 5 · 3:46](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=226)
- "Operating within first 72 hours before baby eats prevents colonization and improves outcomes" (clinical) [Ep 5 · 4:34](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=274)
- "For babies 6 months old with megacolon, clean colon with GoLightly and keep NPO 7-10 days on parenteral nutrition" (clinical) [Ep 5 · 4:58](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=298)
- "Oval-shaped anus without perianal radiations is characteristic of Currarino syndrome" — Sabine (clinical) [Ep 5 · 6:35](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=395)
- "Presacral mass occurs in 30-40% of anal stenosis or rectal atresia cases" (epidemiological) [Ep 5 · 8:38](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=518)
- "MRI is the best way to demonstrate presacral mass" (clinical) [Ep 5 · 8:45](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=525)
- "Opening colostomy in mobile portion of colon guarantees prolapse" (clinical) [Ep 5 · 12:23](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=743)
- "Opening colostomy in fixed portion of colon prevents prolapse" (clinical) [Ep 5 · 12:39](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=759)
- "Loop colostomies are never completely diverting" (clinical) [Ep 5 · 14:37](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=877)
- "Spillage across loop colostomy causes urinary tract infections in patients with fistulas" (clinical) [Ep 5 · 15:09](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=909)
- "Transverse colostomy dysfunctionalizes very long piece of colon" (clinical) [Ep 5 · 16:19](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=979)
- "Difficult to demonstrate fistula on distal colostogram through transverse colostomy due to inability to generate adequate hydrostatic pressure" (clinical) [Ep 5 · 16:27](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=987)
- "Colon perforation with distal colostogram occurs mainly through transverse colostomy" (clinical) [Ep 5 · 16:58](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1018)
- "Cleaning distal colon through transverse colostomy is almost impossible" (clinical) [Ep 5 · 17:07](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1027)
- "With transverse colostomy and rectourinary fistula, urine gets trapped in colon, is absorbed, and causes hyperchloremic acidosis" (clinical) [Ep 5 · 17:30](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1050)
- "More dilated the rectal pouch, the more constipation the patient will have" (clinical) [Ep 5 · 17:59](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1079)
- "Direct relationship exists between degree of megacolon and degree of constipation" (clinical) [Ep 5 · 18:40](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1120)
- "Distal sigmoid colostomy makes laparoscopic operation more difficult" (clinical) [Ep 5 · 20:36](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1236)
- "Abdominal mass in midline of cloaca patient is most likely hydrocolpos" (clinical) [Ep 5 · 24:31](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1471)
- "Hydrocolpos compresses trigon of bladder producing acquired ureterovesical obstruction" (clinical) [Ep 5 · 25:56](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1556)
- "Draining hydrocolpos causes hydronephrosis to disappear" (clinical) [Ep 5 · 26:18](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1578)
- "Consequences of not draining hydrocolpos are urosepsis and infected hydrocolpos (pyocolpos) with permanent vaginal damage" (clinical) [Ep 5 · 27:10](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1630)
- "Curled pigtail tubes are best for hydrocolpos drainage because hydrocolpos recedes into pelvis over months and straight tubes fall out" (clinical) [Ep 5 · 28:14](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1694)
- "Vesicostomy is indicated when common channel is so narrow that bladder cannot empty" (clinical) [Ep 5 · 30:49](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-ii-pediatric-colorectal-416?t=1849)
- "Surgical goals for anorectal malformations are to find the distal rectum, manage the fistula, avoid leaving distal rectum behind, mobilize the rectum with good blood supply, and place it within the sphincter mechanism" — Mark (clinical) [Ep 6 · 0:22](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=22)
- "Literature comparing PSARP to laparoscopy almost never comments on the exact malformation type or the status of the spine or sacrum" — Mark (opinion) [Ep 6 · 0:46](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=46)
- "Without knowing the exact anatomy and the status of the sacrum and spine, you cannot make judgments about the prognosis of a patient" — Mark (clinical) [Ep 6 · 1:01](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=61)
- "In a series of 24 laparoscopic cases, bulbar fistulas are no longer approached laparoscopically because the benefits do not justify the longer operative time compared to PSARP" — ALP (opinion) [Ep 6 · 1:51](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=111)
- "Bladder neck fistulas are approached with laparoscopy as it is a nice easy way of doing it" — ALP (opinion) [Ep 6 · 2:16](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=136)
- "Anal stenosis at the cutaneous junction level occurred in approximately one in three laparoscopic patients, requiring anoplasty" — ALP (clinical) [Ep 6 · 2:40](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=160)
- "Long dissection line and ischemic changes may have contributed to anal stenosis in laparoscopic cases" — ALP (opinion) [Ep 6 · 2:59](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=179)
- "Poor follow-up and inadequate dilatation programs contributed to anal stenosis in a 24-case laparoscopic series" — ALP (clinical) [Ep 6 · 3:08](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=188)
- "During laparoscopic dissection, a catheter is placed from the rectal side of the fistula orifice into the urethra to measure residual fistula length and guide dissection until the fistula is divided approximately 5 millimeters from the urethra" — Yama (clinical) [Ep 6 · 3:49](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=229)
- "For low fistulas, a combined approach using laparoscopy and modified PSARP keeping the sphincter intact is preferred because it is difficult to close the fistula and remnants could cause post-operative diverticulum" — Longley (clinical) [Ep 6 · 4:39](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=279)
- "For rectal bulbar fistula, grasping the distal rectum makes the fistula become shallow and accessible from the abdominal cavity, allowing dissection of the mucosa while leaving the muscular cuff intact to avoid nerve damage" — Longley (clinical) [Ep 6 · 5:56](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=356)
- "If the mucosa is resected completely to the most distal part of the rectum, urethral fistula rarely occurs after laparoscopic operation even without ligation or suturing of the fistula" — Longley (clinical) [Ep 6 · 6:58](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=418)
- "All three fistula types (bladder neck, prostatic, bulbar) are indicated for laparoscopic approach with results comparable to posterior sagittal approach" — Longley (opinion) [Ep 6 · 7:27](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=447)
- "Current laparoscopic instruments are grotesque and rude, but refined instruments are expected in the future" — Pena (opinion) [Ep 6 · 8:15](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=495)
- "When discussing anorectal malformations, the archaic classification into high, intermediate, and low should not be used" — Pena (guideline) [Ep 6 · 9:12](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=552)
- "Evaluation must include the quality of the sacrum and whether the patient has tethered cord when comparing results" — Pena (guideline) [Ep 6 · 9:36](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=576)
- "The advantage of laparoscopy is avoiding laparotomy and the associated pain" — Pena (clinical) [Ep 6 · 9:55](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=595)
- "Some prostatic fistulas that appear accessible on distal colostogram may be more accessible laparoscopically than from below" — Pena (clinical) [Ep 6 · 10:12](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=612)
- "Bulbar fistula repair via PSARP takes approximately one and a half hours with minimal pain, same-day oral intake, and 48-hour discharge with excellent results" — Pena (clinical) [Ep 6 · 10:56](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=656)
- "Patients referred after laparoscopic repair of bulbar fistulas have presented with huge posterior urethral diverticula and metallic staples in the pelvis with associated complications" — Pena (clinical) [Ep 6 · 11:14](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=674)
- "Smaller rectums with prostatic fistulas are easier to dissect and free from the urethra laparoscopically" — Evo (clinical) [Ep 6 · 12:06](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=726)
- "Larger rectums are easier to access from below via PSARP" — Evo (opinion) [Ep 6 · 12:26](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=746)
- "Bulbar fistulas are more easily approached from below because they are very close and do not require a laparoscope" — Evo (opinion) [Ep 6 · 12:51](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=771)
- "Smaller fistulas, especially bladder neck and prostatic fistulas, are appropriate for laparoscopy" — Evo (opinion) [Ep 6 · 13:00](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=780)
- "Laparoscopy is combined with a small PSARP incision (mini PSARP) to place the rectum exactly in the sphincter and muscle complex" — Evo (clinical) [Ep 6 · 13:10](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=790)
- "When the rectum is very low and bulging, it is very difficult transabdominally to dissect the distal rectum elegantly, mobilize enough rectum, and avoid urethral injury, whereas posterior sagittal provides beautiful exposure" — Mark (clinical) [Ep 6 · 13:48](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=828)
- "A high rectum is easier to access transabdominally and laparoscopy is the perfect route for that anatomy" — Mark (clinical) [Ep 6 · 14:15](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=855)
- "When discussing cases, the fistula type (bladder neck, prostatic, or bulbar), sacral quality, and spinal quality must be documented to allow meaningful comparison of results" — Mark (guideline) [Ep 6 · 14:38](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=878)
- "Patient prognosis is based on the malformation type, spine quality, and sacrum quality regardless of surgical approach, provided the operation is done well with adequate rectal mobilization, fistula disconnection, and no retained distal rectum" — Mark (clinical) [Ep 6 · 14:59](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=899)
- "Robotic surgery provides a fantastic three-dimensional view and allows reproduction of hand movements and fine instrument control through digital instruments" — Pena (clinical) [Ep 6 · 15:41](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=941)
- "The future of laparoscopy involves digital instruments that enable fine movements for quick and safe operations" — Pena (opinion) [Ep 6 · 16:17](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=977)
- "In laparoscopic-assisted PSARP, the procedure starts with laparoscopy to mobilize the distal rectum and ligate the fistula, then the legs are lifted over the baby's head (not returning to prone position) and a posterior sagittal incision is made" — Mark (clinical) [Ep 6 · 17:20](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=1040)
- "The posterior sagittal incision is the safe way to get into the perineum; making a tiny anal incision creates a more dangerous operation" — Mark (clinical) [Ep 6 · 17:42](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=1062)
- "Most injuries have occurred because of blind maneuvers to get into the pelvis" — Mark (clinical) [Ep 6 · 17:52](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=1072)
- "The sphincters do not cross the midline; if the surgeon stays perfectly in the midline and reconstructs them, they work" — Mark (clinical) [Ep 6 · 18:20](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=1100)
- "Patients who had vestibular repairs and trans-anorectal approaches with completely split and reconstructed posterior sagittal incisions remain perfectly continent" — Mark (clinical) [Ep 6 · 18:28](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=1108)
- "The posterior sagittal incision allows tacking the rectum to the posterior edge of the muscle complex, which helps avoid prolapse" — Mark (clinical) [Ep 6 · 18:43](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-iii-pediatric-colorectal-415?t=1123)
- "Low anorectal malformations (bucket-handle, perineal fistula) are typically managed with primary perineoanoplasty at birth in Cape Town" — ALP (clinical) [Ep 4 · 1:31](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=91)
- "The most feared intraoperative complication in repair of low malformations is urethral injury" — Mark (clinical) [Ep 4 · 5:58](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=358)
- "When you see a perineum with visible fistula, you can be fairly confident the rectum is located low, but occasionally you follow the narrow track and find the rectum much higher than expected" — Pena (clinical) [Ep 4 · 6:37](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=397)
- "Perineal fistula is the most common malformation associated with presacral mass" — Pena (clinical) [Ep 4 · 10:22](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=622)
- "All patients with perineal fistulas must have an AP film of the sacrum, not only lateral, to screen for sacral defects and presacral masses" — Pena (guideline) [Ep 4 · 10:02](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=602)
- "Perineal fistula is the malformation that runs most frequently in families; when a patient has presacral mass and sacral defect, all family members should be screened for sacral defects" — Pena (clinical) [Ep 4 · 10:55](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=655)
- "Patients with perineal fistula and presacral mass do not have the same excellent prognosis as isolated perineal fistula" — Pena (clinical) [Ep 4 · 11:32](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=692)
- "In females with anterior perineal fistula, if the anus is adequately sized (12 Hegar dilator), some centers do not operate and follow conservatively" — Sabine (clinical) [Ep 4 · 12:07](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=727)
- "Indications for repair of female perineal fistula include: hole too small, distal aspect is fistula tissue (not mucosa) that will remain stenotic, and to center the opening within the sphincter" — Mark (clinical) [Ep 4 · 13:01](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=781)
- "Unoperated perineal fistulas in females may have problems with loose stool or athletic activity as adults, and adequate perineal body length is important to prevent obstetric injury during vaginal delivery" — Mark (clinical) [Ep 4 · 13:34](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=814)
- "Cutback procedure is an operation for a bad surgeon or a surgeon working under very difficult circumstances with a very sick baby; it is a temporary procedure" — Pena (opinion) [Ep 4 · 14:53](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=893)
- "Babies subjected to cutback procedure will also have bowel control" — Pena (clinical) [Ep 4 · 15:28](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=928)
- "The lower the anorectal malformation, the more severe the constipation; the higher the malformation, the less constipation" — Pena (clinical) [Ep 4 · 15:49](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=949)
- "Patients with low malformations suffer the worst constipation in the spectrum of anorectal malformations, requiring aggressive laxative management with doses 2-10 times more than textbook recommendations" — Pena (clinical) [Ep 4 · 16:18](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=978)
- "In China, surgeons prefer cutback procedure for male perineal fistula because functional results are good and the procedure is easy to perform" — Long Lee (clinical) [Ep 4 · 17:40](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1060)
- "Cross-table lateral film (baby in posterior sagittal position, film on lateral side, beam from opposite side) provides the same image as invertogram without inverting the baby" — Pena (clinical) [Ep 4 · 22:13](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1333)
- "If gas is seen below the coccyx on cross-table lateral film, you can be sure the rectum will be found on posterior sagittal approach" — Pena (clinical) [Ep 4 · 22:39](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1359)
- "Primary repair of high malformations without finding the rectum will cause serious problems for the baby" — Pena (clinical) [Ep 4 · 23:13](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1393)
- "Adult females with unoperated perineal fistula may be psychologically upset about anal opening close to vagina and face risk of serious rectal injury during vaginal delivery" — Pena (clinical) [Ep 4 · 23:41](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1421)
- "For a male newborn at 24 hours with flat buttocks and no visible fistula, the clinical appearance suggests a high malformation and colostomy is recommended as first procedure" — ALP (clinical) [Ep 4 · 24:59](https://library.globalcastmd.com/watch/pediatric-colorectal-contraversies-part-i-pediatric-colorectal-contraversies-417?t=1499)
- "Suction rectal biopsy in a 16-year-old requires adequate submucosa, correct level (normal rectal mucosa, not transitional epithelium), assessment of nerve hypertrophy, cholinesterase staining, and calretinin staining to be considered adequate" — Jack (clinical) [Ep 9 · 1:10](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=70)
- "In very short segment Hirschsprung disease, nerve hypertrophy may not be present" — Jack (clinical) [Ep 9 · 1:34](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=94)
- "The gold standard for diagnosis in infants is suction rectal biopsy, advancing to open trans-anal rectal biopsy if inadequate specimen obtained" (guideline) [Ep 9 · 2:25](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=145)
- "In 16-year-olds with new diagnosis of Hirschsprung disease, the colon is almost always very dilated" — Jack (clinical) [Ep 9 · 5:21](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=321)
- "For older children with dilated colons, a stoma for approximately six months to decompress the colon followed by Duhamel procedure is the typical approach" — Jack (clinical) [Ep 9 · 5:36](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=336)
- "Pulling a dilated rectum through the anus using transanal technique requires too much stretching of the sphincter" — Jack (clinical) [Ep 9 · 5:49](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=349)
- "In older children, even with less dilated colon, the rectum will be very thick and pulling it through the anus will require excessive sphincter stretching" — Jack (clinical) [Ep 9 · 6:17](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=377)
- "When disease is very low (ultra-short segment), the functional result of surgery may not justify intervention based on pathology alone" — Bob (opinion) [Ep 9 · 6:37](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=397)
- "It is difficult to explain only two stools per month with a colon appearance like the one shown if the obstruction is truly at the anus" — Bob (clinical) [Ep 9 · 7:47](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=467)
- "Botox is not a good treatment for established Hirschsprung disease but is useful for obstructive symptoms after pull-through when the sphincter is not relaxing normally" — Jack (clinical) [Ep 9 · 8:09](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=489)
- "Botox injection could serve as a diagnostic tool—significant improvement after injection would support proceeding with major surgical intervention in cases where symptoms and imaging do not clearly fit Hirschsprung disease" — Sharif (opinion) [Ep 9 · 8:25](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=505)
- "If a biopsy at 3 centimeters shows all findings of Hirschsprung disease and higher biopsies are normal, the patient still has Hirschsprung disease with a short aganglionic segment" — Jack (clinical) [Ep 9 · 10:53](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=653)
- "If you took an average 16-year-old and did a biopsy at 3 centimeters, you would find normal ganglion cells, not Hirschsprung findings" — Jack (clinical) [Ep 9 · 11:48](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=708)
- "In straightforward cases with positive suction rectal biopsy showing all findings of Hirschsprung disease, a repeat low biopsy in the operating room is not routinely performed" (clinical) [Ep 9 · 11:57](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=717)
- "In confusing cases, repeat biopsies at the same low location have sometimes come back as normal, leading to abortion of the operation" (clinical) [Ep 9 · 12:20](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=740)
- "Hinman-Allen syndrome is a non-neurogenic neurogenic bladder that is very prevalent in trisomy 21 children at this age" (epidemiological) [Ep 9 · 15:13](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=913)
- "Hinman-Allen syndrome results from voluntary contraction of pelvic floor muscles causing both constipation and urinary retention, leading to neurogenic bladder" (clinical) [Ep 9 · 15:13](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=913)
- "Hinman-Allen syndrome is a learned behavior that can be overcome with intermittent catheterizations and behavior modification to salvage kidney function" (clinical) [Ep 9 · 15:39](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=939)
- "Anorectal manometry in a 16-year-old would yield better results than in younger children and could have determined whether the patient physiologically had Hirschsprung disease" (opinion) [Ep 9 · 16:19](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=979)
- "Myomectomy for short segment Hirschsprung patients often does not have long-term success, with patients developing more obstructive symptoms" — Jack (clinical) [Ep 9 · 17:00](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=1020)
- "Myomectomy involving the sphincter carries a higher risk of soiling" — Jack (clinical) [Ep 9 · 17:09](https://library.globalcastmd.com/watch/ultra-short-segment-hirschsprung-disease-difficult-cases-550?t=1029)
- "Infant presented with delayed passage of meconium of more than 48 hours" — Jafar (clinical) [Ep 12 · 0:41](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=41)
- "At day 7 of age, infant presented with signs and symptoms of Hirschsprung disease including abdominal distension, tight rectum with passage of explosive stool after removing examining finger" — Jafar (clinical) [Ep 12 · 0:53](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=53)
- "Full thickness rectal biopsy confirmed the absence of ganglion cells" — Jafar (clinical) [Ep 12 · 1:08](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=68)
- "Surgical exploration revealed malrotation with three bands: one between loops of bowel, one between bowel and liver, and one between bowel and abdominal wall" — Jafar (clinical) [Ep 12 · 1:22](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=82)
- "Biopsies from appendix and terminal ileum proved to be aganglionosis (Hirschsprung disease)" — Jafar (clinical) [Ep 12 · 1:56](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=116)
- "Infant was placed on special high-calorie formula (Ensure) with addition of vitamin B12" — Jafar (clinical) [Ep 12 · 2:17](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=137)
- "Infant developed multiple attacks of dehydration requiring hospital admission for IV fluid replacement" — Jafar (clinical) [Ep 12 · 2:28](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=148)
- "At 70 days of age, infant's weight was 3.5 kg" — Jafar (clinical) [Ep 12 · 2:37](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=157)
- "Only a few cases reported in literature of total colonic aganglionosis associated with malrotation: Philone had 4 patients, Kors had 1 patient, and 3 patients reported by others" — Jafar (epidemiological) [Ep 12 · 3:39](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=219)
- "No cases reported to have all three anomalies (total colonic aganglionosis, malrotation, and congenital bands)" — Jafar (epidemiological) [Ep 12 · 4:00](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=240)
- "Congenital bands are rare and only a few cases reported; etiology unknown but could be attributed to abnormal rotation of bowel" — Jafar (clinical) [Ep 12 · 4:08](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=248)
- "Malrotation and Hirschsprung disease can present together; typical scenario is child with bilious vomiting who undergoes Ladd procedure but then doesn't open up, leading to discovery of total colonic aganglionosis" (clinical) [Ep 12 · 5:42](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=342)
- "Teaching point: once Ladd procedure is done, if baby doesn't open up, must think about other potential causes for bilious vomiting including Hirschsprung disease" (clinical) [Ep 12 · 6:06](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=366)
- "When malrotation and Hirschsprung coexist, they are usually short-segment Hirschsprung, not usually total colonic" (clinical) [Ep 12 · 6:18](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=378)
- "For total colonic Hirschsprung disease, preferred operation is Duhamel because it is simple, safe, and provides a reservoir at the bottom which Soave does not" (opinion) [Ep 12 · 6:50](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=410)
- "Timing of definitive repair should be based on consistency of ileostomy output, not age or weight; prefer to wait until output firms up, which usually happens when infant gets onto solid food" (opinion) [Ep 12 · 7:05](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=425)
- "Infants don't do very well if definitive repair is done too early when ileostomy output is still very liquid" (clinical) [Ep 12 · 7:14](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=434)
- "For long-segment or total colonic Hirschsprung, should leave a relatively short piece of colon, almost making a small reservoir, not the long Martin modification element" (opinion) [Ep 12 · 7:36](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=456)
- "Good continence control in long-segment Hirschsprung disease is really about 50% of patients; the data really isn't that great" (clinical) [Ep 12 · 7:55](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=475)
- "Long-segment Hirschsprung involving more than 50 cm from the ileocecal valve is a much more progressive disease with bigger dysmotility element" (clinical) [Ep 12 · 8:22](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=502)
- "Cannot expect simple fix from classic operations when small bowel is significantly involved in Hirschsprung disease" (opinion) [Ep 12 · 8:36](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=516)
- "No evidence in literature that any particular procedure (Duhamel vs. Soave) is better for long-segment Hirschsprung; best approach is to do what you do best" — Sharif (opinion) [Ep 12 · 8:54](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=534)
- "Duhamel may have higher episodes of enterocolitis compared to other procedures" — Sharif (clinical) [Ep 12 · 9:09](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=549)
- "Poor weight gain in infant with ileostomy often due to sodium loss; unless sodium levels in effluent are checked, this will not be caught because serum sodium will be normal for many months" — Sharif (clinical) [Ep 12 · 10:01](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=601)
- "If ileostomy output contains more than 5 to 7 milliequivalents per liter of sodium, baby will not grow or gain weight" — Sharif (clinical) [Ep 12 · 10:21](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=621)
- "Must get baby gaining weight and growing before performing definitive procedure" — Sharif (opinion) [Ep 12 · 10:28](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=628)
- "Measuring urinary sodium is the best way to guide how much sodium replacement to give" (clinical) [Ep 12 · 10:34](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=634)
- "Every baby with an ileostomy should probably get sodium supplementation" (opinion) [Ep 12 · 10:49](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=649)
- "Iron deficiency is a big long-term issue in these patients that often gets forgotten" (clinical) [Ep 12 · 10:50](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=650)
- "For total colonic Hirschsprung, must wait until baby grows and ileostomy is thicker before doing definitive repair" (opinion) [Ep 12 · 11:10](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=670)
- "After Soave or other procedure for total colonic disease, can continue with bulking agents or anti-diarrheal agents to help patients" (clinical) [Ep 12 · 11:29](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=689)
- "Some patients who had Duhamel abroad came back with problems including enterocolitis, obstruction, and distension of the Duhamel pouch" (clinical) [Ep 12 · 11:44](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=704)
- "Most important thing is to monitor ileostomy output before deciding to do any definitive procedure" (opinion) [Ep 12 · 12:05](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=725)
- "Some patients with ileoanal anastomosis developed severe perianal erosion requiring protective ileostomy before further procedures" (clinical) [Ep 12 · 12:19](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=739)
- "Better to manage total colonic Hirschsprung patients in the long term rather than rushing to definitive repair" (opinion) [Ep 12 · 12:38](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=758)
- "Soave procedure for regular Hirschsprung disease patients (not total colonic) does not result in incontinence if procedure is followed carefully and sphincters are not damaged" (opinion) [Ep 12 · 13:04](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=784)
- "Dissection of the fistula up to the red line is necessary to prevent residual fistula without injuring nerves, prostate, urethra, and sphincters" (clinical) [Ep 11 · 0:21](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=21)
- "23 male patients with rectourethral fistula were studied: 1 vesical, 14 prostatic, 9 bulbar, 5 no fistula" (clinical) [Ep 11 · 0:51](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=51)
- "A fine flexible colonoscope inserted into anterior rectal wall allows observation of both fistula orifice and level of laparoscopic dissection intraluminally" (clinical) [Ep 11 · 1:52](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=112)
- "A calibrated catheter inserted through the fistula opening while another surgeon performs cystoscopy allows measurement of inside fistula length between rectal opening and urethral orifice" (clinical) [Ep 11 · 2:37](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=157)
- "If residual fistula length is longer than 5mm, the rectal end is further dissected toward urethra using mucosectomy to prevent injury of prostate and urethra" (clinical) [Ep 11 · 4:27](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=267)
- "The measurement and dissection procedure is repeated until residual fistula length is ≤5mm, then fistula is ligated and excised" (clinical) [Ep 11 · 4:57](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=297)
- "For bulbar fistula, tube vesicostomy to decompress bladder is very important to obtain clear surgical field of deep pelvic floor" (clinical) [Ep 11 · 6:16](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=376)
- "For bulbar fistula, right and left trocars are placed much closer to telescope compared to prostatic fistula, which is key for reaching deep pelvic structures" (clinical) [Ep 11 · 6:49](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=409)
- "After fistula is tied, catheter is reinserted to gently probe tied fistula, allowing surgeon to reconfirm residual fistula length is ≤5mm" (clinical) [Ep 11 · 8:30](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=510)
- "In first 8 cases, initial fistula measurements from rectal to urethral orifice ranged from 5-21mm; 7 cases required further dissection, 1 did not" (clinical) [Ep 11 · 9:25](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=565)
- "During cystoscopy, normal saline refluxed into pelvic floor through fistula in 6 cases (indicating large fistula), but no reflux in 2 cases (indicating very narrow fistula)" (clinical) [Ep 11 · 9:48](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=588)
- "All 23 cases had no evidence of diverticular formation due to residual fistula on voiding urethrography or MRI after mean 2-year follow-up" (clinical) [Ep 11 · 10:10](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=610)
- "The residual fistula from rectal site to urethral site is much longer than expected" (clinical) [Ep 11 · 10:28](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=628)
- "Sigmoid colostomy placed very proximal in sigmoid or at descending-sigmoid junction provides enough length for pull-through even for high fistula" (clinical) [Ep 11 · 17:19](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1039)
- "Transverse colostomy has too many problems including urine absorption, infection, and prolapse" (opinion) [Ep 11 · 18:37](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1117)
- "With sigmoid colostomy, it is possible to place ports and work around stomas without taking them down for deep pelvic dissection" (clinical) [Ep 11 · 19:14](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1154)
- "For prostatic or bladder neck fistula, dissection can be done without the measurement technique and get very close to end of fistula" (opinion) [Ep 11 · 20:21](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1221)
- "For bulbar fistula, the measurement technique is still needed" (opinion) [Ep 11 · 20:41](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1241)
- "The laparoscopic approach for bulbar fistula is far more difficult and dangerous; PSARP technique is easy for those patients" (opinion) [Ep 11 · 20:55](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1255)
- "There is no convincing data that laparoscopic approach results in better outcomes for bulbar fistulas than PSARP" (opinion) [Ep 11 · 21:20](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1280)
- "Combining VCUG and colostogram with dye from both sides usually allows clear visualization of fistula" (clinical) [Ep 11 · 23:41](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1421)
- "Empty bladder is critically important when doing laparoscopic anorectal malformation repair" (clinical) [Ep 11 · 23:51](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1431)
- "Foley catheter placed at case start may go into fistula and rectum rather than bladder, which may not be discovered until mid-operation" (clinical) [Ep 11 · 24:04](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1444)
- "Cystoscopy at case start is advisable to ensure catheter is in bladder before starting" (clinical) [Ep 11 · 24:22](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1462)
- "Tube vesicostomy is needed to decompress bladder during cystoscopy, otherwise bladder fills with saline and obscures pelvic floor view" (clinical) [Ep 11 · 24:33](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1473)
- "For thoracoscopic TEF repair, gap between proximal and distal esophagus should be checked preoperatively" (clinical) [Ep 11 · 26:21](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1581)
- "Bronchoscopy by anesthesiologist can identify fistula orifice; X-ray taken with bronchoscope stopped at orifice shows gap distance (approximately one vertebra in presented case)" (clinical) [Ep 11 · 26:49](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1609)
- "Leaving one quarter of fistula uncut prevents distal esophagus from retracting cranially and makes anastomosis easier" (clinical) [Ep 11 · 28:00](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1680)
- "Leaving 12-15% of proximal esophageal tip uncut provides a 'cap' to grab with forceps rather than grabbing anastomotic site" (clinical) [Ep 11 · 29:02](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1742)
- "If there is 1-3 vertebra gap, assistant can pull proximal esophagus caudally using the uncut cap" (clinical) [Ep 11 · 29:43](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1783)
- "First anastomotic stitch is placed in middle of posterior wall rather than at edge" (clinical) [Ep 11 · 30:42](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1842)
- "Tracheoesophageal fistula is completely divided after 1-2 anastomotic stitches are placed" (clinical) [Ep 11 · 34:44](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2084)
- "Uncut cap of proximal esophagus is divided after 2-3 anastomotic stitches, avoiding touching the anastomotic site itself" (clinical) [Ep 11 · 35:05](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2105)
- "Transfixing suture to close fistula prevents it from coming off; clips tend to hook behind sutures" (clinical) [Ep 11 · 37:16](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2236)
- "For type C esophageal atresia with considerable gap, two sutures can be placed and made into sliding knots to slowly bring ends together, dividing tension between two esophageal ends" (clinical) [Ep 11 · 37:37](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2257)
- "Clips may erode or be implicated in fistula recurrences" (clinical) [Ep 11 · 42:50](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2570)
- "If fistula clip is applied very tightly, it will crush muscle and erode, causing fistula recurrence; clip should just oppose rather than crush" (clinical) [Ep 11 · 44:18](https://library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2658)
- "Suction rectal biopsy adequacy requires sufficient submucosa depth, correct anatomic level (normal rectal mucosa, not transitional epithelium), assessment of nerve hypertrophy, cholinesterase staining, and calretinin staining." — Jack (clinical) [Ep 13 · 1:10](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=70)
- "In very short segment Hirschsprung disease, nerve hypertrophy may not be present." — Jack (clinical) [Ep 13 · 1:34](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=94)
- "Calretinin staining has become important in Hirschsprung diagnosis in recent years." — Jack (clinical) [Ep 13 · 1:41](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=101)
- "Gold standard for Hirschsprung diagnosis in infants is suction rectal biopsy; if inadequate, proceed to open transanal full-thickness rectal biopsy." — Kristine Thayer (guideline) [Ep 13 · 2:25](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=145)
- "The transanal rectal biopsy at 3 cm above the dentate line showed hypertrophied nerve bundles and abnormal calretinin with lack of significant fiber staining in the mucosa, consistent with short segment Hirschsprung disease." — Kristine Thayer (clinical) [Ep 13 · 3:02](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=182)
- "Barium enema on unprepped bowel showed no distinctive transition zone." — Kristine Thayer (clinical) [Ep 13 · 3:41](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=221)
- "Transanal rectal biopsies at 5, 6, and 7 cm and laparoscopic biopsies at peritoneal reflection, rectosigmoid, proximal and distal sigmoid, and distal descending colon all returned normal." — Kristine Thayer (clinical) [Ep 13 · 4:41](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=281)
- "In 16-year-olds with new diagnosis of Hirschsprung disease, the colon is almost always very dilated." — Jack (clinical) [Ep 13 · 5:21](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=321)
- "In older children with dilated colon, typical approach is to perform a diverting stoma for approximately six months to decompress the colon, followed by a Duhamel procedure." — Jack (clinical) [Ep 13 · 5:36](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=336)
- "Pulling a dilated rectum through the anus using a transanal technique requires excessive stretching of the sphincter, which should be avoided." — Jack (clinical) [Ep 13 · 5:49](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=349)
- "The patient was stooling only twice per month on MiraLAX." — Bob (clinical) [Ep 13 · 6:49](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=409)
- "It is difficult to explain stooling only twice per month with a colon appearance like this if the obstruction is truly at the anus." — Bob (clinical) [Ep 13 · 7:47](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=467)
- "Botox is not a good treatment for established Hirschsprung disease; it is appropriate for obstructive symptoms after pull-through when the sphincter is not relaxing normally." — Jack (opinion) [Ep 13 · 8:09](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=489)
- "Botox injection could serve as a diagnostic test: significant improvement after injection would support proceeding with surgical intervention in a case with conflicting findings." — Sharif (opinion) [Ep 13 · 8:33](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=513)
- "The patient had a nearly 2-liter neurogenic bladder and was experiencing overflow incontinence rather than true voiding." — Kristine Thayer (clinical) [Ep 13 · 9:40](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=580)
- "If a biopsy at 3 cm in an average 16-year-old showed the findings described, it would be abnormal; normal ganglion cells would be expected." — Jack (clinical) [Ep 13 · 11:48](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=708)
- "In straightforward cases with a positive suction rectal biopsy showing all findings of Hirschsprung disease, a repeat low biopsy in the operating room is not routinely performed." (clinical) [Ep 13 · 11:57](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=717)
- "In confusing cases, repeat biopsies at the same low level have sometimes returned normal when the initial biopsy was positive, leading to abortion of the operation." (clinical) [Ep 13 · 12:29](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=749)
- "A strip myomectomy specimen (22 cm width × 6 cm length of posterior submucosa) showed no ganglion cells from the anal verge to 2 cm, sparse ganglion cells from 2 to 4 cm, normal ganglion cells from 4 to 6 cm, hypertrophied nerve bundles throughout the entire specimen including at 6 cm, and abnormal calretinin only in the distal 2 cm." — Kristine Thayer (clinical) [Ep 13 · 13:44](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=824)
- "After the myomectomy, the patient was able to stool spontaneously." — Kristine Thayer (clinical) [Ep 13 · 14:46](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=886)
- "Hinman-Allen syndrome is a non-neurogenic neurogenic bladder resulting from voluntary contraction of pelvic floor muscles, causing both constipation and urinary retention to the point where the bladder becomes neurogenic." — Kristine Thayer (clinical) [Ep 13 · 15:13](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=913)
- "Hinman-Allen syndrome is very prevalent in trisomy 21 adolescents and is a learned behavior that can be overcome with intermittent catheterization." — Kristine Thayer (epidemiological) [Ep 13 · 15:13](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=913)
- "Anorectal manometry in a cooperative 16-year-old could have determined whether the patient physiologically had Hirschsprung disease and would have allowed suspicion of the pathology results." (opinion) [Ep 13 · 16:19](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=979)
- "The patient was very combative and noncompliant, making anorectal manometry impractical." — Kristine Thayer (clinical) [Ep 13 · 16:44](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=1004)
- "This patient had Hirschsprung disease and would have done well with a Hirschsprung operation (Duhamel)." — Jack (opinion) [Ep 13 · 16:53](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=1013)
- "Myomectomy for short segment Hirschsprung patients often does not have long-term success; patients often have more obstructive symptoms and higher risk of soiling because the myomectomy usually involves the sphincter." — Jack (opinion) [Ep 13 · 17:00](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=1020)
- "Thyroid function was normal in this patient." — Kristine Thayer (clinical) [Ep 13 · 17:36](https://library.globalcastmd.com/watch/tricks-ultrashort-segment-hirschsprungs-kristine-thayer-652?t=1056)
- "Laparoscopic approach with biopsy prevents the scenario where a surgeon performing primary transanal pull-through discovers a higher transition zone or total colonic aganglionosis and is left with mobilized colon and no plan" (opinion) [Ep 14 · 2:08](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=128)
- "Three 3-mm laparoscopic ports allow mobilization in approximately 45 minutes for standard rectosigmoid Hirschsprung disease" — Jason Frischer (clinical) [Ep 14 · 5:30](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=330)
- "Patients with complications after Hirschsprung surgery fall into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) or soiling issues (true incontinence vs. pseudo-incontinence from constipation)" — Jason Frischer (clinical) [Ep 14 · 6:12](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=372)
- "Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; biopsy performed if no anatomic cause found" — Jason Frischer (clinical) [Ep 14 · 7:25](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=445)
- "Anastomosis is placed approximately 1 cm above the dentate line (defined as transition from squamous to columnar epithelium, at the bottom of the anal columns)" — Jason Frischer (clinical) [Ep 14 · 9:04](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=544)
- "Going 1 cm above the dentate line in a newborn may become 2.5–3 cm in a 7-year-old, potentially leaving a segment resembling short-segment or ultra-short-segment Hirschsprung disease" — Jason Frischer (clinical) [Ep 14 · 9:04](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=544)
- "Injury to the dentate line can render patients fecally incontinent, which is a devastating complication" — Jason Frischer (clinical) [Ep 14 · 9:43](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=583)
- "For J-pouch procedures in ulcerative colitis or FAP, anastomosis is placed right at the top of the anal columns or slightly lower if polyps are present in that region" — Jason Frischer (clinical) [Ep 14 · 10:39](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=639)
- "The top of the anal columns serves as a consistent anatomic landmark that is easier to identify than the variable definitions of the dentate line" — Belinda (clinical) [Ep 14 · 12:06](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=726)
- "Leaving a zone of aganglionosis above the anastomosis can be overcome with laxatives, whereas fecal incontinence from sphincter injury cannot be overcome" — Belinda (clinical) [Ep 14 · 12:23](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=743)
- "Primary repair of anorectal malformations in the newborn period is technically difficult because it is harder to identify the center of the sphincter complex in a 2-kg baby than in an 8–9-kg baby" — Jason Frischer (clinical) [Ep 14 · 18:07](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1087)
- "Prolonged dilation of vestibular fistulas causes scarring and inflammation, making subsequent repair more difficult; dilation should stop at Hegar size 7 or 8" — Belinda (clinical) [Ep 14 · 16:27](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=987)
- "The dissection between vagina and rectum in a newborn with anorectal malformation is much thinner than in an older infant, increasing technical difficulty" — Belinda (clinical) [Ep 14 · 15:39](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=939)
- "In the setting of vestibular fistula with absent vagina, if the patient has good prognosis for bowel control, a graft (colon or small bowel) can be used to replace the vagina while bringing the rectum down as a pull-through" — Jason Frischer (clinical) [Ep 14 · 18:54](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1134)
- "In vestibular fistula with absent vagina, if the patient has poor prognosis for bowel control (sacral agenesis, tethered cord), the rectum/fistula can be used as the vagina and a more proximal piece of colon brought down as the pull-through" — Jason Frischer (clinical) [Ep 14 · 19:21](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1161)
- "Transabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate" — Jason Frischer (clinical) [Ep 14 · 23:02](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1382)
- "Transanal approaches for rectal prolapse (transanal pull-through or Altmeier procedure) have 15–20% recurrence rate" — Jason Frischer (clinical) [Ep 14 · 23:02](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1382)
- "Resection and rectopexy may be better for patients with constipation problems but has higher complication rate than rectopexy alone" — Jason Frischer (clinical) [Ep 14 · 23:36](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1416)
- "Patients can be discharged the next day or even same day after laparoscopic rectopexy for rectal prolapse" — Jason Frischer (clinical) [Ep 14 · 23:56](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1436)
- "Ventral mesh rectopexy involves placing mesh on the anterior surface of the rectum without posterior dissection, then tacking the mesh to the sacral promontory; can be done open or laparoscopically" — Jason Frischer (clinical) [Ep 14 · 24:33](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1473)
- "The pathophysiology of rectal prolapse in younger patients involves a straighter angle between rectum and anal canal that becomes more acute with age; ventral mesh rectopexy attempts to change this angulation" — Jason Frischer (clinical) [Ep 14 · 24:55](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1495)
- "Sclerosing agent injection for rectal prolapse has high failure rate; most patients ultimately require rectopexy" — Jason Frischer (opinion) [Ep 14 · 22:45](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1365)
- "Re-operating on patients who have had sclerosing agent injection for rectal prolapse is not more difficult" — Jason Frischer (clinical) [Ep 14 · 22:45](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1365)
- "In high common channel cloacas, the common wall between structures (rectum, vagina, bladder) are not long common walls and are actually easy to separate" (clinical) [Ep 15 · 3:04](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=184)
- "For high common channel cloacas visible on contrast study with rectum reachable through abdomen, it is not advisable to search for it posterior sagittally" (clinical) [Ep 15 · 2:53](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=173)
- "Saline perturbation is used intraoperatively to assess patency of the reproductive tract in all cases when in the abdomen" — Bree (clinical) [Ep 15 · 4:08](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=248)
- "If one side of duplicated Mullerian system is well developed and the other is very atretic, it may be advantageous to retain the well developed side and remove the atretic side that might be dangerous at menstruation and not helpful for future childbearing" — Bree (clinical) [Ep 15 · 4:41](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=281)
- "Using the rectum for vaginal replacement may change a patient who is potentially fecally continent into somebody who will not be fecally continent" — Dickey (clinical) [Ep 15 · 8:13](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=493)
- "In patients with vestibular fistulas and absent vagina where rectum was used as vagina, bowel control was less than optimal when followed through the years" — Pena (clinical) [Ep 15 · 8:54](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=534)
- "Preservation of the rectum in patients with good functional prognosis (good sacrum, no tethered cord, good malformation) is extremely important to preserve bowel control" — Pena (clinical) [Ep 15 · 9:21](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=561)
- "The rectum is a natural reservoir and if removed in patients with anorectal malformation, the patient will most likely be incontinent because they cannot tolerate constant passing of stool when colon is connected down to perineum" — Pena (clinical) [Ep 15 · 9:55](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=595)
- "Descending colon is increasingly used for vaginal replacement because the arcades are very nice for preserving blood supply, compared to small bowel, rectum, and other colon segments" — Pena (clinical) [Ep 15 · 10:56](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=656)
- "In long common channel cloacas, vaginas are located very high in pelvis and it is often not possible to bring them down, requiring vaginal replacement" — Pena (clinical) [Ep 15 · 10:40](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=640)
- "Many laparoscopic cloaca repairs reported in literature are really only the rectal repair component of the cloaca" — Dickey (clinical) [Ep 15 · 11:29](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=689)
- "Approximately 65 cases have been seen that came operated originally with colostomy at birth due to phallic-appearing structure, were extensively studied for intersex, only to conclude they were chromosomally normal females with cloacas" — Pena (epidemiological) [Ep 15 · 12:33](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=753)
- "A patient with intersex and a cloaca has never been seen in the speaker's experience" — Pena (clinical) [Ep 15 · 13:09](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=789)
- "To differentiate cloaca with phallic structure from adrenal hyperplasia, palpate the structure: in adrenal hyperplasia you will palpate corpora (real penis), whereas in cloaca the structure is just folded skin" — Pena (clinical) [Ep 15 · 13:15](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=795)
- "The folded skin of the phallic-appearing structure in cloaca can be used to facilitate reconstruction of the vagina" — Pena (clinical) [Ep 15 · 13:30](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=810)
- "Families agonize during the 2-3 weeks that doctors are trying to make the diagnosis of intersex in cases that are actually cloacas" — Pena (opinion) [Ep 15 · 13:50](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=830)
- "Letting a significantly enlarged bladder maximally decompress via vesicostomy may help the bladder have some potential rebound recovery" — Van der Brink (clinical) [Ep 15 · 7:10](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=430)
- "Common channel length measured at cystoscopy versus radiology measurements are sometimes very similar and sometimes just a little bit off" — Dickey (clinical) [Ep 15 · 1:46](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=106)
- "Preserving the appendix at time of colostomy creation is important for long-term need for Malone antegrade continence enema" — Dickey (clinical) [Ep 15 · 0:44](https://library.globalcastmd.com/watch/cloaca-long-common-channel-686?t=44)
- "Harald Hirschsprung presented a paper on constipation in newborns due to dilation and hypertrophy of the colon in 1886 at the Society of Pediatrics in Berlin" — Andrea Bischoff (clinical) [Ep 19 · 5:02](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=302)
- "Harald Hirschsprung was a pediatrician who developed the hydrostatic reduction of ileocolonic intussusception" — Andrea Bischoff (clinical) [Ep 19 · 5:54](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=354)
- "Early theories attempting to explain Hirschsprung disease etiology were all wrong because everyone was obsessed that the dilated portion was the diseased one, not recognizing it as the consequence of the disease" — Andrea Bischoff (clinical) [Ep 19 · 7:15](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=435)
- "William Osler, one of the four founding professors of Johns Hopkins and creator of the residency, proposed colostomy or rectal tube and irrigation as possible treatments for Hirschsprung disease" — Andrea Bischoff (clinical) [Ep 19 · 8:52](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=532)
- "In 1946, Orvar Swenson recognized the finding of no ganglion cells in the narrow rectal sigmoid as the cause of Hirschsprung disease" — Andrea Bischoff (clinical) [Ep 19 · 10:08](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=608)
- "Others before Swenson, including Dr. Dalalé in 1920, had recognized absent ganglion cells in the distal portion but thought it was an acquired condition rather than the cause of the disease" — Andrea Bischoff (clinical) [Ep 19 · 10:25](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=625)
- "Prior to 1946, treatments used for Hirschsprung disease included anal sphincter dilation, rectosigmoid myotomy, spinal anesthesia, lumbar sympathectomy, and electric enemas" — Andrea Bischoff (clinical) [Ep 19 · 10:45](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=645)
- "Electric enemas were described around 1908, involving passing a tube through the rectum with an electrode inside and another electrode on the abdomen, delivering about 40 milliamps of interrupted cycling current to facilitate expulsion of saline solution from the colon" — Alberto Peña (clinical) [Ep 19 · 11:37](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=697)
- "Resection of the distal non-dilated portion was not used as a treatment for Hirschsprung disease prior to 1946" — Andrea Bischoff (clinical) [Ep 19 · 12:39](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=759)
- "Barium enema technique became the standard diagnostic test for Hirschsprung disease in 1948, with Dr. Swenson involved in this publication" — Andrea Bischoff (clinical) [Ep 19 · 13:23](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=803)
- "Barry Shandling, working in Canada, proposed punch biopsies for newborns that required no closure nor anesthesia" — Andrea Bischoff (clinical) [Ep 19 · 15:33](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=933)
- "Dr. Syndergaard from Sweden performed the first successful operation for total colonic aganglionosis in 1953, doing a colon resection with an ileo-anal anastomosis" — Andrea Bischoff (clinical) [Ep 19 · 16:43](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=1003)
- "Swenson observed that when patients had a colostomy, the obstruction was relieved, but when the colostomy was closed, the disease returned" — Andrea Bischoff (clinical) [Ep 19 · 17:43](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=1063)
- "Swenson scoped from the rectum in patients with colostomy and saw there was no true mechanical obstruction" — Andrea Bischoff (clinical) [Ep 19 · 17:57](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=1077)
- "Swenson used a probe on the proximal stoma and observed normal peristalsis, but when he put a probe in the distal stoma, there was no peristalsis" — Andrea Bischoff (clinical) [Ep 19 · 18:09](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=1089)
- "Swenson performed contrast studies and observed a non-dilated portion followed by a dilated portion, leading him to conclude that the distal portion was the diseased one" — Andrea Bischoff (clinical) [Ep 19 · 18:22](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=1102)
- "The most serious challenge in Hirschsprung disease is the basic science approach to solving the problem of enterocolitis and other problems affecting children" — Alberto Peña (opinion) [Ep 19 · 4:05](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=245)
- "Hirschsprung disease is not only about ganglion cells or no ganglion cells; it is a much more complex condition" — Alberto Peña (opinion) [Ep 19 · 4:20](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=260)
- "Pediatric surgeons manage Hirschsprung disease very diversely all over the world" — Andrea Bischoff (epidemiological) [Ep 19 · 1:39](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=99)
- "Orvar Swenson's principles in the management of Hirschsprung disease are still followed today" — Alberto Peña (opinion) [Ep 19 · 3:13](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=193)
- "Ganglion cells are present in the rectal submucosa at 28 weeks gestation normally" — Margaret Collins (clinical) [Ep 21 · 2:43](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=163)
- "Immature ganglion cells at 28 weeks do not necessarily look like mature ganglion cells but an experienced pediatric pathologist will be able to recognize them" — Margaret Collins (clinical) [Ep 21 · 3:03](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=183)
- "Suction rectal biopsies to rule out Hirschsprung disease on 28 week gestation newborns are extremely rare" — Margaret Collins (epidemiological) [Ep 21 · 3:17](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=197)
- "The failure rate for suction rectal biopsy increases after one year of age" — Margaret Collins (clinical) [Ep 21 · 5:27](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=327)
- "Beyond infancy there is increased separation of ganglia as a result of growth" — Margaret Collins (clinical) [Ep 21 · 5:39](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=339)
- "Beyond infancy there is increased toughness of the stroma making it more difficult to obtain a good suction rectal biopsy" — Margaret Collins (clinical) [Ep 21 · 5:47](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=347)
- "The anal canal becomes longer and thicker beyond infancy" — Margaret Collins (clinical) [Ep 21 · 5:54](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=354)
- "It is not a good idea to base an entire surgical procedure on the frozen section of a biopsy obtained intraoperatively" — Margaret Collins (opinion) [Ep 21 · 15:45](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=945)
- "When making a diagnosis of Hirschsprung disease on suction rectal biopsy, you are committing that child to losing at least some rectum" — Raj Kapoor (clinical) [Ep 21 · 17:26](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1046)
- "If a surgeon finds ganglion cells at the peritoneal reflection after a positive suction rectal biopsy, the patient still has short segment disease" — Raj Kapoor (clinical) [Ep 21 · 18:13](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1093)
- "Large nerves are not present in the submucosa of all cases of Hirschsprung disease" — Margaret Collins (clinical) [Ep 21 · 23:58](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1438)
- "Total colonic aganglionosis is a classic example where large nerves may not be present in the submucosa" — Margaret Collins (clinical) [Ep 21 · 24:03](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1443)
- "Nerve hypertrophy may be less apparent in the very young as well as in older children" — Margaret Collins (clinical) [Ep 21 · 24:28](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1468)
- "The pathology could be distal to the peritoneal reflection, leading to a false positive reading if only biopsying at that level" — Margaret Collins (clinical) [Ep 21 · 15:02](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=902)
- "A better way to evaluate for transition zone is a full thickness biopsy rather than a seromuscular biopsy" — Margaret Collins (clinical) [Ep 21 · 15:18](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=918)
- "Calretinin or acetylcholinesterase abnormalities can be enough to make a diagnosis of Hirschsprung disease even without hypertrophic nerves" — Raj Kapoor (clinical) [Ep 21 · 26:36](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1596)
- "In young infants under 6 months of age, you should not see in the distal rectum nerves greater than 40 microns in diameter" — Raj Kapoor (clinical) [Ep 21 · 27:31](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1651)
- "The 40 micron rule does not hold in older age children" — Raj Kapoor (clinical) [Ep 21 · 27:47](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1667)
- "Transition zone contains ganglion cells but they are not in their normal distribution completely around the circumference" — Margaret Collins (clinical) [Ep 21 · 32:29](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1949)
- "Transition zone has hypoganglionosis by definition" — Margaret Collins (clinical) [Ep 21 · 32:37](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1957)
- "Transition zone has hypertrophic nerves more in the submucosa than in the myenteric plexus" — Margaret Collins (clinical) [Ep 21 · 32:44](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1964)
- "Submucosal hyperganglionosis with at least 10 ganglion cells in one ganglion is a feature of transition zone" — Margaret Collins (clinical) [Ep 21 · 32:59](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1979)
- "Ectopic ganglion cells can be present in normal biopsies and normally innervated bowels" — Margaret Collins (clinical) [Ep 21 · 33:22](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2002)
- "A positive calretinin stain proximal to an aganglionic segment is a sign that there are ganglion cells even if not present in that particular section" — Margaret Collins (clinical) [Ep 21 · 33:48](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2028)
- "The methodology used for IND diagnosis in Europe requires 15 micron thick sections, at least 3 times the thickness of normal sections in the United States" — Margaret Collins (clinical) [Ep 21 · 34:34](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2074)
- "The histochemical stains used for IND are not commonly used in the United States" — Margaret Collins (clinical) [Ep 21 · 34:46](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2086)
- "There have been inconsistent diagnostic criteria for IND with definitions changing several times over decades" — Margaret Collins (clinical) [Ep 21 · 34:55](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2095)
- "IND diagnosis lacks adequate control data from age-matched children who are not constipated" — Margaret Collins (clinical) [Ep 21 · 35:07](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2107)
- "IND should not be diagnosed in infants" — Margaret Collins (guideline) [Ep 21 · 35:43](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2143)
- "IND is outgrown by the age of 4 years" — Margaret Collins (clinical) [Ep 21 · 35:47](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2147)
- "IND does not require surgical therapy and is self-correcting" — Margaret Collins (clinical) [Ep 21 · 35:55](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2155)
- "There is not a single topographic study of intestinal neuronal dysplasia describing the extension of the defect" — Alberto Peña (epidemiological) [Ep 21 · 37:45](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2265)
- "The best way to diagnose hypoganglionosis is to only consider myenteric ganglion cell density, which requires resected bowel not just suction biopsy" — Margaret Collins (clinical) [Ep 21 · 42:31](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2551)
- "Severe hypoganglionosis is diagnosed based on long stretches of myenteric plexus containing small ganglia with one or two ganglion cells per ganglion with minimal neuropil" — Margaret Collins (clinical) [Ep 21 · 42:50](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2570)
- "There is huge normal variation in ganglion cell counts requiring counting large areas to get accurate assessment" — Margaret Collins (clinical) [Ep 21 · 43:19](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2599)
- "Irrigations are probably the best treatment for Hirschsprung disease and it is very rare that Hirschsprung disease is a surgical emergency, but without irrigation it will become an emergency" — Marc Levitt (clinical) [Ep 29 · 8:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=530)
- "Proper irrigation technique requires a large bore tube (20 French Foley), instilling 10-20 cc aliquots of warm saline at a time, moving the tube to and fro, and allowing fluid mixed with stool to drip back" — Marc Levitt (clinical) [Ep 29 · 9:13](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=553)
- "The biggest mistake with irrigations is using too small of a tube and just putting fluid in and letting it sit (an enema), when babies with Hirschsprung disease have no ability to expel enema fluid" — Marc Levitt (clinical) [Ep 29 · 10:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=651)
- "Rectal biopsies must be taken at least 1 centimeter in from the dentate line because everyone has an aganglionic segment at the dentate line and biopsying too close can give a false positive diagnosis" — Marc Levitt (clinical) [Ep 29 · 12:38](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=758)
- "The pathologist must confirm both the absence of ganglion cells AND the presence of hypertrophic nerves; absence of ganglion cells alone is not Hirschsprung disease as that could be a biopsy taken too low" — Marc Levitt (clinical) [Ep 29 · 13:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=803)
- "Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia due to an immune component that makes the bowel mucosa more susceptible to translocation" — Marc Levitt (clinical) [Ep 29 · 14:35](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=875)
- "When irrigations fail and the baby is ill, diversion should be done at the ileum rather than a leveling colostomy, especially without reliable frozen section pathology" — Marc Levitt (clinical) [Ep 29 · 15:42](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=942)
- "Frozen section results can be inaccurate, particularly for transition zones higher in the colon, making permanent section more reliable for determining resection level" — Marc Levitt (clinical) [Ep 29 · 16:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1000)
- "The Swenson operation was done incorrectly historically with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence" — Marc Levitt (clinical) [Ep 29 · 18:17](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1097)
- "The Soave procedure involves a mucosal dissection inside the outer rectal wall to avoid injuring pelvic nerves, which was quite brilliant" — Marc Levitt (clinical) [Ep 29 · 19:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1159)
- "Of the four classic procedures (Swenson, Soave, Duhamel, Rebein), only the Swenson actually leaves behind virtually no Hirschsprung tissue" — Marc Levitt (clinical) [Ep 29 · 21:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1278)
- "Many patients with residual aganglionic bowel (from Soave, Duhamel, or Rebein) did perfectly well because ganglionic bowel, if it's good, can overcome a lot" — Marc Levitt (clinical) [Ep 29 · 21:43](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1303)
- "The transanal Swenson is the preferred approach because it is the purest operation, leaving behind no Hirschsprung except at the very bottom just above the dentate line" — Marc Levitt (opinion) [Ep 29 · 25:34](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1534)
- "If you find the right plane for transanal Swenson it's elegant and bloodless, but if you find the wrong plane you can really injure the patient by dissecting too wide" — Marc Levitt (clinical) [Ep 29 · 26:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1570)
- "Overly aggressive transanal-only approach trying to reach the transition zone without laparoscopy has resulted in significant morbidity" — Marc Levitt (clinical) [Ep 29 · 28:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1730)
- "Transanal-only approach is appropriate when there is a very reachable transition zone comfortably at mid-sigmoid and the transition zone is obvious" — Marc Levitt (clinical) [Ep 29 · 29:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1758)
- "Prone positioning for transanal approach is preferred because the tough anterior dissection becomes easier when looking down on it rather than up at it" — Marc Levitt (opinion) [Ep 29 · 29:52](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1792)
- "Total colonic Hirschsprung patients present differently: diagnosis isn't made right away, contrast study is not typical, and irrigations don't go well" — Marc Levitt (clinical) [Ep 29 · 31:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1878)
- "The biggest problem in technique is surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or they overstretch the sphincters with aggressive exposure" — Marc Levitt (clinical) [Ep 29 · 33:55](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2035)
- "The dissection must start 1 centimeter proximal to the dentate line, which by definition leaves behind 1 centimeter of aganglionic columnar epithelium and the internal sphincter, but ganglionic bowel can overcome this" — Marc Levitt (clinical) [Ep 29 · 35:42](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2142)
- "Sequential stitches placed at the 6 o'clock position (in prone) as the bowel is pulled out helps maintain alignment and prevents twisting of the pull-through" — Marc Levitt (clinical) [Ep 29 · 48:34](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2914)
- "Seromuscular laparoscopic biopsies can show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa, potentially leading to a transition zone pull-through" — Marc Levitt (clinical) [Ep 29 · 40:48](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2448)
- "Normal nerve size is 40 microns or less; anything bigger than 40 microns indicates transition zone bowel requiring higher resection" — Marc Levitt (clinical) [Ep 29 · 44:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2645)
- "The concept of going 5 centimeters above the transition zone is inaccurate because transition zone is a spectrum ranging from 3 to 10 centimeters" — Marc Levitt (clinical) [Ep 29 · 44:14](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2654)
- "Taking the IMA and preserving the marginal arcade makes the left colon and sigmoid straight down into the perineum, creating an easy-to-irrigate configuration" — Marc Levitt (clinical) [Ep 29 · 45:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2751)
- "Many patients have not had enough of a pull-through when the entire sigmoid loop is still present, requiring redo surgery to remove more bowel" — Marc Levitt (clinical) [Ep 29 · 46:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2765)
- "For transition zones proximal to the splenic flexure, colonic biopsies and ileostomy should be performed rather than relying on frozen section, which is notoriously fraught with errors in these cases" — Marc Levitt (clinical) [Ep 29 · 46:46](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2806)
- "Postoperative feeding should be delayed until the abdomen is absolutely soft and flat with bowel function, usually 3-4 days, to prevent enterocolitis readmission" — Marc Levitt (clinical) [Ep 29 · 53:06](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3186)
- "Abdominal distention can be subclinical, so an X-ray should be obtained before feeding to confirm the bowel is decompressed" — Marc Levitt (clinical) [Ep 29 · 53:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3203)
- "Families must be taught irrigation technique preoperatively and made paranoid about distention so they will seek care immediately if it develops" — Marc Levitt (clinical) [Ep 29 · 54:02](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3242)
- "Anal calibration (not true dilation) should be performed at one month using Hegar dilators, as the stimulation helps the baby more successfully empty" — Marc Levitt (clinical) [Ep 29 · 54:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3268)
- "For hepatic flexure transition zones, the entire right colon must be taken down, the ileocolic vessel preserved, and the colon de-rotated so the cecum is at the hepatic liver bed to achieve adequate length" — Marc Levitt (clinical) [Ep 29 · 57:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3425)
- "When bringing de-rotated colon down the left side of the abdomen, the ligament of Treitz must be mobilized to prevent the mesenteric vessel from draping across the third portion of the duodenum and causing obstruction" — Marc Levitt (clinical) [Ep 29 · 57:57](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3477)
- "Patients with anorectal malformation with good prognosis for bowel control will have well-formed buttocks with a good midline groove and a good anal dimple" — Andrea Bischoff (clinical) [Ep 30 · 1:52](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=112)
- "In a newborn baby one should be able to accommodate a number 12 Hegar dilator for a normal caliber anus" — Andrea Bischoff (clinical) [Ep 30 · 2:31](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=151)
- "In a rectal perineal fistula, the sphincter mechanism is in a horseshoe shape with posterior and lateral portions having sphincter but the anterior does not" — Andrea Bischoff (clinical) [Ep 30 · 3:42](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=222)
- "8% of patients with anorectal malformation will have esophageal atresia" — Andrea Bischoff (epidemiological) [Ep 30 · 5:01](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=301)
- "30% of patients with anorectal malformation will have cardiac anomalies, but in only 10% of them these anomalies are hemodynamically significant" — Andrea Bischoff (epidemiological) [Ep 30 · 5:27](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=327)
- "50% of patients with anorectal malformation have associated urological defects" — Andrea Bischoff (epidemiological) [Ep 30 · 5:54](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=354)
- "25% of patients with anorectal malformation have tethered cord" — Andrea Bischoff (epidemiological) [Ep 30 · 6:02](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=362)
- "The sacral ratio correlates with future functional prognosis for bowel control" — Andrea Bischoff (clinical) [Ep 30 · 6:17](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=377)
- "Cross-table lateral film should never be done before 24 hours of life because it will give false impression of a high malformation due to muscle tone" — Andrea Bischoff (clinical) [Ep 30 · 7:17](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=437)
- "Spinal ultrasound is adequate until 3 months of age; after that MRI is needed due to ossification process" — Andrea Bischoff (clinical) [Ep 30 · 8:22](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=502)
- "Tethered cord has more influence on the urinary tract rather than the gastrointestinal tract in terms of prognosis" — Andrea Bischoff (clinical) [Ep 30 · 8:47](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=527)
- "Presacral masses are most commonly found in malformations with good prognosis such as rectal perineal fistula, rectal vestibular fistula, and rectal atresia, but when present the prognosis changes" — Andrea Bischoff (clinical) [Ep 30 · 9:53](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=593)
- "The advantage of primary newborn repair is that bowel preparation is not required since meconium is considered sterile" — Andrea Bischoff (clinical) [Ep 30 · 11:55](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=715)
- "It is better to open a colostomy and have a perfect operation than to do a primary repair and have a complication such as dehiscence or retraction that requires re-operation" — Andrea Bischoff (opinion) [Ep 30 · 12:20](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=740)
- "Patients with anorectal malformation have one chance to have the right operation; secondary operations or re-operations usually change the prognosis for bowel control" — Andrea Bischoff (clinical) [Ep 30 · 12:33](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=753)
- "Vestibular fistula is the most common type of anorectal malformation anomaly" — Andrea Bischoff (epidemiological) [Ep 30 · 13:36](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=816)
- "Cloaca patients are all females with normal ovaries; they never have disorder of sexual differentiation" — Andrea Bischoff (clinical) [Ep 30 · 25:12](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1512)
- "High-pressure distal colostogram is the most important study for male patients with anorectal malformation" — Andrea Bischoff (clinical) [Ep 30 · 17:03](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1023)
- "The ideal colostomy should be totally diverting, located in descending colon, with proximal stoma centered in triangle formed by left rib, umbilicus, and iliac crest" — Andrea Bischoff (clinical) [Ep 30 · 17:58](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1078)
- "Rectal perineal fistula patients with normal sacrum and no tethered cord have 100% chance of bowel control" — Andrea Bischoff (clinical) [Ep 30 · 28:08](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1688)
- "Rectal vestibular fistula patients with normal sacrum and no tethered cord have 95% chance of bowel control" — Andrea Bischoff (clinical) [Ep 30 · 28:40](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1720)
- "Rectal urethral bulbar fistula patients have 85% chance of bowel control" — Andrea Bischoff (clinical) [Ep 30 · 28:57](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1737)
- "Rectal malformation without fistula patients have 80% chance of bowel control" — Andrea Bischoff (clinical) [Ep 30 · 29:02](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1742)
- "Rectal urethral prostatic fistula patients have 60% chance of bowel control" — Andrea Bischoff (clinical) [Ep 30 · 29:08](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1748)
- "Rectal bladder neck fistula patients have 20% chance of bowel control" — Andrea Bischoff (clinical) [Ep 30 · 29:14](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1754)
- "Malformations with better prognosis for bowel control will suffer from more constipation" — Andrea Bischoff (clinical) [Ep 30 · 28:18](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1698)
- "The only indication to keep a colostomy would be incapacity to form solid stool" — Andrea Bischoff (opinion) [Ep 30 · 29:57](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1797)
- "All children with anorectal malformations should be out of diapers at the same age that other children are normally out of diapers, usually at 3 years of age in the United States" — Andrea Bischoff (guideline) [Ep 30 · 30:43](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=1843)
- "The Malone procedure or appendicostomy is not the treatment for fecal incontinence; the treatment is finding the enema that works for the child" — Andrea Bischoff (clinical) [Ep 30 · 40:32](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=2432)
- "Disimpaction protocol consists of 3 enemas per day for 3 days, and most children are disimpacted after day 3" — Andrea Bischoff (clinical) [Ep 30 · 42:35](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=2555)
- "Senna dosage for constipation management ranges from 8.8 mg to 175 mg given once daily, typically at 6 PM" — Andrea Bischoff (clinical) [Ep 30 · 44:58](https://library.globalcastmd.com/watch/anorectal-malformations-with-dr-andrea-bischoff-937?t=2698)
- "In vestibular fistulas that appear close to the expected anal position, the distance from expected anus location may decrease over the first month of life" — Mark (clinical) [Ep 34 · 1:17](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=77)
- "As long as the child is stooling through a vestibular fistula, there is no urgency to intervene in the first month" — Mark (opinion) [Ep 34 · 1:55](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=115)
- "Primary repair of vestibular fistula in the newborn period is not the easiest operation" — Belinda (clinical) [Ep 34 · 2:41](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=161)
- "The dissection plane between vagina and rectum is much thinner in newborns" — Belinda (clinical) [Ep 34 · 2:41](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=161)
- "In settings without access to TPN and IV fluids, colostomy with delayed repair may be more appropriate than primary repair" — Belinda (opinion) [Ep 34 · 2:55](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=175)
- "Prolonged dilations cause scarring and inflammation" — Belinda (clinical) [Ep 34 · 3:20](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=200)
- "Dilations should typically stop at Hegar size 7 or 8, with stool softeners added" — Belinda (clinical) [Ep 34 · 3:29](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=209)
- "Dilating up to size 11 or 12 makes subsequent repair more difficult" — Belinda (clinical) [Ep 34 · 3:33](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=213)
- "Local trauma from dilations can make dissection at 3-6 months as tedious as in the newborn period" (clinical) [Ep 34 · 3:40](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=220)
- "Traditional teaching held that operations should be done in newborn period when meconium is sterile, or after colostomy to avoid operating in presence of colonized stool" — Jason (guideline) [Ep 34 · 4:01](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=241)
- "There is no data supporting the sterile meconium concept for timing of anorectal malformation repair" (clinical) [Ep 34 · 4:50](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=290)
- "Some pediatric surgeons repair anorectal malformations at any age with dirty stool present and feed the child on postoperative day 1-2, with probably similar complication rates" (clinical) [Ep 34 · 4:52](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=292)
- "Conservative postoperative management includes keeping patients NPO for about a week with hyperalimentation (medical colostomy)" (clinical) [Ep 34 · 4:30](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=270)
- "It is harder to identify the center of the sphincter in a 2 kg baby than in an 8-9 kg baby" (clinical) [Ep 34 · 5:18](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=318)
- "In patients with good prognosis for bowel control and absent vagina found intraoperatively, vaginal reconstruction can be performed using colon or small bowel graft while bringing down the rectum" (clinical) [Ep 34 · 5:57](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=357)
- "In patients with poor prognosis for bowel control (sacral agenesis, tethered cord) and absent vagina, the rectum/fistula can be used as the vagina with more proximal colon brought down as the pull-through" (clinical) [Ep 34 · 6:23](https://library.globalcastmd.com/watch/imperforate-anus-rapid-fire-update-course-2015-984?t=383)
- "Dr. Jason Frischer is head of the colorectal Center at Cincinnati Children's Hospital" (clinical) [Ep 36 · 0:00](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=0)
- "The case involves a newborn with increased abdominal distention, not tolerating feeds, and hasn't passed meconium" — Jason Frischer (clinical) [Ep 36 · 0:39](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=39)
- "Suction rectal biopsy demonstrated no ganglion cells, hypertrophic nerves, and abnormal ACE staining, confirming Hirschsprung's disease" — Jason Frischer (clinical) [Ep 36 · 0:56](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=56)
- "The contrast enema shows a transition zone at almost the descending colon level, higher than standard rectosigmoid" — Jason Frischer (clinical) [Ep 36 · 1:48](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=108)
- "For the standard average pediatric surgeon doing transanal-only approach, 1 in 10 times or 1 in 15 times in a career, the transition will be higher than expected or involve total colon" (clinical) [Ep 36 · 2:09](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=129)
- "If doing transanal without biopsy, surgeons should have a plan for what to do if they encounter a higher transition zone than expected" (opinion) [Ep 36 · 2:44](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=164)
- "The safe way to proceed is some sort of biopsy, whether laparoscopically or through the umbilicus for full thickness biopsy" — Jason Frischer (opinion) [Ep 36 · 3:06](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=186)
- "Leveling colostomy may be appropriate if pathology support is limited or pathologist is not comfortable reading for Hirschsprung's disease" — Jason Frischer (clinical) [Ep 36 · 3:46](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=226)
- "Leveling colostomy is used on mission trips where pathologists are not available, making it almost a three-stage procedure" — Jason Frischer (clinical) [Ep 36 · 4:03](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=243)
- "Pure transanal approach is not necessarily less invasive than laparoscopic approach with 3 abdominal incisions" (opinion) [Ep 36 · 4:22](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=262)
- "Transanal dissection beyond the pelvic reflection involves pulling and stretching" — Belinda (clinical) [Ep 36 · 4:54](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=294)
- "Prolonged transanal dissection (4 hours) stretching sphincters should be avoided when laparoscopic mobilization could be done in 45 minutes" — Jason Frischer (opinion) [Ep 36 · 5:07](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=307)
- "Standard rectosigmoid Hirschsprung (6, 8, 10 centimeters up) can be done transanally in a couple hours if the level is known from good contrast study" — Jason Frischer (clinical) [Ep 36 · 5:46](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=346)
- "Patients with complications after Hirschsprung disease are divided into two categories: obstructive symptoms (enterocolitis, failure to thrive, abdominal distention) or soiling issues" — Jason Frischer (clinical) [Ep 36 · 6:12](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=372)
- "Soiling issues are divided into true incontinence and pseudo-incontinence" — Jason Frischer (clinical) [Ep 36 · 6:31](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=391)
- "For obstructive symptoms, must discern whether the problem is anatomic or pathologic" — Jason Frischer (clinical) [Ep 36 · 6:45](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=405)
- "True fecal incontinence can be due to injury to the sphincter or injury to the dentate line" — Jason Frischer (clinical) [Ep 36 · 6:52](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=412)
- "Pseudo-incontinence can be caused by constipation issues" — Jason Frischer (clinical) [Ep 36 · 7:04](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=424)
- "Jack Langer published an algorithm describing workup for patients with problems after Hirschsprung disease" — Jason Frischer (guideline) [Ep 36 · 7:08](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=428)
- "Workup includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists" — Jason Frischer (clinical) [Ep 36 · 7:25](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=445)
- "Cloaca management has become a collaborative team effort involving urology, pediatric surgery, and gynecology as the three main players." (clinical) [Ep 41 · 5:17](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=317)
- "On ultrasound, the first cystic structure seen from the abdominal cord insertion is the bladder, outlined by umbilical arteries; a cystic structure posterior/inferior to the bladder reaching into the abdomen is hydrocolpos in a cloacal malformation." — Cappels (clinical) [Ep 41 · 8:16](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=496)
- "Echogenic concretions or meconium in the hydrocolpos are clues for a recto-urinary fistula in an anorectal malformation." — Cappels (clinical) [Ep 41 · 9:11](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=551)
- "Fetal bowel contains natural contrast media: proximal bowel has bright fluid on T2-weighted MRI, distal bowel has dark meconium on T2, and meconium is bright on T1-weighted imaging." — Cappels (clinical) [Ep 41 · 10:50](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=650)
- "Meconium does not reach the rectum until 20 weeks gestation and fills the entire colonic column by 26 weeks." — Cappels (clinical) [Ep 41 · 11:49](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=709)
- "On fetal MRI sagittal view, the normal rectum measures at least 10 millimeters from the bladder base to the most distal rectal segment." — Cappels (clinical) [Ep 41 · 12:10](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=730)
- "Long common channel cloaca presents on prenatal MRI with high position of the rectum and dilatation." — Cappels (clinical) [Ep 41 · 13:28](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=808)
- "Cloacas and imperforate anus with recto-urinary fistula can present with fluid distention of the rectum and enterolith formation." — Cappels (clinical) [Ep 41 · 14:28](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=868)
- "Increased fluid content in the rectum (bright signal on T2 instead of dark meconium) is a clue for recto-urinary fistula." — Cappels (clinical) [Ep 41 · 14:46](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=886)
- "In urogenital sinus, the rectum follows a normal posterior course behind the bladder and then to the hydrocolpos, unlike cloaca where the rectum is abnormally positioned." — Cappels (clinical) [Ep 41 · 16:15](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=975)
- "Cloacal exstrophy typically presents with persistent absent bladder visualization, normal amniotic fluid, an omphalocele (often low position), and skin-covered spinal defects." — Cappels (clinical) [Ep 41 · 17:40](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1060)
- "The elephant trunk sign (prolapsed terminal ileum protruding and floating in amniotic fluid) is characteristic of cloacal exstrophy." — Cappels (clinical) [Ep 41 · 18:31](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1111)
- "Cloacal exstrophy patients do not present meconium signal in the expected distribution of the rectum on fetal MRI, unlike bladder exstrophy which shows a normal rectum." — Cappels (clinical) [Ep 41 · 20:20](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1220)
- "Many cloacas not diagnosed prenatally had visible abnormalities on ultrasound but were misdiagnosed by radiologists as ureterocoele, double bladder, ovarian cysts, or bladder diverticulum due to lack of familiarity with hydrocolpos." (clinical) [Ep 41 · 26:30](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1590)
- "If a female fetus has an ovarian cyst, double bladder, or ureterocoele on prenatal ultrasound, especially with abnormal vertebrae, hydronephrosis, or dilated bowel, suspect cloaca." (clinical) [Ep 41 · 27:48](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1668)
- "Prenatal diagnosis of cloaca allows transfer to a specialized center for proper initial management (colostomy, hydrocolpos drainage) and gives families time to prepare emotionally and logistically." — Andrea (opinion) [Ep 41 · 28:12](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1692)
- "Current prenatal imaging cannot fully predict future outcomes in cloaca patients; common channel length and sacral anatomy details needed for counseling on bowel control, urinary control, and sexual function are still limited." — Andrea (clinical) [Ep 41 · 28:56](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1736)
- "At 20 weeks gestation, routine ultrasound findings for anorectal malformations may be very subtle, and community obstetricians may not have a high enough index of suspicion to look for them." — Langer (opinion) [Ep 41 · 30:26](https://library.globalcastmd.com/watch/prenatal-imaging-and-counseling-cloaca-and-complex-arms-2015-1021?t=1826)
- "Ganglion cells are present in the rectal submucosa at 28 weeks gestation normally, though they may not look like mature ganglion cells" — Collins (clinical) [Ep 43 · 1:53](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=113)
- "An experienced pediatric pathologist will be able to recognize immature ganglion cells at 28 weeks gestation" — Collins (clinical) [Ep 43 · 2:13](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=133)
- "Suction rectal biopsies to rule out Hirschsprung's disease on 28 week gestation newborns are extremely rare" — Collins (epidemiological) [Ep 43 · 2:27](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=147)
- "The suction rectal biopsy is diagnostic and can be diagnostic for a patient of any age" — Collins (clinical) [Ep 43 · 4:26](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=266)
- "The failure rate for suction rectal biopsy increases after one year of age" — Collins (clinical) [Ep 43 · 4:37](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=277)
- "Beyond infancy, there is increased separation of the ganglia as a result of the growth of the baby" — Collins (clinical) [Ep 43 · 4:43](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=283)
- "There is increased toughness of the stroma after infancy, making it more difficult to obtain a good suction rectal biopsy" — Collins (clinical) [Ep 43 · 4:57](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=297)
- "The anal canal becomes longer and thicker with age, contributing to suction biopsy failure" — Collins (clinical) [Ep 43 · 5:04](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=304)
- "It is not a good idea to base an entire surgical procedure on the frozen section of a biopsy obtained intraoperatively" — Collins (opinion) [Ep 43 · 14:55](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=895)
- "When making a diagnosis of Hirschsprung disease on suction rectal biopsy, the pathologist is committing that child to losing at least some rectum" — Raj Kapoor (clinical) [Ep 43 · 16:36](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=996)
- "If a suction rectal biopsy confidently shows no ganglion cells and a peritoneal reflection biopsy shows ganglion cells, the patient still has short segment disease" — Raj Kapoor (clinical) [Ep 43 · 17:10](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1030)
- "Large nerves are not present in the submucosa of all cases of Hirschsprung disease" — Collins (clinical) [Ep 43 · 23:08](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1388)
- "Total colonic aganglionosis is a classic example where large nerves may not be present in the submucosa" — Collins (clinical) [Ep 43 · 23:13](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1393)
- "Nerve hypertrophy may be less apparent in the very young as well as in older children" — Collins (clinical) [Ep 43 · 23:38](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1418)
- "Calretinin immunoreactivity or acetylcholinesterase staining fitting with Hirschsprung disease pattern can be enough to make the diagnosis even without hypertrophic nerves" — Raj Kapoor (clinical) [Ep 43 · 25:43](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1543)
- "In a young infant under 6 months of age, you shouldn't see in the distal rectum nerves greater than 40 microns in diameter" — Raj Kapoor (clinical) [Ep 43 · 26:29](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1589)
- "The 40 micron rule for nerve diameter does not hold in older age children" — Raj Kapoor (clinical) [Ep 43 · 26:48](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1608)
- "Transition zone contains ganglion cells, but they're not in their normal distribution completely in the circumference of the bowel" — Collins (clinical) [Ep 43 · 31:39](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1899)
- "There is hypoganglionosis by definition in transition zone" — Collins (clinical) [Ep 43 · 31:47](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1907)
- "Hypertrophic nerves in transition zone can be evaluated more in the submucosa than in the myenteric plexus" — Collins (clinical) [Ep 43 · 31:52](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1912)
- "Submucosal hyperganglionosis with at least 10 ganglion cells in one ganglion is a feature of transition zone" — Collins (clinical) [Ep 43 · 32:09](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1929)
- "Ectopic ganglion cells can be present in normal biopsies and normally innervated bowels" — Collins (clinical) [Ep 43 · 32:29](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1949)
- "If calretinin stain is positive proximal to an aganglionic segment, showing nerve twigs in the lamina propria, that's a sign that there are ganglion cells even if they are not present in that particular section" — Collins (clinical) [Ep 43 · 32:46](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1966)
- "15 micron thick sections are required for IND diagnosis in Europe, which is at least 3 times the thickness of normal sections cut in the United States" — Collins (clinical) [Ep 43 · 33:44](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2024)
- "The histochemical stains used for IND diagnosis in Europe are not commonly used in the United States" — Collins (clinical) [Ep 43 · 33:57](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2037)
- "There have been inconsistent diagnostic criteria for IND, with definitions changing several times over the last several decades" — Collins (clinical) [Ep 43 · 34:05](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2045)
- "IND diagnosis lacks adequate control data from age-matched children who are not constipated" — Collins (clinical) [Ep 43 · 34:17](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2057)
- "The recommendation is that IND diagnosis should not be made in infants" — Collins (guideline) [Ep 43 · 34:53](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2093)
- "IND is outgrown by the age of 4 years" — Collins (clinical) [Ep 43 · 34:57](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2097)
- "IND is not a disorder that requires surgical therapy and is self-correcting" — Collins (clinical) [Ep 43 · 35:01](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2101)
- "There is not a single topographic study of neuronal intestinal dysplasia describing the extension of the defect" — Pena (Alberto) (epidemiological) [Ep 43 · 36:55](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2215)
- "The best way to diagnose hypoganglionosis is to only consider the myenteric ganglion cell density, which means dealing with resected bowel, not just a suction biopsy" — Collins (clinical) [Ep 43 · 41:41](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2501)
- "Currently only severe hypoganglionosis is confidently diagnosed, based on long stretches of myenteric plexus containing small ganglia with one or two ganglion cells per ganglion with minimal neuropil" — Collins (clinical) [Ep 43 · 41:55](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2515)
- "Fluoroscopy was done very well in the 1960s and 1970s when it was the primary modality, but with the advent of MRI, CT, and ultrasound, fluoroscopy has become almost a lost art" (opinion) [Ep 39 · 0:20](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=20)
- "Signs of Hirschsprung disease on plain abdominal radiographs include distal bowel obstruction, dilated colon, and bowel mucosal irregularities" (clinical) [Ep 39 · 0:56](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=56)
- "In a newborn, you cannot tell the difference between colon and small bowel on plain radiographs" (clinical) [Ep 39 · 2:38](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=158)
- "Bubbles of meconium in the bowel are not necessarily pneumatosis and are a fairly common appearance" (clinical) [Ep 39 · 2:52](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=172)
- "The most common causes of distal bowel obstruction in neonates are Hirschsprung disease, small left colon syndrome (meconium plug syndrome), anorectal malformation, meconium ileus, and ileal atresia, which make up about 99% of cases" (epidemiological) [Ep 39 · 3:12](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=192)
- "Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise" (clinical) [Ep 39 · 7:29](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=449)
- "The false negative rate of contrast enema for Hirschsprung disease is between 20% and 25%" (clinical) [Ep 39 · 9:47](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=587)
- "The false positive transition zone rate on contrast enema is up to 43%" (clinical) [Ep 39 · 10:35](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=635)
- "Radiologist agreement on the location of the transition zone is fairly high at 90%" (clinical) [Ep 39 · 10:50](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=650)
- "The concordance rate between radiology and pathology for transition zone location is only about 62%" (clinical) [Ep 39 · 11:02](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=662)
- "For short segment (rectosigmoid) disease, the concordance between radiologic and pathologic transition zones is about 75%" (clinical) [Ep 39 · 12:43](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=763)
- "For long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zones is only about 25%" (clinical) [Ep 39 · 13:09](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=789)
- "Repeat enemas in patients with long segment disease are futile and will not give better knowledge of the transition zone location" (opinion) [Ep 39 · 13:44](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=824)
- "Never use a Foley catheter inside the rectum for contrast enema" — Rodrigo Ocelami (clinical) [Ep 39 · 15:57](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=957)
- "Use water-soluble contrast diluted 50% with saline for neonatal contrast enemas" — Rodrigo Ocelami (clinical) [Ep 39 · 16:19](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=979)
- "Inject contrast very slowly and gently via syringe under continuous fluoroscopy to avoid distending the aganglionic segment" — Rodrigo Ocelami (clinical) [Ep 39 · 16:31](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=991)
- "After the neonatal period, only fill the colon up to the transverse colon if the distal segments appear normal" — Rodrigo Ocelami (clinical) [Ep 39 · 16:56](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1016)
- "Take images in left lateral, right lateral decubitus, and AP positions, and remove the tube to visualize the rectum without obstruction" — Rodrigo Ocelami (clinical) [Ep 39 · 17:25](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1045)
- "Always counsel families about post-procedure hydration and show them the contrast material so they know what to expect when the child evacuates" — Rodrigo Ocelami (clinical) [Ep 39 · 19:23](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1163)
- "The iodinated water-soluble contrast used has an osmolality of about 400, similar to colon-cleansing agents, which helps clean the colon but can cause dehydration in neonates if it remains" (clinical) [Ep 39 · 20:59](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1259)
- "Use gravity infusion rather than injection, with large-bore IV tubing from a bag, at a moderate pace to rapidly visualize both distal and proximal segments" (clinical) [Ep 39 · 21:45](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1305)
- "Early maximal distention is best for seeing the transition zone because waiting too long can cause distention of the distal aganglionic segment" (clinical) [Ep 39 · 22:18](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1338)
- "If a Foley catheter balloon is inflated in the distal rectum, it will miss very short segment Hirschsprung disease every time" (clinical) [Ep 39 · 23:53](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1433)
- "Contrast enemas in premature infants do not follow the rules and may show a small colon that could be immaturity rather than Hirschsprung disease" (clinical) [Ep 39 · 25:02](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1502)
- "Contrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy" (clinical) [Ep 39 · 25:18](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1518)
- "Below 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of contrast enema decreases" (clinical) [Ep 39 · 25:30](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1530)
- "The rectosigmoid transition in Hirschsprung disease is typically at the S2 level; if distal to S1-S2 it is considered distal rectal disease" (clinical) [Ep 39 · 26:45](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1605)
- "Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt" (clinical) [Ep 39 · 27:21](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1641)
- "The rectosigmoid index (rectum larger than sigmoid) is a good principle but not definitive; the entire colon up to the splenic flexure should be evaluated" (clinical) [Ep 39 · 28:48](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1728)
- "In patients with proximal transition zones, the actual pathologic transition can be much more proximal than the radiologic appearance suggests" (clinical) [Ep 39 · 30:14](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1814)
- "For patients with high transition zones on enema, a more invasive approach (laparoscopic or open) may be preferable to transanal pull-through because the true transition location is uncertain" (opinion) [Ep 39 · 30:34](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1834)
- "Rectal biopsy should be performed in almost any patient who needed a contrast enema to rule out distal obstruction, including cases of meconium plug or small left colon" (opinion) [Ep 39 · 31:01](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1861)
- "In clearly diagnosed meconium ileus with reflux into terminal ileum and clinical improvement, rectal biopsy may not be necessary" (opinion) [Ep 39 · 31:35](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1895)
- "In the Soave procedure, partial thickness dissection leaves a muscular cuff that causes widening of the presacral space visible on lateral radiographs" (clinical) [Ep 39 · 33:42](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2022)
- "The Duhamel procedure creates a chimera of aganglionic distal segment with ganglionic proximal segment, forming an anterior pouch that can fill with stool and cause obstruction" (clinical) [Ep 39 · 35:06](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2106)
- "Patients with untreated Hirschsprung disease never develop a dilated rectum, even after 10-15 years, because by definition the aganglionic segment does not distend" — Pena (clinical) [Ep 39 · 36:09](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2169)
- "Patients who develop the characteristic dilated Duhamel pouch may never have had true Hirschsprung disease, and pathologists should carefully examine resected pouches for ganglion cells" — Pena (opinion) [Ep 39 · 36:45](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2205)
- "In a patient with a contrast enema showing dilated colon with normal-appearing rectum and presacral space, rectal biopsy is a waste of time because the patient does not have Hirschsprung disease" — Pena (opinion) [Ep 39 · 39:43](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2383)
- "There is no way to differentiate so-called ultra-short segment Hirschsprung disease from idiopathic constipation" — Pena (opinion) [Ep 39 · 40:15](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2415)
- "The length of the normal physiologic aganglionic segment in the distal rectum has never been accurately determined at different ages in humans" — Pena (clinical) [Ep 39 · 40:47](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2447)
- "The internal anal sphincter is defined as a thickening of the circular muscle layer, but this thickening has never been consistently demonstrated anatomically and its exact limits at different ages have never been determined" — Pena (opinion) [Ep 39 · 41:29](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2489)
- "Internal anal sphincter achalasia is a manometric concept, not an anatomic concept" — Pena (opinion) [Ep 39 · 42:31](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2551)
- "Botulinum toxin injection paralyzes muscle and facilitates stool passage but does not cure a condition of unknown origin" — Pena (opinion) [Ep 39 · 42:48](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2568)
- "Harald Hirschsprung presented a paper on constipation in newborns due to dilation and hypertrophy of the colon in 1886 at the Society of Pediatrics in Berlin" (clinical) [Ep 40 · 0:14](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=14)
- "Hirschsprung was a pediatrician who developed the hydrostatic reduction of ileocolonic intussusception" (clinical) [Ep 40 · 1:06](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=66)
- "Early theories to explain Hirschsprung disease etiology included obstruction from redundant colon or rectal valves, malformation with hypertrophied colon as primary defect, and spastic distal colon causing functional obstruction" (clinical) [Ep 40 · 1:25](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=85)
- "All early theories were wrong because everyone was obsessed that the dilated portion was the diseased one, trying to explain why the dilated portion was the cause rather than the consequence" (clinical) [Ep 40 · 2:29](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=149)
- "William Osler, one of the four founding professors of Johns Hopkins and creator of the residency, proposed colostomy or rectal tube and irrigation as treatments for Hirschsprung disease" (clinical) [Ep 40 · 4:05](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=245)
- "The finding of no ganglion cells in the narrow rectal sigmoid was recognized in 1946 by Orvar Swenson" (clinical) [Ep 40 · 4:27](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=267)
- "Others before Swenson, including Dr. Dalale in 1920, recognized absent ganglion cells in the distal portion but thought it was an acquired condition rather than the cause of disease" (clinical) [Ep 40 · 5:26](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=326)
- "Treatments used for Hirschsprung prior to 1946 included anal sphincter dilation, rectosigmoid myotomy, spinal anesthesia, lumbar sympathectomy, and electric enemas" (clinical) [Ep 40 · 5:58](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=358)
- "Electric enema was described around 1908, involving passing a tube through the rectum with an electrode inside and another electrode on the abdomen, delivering about 40 milliamps of interrupted cycling current to facilitate expulsion of saline solution" — Pena (clinical) [Ep 40 · 6:50](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=410)
- "Barium enema technique became the standard diagnostic test for Hirschsprung disease in 1948, with Dr. Swenson involved in the publication" (clinical) [Ep 40 · 8:00](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=480)
- "Barry Shandling, working in Canada, proposed punch biopsies for newborns that required no closure nor anesthesia" (clinical) [Ep 40 · 9:42](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=582)
- "Dr. Sydegaard from Sweden performed the first successful operation for total colonic aganglionosis in 1953, doing a colon resection with an ileoanal anastomosis" (clinical) [Ep 40 · 11:13](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=673)
- "Swenson observed that when patients had a colostomy the obstruction was relieved, but when the colostomy was closed the disease returned" (clinical) [Ep 40 · 12:48](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=768)
- "Swenson scoped from the rectum in patients with colostomy and saw there was no true mechanical obstruction" (clinical) [Ep 40 · 13:10](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=790)
- "Swenson used a probe on the proximal stoma and observed normal peristalsis, but when he put a probe in the distal stoma he saw no peristalsis" (clinical) [Ep 40 · 13:21](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=801)
- "Swenson performed contrast studies and observed a non-dilated portion followed by a dilated portion, leading him to conclude the distal portion was the diseased one" (clinical) [Ep 40 · 13:35](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=815)
- "Finland uses a national social security number that allows tracking of all patients and access to national medical records." (epidemiological) [Ep 42 · 0:08](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=8)
- "There are very few controlled studies in adults operated for Hirschsprung disease in childhood." (epidemiological) [Ep 42 · 0:52](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=52)
- "The study cohort comprised patients operated 1960–1986, with 143 eligible after excluding deaths and migrants, and 86 matched controls." (epidemiological) [Ep 42 · 1:23](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=83)
- "Most operations were Duhamel procedures, with Soave and Swenson operations in about 10% and 25% respectively." (clinical) [Ep 42 · 1:55](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=115)
- "The average bowel function score in healthy adults is 1.1 (low score = poor function, high score = good function)." (clinical) [Ep 42 · 4:07](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=247)
- "The average gastrointestinal quality-of-life score (GIQLI) in healthy adults is 125.8, with a maximum of 144." (clinical) [Ep 42 · 4:42](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=282)
- "Constipation, soiling, and social problems related to bowel function were much more frequent in Hirschsprung patients than controls." (clinical) [Ep 42 · 5:16](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=316)
- "Mean bowel function score was 17.1 in patients vs 19.1 in controls, a statistically significant difference." (clinical) [Ep 42 · 5:53](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=353)
- "25% of patients scored full 20 points on bowel function vs 50% of controls." (clinical) [Ep 42 · 6:10](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=370)
- "13% of patients reported frequent soiling, 2% had accidents, and 10% had complications requiring treatment." (clinical) [Ep 42 · 6:24](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=384)
- "Gastrointestinal quality-of-life scores were marginally lower in patients but not statistically significant." (clinical) [Ep 42 · 8:11](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=491)
- "22% of patients had a GIQLI score lower than 110, indicating poor gastrointestinal quality of life." (clinical) [Ep 42 · 8:24](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=504)
- "Patients scored worse on 11 of 36 quality-of-life items but better on ability to participate in activities and quality of sleep." (clinical) [Ep 42 · 8:34](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=514)
- "Increasing age was the only significant predictor of poor functional outcome (bowel function score <17)." (clinical) [Ep 42 · 9:16](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=556)
- "Age was inversely related to bowel function score in patients but not in controls, suggesting outcomes may worsen with aging." (clinical) [Ep 42 · 10:08](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=608)
- "Low bowel function score was the only predictor of poor quality of life (GIQLI <110)." (clinical) [Ep 42 · 10:32](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=632)
- "Bowel function continues to be impaired in a significant proportion of adults with Hirschsprung disease." (clinical) [Ep 42 · 10:48](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=648)
- "Abnormalities in urge to defecate, fecal soiling, constipation, and social problems affect about one-third to 15% of adult Hirschsprung patients." (clinical) [Ep 42 · 10:56](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=656)
- "Overall gastrointestinal quality of life is comparable to controls, but decreased QOL was found in one-fifth of patients." (clinical) [Ep 42 · 11:13](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=673)
- "The long-segment cohort included 25 patients born 1984–2013 with total colonic aganglionosis ± small-bowel extension." (epidemiological) [Ep 42 · 11:31](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=691)
- "21 patients were alive at follow-up; 15 male, 6 female. Four had Down syndrome, two had cartilage-hair hypoplasia, one had congenital central hypoventilation syndrome with neuroblastoma, one had Shah-Waardenburg syndrome." (epidemiological) [Ep 42 · 12:26](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=746)
- "Median follow-up was 6.5 years." (epidemiological) [Ep 42 · 13:02](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=782)
- "Five patients had aganglionosis extending very near the duodenojejunal flexure (essentially total bowel aganglionosis); four are alive, only one weaned from parenteral nutrition, all have bowel continuity, one underwent successful small-bowel transplantation, another is awaiting transplant." (clinical) [Ep 42 · 13:10](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=790)
- "Four patients had aganglionosis to mid-small-bowel level; two had syndromic disease contraindicating transplant, two died from severe bowel dysmotility and recurrent sepsis, none weaned from parenteral nutrition, only one has bowel continuity." (clinical) [Ep 42 · 14:08](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=848)
- "Seven patients had aganglionosis involving less than 50% of small bowel; six had pouch procedures, one had Duhamel; all alive, none on parenteral nutrition, all have bowel continuity." (clinical) [Ep 42 · 16:41](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1001)
- "Five patients had purely colonic aganglionosis; all alive, all weaned from parenteral nutrition, all have bowel continuity." (clinical) [Ep 42 · 17:07](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1027)
- "Patients with aganglionosis extending to mid-small-bowel or more proximally are rarely weaned from parenteral nutrition, and this extent affects survival." (clinical) [Ep 42 · 17:29](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1049)
- "All patients with pouch anal anastomosis have voluntary bowel movements; nine are toilet-trained." (clinical) [Ep 42 · 18:10](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1090)
- "Stooling frequency is median 4 per 24 hours (range 1–10)." (clinical) [Ep 42 · 18:25](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1105)
- "Four of ten patients have bowel movements at nighttime." (clinical) [Ep 42 · 18:32](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1112)
- "Two patients have fecal soiling to some degree; none suffer from constipation." (clinical) [Ep 42 · 18:36](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1116)
- "Most patients had at least one episode of enterocolitis, treated with oral metronidazole or ciprofloxacin." (clinical) [Ep 42 · 18:45](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1125)
- "Obstructive episodes were common and mainly treated by Botox injections; some patients required more than two injections, maximum six." (clinical) [Ep 42 · 19:04](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1144)
- "Aganglionosis beyond 50 cm of terminal ileum makes achievement of functional bowel continuity or autonomy exceptional and long-term survival poor without intestinal transplantation." (clinical) [Ep 42 · 19:28](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1168)
- "If aganglionosis is limited to colon, bowel function after pouch anal anastomosis is reassuring, although obstructive symptoms and enterocolitis are frequent but manageable with Botox and metronidazole." (clinical) [Ep 42 · 19:45](https://library.globalcastmd.com/watch/adult-outcomes-hirschsprung-disease-1033?t=1185)
- "Infant presented with delayed passage of meconium of more than 48 hours" — Jafar (clinical) [Ep 45 · 0:18](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=18)
- "At day 7 of age, infant presented with signs and symptoms of Hirschsprung disease including abdominal distension, tight rectum with passage of explosive stool after removing examining finger" — Jafar (clinical) [Ep 45 · 0:30](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=30)
- "Full thickness rectal biopsy confirmed absence of ganglion cells" — Jafar (clinical) [Ep 45 · 0:44](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=44)
- "On laparotomy, malrotation with multiple bands was found: one band between loops of bowel, one between bowel and liver, and one between bowel and abdominal wall" — Jafar (clinical) [Ep 45 · 0:58](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=58)
- "Collapsed colon and anterior ileum with typical cone segment were observed" — Jafar (clinical) [Ep 45 · 1:14](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=74)
- "Biopsy from appendix and terminal ileum proved total colonic disease" — Jafar (clinical) [Ep 45 · 1:32](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=92)
- "Postoperatively, infant received IV fluids, antibiotics, total parenteral nutrition, and after bowel function returned, a high-calorie formula (Ensure) with vitamin B12 supplementation" — Jafar (clinical) [Ep 45 · 1:39](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=99)
- "Infant developed multiple attacks of dehydration requiring hospital admission for IV replacement" — Jafar (clinical) [Ep 45 · 2:04](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=124)
- "At 70 days of age, infant's weight was 3.5 kg" — Jafar (clinical) [Ep 45 · 2:13](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=133)
- "Only a few cases have been reported of total colonic Hirschsprung disease associated with malrotation (Philone had 4 patients, one other author had 1 patient, Zbra reported 3 patients)" — Jafar (epidemiological) [Ep 45 · 3:16](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=196)
- "No cases have been reported with all three anomalies (total colonic Hirschsprung, malrotation, and congenital bands)" — Jafar (epidemiological) [Ep 45 · 3:26](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=206)
- "Congenital bands are rare and only a few cases have been reported; etiology is unknown but could be attributed to antenatal perforation of the bowel" — Jafar (epidemiological) [Ep 45 · 3:46](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=226)
- "The usual scenario for malrotation with Hirschsprung disease is a child with bilious vomiting who gets a contrast study showing malrotation, undergoes Ladd procedure, but then doesn't open up, leading to discovery of total colonic Hirschsprung disease" (clinical) [Ep 45 · 5:20](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=320)
- "After a Ladd procedure, if the baby doesn't open up, you must think about other potential causes for bilious vomiting" (clinical) [Ep 45 · 5:42](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=342)
- "Hirschsprung disease associated with malrotation is usually short segment, not total colonic" (clinical) [Ep 45 · 5:54](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=354)
- "For total colonic Hirschsprung disease, preferred operation is Duhamel because it is simple, safe, and provides a reservoir at the bottom, which Soave does not" (opinion) [Ep 45 · 6:26](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=386)
- "Timing of definitive repair should be based on consistency of ileostomy output, not age or weight" (opinion) [Ep 45 · 6:41](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=401)
- "Infants don't do well if definitive repair is done too early when ileostomy output is still very liquid; better to wait until it firms up, which usually happens when they get onto solid food" (opinion) [Ep 45 · 6:50](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=410)
- "For long segment or total colonic Hirschsprung disease, a relatively short piece of colon should be left, creating a small reservoir rather than a long Martin modification element" (opinion) [Ep 45 · 7:13](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=433)
- "Good continence control in long segment Hirschsprung disease is achieved in only about 50% of patients" (epidemiological) [Ep 45 · 7:32](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=452)
- "When small bowel involvement extends more than 50 cm from the ileocecal valve, it represents a more progressive disease with a bigger dysmotility element" (clinical) [Ep 45 · 7:54](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=474)
- "There is no evidence in the literature that any particular procedure is definitively better for long segment Hirschsprung disease; surgeons should use the procedure they have the best results with" — Sharif (opinion) [Ep 45 · 8:31](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=511)
- "Poor weight gain in an infant with ileostomy receiving adequate calories and normal blood tests is often due to sodium loss" — Sharif (clinical) [Ep 45 · 9:18](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=558)
- "Serum sodium will remain normal for many months before decreasing, so sodium levels in the ileostomy effluent must be checked" — Sharif (clinical) [Ep 45 · 9:49](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=589)
- "If ileostomy effluent contains more than 5 to 7 mEq per liter of sodium, the baby will not gain weight" — Sharif (clinical) [Ep 45 · 9:57](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=597)
- "The baby must be gaining weight and growing before proceeding with definitive repair" — Sharif (opinion) [Ep 45 · 10:04](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=604)
- "Measuring urinary sodium is the best way to guide sodium replacement dosing" (opinion) [Ep 45 · 10:10](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=610)
- "Every baby with an ileostomy should probably receive sodium supplementation" (opinion) [Ep 45 · 10:10](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=610)
- "Iron deficiency is a long-term issue in children with ileostomies and any repairs performed" (clinical) [Ep 45 · 10:26](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=626)
- "For total colonic Hirschsprung disease, if doing Soave or other procedure, must wait until baby grows and ileostomy is thicker, then can continue with bulking agents or antidiarrheal agents" (opinion) [Ep 45 · 10:46](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=646)
- "Some patients who had Duhamel performed abroad came back with enterocolitis, obstruction, and distension of the Duhamel pouch" (clinical) [Ep 45 · 11:20](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=680)
- "Monitoring ileostomy output before deciding on any procedure is critical" (opinion) [Ep 45 · 11:42](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=702)
- "Some patients who had ileal-anal anastomosis developed severe erosive perianal skin breakdown requiring protective ileostomy before further procedures" (clinical) [Ep 45 · 11:42](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=702)
- "In regular (non-total colonic) Hirschsprung disease patients treated with Soave, incontinence is not seen if the procedure is performed well without damaging sphincters" (opinion) [Ep 45 · 12:40](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=760)
- "In newborn with distal bowel obstruction and distal air, contrast enema is preferred initial study over upper GI" (clinical) [Ep 53 · 2:15](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=135)
- "Tissue diagnosis is absolutely required before operating for Hirschsprung disease" (clinical) [Ep 53 · 5:06](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=306)
- "False positive contrast enemas showing transition zones can occur in newborns without Hirschsprung disease" — Langer (clinical) [Ep 53 · 5:13](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=313)
- "Occasional severely ill patient with enterocolitis may require operation before tissue diagnosis is available" (clinical) [Ep 53 · 5:30](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=330)
- "Most cecal perforations from Hirschsprung disease are not total colonic disease but shorter segment disease" — Langer (clinical) [Ep 53 · 21:10](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1270)
- "In long segment disease, wait 6 to 12 months before pull-through to allow stoma output to thicken and prevent perianal excoriation" — Langer (clinical) [Ep 53 · 23:03](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1383)
- "Very short pull-through using only cecum has poor outcomes with stasis and enterocolitis" — Langer (clinical) [Ep 53 · 24:03](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1443)
- "For ascending colon transition zones, ileal Duhamel is preferred over attempting to use cecum" — Langer (opinion) [Ep 53 · 24:03](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1443)
- "If transition zone is at hepatic flexure rather than ascending colon, preserve the colon and bring it down" — Langer (clinical) [Ep 53 · 24:40](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1480)
- "Manometry showing normal rectoanal inhibitory reflex rules out Hirschsprung disease in older children" — Langer (clinical) [Ep 53 · 14:43](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=883)
- "Absence of rectoanal inhibitory reflex can have false positives, so biopsy still required if reflex absent" — Langer (clinical) [Ep 53 · 14:52](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=892)
- "Two definitions exist for ultra-short segment: absence of inhibitory reflex with normal ganglion cells (internal sphincter achalasia) versus very short aganglionic segment" — Langer (clinical) [Ep 53 · 15:30](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=930)
- "Internal sphincter achalasia is not Hirschsprung disease" — Langer (clinical) [Ep 53 · 15:56](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=956)
- "For confirmed ultra-short segment Hirschsprung (aganglionic at 3 cm with ganglion cells at 5 cm), pull-through is preferred over myectomy" — Langer (opinion) [Ep 53 · 16:47](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1007)
- "In 16-year-olds with newly diagnosed Hirschsprung, diversion is usually needed because bowel is so dilated" — Langer (clinical) [Ep 53 · 16:57](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1017)
- "Laparoscopic Duhamel is preferred for older patients because thickened rectum makes transanal dissection difficult and causes excessive sphincter stretch" — Langer (opinion) [Ep 53 · 17:05](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1025)
- "Anal canal in adults is 3 to 4 centimeters long versus 1 centimeter in infants" (clinical) [Ep 53 · 17:24](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1044)
- "Biopsies of anal canal show no ganglion cells normally but should not show hypertrophic nerves or transitional epithelium" (clinical) [Ep 53 · 17:45](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1065)
- "Manometry is not reliable in children under age 5 or 6 years" — Langer (clinical) [Ep 53 · 29:06](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1746)
- "Open rectal biopsy under general anesthesia is preferred over suction biopsy in 3-year-old" (clinical) [Ep 53 · 29:16](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1756)
- "Dilated proximal bowel in 3-year-old can shrink down with diverting colostomy over 6 to 8 months" — Langer (clinical) [Ep 53 · 32:47](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1967)
- "Older the child, less likely dilated bowel will shrink with diversion" — Langer (clinical) [Ep 53 · 32:57](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1977)
- "Colonoscopic biopsies can miss Hirschsprung disease; rectal biopsy is more reliable" — Jason Frischer (clinical) [Ep 53 · 33:42](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2022)
- "Incidence of enterocolitis is significantly higher (approximately double) in children with trisomy 21" (epidemiological) [Ep 53 · 36:20](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2180)
- "For recurrent enterocolitis, must rule out distal obstruction and persistent aganglionic segment" — Langer (clinical) [Ep 53 · 37:07](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2227)
- "Chronic oral metronidazole is used liberally for recurrent enterocolitis and some children need it for extended periods" — Langer (clinical) [Ep 53 · 37:32](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2252)
- "Botox injection decreases number of hospitalizations for enterocolitis but does not always work" — Langer (clinical) [Ep 53 · 38:03](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2283)
- "8% of cases with apparent short transition zone on contrast enema have pathologically higher transition zone (long transition zone)" — Langer (epidemiological) [Ep 53 · 8:16](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=496)
- "For total colonic Hirschsprung disease, Duhamel procedure is preferred initially" — Alp Numoglu (clinical) [Ep 52 · 0:21](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=21)
- "For shorter segment Hirschsprung disease, laparoscopy is used to establish the level, followed by laparoscopic-assisted pelvic dissection and perirectal dissection" — Alp Numoglu (clinical) [Ep 52 · 0:36](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=36)
- "Transanal approach after de la Torre technique has been used for the last 40 cases" — Stephanie (clinical) [Ep 52 · 1:10](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=70)
- "For total colonic Hirschsprung disease, pull-through should be delayed and protective ileostomy is important" — Al's house (clinical) [Ep 52 · 1:51](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=111)
- "Patient with total colonic aganglionosis and destroyed anal canal will not have bowel control" — Ramon (clinical) [Ep 52 · 6:52](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=412)
- "Total colonic aganglionosis produces liquid stool, making bowel management impossible" — Ramon (clinical) [Ep 52 · 7:03](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=423)
- "Permanent abdominal ileostomy is indicated when anal canal is destroyed in total colonic aganglionosis" — Ramon (clinical) [Ep 52 · 7:11](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=431)
- "Parents are taught rectal irrigation technique by bedside nurses before surgery, and must demonstrate competence before proceeding to operation" — Monica (clinical) [Ep 52 · 9:19](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=559)
- "Common irrigation problems include not advancing catheter far enough and not using enough saline to get clear return" — Monica (clinical) [Ep 52 · 10:27](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=627)
- "Only contraindication for irrigation is recent operation; surgeon who operated should perform first postoperative irrigation to avoid perforating anastomosis" (clinical) [Ep 52 · 10:59](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=659)
- "Enterocolitis in Hirschsprung patients is often misdiagnosed as simple gastroenteritis by doctors unfamiliar with the condition" — Alp Numoglu (clinical) [Ep 52 · 11:34](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=694)
- "Most pediatricians worldwide do not understand the difference between enterocolitis and gastroenteritis" — Ramon (opinion) [Ep 52 · 12:56](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=776)
- "When anastomosis is performed 2 centimeters above dentate line, mucosal damage during dissection typically results in final anastomosis approximately 1 centimeter above dentate line" — Ramon (clinical) [Ep 52 · 14:25](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=865)
- "Surgeons performing neonatal Soave with zero enterocolitis often produce fecal incontinence by damaging the anal canal" — Ramon (clinical) [Ep 52 · 15:12](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=912)
- "Patients with destroyed anal canal or stoma rarely have enterocolitis" — Ramon (clinical) [Ep 52 · 15:48](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=948)
- "Sphincter closure creates stasis which produces enterocolitis" — Ramon (clinical) [Ep 52 · 16:05](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=965)
- "Fecal incontinence is preferable to deal with than enterocolitis because fecal incontinence is for life" — Ramon (opinion) [Ep 52 · 16:19](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=979)
- "When re-biopsying for suspected transition zone, biopsy as high as possible above anastomosis to avoid sampling hypoganglionosis" (clinical) [Ep 52 · 16:45](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1005)
- "It is rare for post-operative Hirschsprung patient to have normal anorectal manometry" — Al's house (clinical) [Ep 52 · 17:45](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1065)
- "Patients with Hirschsprung disease are sometimes misdiagnosed with chronic bacterial overgrowth syndrome when they actually have enterocolitis" — Al's house (clinical) [Ep 52 · 17:58](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1078)
- "Saline for irrigation should be warmed, especially for neonatal babies, to maintain normal body temperature" — Monica (clinical) [Ep 52 · 18:56](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1136)
- "Incidence of enterocolitis in pull-through patients is approximately 30%" — Ramon (epidemiological) [Ep 52 · 19:16](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1156)
- "48-hour waiting period after rectal biopsy before starting irrigation is practiced, though no perforations from irrigation after biopsy have been observed" (clinical) [Ep 52 · 20:16](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1216)
- "Fecal incontinence is more frequently seen with Swenson and Soave operations compared to Duhamel and Rehbein" (clinical) [Ep 52 · 21:21](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1281)
- "Regularity of bowel movements (2-3 times daily at consistent times) by age 3 is a good indicator that patient will likely potty train for stool" (clinical) [Ep 52 · 22:12](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1332)
- "Resecting rectosigmoid introduces significant physiological change that makes toilet training difficult even with perfect pull-through preserving anal canal" — Ramon (clinical) [Ep 52 · 23:16](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1396)
- "Hyperactive children with attention deficit disorder have more problems with toilet training after Hirschsprung surgery" — Ramon (clinical) [Ep 52 · 23:30](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1410)
- "Migrating motor complexes or high amplitude contractions stop in sigmoid colon in most people and do not reach rectum" — Al's house (clinical) [Ep 52 · 24:24](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1464)
- "After pull-through, patients do not get same warning of impending bowel movement and have less time to respond" — Al's house (clinical) [Ep 52 · 24:47](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1487)
- "Rectal manometry is not useful for clinical decisions in patients with constipation, anorectal malformations, or Hirschsprung disease" — Ramon (opinion) [Ep 52 · 24:59](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1499)
- "Patients still requiring three daily irrigations at 6 months postoperatively should be considered for additional resection of normal ganglionic colon" — Ramon (clinical) [Ep 52 · 26:25](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1585)
- "Some patients with Hirschsprung disease never have enterocolitis, become toilet trained early, and behave like normal children" — Ramon (clinical) [Ep 52 · 27:30](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1650)
- "Other patients have severe enterocolitis from day one and are a persistent problem" — Ramon (clinical) [Ep 52 · 27:37](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1657)
- "Benign Hirschsprung disease patients may present at 8-10 years old with classic imaging and abdominal distention but never had enterocolitis episode" — Ramon (clinical) [Ep 52 · 27:45](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1665)
- "Earlier diagnosis in United States is identifying more patients with 'bad Hirschsprung' who have enterocolitis from day one" — Ramon (epidemiological) [Ep 52 · 28:13](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1693)
- "Hirschsprung disease pathophysiology involves much more than absent ganglion cells" — Ramon (clinical) [Ep 52 · 28:34](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1714)
- "Neuronal intestinal dysplasia is a very controversial histopathological diagnosis" — Ramon (clinical) [Ep 52 · 28:46](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1726)
- "Long muscular cuff after Soave procedure should be observed if patient is asymptomatic" (clinical) [Ep 52 · 29:59](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1799)
- "If long cuff produces obstructive symptoms with narrow bowel and very dilated proximal bowel on contrast enema, perform Swenson-type full-thickness resection" (clinical) [Ep 52 · 30:12](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1812)
- "Myectomies, myotomies, Botox, and massive dilatation are procedures moving toward temporary or permanent fecal incontinence" — Ramon (clinical) [Ep 52 · 32:55](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1975)
- "Patients subjected to myotomies, myectomies, or repeated Botox eventually develop more severe fecal incontinence" — Ramon (clinical) [Ep 52 · 33:11](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1991)
- "Botox produces temporary effect and temporary incontinence, not appropriate for chronic disease management" (clinical) [Ep 52 · 32:21](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1941)
- "In normal patients the sacral ratio is 0.7 or more" (clinical) [Ep 48 · 1:43](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=103)
- "A sacral ratio of 0.7 or more means good prognosis for bowel control" (clinical) [Ep 48 · 1:50](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=110)
- "When sacral ratio is 0.4 or less, the patient will be fecally incontinent regardless of the type of malformation" (clinical) [Ep 48 · 2:35](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=155)
- "We have never seen a patient with a sacral ratio of less than 0.4 that is fecally continent" (clinical) [Ep 48 · 2:56](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=176)
- "A patient with sacral ratio less than 0.4 will need enemas for life" (clinical) [Ep 48 · 2:56](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=176)
- "The only indication for a stoma for life is incapacity to form solid stool" (clinical) [Ep 48 · 5:38](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=338)
- "Patients with bad prognosis for bowel control are not candidates for stoma for life" (clinical) [Ep 48 · 5:59](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=359)
- "Patients subjected to bowel management tell us that the quality of life with bowel management is much better than the quality of life of having a colostomy" (opinion) [Ep 48 · 6:25](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=385)
- "With incapacity to form solid stool there is no bowel management" (clinical) [Ep 48 · 6:55](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=415)
- "Patients with Down syndrome and anorectal malformation have 80% chance of bowel control" (epidemiological) [Ep 48 · 7:57](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=477)
- "Most patients with Down syndrome have anorectal malformation without fistula" (epidemiological) [Ep 48 · 8:01](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=481)
- "Only 15% of patients with rectal bladder neck fistula have bowel control" (epidemiological) [Ep 48 · 8:55](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=535)
- "Rectal bladder neck fistula is a bad malformation in terms of prognosis for bowel control" (clinical) [Ep 48 · 9:01](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=541)
- "Rectal perineal fistula is the malformation with the best prognosis" (clinical) [Ep 48 · 9:36](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=576)
- "Good prognosis depends upon having a good operation, good sacrum, no tethered cord" (clinical) [Ep 48 · 9:49](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=589)
- "It is important to rule out a presacral mass before discussing prognosis for bowel control" (clinical) [Ep 48 · 9:54](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=594)
- "Hemisacrum indicates that the patient has a presacral mass" (clinical) [Ep 48 · 10:19](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=619)
- "If a patient has rectal perineal fistula but also has hemisacrum and presacral mass, the prognosis for bowel control changes completely and cannot be called good" (clinical) [Ep 48 · 10:19](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=619)
- "Many patients born with perineal fistula had terrible problems because the presacral mass was not detected and not treated when surgeons did not take an x-ray film of the sacrum" (clinical) [Ep 48 · 10:54](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=654)
- "The majority of patients with cloacal exstrophy will be fecally incontinent because of high numbers of tethered cord, myelomeningocele, or bad sacrum" (epidemiological) [Ep 48 · 11:55](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=715)
- "There are a few patients with cloacal exstrophy that are fecally continent" (clinical) [Ep 48 · 11:55](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-i-pediatric-bowel-management-2013-1070?t=715)
- "The anal canal from 2 centimeters above the pectinate line is the most sensitive part of the body, capable of distinguishing between gas, liquid, and solid" (clinical) [Ep 49 · 0:12](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=12)
- "Damaging the anal canal results in poor sensation and fecal incontinence" (clinical) [Ep 49 · 0:39](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=39)
- "The institution performs more reoperations for Hirschsprung disease than primary operations" (epidemiological) [Ep 49 · 1:15](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=75)
- "Full-thickness rectal dissection staying close to the bowel wall prevents damage to pelvic structures including nerves and bladder" (clinical) [Ep 49 · 1:43](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=103)
- "The endorectal dissection technique was created by Dr. Franco Suave to avoid complications that occurred when surgeons tried to reproduce Dr. Swenson's operation" (clinical) [Ep 49 · 1:57](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=117)
- "Biopsies are taken every 5 centimeters during resection and sent for frozen section pathology" (clinical) [Ep 49 · 2:55](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=175)
- "Not all board-certified pathologists have experience with Hirschsprung disease frozen sections; specific expertise is required" (clinical) [Ep 49 · 3:08](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=188)
- "Traction creates the dissection plane; without traction there is no plane and no good dissection" (clinical) [Ep 49 · 5:02](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=302)
- "80% of the time the transanal approach can reach normal ganglionic bowel; 20% require laparoscopy or laparotomy" (epidemiological) [Ep 49 · 5:42](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=342)
- "The institution has performed 125 transanal resections" (epidemiological) [Ep 49 · 7:06](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=426)
- "Patients with Hirschsprung disease ages 4-7 years old with fecal incontinence undergo contrast enema to determine if they have constipation with overflow pseudo-incontinence or hypermotility with non-dilated colon" (clinical) [Ep 49 · 11:28](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=688)
- "Patients with intact anal canal and severe constipation may achieve continence with appropriate laxative management" (clinical) [Ep 49 · 12:28](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=748)
- "Patients with intact anal canal and diarrhea tendency may achieve control with constipating diet, Imodium, 3 meals per day, and special fiber to bulk stool" (clinical) [Ep 49 · 12:51](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=771)
- "Patients without an intact anal canal will require bowel management for life" (clinical) [Ep 49 · 13:11](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=791)
- "Enterocolitis in Hirschsprung disease is non-preventable; the mechanism is unknown and involves bacterial overgrowth" (clinical) [Ep 49 · 13:35](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=815)
- "Constipation after Hirschsprung surgery is partially preventable by resecting the dilated ganglionic segment, as dilated bowel lacks normal peristalsis" (clinical) [Ep 49 · 14:11](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=851)
- "Preventable complications include dehiscence, stenosis, retraction, fistula formation (vaginal, urinary tract), and fecal incontinence from anal canal destruction—all are technical surgical errors" (opinion) [Ep 49 · 14:58](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=898)
- "Enterocolitis can cause C. difficile infection with toxin release leading to death" (clinical) [Ep 49 · 15:53](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=953)
- "After pull-through without colostomy, patients are kept in hospital with serial X-rays and rectal irrigations started at first suspicion of enterocolitis" (clinical) [Ep 49 · 16:23](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=983)
- "Rectal irrigation is the most valuable life-saving maneuver in Hirschsprung disease; all mothers should learn the technique" (opinion) [Ep 49 · 16:49](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1009)
- "Enemas can worsen enterocolitis and may cause bowel perforation; irrigation is the correct technique" (clinical) [Ep 49 · 17:12](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1032)
- "Post-operative protocol: discharge with 3 irrigations per day and Flagyl, taper at 1 month if X-ray and growth normal, further taper at 2 months" (clinical) [Ep 49 · 17:59](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1079)
- "Using this proactive irrigation protocol, the institution has not lost a patient to enterocolitis" (epidemiological) [Ep 49 · 18:40](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1120)
- "Parents should perform irrigation at home before seeking emergency care, as emergency departments often lack supplies and care is delayed" (clinical) [Ep 49 · 25:40](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1540)
- "Dr. Lester Martin pioneered treatment for total colonic aganglionosis at Cincinnati Children's Hospital, creating a pouch using ganglionic bowel for water absorption" (clinical) [Ep 49 · 28:06](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1686)
- "Pouch procedures (Martin, Kimura) for total colonic aganglionosis cause bacterial proliferation and secretory diarrhea when stool is retained" (clinical) [Ep 49 · 29:57](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1797)
- "Preferred approach for total colonic aganglionosis: total colectomy with ileorectal anastomosis above pectinate line and protective ileostomy" (opinion) [Ep 49 · 30:34](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1834)
- "Ileostomy is maintained until patient is toilet-trained for urine, typically over 3 years old" (clinical) [Ep 49 · 30:56](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1856)
- "Closing ileostomy in infants results in severe diaper rash because babies do not attempt to hold liquid stool" (clinical) [Ep 49 · 31:40](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1900)
- "Ileostomy closure criteria: toilet-trained for urine, child can communicate need to use toilet, accepts rectal irrigations without distress" (clinical) [Ep 49 · 32:07](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1927)
- "When anal canal is preserved and ileostomy closed in toilet-trained child, patient achieves stool training within 3 days" (clinical) [Ep 49 · 33:01](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1981)
- "Patients with total colonic aganglionosis have very high incidence of enterocolitis" (epidemiological) [Ep 49 · 32:18](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=1938)
- "Patients without colon cannot have enemas because small bowel absorbs nutrients and cannot be cleaned or stopped between enemas like colon" (clinical) [Ep 49 · 34:03](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-patients-pediatric-bowel-1069?t=2043)
- "The anal canal (2 cm above pectinate line) is the most sensitive part of the body and can distinguish between gas, liquid, and solid; no other tissue can do this" (clinical) [Ep 54 · 0:12](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=12)
- "Damaging the anal canal results in poor sensation and fecal incontinence" (clinical) [Ep 54 · 0:39](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=39)
- "The speaker's institution performs more reoperations for Hirschsprung disease than primary operations" (epidemiological) [Ep 54 · 1:15](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=75)
- "Full-thickness rectal resection is preferred over submucosal endorectal dissection because staying close to the bowel wall prevents damage to pelvic structures" (opinion) [Ep 54 · 1:37](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=97)
- "The endorectal dissection was designed by Dr. Franco Suave to avoid complications that occurred when surgeons tried to reproduce Dr. Swenson's operation, including neurogenic bladder and vaginal injury" (clinical) [Ep 54 · 1:57](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=117)
- "The speaker's technique involves taking biopsies every 5 cm and sending them for frozen section pathology" (clinical) [Ep 54 · 2:55](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=175)
- "Not all board-certified pathologists have experience with Hirschsprung disease frozen sections; surgeon must verify pathologist's specific experience" (clinical) [Ep 54 · 3:08](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=188)
- "Traction creates the dissection plane; without traction there is no plane, leading to poor dissection and complications" (clinical) [Ep 54 · 5:02](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=302)
- "80% of the time the transanal approach can reach normal ganglionic bowel; 20% require laparoscopy or laparotomy" (epidemiological) [Ep 54 · 5:42](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=342)
- "The speaker's institution has performed 125 transanal resections" (epidemiological) [Ep 54 · 7:06](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=426)
- "Patients 4-7 years old with Hirschsprung disease who are fecally incontinent undergo protocol evaluation including contrast enema and examination under anesthesia to assess anal canal integrity" (clinical) [Ep 54 · 11:28](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=688)
- "When the anal canal is destroyed and bowel is sutured to skin, the patient will have lifelong fecal incontinence and require lifelong bowel management" (clinical) [Ep 54 · 12:11](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=731)
- "Constipated patients with intact anal canal may have overflow pseudo-incontinence treatable with laxatives" (clinical) [Ep 54 · 12:32](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=752)
- "Patients with diarrhea tendency and intact anal canal may achieve control with constipating diet, Imodium, 3 meals per day, and special fiber to bulk stool" (clinical) [Ep 54 · 12:51](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=771)
- "Complications in Hirschsprung disease are classified as non-preventable (enterocolitis), partially preventable (constipation), and preventable (dehiscence, stenosis, retraction, fistula, fecal incontinence from anal canal destruction)" (clinical) [Ep 54 · 13:35](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=815)
- "The cause of enterocolitis in Hirschsprung disease is unknown; patients grow bad bacteria in the colon" (clinical) [Ep 54 · 13:48](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=828)
- "Constipation is partially preventable by resecting not only aganglionic bowel but also the dilated normal ganglionic segment, because dilated bowel lacks normal peristalsis" (clinical) [Ep 54 · 14:11](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=851)
- "Enterocolitis can cause abdominal distention, bacterial proliferation including C. difficile, toxin release, and death" (clinical) [Ep 54 · 15:46](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=946)
- "Most pull-through operations are done without colostomy, but patients are kept in hospital with X-ray monitoring and early rectal irrigations at first suspicion of enterocolitis" (clinical) [Ep 54 · 16:23](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=983)
- "Rectal irrigation is the most valuable life-saving maneuver in Hirschsprung disease; all mothers should learn the technique" (clinical) [Ep 54 · 16:49](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1009)
- "Enemas and irrigations are different; giving enemas to a patient with enterocolitis may worsen the condition or cause bowel perforation" (clinical) [Ep 54 · 17:03](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1023)
- "Post-operative protocol: discharge with prophylactic irrigations 3 times daily plus metronidazole, taper over months based on X-ray and clinical response" (clinical) [Ep 54 · 17:59](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1079)
- "Using this proactive enterocolitis protocol, the speaker's institution has not lost a patient to enterocolitis" (epidemiological) [Ep 54 · 18:40](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1120)
- "Parents should perform irrigation at home before seeking emergency care, because many emergency departments lack irrigation supplies and care may be delayed for hours" (clinical) [Ep 54 · 25:40](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1540)
- "Dr. Lester Martin pioneered treatment for total colonic aganglionosis at Cincinnati Children's Hospital, creating a pouch using lateral-lateral anastomosis between aganglionic and ganglionic bowel" (clinical) [Ep 54 · 28:06](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1686)
- "Pouch procedures (Martin, Kimura) for total colonic aganglionosis cause stool retention, bacterial proliferation, inflammatory changes, and secretory diarrhea" (opinion) [Ep 54 · 29:57](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1797)
- "For total colonic aganglionosis, the speaker prefers straight ileoproctostomy (preserving anal canal) with protective ileostomy maintained until the patient is toilet-trained for urine (typically over 3 years old)" (opinion) [Ep 54 · 30:34](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1834)
- "Closing ileostomy in infants with total colonic aganglionosis results in terrible diaper rash because babies pass liquid stool constantly without effort to hold it" (clinical) [Ep 54 · 31:40](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1900)
- "When ileostomy is closed after toilet training for urine and with preserved anal canal, patients become stool-trained within 3 days" (clinical) [Ep 54 · 32:56](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1976)
- "Patients with total colonic aganglionosis have very high incidence of enterocolitis" (epidemiological) [Ep 54 · 32:18](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=1938)
- "Patients without a colon cannot have enemas because small bowel absorbs nutrients and cannot be cleaned or stopped from moving between enemas like colon" (clinical) [Ep 54 · 34:03](https://library.globalcastmd.com/watch/bowel-management-for-hirschsprung-s-disease-1073?t=2043)
- "2 to 5% of vestibular fistulas have a vaginal septum" (epidemiological) [Ep 57 · 0:01](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1)
- "The ideal time to remove a vaginal septum is when the rectum is being mobilized and the perineal body is open" (clinical) [Ep 57 · 0:18](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=18)
- "Women with longitudinal vaginal septa often learn to use one side of the vagina more than the other during intercourse and may be asymptomatic" — Jerry (clinical) [Ep 57 · 2:37](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=157)
- "During labor, women with longitudinal vaginal septa often blow the septum out, which can be repaired at that time" — Jerry (clinical) [Ep 57 · 2:57](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=177)
- "Menstrual hygiene is a major reason to remove vaginal septa, as patients report needing tampons on each side or requiring both tampon and pad" — Jerry (clinical) [Ep 57 · 3:10](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=190)
- "Vaginal septum resection in adolescents is not a difficult operation and can be done with electrocautery, resecting as close to the cervix as possible without damaging it" — Jerry (clinical) [Ep 57 · 3:50](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=230)
- "97% of vestibular fistula patients have normal vaginal anatomy without septa" (epidemiological) [Ep 57 · 5:04](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=304)
- "Of 33 patients with vestibular fistula and absent vagina, 75% had urologic problems including neurogenic bladder" — Shammael (epidemiological) [Ep 57 · 9:34](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=574)
- "Of patients with vestibular fistula and absent vagina, 50% had CKD stage 3 or greater" — Shammael (epidemiological) [Ep 57 · 9:47](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=587)
- "Urologic problems in absent vagina cohort include solitary kidneys, reflux, hydronephrosis, neurogenic bladder, and urinary tract infections" — Shammael (clinical) [Ep 57 · 9:52](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=592)
- "In vestibular fistula with absent vagina, the rectum separates nicely from the urethra with thick fibrous tissue, less adherent than rectum to posterior vagina" (clinical) [Ep 57 · 10:38](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=638)
- "Neovagina construction is technically easier in younger children because the pedicle reaches more easily when the pelvis is shorter" (clinical) [Ep 57 · 12:02](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=722)
- "About 50% of cloacas have a bifid gynecologic system" (epidemiological) [Ep 57 · 18:11](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1091)
- "Hydrocolpos may obstruct the distal ureters and cause bilateral hydronephrosis" (clinical) [Ep 57 · 17:59](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1079)
- "Creating a colostomy in patients with large hydrocolpos can be challenging and may require decompressing the vagina first" — Jack (clinical) [Ep 57 · 18:51](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1131)
- "Attempting cystoscopy at the time of colostomy creation in cloaca patients makes the colostomy creation very difficult" — Jack (clinical) [Ep 57 · 19:09](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1149)
- "With hydrocolpos, as the vagina distends it obstructs the urethra, resulting in more urine leaking into the vagina in a perpetuating cycle" — Curry (clinical) [Ep 57 · 23:58](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1438)
- "After the initial newborn period, the uterus stops secreting and most fluid trapped in the vaginal part of the cloaca is urine refluxing back" — Curry (clinical) [Ep 57 · 23:37](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1417)
- "Hydrocolpos can be managed by catheterizing the cloaca intermittently 2-3 times per day to drain urine, avoiding the need for a tube in many cases" — Curry (clinical) [Ep 57 · 23:30](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1410)
- "When catheterizing a cloaca, the tube can go into the right vagina, left vagina, bladder, or rectum, and may miss the intended structure for days without ultrasound guidance" (clinical) [Ep 57 · 24:30](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1470)
- "With straight tubes for vaginostomy, as hydrocolpos inflammation resolves and it recedes from the abdominal wall, the tube falls out at about two months" (clinical) [Ep 57 · 22:23](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1343)
- "Curled tubes (Pezzer or Malecot) for vaginostomy are preferred over straight tubes because they don't fall out as the hydrocolpos recedes" (clinical) [Ep 57 · 22:06](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-ii-pediatric-1090?t=1326)
- "Standard follow-up after ARM repair includes seeing patients at 2 weeks to start dilations, then at 1 month, 3 months, 6 months, and yearly thereafter for local patients" (clinical) [Ep 56 · 0:23](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=23)
- "For remote patients in Alaska or Montana, local follow-up is arranged with efforts to bring patients back at 3 and 6 months" (clinical) [Ep 56 · 0:46](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=46)
- "Dilatation protocol involves starting at 2 weeks, teaching parents to dilate at home with Hagar dilators up to size 12 or 13 depending on patient size" — Jeff (clinical) [Ep 56 · 1:06](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=66)
- "First-year follow-up occurs every 3 months with strict protocol for constipation management, advising parents not to let child go more than 1.5-2 days without stool" — Jeff (clinical) [Ep 56 · 1:35](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=95)
- "Weekly in-clinic calibration for 6 weeks without parental home dilatation shows no difference in stricture rate, perforation rate, or enterocolitis rate compared to daily parental dilatation" (clinical) [Ep 56 · 2:16](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=136)
- "Approximately 10% of patients managed with weekly calibration develop narrowing and require home dilatation" (epidemiological) [Ep 56 · 3:01](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=181)
- "Daily dilatation by parents is a psychological hardship and not necessary most of the time" (opinion) [Ep 56 · 3:10](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=190)
- "Patients should be kept around Toronto for at least 3-4 weeks postoperatively for weekly follow-up" (clinical) [Ep 56 · 3:38](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=218)
- "Children aged 3-4 years who missed early anoplasty window cannot be dilated by parents at home but do fine with clinic dilatation every 1-2 weeks" (clinical) [Ep 56 · 3:56](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=236)
- "European centers are considering a trial protocol starting with 6 weeks of dilatations to potentially reduce current protocols" — Ivo (clinical) [Ep 56 · 5:18](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=318)
- "Retained vestibular fistula after ARM repair is of no consequence if the neoanal opening is adequate, but can be problematic if large and extending behind the perineal body" (clinical) [Ep 56 · 6:41](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=401)
- "Surgical repair goal for dehisced perineal body is to position healthy rectum down, healthy vagina up, and create muscular perineal body structure in between" (clinical) [Ep 56 · 7:27](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=447)
- "Postoperative management options include colostomy for diversion or keeping patient NPO" (clinical) [Ep 56 · 7:49](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=469)
- "Most common problem in cloacal repairs is addressing only the rectum without managing the urogenital sinus" (clinical) [Ep 56 · 8:53](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=533)
- "Misidentification of bladder neck as rectum during pull-through can occur if anatomy is not understood preoperatively" (clinical) [Ep 56 · 9:33](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=573)
- "Staged hemi-anoplasty for rectal prolapse, with second half done 3 months later as ambulatory procedure, eliminates need for dilatations" (clinical) [Ep 56 · 10:36](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=636)
- "Half-circumferential anoplasty heals quickly and does not stricture, unlike full circumferential dissection" (clinical) [Ep 56 · 11:09](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=669)
- "Posterior urethral diverticulum represents retained original distal rectum after inadequate distal dissection during pull-through" (clinical) [Ep 56 · 12:00](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=720)
- "If uncertain of anatomy during laparoscopic pull-through, the colon should be opened to identify the fistula from inside" — Jeff (clinical) [Ep 56 · 12:25](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=745)
- "Posterior urethral diverticulum with colonic mucosa bathed in urine for 30 years developed into adenocarcinoma in one case" (clinical) [Ep 56 · 12:50](https://library.globalcastmd.com/watch/problematic-anorectal-malformation-cases-pediatric-colorectal-controversies-1096?t=770)
- "The PSARP approach revolutionized pelvic surgery management beyond just anorectal malformations" (opinion) [Ep 66 · 1:37](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=97)
- "Opening the rectum too high during PSARP is safer than opening too low, which risks entering the urethra" (clinical) [Ep 66 · 5:24](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=324)
- "In laparoscopy, staying on the rectal wall from the beginning prevents wandering into the urethra" — Keith (clinical) [Ep 66 · 6:34](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=394)
- "The lateral wall dissection defines the anterior plane and should be done first" (clinical) [Ep 66 · 6:59](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=419)
- "If fat is visible on the rectal wall during dissection, the surgeon can get closer to the rectum" (clinical) [Ep 66 · 8:03](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=483)
- "Surgeons who stay too lateral thinking they are being safe are actually at greater risk; intimate attachment to the rectal wall is safest" — Keith (clinical) [Ep 66 · 8:36](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=516)
- "Traction suture on the fistula opening at 6 o'clock is critical because the urethral opening can disappear after disconnecting the rectum" — Don (clinical) [Ep 66 · 4:45](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=285)
- "Presacral fascia fixation with permanent sutures prevents prolapse in laparoscopic repairs" — Keith (clinical) [Ep 66 · 10:53](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=653)
- "Leaving too much laxity in the rectum contributes to prolapse" — Keith (clinical) [Ep 66 · 11:06](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=666)
- "Minimal perineal incision with lateral stitches about 1 cm cephalad to skin in 4 quadrants helps prevent prolapse" — Jack (clinical) [Ep 66 · 13:51](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=831)
- "Mobilizing only enough rectum to reach comfortably with slight tension, rather than extensive mobilization followed by tacking, reduces prolapse risk" — Jack (clinical) [Ep 66 · 14:43](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=883)
- "Desufflating the abdomen before final assessment of rectal length is essential to avoid having too much redundant rectum" (clinical) [Ep 66 · 16:01](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=961)
- "Every little bit of muscle preserved helps prevent leakage; cutting muscle weakens it" — Keith (clinical) [Ep 66 · 17:10](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1030)
- "Distal colostogram with both lateral and AP views plus exact measurements is the standard imaging protocol" — Bates (clinical) [Ep 66 · 28:26](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1706)
- "Combined distal colostogram with VCUG at the same setting provides comprehensive anatomic information" — Bates (clinical) [Ep 66 · 28:31](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1711)
- "Cystoscopy fails to identify the fistula in approximately 7 out of 10 primary ARM cases, particularly bulbar fistulae" (clinical) [Ep 66 · 38:14](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2294)
- "Bladder neck fistulae usually enter at right angles and narrow down, making them easier to define laparoscopically" — Keith (clinical) [Ep 66 · 32:56](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1976)
- "Opening the colon to look for the fistula from inside is a safe technique when external identification is difficult" — Keith (clinical) [Ep 66 · 33:16](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1996)
- "The endo-loop should trail the Maryland stick, with the stick placed distally for better control during fistula ligation" — Keith (clinical) [Ep 66 · 36:02](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2162)
- "Metal clips tend to erode into the urethra and should be avoided for fistula closure" — Keith (clinical) [Ep 66 · 34:42](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2082)
- "The urethral angle on lateral imaging is used to distinguish bulbar (at or below the angle) from prostatic (above the angle) fistulae" — Bates (clinical) [Ep 66 · 36:42](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2202)
- "In ARM, the IMA cannot be taken because colostomy creation has divided distal blood supply; the rectum depends on IMA branches and intramural vessels" (clinical) [Ep 66 · 46:32](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2792)
- "In Hirschsprung's disease, the IMA can be taken safely because the left colic and sigmoid arcade remain intact" (clinical) [Ep 66 · 46:32](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2792)
- "Heineke-Mikulicz plasty (cutting horizontally, suturing vertically) can gain 2-3 cm of additional rectal length while addressing dilation" (clinical) [Ep 66 · 47:30](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2850)
- "Rectum should reach 2 finger breadths (4 cm) below the pubic bone to ensure it will reach the anus after pull-through" (clinical) [Ep 66 · 50:04](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=3004)
- "Taking down the mucous fistula may gain length but creates a difficult colostomy closure requiring colocolonic anastomosis" (clinical) [Ep 66 · 49:41](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2981)
- "Properly placed newborn colostomy as proximal in the sigmoid as possible prevents need for colostomy takedown during definitive repair" (clinical) [Ep 66 · 49:26](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2966)
- "Mucosal prolapse is preferable to stricture because it can be trimmed" (opinion) [Ep 66 · 15:37](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=937)
- "If the rectum is not mobilizing easily, the dissection plane is wrong" (clinical) [Ep 66 · 7:52](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=472)
- "Persistent fistula (never managed) can result when surgeons perform anoplasty on low bulbar fistula without addressing the fistula, causing patients to urinate through the anus" (clinical) [Ep 66 · 40:38](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2438)
- "High-grade reflux with ureteral dilation and renal pelvic dilation indicates a child at relatively high risk who should be followed closely and warrants urologic evaluation." — Shamel Elam (clinical) [Ep 58 · 0:57](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=57)
- "A normal renal ultrasound is very reassuring that the kidneys at birth are in good shape, but it does not give all the answers—you can have a normal appearing kidney and still have high-grade reflux and bladder pathology." — Rama (clinical) [Ep 58 · 2:01](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=121)
- "Every child with an anorectal malformation must have initial ultrasonography of the urinary tract at presentation and in follow-up." — Rama (guideline) [Ep 58 · 3:00](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=180)
- "Solitary kidney patients are at higher risk for further injury of that solitary kidney, generally in the case of unrecognized or underdiagnosed neurogenic bladder." — Shamel Elam (clinical) [Ep 58 · 4:33](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=273)
- "All humans are born with all the nephrons they will have for the rest of their lives, with continued nephron development only for the first 6 months after birth." — Rama (clinical) [Ep 58 · 5:36](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=336)
- "Reflux itself does not damage kidneys, but infection does. Reflux in conjunction with bladder dysfunction can damage kidneys." — Rama (clinical) [Ep 58 · 6:16](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=376)
- "Children with high-grade reflux, solitary kidney, and bladder neck fistula need very close follow-up with serial ultrasonography, maintenance of sterile urine, blood work (serum creatinine, cystatin C), and regular urodynamic studies." — Rama (guideline) [Ep 58 · 5:23](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=323)
- "A creatinine of 0.3 for the first 12-18 months of life may seem normal, but if the child is at the 4th percentile for height and weight, that is not a normal condition—growth parameters are important indicators of renal function." — Shamel Elam (clinical) [Ep 58 · 7:05](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=425)
- "In high-risk ARM cases (solitary kidney, reflux, bladder neck fistula), a divided colostomy is preferable to a loop colostomy to ensure complete fecal diversion." — Donald Shaw (clinical) [Ep 58 · 7:30](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=450)
- "Total urogenital mobilization eliminates any future function of the external urinary sphincter, making continence dependent solely on bladder neck function." — Donald Shaw (clinical) [Ep 58 · 9:33](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=573)
- "Continence after total urogenital mobilization depends more on bladder function and bladder compliance than on the bladder neck itself." — Donald Shaw (clinical) [Ep 58 · 10:12](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=612)
- "A 12-year-old ex-cloaca patient who is voiding well, has urinary control, and has no UTIs is not necessarily safe—underlying neuropathic bladder can cause long-term renal damage without obvious symptoms." — Shamel Elam (clinical) [Ep 58 · 10:41](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=641)
- "Neuropathic bladder does not always mean the patient leaks or has urinary tract infections—the functional morbidity can be silent." — Shamel Elam (clinical) [Ep 58 · 11:19](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=679)
- "The bladder stores urine for about 23 hours and 40 minutes during the day—the storage function is more important than the emptying function for long-term renal health." — Rama (clinical) [Ep 58 · 12:06](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=726)
- "Asking if a patient is continent is not enough to assess bladder health—you need evidence of how the bladder is storing urine." — Rama (clinical) [Ep 58 · 12:34](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=754)
- "In ARM patients with bladder neck fistula, single kidney, reflux, and tethered cord, expectations should not be set for volitional voiding—these patients are at high risk for neurogenic bladder." — Shamel Elam (clinical) [Ep 58 · 13:04](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=784)
- "The appendix makes a nice Mitrofanoff that tends to have longer durability than a tapered ileal piece." — Shamel Elam (clinical) [Ep 58 · 17:25](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1045)
- "When doing split-appendix technique, implant the Mitrofanoff very carefully first, then see where the Malone goes—pushing the Malone to the umbilicus after Mitrofanoff implantation risks blood supply compromise and tissue tearing." — Shamel Elam (clinical) [Ep 58 · 18:04](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1084)
- "In ARM patients with absent sacrum and malrotation requiring Ladd's procedure, the appendix should be preserved (not removed) for potential future use in Mitrofanoff or Malone procedures." — Marc Levitt (guideline) [Ep 58 · 21:00](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1260)
- "At the onset of puberty in cloaca patients, parents must be educated to watch for undrained fluid collections, especially if rudimentary uterine structures were left in place." — Donald Shaw (guideline) [Ep 58 · 25:04](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1504)
- "For fertility potential, a connected system is needed: distal fallopian tube to uterine Müllerian structure to cervix (important for carrying pregnancy) to vaginal outflow tract." — Jerry (clinical) [Ep 58 · 27:09](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1629)
- "Performing ureteral reimplantation at the time of initial cloaca repair (rather than delayed) makes the secondary operation for continence and augmentation more pleasant and leads to faster patient recovery." — Shamel Elam (opinion) [Ep 58 · 28:16](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1696)
- "It is very important to know whether the patient has reflux before undertaking a cloaca repair—sometimes cystoscopy is needed to catheterize the bladder for a VCUG." — Donald Shaw (guideline) [Ep 58 · 29:49](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1789)
- "Reimplanting the ureter after a complex cloaca repair with long common channel and bladder neck mobilization is a totally difficult operation—better to do it at the time of cloaca repair if reflux is present." — Donald Shaw (clinical) [Ep 58 · 30:15](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1815)
- "Cutaneous ureterostomy should only be done if the ureter is dilated, as the biggest complication is stenosis." — Rama (clinical) [Ep 58 · 30:53](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1853)
- "A massively dilated ectopic ureter is a situation where ureterostomy may be safer than primary reconstruction, with reimplantation deferred to a later date." — Rama (clinical) [Ep 58 · 31:07](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1867)
- "Five-centimeter common channel cloaca patients rarely have volitional voiding that is functional later in life." — Shamel Elam (clinical) [Ep 58 · 32:05](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1925)
- "If a newborn requires vaginostomy and/or vesicostomy, those structures must be taken down to perform the cloaca repair—they cannot be left in place." — Donald Shaw (clinical) [Ep 58 · 33:07](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=1987)
- "A circle stent (small 6 or 8 French elastic catheter) coming out of the urethral repair and bladder, tied to itself and protected with suprapubic tube, allows 100% certainty about urethral healing and avoids perineal catheter trauma." — Shamel Elam (clinical) [Ep 58 · 34:01](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2041)
- "Patients who need vesicostomy probably have some impairment in bladder function and may need intermittent catheterization long-term." — Shamel Elam (clinical) [Ep 58 · 34:36](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2076)
- "Total urogenital mobilization patients are likely to void and be easily catheterized, but complex urethral reconstructions may not be easily catheterizable, warranting prolonged urethral stenting or vesicostomy." — Marc Levitt (clinical) [Ep 58 · 34:52](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2092)
- "A vesicostomy with refluxing ureters provides safety and allows waiting until ultimate urologic reconstruction at age 4." — Marc Levitt (clinical) [Ep 58 · 35:33](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2133)
- "The fundamental principle is to keep the kidneys at low pressure—there are many different ways to accomplish this." — Marc Levitt (guideline) [Ep 58 · 36:20](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2180)
- "A suprapubic cystostomy tube at definitive cloaca reconstruction diverts urine, keeps the perineum dry, and automatically provides a way to assess bladder emptying." — Jerry (clinical) [Ep 58 · 36:40](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2200)
- "Teaching families intermittent catheterization gives them control and prevents no-care-zone situations, especially for families traveling long distances." — Brad Kropp (opinion) [Ep 58 · 37:25](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2245)
- "A febrile urinary tract infection should prompt immediate assumption that the bladder is not successfully emptying—pre- and post-void residuals and assessment for scarring are essential." — Marc Levitt (guideline) [Ep 58 · 38:30](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2310)
- "Excellent nursing staff who can teach families intermittent catheterization is as important as any surgical procedure—families are scared and need professional guidance." — Rama (opinion) [Ep 58 · 39:14](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2354)
- "Teaching catheterization in the OR with the child asleep alleviates huge anxiety for families, allowing them to practice multiple times and learn nuances before the child wakes." — Brad Kropp (clinical) [Ep 58 · 39:56](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2396)
- "If total urogenital mobilization does not get the urethral opening as far out on the perineum as possible, it leaves a female hypospadias or enteritis that is harder for families to catheterize." — Donald Shaw (clinical) [Ep 58 · 41:10](https://library.globalcastmd.com/watch/urologic-and-gynecologic-aspects-in-anorectal-malformations-pediatric-1098?t=2470)
- "Perineal fistula is diagnosed when the fistula opening is at or anterior to the fourchette, with normal urethra and vagina visible" — Marc Levitt (clinical) [Ep 64 · 0:23](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=23)
- "Vestibular fistula is diagnosed when the fistula opens posterior to the fourchette within the vestibule" — Marc Levitt (clinical) [Ep 64 · 1:53](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=113)
- "For perineal fistula mobilization, the goal is to mobilize just enough to reach perineal skin with a little bit of tension" — Don (opinion) [Ep 64 · 2:27](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=147)
- "Complete separation from vagina is preferred because incomplete mobilization may lead to retraction and wound problems" — Marc Levitt (opinion) [Ep 64 · 2:50](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=170)
- "In every redo of a female ARM, areolar tissue is found that had never been dissected by the original surgeon" — Marc Levitt (clinical) [Ep 64 · 5:40](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=340)
- "Inadequate anterior rectal wall mobilization can lead to perineal body disruption as the anterior wall pulls back" — Marc Levitt (clinical) [Ep 64 · 6:10](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=370)
- "Many newborn female vestibular fistula redos were done without a colostomy" — Don (clinical) [Ep 64 · 6:52](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=412)
- "The rectal blood supply is intramural, so injuring the rectal wall hurts its blood supply" — Marc Levitt (clinical) [Ep 64 · 13:09](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=789)
- "Starting laterally before attempting anterior separation is key to avoiding injury when separating rectum from vagina" — Marc Levitt (clinical) [Ep 64 · 13:35](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=815)
- "Coming in from lateral to anterior and starting more proximally makes separation easier than starting at the perineum" — Don (clinical) [Ep 64 · 14:25](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=865)
- "Primary vestibular repair without colostomy can be done in newborn or within 3-4 months depending on child's condition" — Marc Levitt (opinion) [Ep 64 · 15:00](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=900)
- "Waiting until perineal body is healed (day 6-7) before feeding allows intervention if dehiscence is developing" — Marc Levitt (opinion) [Ep 64 · 16:28](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=988)
- "10% dextrose can be used for NPO periods up to 7 days in well-nourished children, avoiding need for hyperalimentation" — Marc Levitt (clinical) [Ep 64 · 17:18](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1038)
- "Systematic review shows early enteral nutrition appears better than later nutrition in ARM patients, but all studies are retrospective and poor quality" — Marc Levitt (epidemiological) [Ep 64 · 18:48](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1128)
- "About 2-5% of vestibular fistulas have a vaginal septum" — Marc Levitt (epidemiological) [Ep 64 · 26:39](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1599)
- "The ideal time to remove a vaginal septum is when the rectum is being mobilized and the perineal body is open" — Marc Levitt (opinion) [Ep 64 · 26:58](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1618)
- "Women with longitudinal vaginal septum often learn to work around it for intercourse but have problems with tampon use" — Marc Levitt (clinical) [Ep 64 · 29:17](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1757)
- "Vaginal septum resection in adolescents is not a difficult operation and can be done with electrocautery" — Marc Levitt (clinical) [Ep 64 · 30:30](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1830)
- "True vaginal fistula (within introitus) is rare and requires slightly more rectal mobilization than vestibular fistula" — Marc Levitt (clinical) [Ep 64 · 32:28](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=1948)
- "In vestibular fistula with absent vagina, 75% have urologic problems including neurogenic bladder" — Don (epidemiological) [Ep 64 · 36:15](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2175)
- "Of patients with vestibular fistula and absent vagina, 50% have CKD stage 3 or greater" — Don (epidemiological) [Ep 64 · 36:27](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2187)
- "Sigmoid colon can be used as neovagina in vestibular fistula with absent vagina" — Don (clinical) [Ep 64 · 34:12](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2052)
- "Using rectum as vagina and mobilizing proximal bowel as neo-rectum should only be done if patient unlikely to be continent (spinal anomaly, absent sacrum)" — Marc Levitt (opinion) [Ep 64 · 35:33](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2133)
- "Rectum separates from urethra more easily than from vagina in absent vagina cases, with thick fibrous tissue rather than adherent common wall" — Marc Levitt (clinical) [Ep 64 · 37:18](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2238)
- "Neovagina is technically easier in younger children because the pedicle reaches more easily in a shorter pelvis" — Marc Levitt (clinical) [Ep 64 · 38:42](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2322)
- "There are two types of cloacas: lower ones (common channel ≤3 cm) and complicated ones (>3 cm)" — Marc Levitt (clinical) [Ep 64 · 44:12](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2652)
- "About 50% of cloacas have a duplicated gynecologic system" — Marc Levitt (epidemiological) [Ep 64 · 44:51](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2691)
- "Hydrocolpos in cloaca may obstruct distal ureters and cause bilateral hydronephrosis" — Marc Levitt (clinical) [Ep 64 · 44:40](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2680)
- "For newborn cloaca with hydrocolpos, open divided colostomy with pigtail catheter decompression of vagina is preferred over formal vaginostomy" — Marc Levitt (opinion) [Ep 64 · 45:10](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2710)
- "Attempting cystoscopy at time of colostomy creation in cloaca makes the colostomy very difficult" — Marc Levitt (clinical) [Ep 64 · 45:49](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2749)
- "Laparoscopic approach for cloaca colostomy allows visualization of pelvic structures and percutaneous vaginostomy tube placement" — Marc Levitt (clinical) [Ep 64 · 47:53](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2873)
- "Curled tube is preferred over straight tube for vaginostomy because straight tubes fall out at 2 months when inflammation resolves" — Marc Levitt (clinical) [Ep 64 · 48:50](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2930)
- "Much of hydrocolpos fluid is urine refluxing up, not just vaginal secretions" — Don (clinical) [Ep 64 · 49:30](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=2970)
- "Intermittent catheterization of cloaca 2-3 times daily can drain urine and avoid need for vaginostomy tube in many cases" — Marc Levitt (clinical) [Ep 64 · 50:11](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3011)
- "Catheterization teaching should be done under ultrasound guidance because tube can go into right vagina, left vagina, bladder, or rectum" — Marc Levitt (clinical) [Ep 64 · 51:00](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3060)
- "Once hydrocolpos is drained, the bladder can fill, demonstrating that hydrocolpos compresses ureters and prevents bladder filling" — Marc Levitt (clinical) [Ep 64 · 52:45](https://library.globalcastmd.com/watch/arms-in-female-patients-pediatric-colorectal-controversies-2014-1101?t=3165)
- "Botox paralyzes skeletal muscle theoretically but clearly has some impact on smooth muscle" — Marc Levitt (clinical) [Ep 78 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=117)
- "Babies have very tight anal sphincter with or without Hirschsprung's disease" — Marc Levitt (clinical) [Ep 78 · 2:06](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=126)
- "In normal babies who hold stool in successfully they get constipated, in Hirschsprung babies they get enterocolitis" — Marc Levitt (clinical) [Ep 78 · 2:14](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=134)
- "After a perfectly done operation preserving 1 centimeter of anal canal, you can have high tone in a baby that doesn't know how to relax" — Marc Levitt (clinical) [Ep 78 · 2:26](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=146)
- "Botox is valuable if a baby is coming back with enterocolitis episodes after ruling out anatomic or pathologic problems" — Marc Levitt (clinical) [Ep 78 · 3:15](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=195)
- "In the early period up to one year of age, you can have bad behavior by the patient even with a perfectly done pull-through" — Marc Levitt (clinical) [Ep 78 · 3:27](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=207)
- "After a year or so of age, there may be an anatomic or pathologic problem and Botox is not very valuable because you have to figure out what the problem is" — Marc Levitt (clinical) [Ep 78 · 3:36](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=216)
- "A retained cuff that is too big, not split completely, or rolled up is particularly offensive to the ability of the pull-through to empty" — Marc Levitt (clinical) [Ep 78 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=287)
- "Patients with retained cuff will get better temporarily with Botox but will continue to fall off the wagon every 2 or 3 months" — Marc Levitt (clinical) [Ep 78 · 5:09](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=309)
- "Nerves greater than 40 microns indicate a transition zone pull-through" — Marc Levitt (clinical) [Ep 78 · 5:35](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=335)
- "Many pathologists are not measuring the nerves, and pediatric surgeons should demand that their pathologists do that" — Marc Levitt (opinion) [Ep 78 · 5:43](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=343)
- "If anatomic and pathologic issues are completely ruled out, Botox maybe gets done once, maybe a second time, and then you're done" — Marc Levitt (clinical) [Ep 78 · 5:58](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=358)
- "If a patient over 1 year of age keeps misbehaving, there is likely an anatomic or pathologic problem" — Marc Levitt (opinion) [Ep 78 · 6:14](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=374)
- "Dr. Levitt has never met a patient with Hirschsprung disease that is anatomically perfect (no stricture, no cuff, no duhamel pouch causing trouble, no twist) with normal ganglion cells and nerves less than 40 microns that does not spontaneously empty, except rare patients under a year of age who have not learned to relax their anal canal" — Marc Levitt (opinion) [Ep 78 · 6:24](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=384)
- "If an older child is not emptying spontaneously, there is an anatomic or pathologic problem that has not yet been identified" — Marc Levitt (opinion) [Ep 78 · 7:00](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=420)
- "Botox injection technique: 100 units in 10cc saline, 2.5cc submucosal into each quadrant right into the muscle surrounding the anal canal" — Marc Levitt (clinical) [Ep 78 · 7:07](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=427)
- "Dr. Levitt will never do an internal sphincterotomy because it is permanent Botox and could cause permanent incontinence" — Marc Levitt (opinion) [Ep 78 · 7:30](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=450)
- "Patients will eventually figure out how to relax, so there is no need to make sphincterotomy a permanent anatomic solution" — Marc Levitt (opinion) [Ep 78 · 7:45](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=465)
- "Most people use between 60 units and 100 units of Botox for Hirschsprung patients" — Scott Ingham (clinical) [Ep 78 · 8:08](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=488)
- "Some practitioners use much less volume (1mL total, 0.25mL per quadrant) for Botox injection" — Scott Ingham (clinical) [Ep 78 · 8:47](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=527)
- "A dilated pull-through segment may be secondary to noncompliance with dilations or bowel regimen, or the surgeon may not have taken out enough bowel at the original surgery" — Marc Levitt (clinical) [Ep 78 · 9:35](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=575)
- "For patients with a dilated segment and no other anatomic abnormality who continue to misbehave, redo surgery to remove the dilated segment can be offered" — Marc Levitt (clinical) [Ep 78 · 10:01](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=601)
- "Almost always there is something causing the dilation, either a cuff or a transition zone segment of bowel" — Marc Levitt (clinical) [Ep 78 · 10:12](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=612)
- "If a tapered segment is created during redo, it will be a fairly dysmotile segment of bowel for many, many months" — Marc Levitt (clinical) [Ep 78 · 11:24](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=684)
- "If tapering or redo is necessary, the patient should always be diverted with an ileostomy" — Marc Levitt (clinical) [Ep 78 · 11:31](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=691)
- "Most likely you can remove the dilated segment and bring the healthy segment down without tapering" — Marc Levitt (clinical) [Ep 78 · 11:40](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=700)
- "You must make sure any distal obstruction is removed during redo surgery" — Marc Levitt (clinical) [Ep 78 · 11:46](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=706)
- "VACTERL association screening includes plain abdominal X-ray for vertebral abnormalities including hemivertebrae" — Marc Levitt (guideline) [Ep 84 · 3:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=192)
- "Cardiac evaluation for anorectal malformation includes both physical exam and echocardiogram" — Marc Levitt (guideline) [Ep 84 · 3:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=214)
- "Esophageal atresia screening requires NG tube passage" — Marc Levitt (guideline) [Ep 84 · 3:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=220)
- "Renal evaluation requires kidney ultrasound" — Marc Levitt (guideline) [Ep 84 · 3:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=227)
- "True sacral ratio measurements should wait until the child is 3 months of age" — Marc Levitt (clinical) [Ep 84 · 3:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=237)
- "Radiologists evaluating anorectal malformation patients should examine the presacral space with spinal ultrasound" — Marc Levitt (guideline) [Ep 84 · 4:22](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=262)
- "Presacral masses are rare in typical imperforate anus but found almost half the time in anal stenosis or rectal atresia defects" — Marc Levitt (epidemiological) [Ep 84 · 4:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=273)
- "Patients with anal stenosis or rectal atresia and presacral mass will require MRI" — Marc Levitt (clinical) [Ep 84 · 4:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=273)
- "Cross-table lateral radiograph is obtained at approximately 24 hours of life to visualize the rectal gas column position" — Jason Frischer (guideline) [Ep 84 · 5:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=308)
- "The 24-hour waiting period allows the baby to declare whether they need colostomy or might benefit from primary repair" — Marc Levitt (clinical) [Ep 84 · 5:44](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=344)
- "Cross-table lateral is performed with the baby prone and a bump under the buttocks to position the buttock as the highest point where air will rise" — Jason Frischer (clinical) [Ep 84 · 6:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=370)
- "A marker should be placed at the expected anal location on cross-table lateral to enable distance measurements" — Jason Frischer (clinical) [Ep 84 · 6:28](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=388)
- "A sacral ratio greater than 0.7 connotes very good prognosis for bowel control" — Marc Levitt (clinical) [Ep 84 · 7:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=440)
- "Well-formed buttocks and visible sphincter mechanism location on physical exam contribute to good prognosis" — Jason Frischer (clinical) [Ep 84 · 7:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=467)
- "The danger of primary posterior sagittal approach without knowing rectal location is finding midline white structures like urethra, bladder neck, or bladder instead of rectum" — Marc Levitt (clinical) [Ep 84 · 9:25](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=565)
- "Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically" — Marc Levitt (clinical) [Ep 84 · 9:42](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=582)
- "Colostomy carries its own complications both from the initial procedure and from subsequent closure" — Marc Levitt (clinical) [Ep 84 · 10:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=634)
- "Performing anoplasty without identifying and addressing a fistula can result in the child urinating through the anus postoperatively" — Marc Levitt (clinical) [Ep 84 · 11:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=680)
- "During primary posterior sagittal anorectoplasty, the posterior rectal wall should be opened and the anterior wall inspected to rule out fistula" — Marc Levitt (clinical) [Ep 84 · 12:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=729)
- "In low rectal lesions, inspecting and dissecting a small portion of the anterior rectal wall will usually rule out fistula" — Marc Levitt (clinical) [Ep 84 · 12:17](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=737)
- "Low bulbar fistulas are located very close to the rectum, requiring careful plane dissection" — Jason Frischer (clinical) [Ep 84 · 12:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=754)
- "Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra" — Jason Frischer (clinical) [Ep 84 · 13:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=780)
- "95% of Down syndrome patients with anorectal malformation have no fistula, but 5% do have fistulas" — Marc Levitt (epidemiological) [Ep 84 · 13:44](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=824)
- "Distal colostogram should still be performed in Down syndrome patients with imperforate anus despite the low fistula rate" — Marc Levitt (guideline) [Ep 84 · 13:44](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-arm-low-bulbar-fistula-3527?t=824)
- "Deep laparoscopic dissection into the pelvis minimizes transanal work and prevents overstretching of sphincters, a significant source of morbidity in Hirschsprung surgery" — Marc Levitt (clinical) [Ep 88 · 6:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=361)
- "Transanal dissection in primary pull-through should take well under 1 hour when preceded by adequate laparoscopic dissection" — Jason Frischer (clinical) [Ep 88 · 6:37](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=397)
- "Full-thickness biopsy should be cut as a cube with seromuscular side matching mucosal side dimensions" — Marc Levitt (clinical) [Ep 88 · 7:37](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=457)
- "Pathology must confirm ganglion cells present and nerves less than 40 microns in diameter" — Andrea Badillo (clinical) [Ep 88 · 10:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=608)
- "Biopsy specimen must include submucosa because ganglion cells may be present in seromuscular layer while hypertrophic nerves persist in submucosal layer" — Marc Levitt (clinical) [Ep 88 · 10:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=620)
- "Mesenteric dissection should stay as close to the bowel as possible without entering it, remaining in a less bloody plane" — Aaron Garrison (clinical) [Ep 88 · 11:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=673)
- "Too wide dissection of distal rectum in old Swenson technique caused urinary retention and incontinence, likely from injury to nervi erigentes" — Marc Levitt (clinical) [Ep 88 · 11:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=712)
- "For distal disease, only distal IMA branches need division; for left colon involvement, IMA itself may require division to achieve adequate reach" — Jason Frischer (clinical) [Ep 88 · 12:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=746)
- "Transanal mucosal incision should be made 1 centimeter above the dentate line" — Andrea Badillo (clinical) [Ep 88 · 13:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=790)
- "Lone Star retractor pins advance in three stages: starting at skin to identify dentate line, advancing to cover dentate line, then positioning at mucosal opening site" — Andrea Badillo (clinical) [Ep 88 · 13:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=804)
- "Swenson full-thickness dissection in the areolar plane is essentially bloodless" — Marc Levitt (clinical) [Ep 88 · 14:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=852)
- "If performing Soave technique with muscular cuff, the cuff should be very short (approximately 1 cm) and must be split" — Marc Levitt (clinical) [Ep 88 · 14:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=864)
- "Patient can remain supine with legs wrapped and fastened to ether screen for standard rectosigmoid cases; prone positioning reserved for more complex cases" — Aaron Garrison (clinical) [Ep 88 · 15:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=903)
- "Resection margin should be approximately 5 cm above the biopsy site where bowel appears healthy" — Andrea Badillo (clinical) [Ep 88 · 16:06](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=966)
- "Seromuscular tacking sutures to pelvic sidewall at 3 and 6 o'clock positions anchor the pull-through and facilitate mucosa-to-mucosa alignment" — Aaron Garrison (clinical) [Ep 88 · 16:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=990)
- "Hypertrophic nerves are mainly a sacral nerve plexus entity, found in sigmoid and rectum, not in more proximal colon" — Levitt (clinical) [Ep 89 · 5:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=348)
- "On frozen section, you can rule out Hirschsprung disease but cannot rule it in" — Rod Gerardo (clinical) [Ep 89 · 5:23](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=323)
- "If you don't have ganglion cells and you're at the splenic flexure, you should not do a pull-through that day and need to wait for permanent section" — Levitt (guideline) [Ep 89 · 9:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=572)
- "If you have even a little bit of colon, if you have your right colon, you can make one formed stool per day" — Levitt (clinical) [Ep 89 · 10:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=620)
- "For mid-transverse pull-through, you need to ligate the middle colic and very likely ligate the right colic, with blood supply dependent on ileocolic and the marginal artery paralleling the right colon" — Levitt (clinical) [Ep 89 · 11:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=698)
- "For proximal pull-through, you de-rotate by putting the cecum at the liver bed and bringing the pull-through down the right side, with all small bowel on the left side, which is essentially a rotation opposite to a Ladd's procedure" — Levitt (clinical) [Ep 89 · 11:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=718)
- "When bringing down mid-transverse colon, you need to de-rotate the bowel, otherwise you will bring the mesentery right across the duodenum and create an obstruction" — Andrea Badillo (clinical) [Ep 89 · 11:21](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=681)
- "There are functional outcome differences if you start pulling through transverse colon versus pulling through left-sided colon" — Fisher (clinical) [Ep 89 · 9:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=585)
- "An ileostomy almost definitely is going to successfully divert the patient, whereas with a diverting colostomy based on frozen section there is concern it may not be at a good level" — Levitt (opinion) [Ep 89 · 6:49](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=409)
- "In parts of the world without pathology support, diverting in the dilated segment is a very reasonable strategy, and if that bowel works, that is where the pull-through will go" — Levitt (guideline) [Ep 89 · 7:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=427)
- "Biopsies should be marked with permanent suture using different numbers of tails for each biopsy site to enable identification at subsequent operation" — Fisher (guideline) [Ep 89 · 7:29](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=449)
- "When doing a proximal pull-through, there is a slight twist in the mesentery when pulling it down, so ensuring adequate blood supply without kinking is very important" — Fisher (clinical) [Ep 89 · 12:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=730)
- "Personal preference is to do proximal pull-through open, probably through the incision for ileostomy closure, though some have done it laparoscopically" — Levitt (opinion) [Ep 89 · 12:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=744)
- "If you are going to do a primary pull-through 4 days later waiting for permanent sections, you must ensure the child is being irrigated and doing well with irrigation, not having smoldering or low-grade enterocolitis features" — Fisher (guideline) [Ep 89 · 6:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=369)
- "You can always get out of the OR without doing something permanent" — Aaron Garrison (guideline) [Ep 89 · 4:18](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=258)
- "For mid-transverse pull-through, the blood supply is based on right colic artery" — Andrea Badillo (clinical) [Ep 89 · 11:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=675)
- "If the colon is incredibly backed up with chalky stool after several months, irrigations will not do anything, but if you don't have that issue the colon can stay without needing a way to irrigate it" — Andrea Badillo (clinical) [Ep 89 · 8:46](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=526)
- "Anal calibration is performed about 2 weeks after Hirschsprung pull-through surgery to assess for cicatrix or narrowing" — Megan Durham (clinical) [Ep 90 · 1:58](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=118)
- "Problems after Hirschsprung pull-through commonly occur later rather than very early on" — Megan Durham (clinical) [Ep 90 · 2:13](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=133)
- "Routine therapies including finger or dilator insertion should be avoided initially after pull-through due to risk of disrupting the healing anastomosis" — Eunice Huang (clinical) [Ep 90 · 2:23](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=143)
- "Post-operative outcomes after Hirschsprung pull-through vary significantly between patients despite identical surgical technique" — Eunice Huang (clinical) [Ep 90 · 2:52](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=172)
- "Treatment for Hirschsprung patients should be tailored to the individual rather than following a standard protocol" — Eunice Huang (opinion) [Ep 90 · 3:04](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=184)
- "At Children's Healthcare of Atlanta, acute enterocolitis management does not include fixed NPO time or immediate TPN" — Megan Durham (clinical) [Ep 90 · 5:13](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=313)
- "Rectal irrigations for Hirschsprung-associated enterocolitis typically use 10 cc per kg of normal saline every 8 hours for the first 24 to 48 hours" — Megan Durham (clinical) [Ep 90 · 5:19](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=319)
- "IV Flagyl is typically started for acute Hirschsprung-associated enterocolitis" — Megan Durham (clinical) [Ep 90 · 5:29](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=329)
- "Enterocolitis treatment must be individualized based on presentation spectrum, from mild white count elevation to gross distention with shock" — Rod Gerardo (clinical) [Ep 90 · 5:32](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=332)
- "Some Hirschsprung patients have a tendency to dilate their colon and require ongoing management to prevent recurrent enterocolitis" — Megan Durham (clinical) [Ep 90 · 6:28](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=388)
- "Teaching parents to perform home washouts improves quality of life by allowing early intervention when the child shows signs of illness" — Eunice Huang (clinical) [Ep 90 · 6:48](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=408)
- "Nursing staff education on rectal irrigations and enemas is necessary because these procedures are not common everyday occurrences" — Megan Durham (clinical) [Ep 90 · 7:13](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=433)
- "Standardized order forms with links to policy improve clarity for nurses performing rectal irrigations" — Megan Durham (clinical) [Ep 90 · 7:37](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=457)
- "An APSA guideline by Dr. Langer provides an algorithm for diagnosis and management of obstructive symptoms after Hirschsprung pull-through" — Megan Durham (guideline) [Ep 90 · 8:10](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=490)
- "The diagnostic algorithm for post-pull-through obstruction includes rectal exam, contrast enema, rectal biopsy, and potentially botulinum toxin injection" — Rod Gerardo (guideline) [Ep 90 · 8:47](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=527)
- "Motility workup may be needed to determine if further colonic resection, bowel management, stoma, or ACE procedure is required" — Rod Gerardo (guideline) [Ep 90 · 9:01](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=541)
- "Obstructive symptoms after Hirschsprung pull-through are easier for parents to recognize than hypermotility with incontinence" — Megan Durham (clinical) [Ep 90 · 9:37](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=577)
- "High-amplitude propagating contractions with pressures upward of 400 mmHg extending to the anus cannot be controlled voluntarily" — Megan Durham (clinical) [Ep 90 · 10:56](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=656)
- "Pseudo-incontinence from hypermotility can be managed with fiber intake adjustment, daily Imodium, and cholestyramine" — Rod Gerardo (clinical) [Ep 90 · 11:21](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=681)
- "Failure of medical management is defined as appropriate treatment with no appropriate response, patient cannot take treatment, persistent symptoms or pain with treatment, or failure to grow" — Kahleb Graham (clinical) [Ep 91 · 2:51](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=171)
- "Failure of retrograde enemas is considered failure of medical management" — Kahleb Graham (clinical) [Ep 91 · 3:21](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=201)
- "Reliance on rectal therapy or retrograde enemas with continued soiling causing significant effect on functioning is considered failure of medical management" — Anil Darbari (clinical) [Ep 91 · 3:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=215)
- "General pediatricians typically prescribe osmotic laxatives like MiraLax or lactulose and stimulant laxatives such as Senna or bisacodyl, but there are other medications that pediatricians are not used to prescribing that GI doctors are" — Anil Darbari (clinical) [Ep 91 · 3:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=237)
- "Some children stool every day but do not completely evacuate" — Rod (clinical) [Ep 91 · 4:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=298)
- "Initial evaluation includes history of triggers, stooling frequency, timing, and sensation of complete emptying, plus physical exam looking for palpable stool and distension, rectal exam, and diagnostic imaging" — Anil Darbari (clinical) [Ep 91 · 4:46](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=286)
- "In patients with long-standing constipation where appropriate treatments have been tried and failed, the first step in management is diagnostic studies including contrast enema" — Kahleb Graham (clinical) [Ep 91 · 5:27](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=327)
- "Contrast enema is used to assess degree of colonic dilatation and redundancy and to ensure the ratio is normal" — Kahleb Graham (clinical) [Ep 91 · 5:56](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=356)
- "There are probably many people with redundant colons that stool perfectly normally without imaging documentation" — Jason Frischer (opinion) [Ep 91 · 6:53](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=413)
- "It is unclear whether colonic dilation and redundancy precedes constipation or results from outlet obstruction" — Rod (clinical) [Ep 91 · 6:59](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=419)
- "Contrast study is not a great predictor of how patients will respond to medical or surgical management" — Rod (clinical) [Ep 91 · 7:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=432)
- "Crazy looking colons can respond really nicely to treatment, and colons that look totally normal on contrast study may not respond at all to treatment" — Rod (clinical) [Ep 91 · 7:19](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=439)
- "Colons used to be resected based on appearance, but patients with motility disorders did not need resection" — Marc Levitt (clinical) [Ep 91 · 7:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=456)
- "Many dilated colons will respond to treatment" — Marc Levitt (clinical) [Ep 91 · 7:54](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=474)
- "Water-soluble contrast is used instead of barium because it helps empty the colon and acts as a cleanout for patients starting new medical therapy" — Jason Frischer (clinical) [Ep 91 · 8:06](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=486)
- "Reviewing diagnostic imaging with the family helps them understand anatomy and issues and builds rapport" — Rod (clinical) [Ep 91 · 8:37](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=517)
- "The rectoanal inhibitory reflex (RAIR) is when the rectum becomes distended with stool and the internal anal sphincter relaxes" — Rod (clinical) [Ep 91 · 9:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=551)
- "Anorectal manometry uses a catheter with sensors measuring pressure and a balloon to assess anal sphincter function and its relationship to the rectum" — Anil Darbari (clinical) [Ep 91 · 9:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=575)
- "High pressures on anorectal manometry may suggest underlying inability to relax causing functional obstruction" — Anil Darbari (clinical) [Ep 91 · 10:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=600)
- "Patients with Hirschsprung disease have an absent rectoanal inhibitory reflex (RAIR)" — Anil Darbari (clinical) [Ep 91 · 10:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=609)
- "Anorectal manometry provides information about defecation dynamics by having patients bear down, squeeze, and attempt to defecate while comparing sensation to defecate versus internal anal sphincter response" — Anil Darbari (clinical) [Ep 91 · 10:19](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=619)
- "Anorectal manometry is a functional test that provides baseline and functional information" — Anil Darbari (clinical) [Ep 91 · 10:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=636)
- "In the past, the sphincter and its major role in constipation patients was not well understood" — Jason Frischer (clinical) [Ep 91 · 10:51](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=651)
- "Anorectal manometry is critical for determining whether a patient needs surgery or resection, because patients with motility disorders do not need resection" — Rod (clinical) [Ep 91 · 12:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=723)
- "Majority of pediatric rectal prolapse cases do not need surgery" — Rod (clinical) [Ep 92 · 2:26](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=146)
- "Most common reasons for rectal prolapse are constipation, sitting on the potty too long, or sitting on it incorrectly" — Rod (clinical) [Ep 92 · 2:33](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=153)
- "Rectal prolapse happens in kids because they have a very weak pelvic floor and the rectum is very low, so it tends to pop out easily if you strain hard enough" — Eunice Huang (clinical) [Ep 92 · 2:44](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=164)
- "Physical exam must distinguish rectal prolapse from intussusception, polyps, and rectal hemorrhoids" — Rod (clinical) [Ep 92 · 2:55](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=175)
- "Treatment includes managing constipation, teaching appropriate sitting on the potty with a smaller seat and step stool, and limiting time on toilet" — Eunice Huang (clinical) [Ep 92 · 3:13](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=193)
- "Parents should be taught how to safely reduce a prolapse to avoid incarceration" — Rod (clinical) [Ep 92 · 3:39](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=219)
- "Sclerotherapy is simple, innocuous, and can provide a window of a couple months without prolapse that helps younger kids see it less frequently" — Shawn St. Peter (opinion) [Ep 92 · 4:11](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=251)
- "Sclerotherapy protocol uses 5 ccs of Sotradechol injected in 4 quadrants" — Shawn St. Peter (clinical) [Ep 92 · 4:30](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=270)
- "A systematic review included 27 publications with 900 patients: 300 underwent sclerotherapy (8 studies, 3 sclerosing agents) and 600 underwent operative management (22 studies, 17 procedures)" — Eunice Huang (epidemiological) [Ep 92 · 5:10](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=310)
- "The large volume of different operative procedures indicates uncertainty about which is the best procedure for rectal prolapse" — Eunice Huang (opinion) [Ep 92 · 5:46](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=346)
- "Transabdominal procedures have a pretty high success rate for correcting prolapse" — Eunice Huang (clinical) [Ep 92 · 5:56](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=356)
- "The most popular sclerosing agent is alcohol and it is pretty effective" — Rod (clinical) [Ep 92 · 6:51](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=411)
- "Alcohol is easy to obtain in the hospital setting" — Rod (clinical) [Ep 92 · 7:04](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=424)
- "Complication rate with sclerotherapy is mostly negligible, complications are acute, and there is minimal risk of long-term problems" — Eunice Huang (clinical) [Ep 92 · 7:14](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=434)
- "Underlying diseases, especially cystic fibrosis, should be ruled out in patients with rectal prolapse" — Eunice Huang (guideline) [Ep 92 · 7:41](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=461)
- "Small children in the potty training phase should receive appropriate medical management and constipation treatment" — Eunice Huang (guideline) [Ep 92 · 7:51](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=471)
- "If conservative management fails, sclerotherapy with ethyl alcohol is the recommended first option" — Rod (guideline) [Ep 92 · 8:04](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=484)
- "Sclerotherapy can be done up to 3 times with an estimated cumulative success rate of a little bit over 80%" — Rod (clinical) [Ep 92 · 8:11](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=491)
- "If sclerotherapy fails, laparoscopic rectopexy is the recommended operative approach because it has the lowest complication rate and highest success rate" — Rod (guideline) [Ep 92 · 8:12](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=492)
- "Patients with rectal prolapse may have anxiety that creates a feedback loop where prolapse becomes an emotional release for evacuating stool" — Eunice Huang (clinical) [Ep 92 · 9:34](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=574)
- "Pelvic floor therapy is useful in strengthening pelvic floor musculature and leads to more durable outcomes after sclerotherapy" — Eunice Huang (clinical) [Ep 92 · 9:34](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=574)
- "Patients with rectal prolapse may necessitate a multidisciplinary team approach including behavioral therapy and physical therapy" — Rod (opinion) [Ep 92 · 9:20](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=560)
- "10% of patients with meconium plug have Hirschsprung disease" — Marc Levitt (epidemiological) [Ep 94 · 3:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=193)
- "Failure to pass meconium in newborns is most commonly caused by Hirschsprung disease, meconium plug syndrome, meconium ileus, or anorectal malformation" — Rod Gerardo (clinical) [Ep 94 · 4:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=247)
- "Rare causes of failure to pass meconium include small left colon syndrome, hypothyroidism, opiates in the newborn system, magnesium sulfate exposure, milk protein allergy, and microcolon intestinal hypoperistalsis syndrome" — Amanda Jensen (clinical) [Ep 94 · 4:21](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=261)
- "In total colonic Hirschsprung disease, contrast enema shows cylindrical, amorphous colon without the classic rectosigmoid narrowing seen in typical Hirschsprung disease" — Rod Gerardo (clinical) [Ep 94 · 6:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=393)
- "Age cutoff for switching from suction rectal biopsy to full-thickness biopsy is around 6 months" — Jason Frischer (opinion) [Ep 94 · 7:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=446)
- "Suction biopsies are problematic when they do not provide a definitive diagnosis, requiring subsequent formal biopsy in the operating room" — Marc Levitt (clinical) [Ep 94 · 7:46](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=466)
- "Rectal biopsies should be attempted pre-operatively before proceeding to the operating room" — Amanda Jensen (guideline) [Ep 94 · 8:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=483)
- "If a patient is doing well and can be managed with irrigations, final diagnosis of Hirschsprung disease should be obtained through rectal biopsy before entering the abdomen" — Jason Frischer (guideline) [Ep 94 · 8:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=518)
- "If a patient is not doing well with irrigations, a procedure to relieve pressure such as ileostomy or leveling colostomy is necessary" — Amanda Jensen (guideline) [Ep 94 · 8:53](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=533)
- "Loop ostomies should be avoided in Hirschsprung disease because stool may spill into the non-functional part of the colon" — Amanda Jensen (guideline) [Ep 94 · 9:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=544)
- "Standard intraoperative biopsy sites include rectosigmoid, proximal sigmoid, left colon, splenic flexure area, transverse colon, right colon, and hepatic flexure area" — Jason Frischer (guideline) [Ep 94 · 9:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=553)
- "When no transition zone is visible during surgery, additional biopsies should be obtained at multiple sites along the colon" — Amanda Jensen (guideline) [Ep 94 · 9:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=575)
- "A definitive pull-through procedure should not be performed based solely on frozen section if there is uncertainty about the diagnosis" — Amanda Jensen (guideline) [Ep 94 · 10:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=609)
- "In meconium plug cases, the initial contrast enema may show what appears to be a meconium plug but is actually a segment of Hirschsprung disease" — Amanda Jensen (clinical) [Ep 94 · 3:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=210)
- "After meconium passes in suspected Hirschsprung cases, obtaining another contrast image can reveal the characteristic appearance of Hirschsprung disease" — Amanda Jensen (clinical) [Ep 94 · 3:53](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=233)
- "Water-soluble contrast enema showed a tortuous and redundant colon that was dilated and full of stool" (clinical) [Ep 93 · 0:53](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=53)
- "Anorectal manometry showed an absent rectoanal inhibitory reflex (RAIR)" — Rogerardo (clinical) [Ep 93 · 1:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=63)
- "The patient is showing massively dilated colon as a result of colonic dysfunction, although the dilatation is predominantly in the rectal sigmoid" — Anil Darbari (clinical) [Ep 93 · 2:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=124)
- "High resting pressure on manometry might indicate a patient amenable to anal Botox" — Kahleb Graham (clinical) [Ep 93 · 2:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=155)
- "Dyssynergia is when patients push from their belly but create a negative pressure at the bottom instead of relaxing the sphincter" — Kahleb Graham (clinical) [Ep 93 · 3:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=182)
- "Patients with dyssynergia might benefit from pelvic floor physical therapy or biofeedback" — Kahleb Graham (clinical) [Ep 93 · 3:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=195)
- "Sitz marker study is performed by taking markers and obtaining an X-ray at day 5" — Kahleb Graham (clinical) [Ep 93 · 3:39](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=219)
- "If Sitz markers are scattered throughout the colon or predominantly on the right side, it suggests colonic dysmotility and may warrant colonic manometry" — Kahleb Graham (clinical) [Ep 93 · 3:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=228)
- "If all markers are sitting at the bottom of the colon, it fits more with an outlet issue" — Rogerardo (clinical) [Ep 93 · 4:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=247)
- "If all markers have disappeared on day 5 X-ray, the patient did stool even if they reported not stooling" — Kahleb Graham (clinical) [Ep 93 · 4:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=253)
- "Sitz markers do not dissolve" — Kahleb Graham (clinical) [Ep 93 · 4:22](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=262)
- "Colonic manometry is not available everywhere, but Sitz marker study should be available pretty much anywhere" — Marc Levitt (epidemiological) [Ep 93 · 4:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=278)
- "Sitz marker study can be used as a colonic transit study by obtaining X-rays at day 0, 1, 2, and 4 to see transit of markers" — Anil Darbari (clinical) [Ep 93 · 4:51](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=291)
- "Sitz marker study is not a replacement for colonic manometry" — Amanda Jensen (opinion) [Ep 93 · 5:17](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=317)
- "Nuclear scintigraphy is available in most centers that have nuclear medicine capacity" — Marc Levitt (epidemiological) [Ep 93 · 5:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=332)
- "Three colonic motility scenarios: diffusely slow but functional, normal motility with segmental obstruction, and entire colon severely slow and amodal" — Marc Levitt (clinical) [Ep 93 · 5:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=340)
- "Anorectal manometry is the gold standard but is a sophisticated, expensive test not available everywhere" — Rogerardo (opinion) [Ep 93 · 6:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=400)
- "Colonic manometry provides information on peristaltic activity, which is the motion of the colon" — Anil Darbari (clinical) [Ep 93 · 7:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=427)
- "Throughout the day, you should have two really strong contractions throughout your colon called high amplitude propagating contractions (HAPCs)" — Rogerardo (clinical) [Ep 93 · 7:21](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=441)
- "HAPCs start on the right side of the colon in the cecum area and progress distally" — Anil Darbari (clinical) [Ep 93 · 7:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=452)
- "If a patient has two HAPCs during an 18 or 24 hour study period, they do not have colonic dysmotility" — Rogerardo (clinical) [Ep 93 · 7:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=465)
- "Many patients get colonic manometry but the results come back normal" — Jason Frischer (epidemiological) [Ep 93 · 8:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=482)
- "No one normal or typical gets a colonic motility test" — Marc Levitt (opinion) [Ep 93 · 8:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=490)
- "If the colon moves uniformly with HAPCs throughout, antegrade flush will work well and reliably" — Marc Levitt (clinical) [Ep 93 · 8:22](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=502)
- "Some patients have a truly outlet issue and their colon is actually normal on manometry" — Kahleb Graham (clinical) [Ep 93 · 8:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=518)
- "Manometry can characterize if contractions are well coordinated (neuropathic problem) or low amplitude (myopathic problem)" — Kahleb Graham (clinical) [Ep 93 · 8:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=527)
- "Contractions should go from the right side of the colon all the way down to the rectum, but the rectum does not have those same contractions" — Kahleb Graham (clinical) [Ep 93 · 9:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=543)
- "In Hirschsprung's patients post pull-through, the rectal sigmoid brake is removed and contractions may go all the way to the sphincters" — Kahleb Graham (clinical) [Ep 93 · 9:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=552)
- "If there is no response to stimulants on colonic manometry, the patient does not have normal colonic motility by definition" — Anil Darbari (clinical) [Ep 93 · 9:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=576)
- "The case was concluded to not be Hirschsprung's disease; the absent RAIR was a sampling error" — Marc Levitt (clinical) [Ep 93 · 10:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=611)
- "The surgeon did not re-biopsy because of calretinin positivity" — Marc Levitt (clinical) [Ep 93 · 10:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=620)
- "Anorectal manometry showed the colon was diffusely slow and the problem was the sphincter due to absent RAIR" — Rogerardo (clinical) [Ep 93 · 10:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=626)
- "The patient was offered a Malone for antegrade flushes in combination with Botox and biofeedback physiotherapy" — Rogerardo (clinical) [Ep 93 · 10:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=638)
- "Over time, the colon could probably rehab and the patient may eventually need just laxatives alone" — Rogerardo (opinion) [Ep 93 · 10:50](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=650)
- "A perfectly good endpoint is to have a mechanically emptying colon, not necessarily weaning to laxatives alone" — Marc Levitt (opinion) [Ep 93 · 11:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=660)
- "Enemas from below or from above (through a Malone or cecostomy) are acceptable long-term management; resection is reserved for failures of conservative therapy" — Marc Levitt (opinion) [Ep 93 · 11:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=671)
- "Patients who fail conservative management are those with slow transit throughout or segmental disease" — Rogerardo (clinical) [Ep 93 · 11:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=684)
- "The vast majority of patients with segmental disease respond to antegrade enema only and never need resection" — Marc Levitt (clinical) [Ep 93 · 11:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=692)
- "A collaborative model between surgery and gastroenterology should be promoted in every center providing colorectal care" — Anil Darbari (opinion) [Ep 93 · 12:17](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=737)
- "Harold Hirschsprung identified that a baby could be sick due to this problem but did not understand the pathology" — Marc Levitt (clinical) [Ep 108 · 1:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=63)
- "The correct nomenclature is Hirschsprung disease, not with apostrophe S" — Marc Levitt (guideline) [Ep 108 · 1:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=75)
- "Orvar Swenson defined the pathology by identifying the absence of ganglion cells" — Marc Levitt (clinical) [Ep 108 · 1:27](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=87)
- "Prior to Swenson's discovery, removal of the dilated colon was the treatment, which was a mistake because the distal narrow colon was the actual problem" — Marc Levitt (clinical) [Ep 108 · 1:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=95)
- "Swenson developed the first operation for Hirschsprung disease, which is a full thickness rectal dissection" — Marc Levitt (clinical) [Ep 108 · 1:46](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=106)
- "Modern Suave procedures are becoming more Swenson-like, making maybe a 1 centimeter cuff, which are basically Swensons with a 1 centimeter cuff according to Dan von Almen" — Marc Levitt (opinion) [Ep 108 · 2:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=120)
- "Doctor Yancey was the first surgeon to describe a submucosal dissection for Hirschsprung disease, but published in a journal that not many people read" — Marc Levitt (clinical) [Ep 108 · 2:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=133)
- "Doctor Suave published his article on submucosal dissection years later in a more widely read journal, which is why the procedure bears his name rather than Yancey's" — Marc Levitt (clinical) [Ep 108 · 2:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=154)
- "The Suave procedure was developed because people believed the Swenson caused fecal and urinary incontinence or voiding dysfunction" — Marc Levitt (clinical) [Ep 108 · 2:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=160)
- "Swenson wrote that the incontinence complications were due to surgeons doing the operation wrong by dissecting too wide, not due to the technique itself" — Marc Levitt (opinion) [Ep 108 · 2:56](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=176)
- "The Yancey, Suave, and Duhamel techniques were all designed to avoid full thickness rectal dissection and stay out of the rectal plane to avoid injury to the nerve erigens" — Marc Levitt (clinical) [Ep 108 · 3:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=190)
- "A proper Swenson dissection should be done right on the bowel wall like a PSARP; if you see fat you can get closer, and the nerves are in the fatty layer" — Marc Levitt (clinical) [Ep 108 · 3:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=210)
- "Swenson was 105 when he died" — Marc Levitt (clinical) [Ep 108 · 3:56](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=236)
- "Duhamel's technique involved leaving the original rectum behind, doing a pull-through next to it, and then mating the two lumens" — Marc Levitt (clinical) [Ep 108 · 4:06](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=246)
- "The Duhamel procedure is now only appropriate for an ileoduhamel, though some surgeons would still do an ileoanal" — Marc Levitt (opinion) [Ep 108 · 4:22](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=262)
- "Rabine performed a low anterior resection for Hirschsprung disease, leaving about 6 centimeters of aganglionic bowel behind" — Marc Levitt (clinical) [Ep 108 · 4:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=275)
- "Some patients who had Rabine's procedure with 6 centimeters of aganglionic bowel left behind did perfectly fine, with ganglionated bowel functioning through the aganglionic segment" — Marc Levitt (clinical) [Ep 108 · 4:42](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=282)
- "Doctor Boley was the first to do primary coloanal anastomosis of a Suave, eliminating the need to leave bowel hanging out and return at day 7" — Marc Levitt (clinical) [Ep 108 · 6:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=375)
- "The proper description of the modified technique is the Suave technique with the Boley modification, or Suave-Boley" — Marc Levitt (guideline) [Ep 108 · 6:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=396)
- "Henry So was the first surgeon to do a primary pull-through for Hirschsprung disease, performing the entire operation without a preceding stoma" — Marc Levitt (clinical) [Ep 108 · 8:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=518)
- "Henry So performed primary pull-throughs because patients with stomas in the Philippines faced severe social stigma and babies were basically left to die by their families" — Marc Levitt (clinical) [Ep 108 · 8:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=538)
- "Doctor Martin developed the Martin procedure, an expansion of the Duhamel leaving a longer aganglionic segment of rectum for long segment Hirschsprung disease" — Jason Frischer (clinical) [Ep 108 · 10:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=608)
- "Doctor Martin published in 1977 the application of endorectal pull-through technique from Hirschsprung disease to the surgical treatment of ulcerative colitis" — Jason Frischer (clinical) [Ep 108 · 10:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=640)
- "Martin performed total proctocolectomy using endorectal techniques from Hirschsprung surgery and did an ileoanal anastomosis for ulcerative colitis, before the J pouch was developed" — Jason Frischer (clinical) [Ep 108 · 11:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=663)
- "The transanal dissection and Suave plane dissection is the same concept as the mucosectomy in ulcerative colitis" — Marc Levitt (clinical) [Ep 108 · 11:28](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=688)
- "Helen Noblett figured out the suction rectal biopsy technique and is from Melbourne, Australia" — Marc Levitt (clinical) [Ep 108 · 12:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=752)
- "Keith Jorgeson performed the laparoscopic version of the Suave procedure" — Marc Levitt (clinical) [Ep 108 · 12:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=760)
- "In Jorgeson's original description of laparoscopic Suave, they discussed leaving a 5 centimeter cuff, which nowadays would be way too much" — Marc Levitt (opinion) [Ep 108 · 12:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=777)
- "Jack Langer and Luis de la Torre developed transanal resection of the rectosigmoid around the same time" — Marc Levitt (clinical) [Ep 108 · 13:17](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=797)
- "Some places around the world are doing transanal-only approaches for Hirschsprung disease" — Marc Levitt (clinical) [Ep 108 · 13:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=815)
- "Dan Teitelbaum did significant research work in Hirschsprung disease, particularly in enterocolitis" — Marc Levitt (clinical) [Ep 108 · 13:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=827)
- "For examination under anesthesia in Hirschsprung's patients, digital exam should assess for circumferential stricture at the anastomosis" — Hira Ahmad (clinical) [Ep 107 · 1:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=96)
- "Some surgeons advocate using a Hagar dilator to size the anastomotic opening to ensure adequate caliber" — Hira Ahmad (clinical) [Ep 107 · 1:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=117)
- "Passing a Foley catheter can determine if there is a twist in the pull-through segment" — Hira Ahmad (clinical) [Ep 107 · 2:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=124)
- "Swabé cuff presents as a 1-2 cm circumferential narrowing that is not the anastomosis itself" — Hira Ahmad (clinical) [Ep 107 · 2:23](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=143)
- "For patients with previous Duhamel procedure, full-thickness rectal biopsy should be performed posteriorly because that segment should be ganglionic" — Hira Ahmad (clinical) [Ep 107 · 2:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=160)
- "In Duhamel pull-through, rectal exam should assess for two lumens and a spur between them" — Marc Levitt (clinical) [Ep 107 · 2:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=177)
- "In Duhamel procedure, stool can flow into the Duhamel pouch, fill it, and compress the ganglionic pull-through causing obstruction" — Marc Levitt (clinical) [Ep 107 · 3:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=192)
- "Treatment for obstructing Duhamel spur is excision of the common wall; occasionally the entire Duhamel pouch requires excision" — Marc Levitt (clinical) [Ep 107 · 3:25](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=205)
- "Before anesthesia induction, the anus should be inspected for sphincteric contraction versus patulous appearance" — Marc Levitt (clinical) [Ep 107 · 3:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=216)
- "A patulous anus will not develop enterocolitis" — Marc Levitt (clinical) [Ep 107 · 3:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=228)
- "During EUA, the dentate line must be examined to ensure it was preserved at the original pull-through" — Marc Levitt (clinical) [Ep 107 · 4:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=242)
- "If the dentate line was lost or sphincters overstretched at original pull-through, the patient will not have enterocolitis but will have fecal incontinence" — Marc Levitt (clinical) [Ep 107 · 4:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=252)
- "Botox is being investigated to prevent enterocolitis through chemical denervation of nerves in the area, as an alternative to permanent stretch or anatomic destruction from surgery" — Jason Frischer (clinical) [Ep 107 · 4:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=266)
- "Lone Star retractor should be used during EUA to obtain a circumferential view of the anastomotic area" — Rebecca Rentia (clinical) [Ep 107 · 4:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=297)
- "Many institutions use pre-made operative reports as a checklist model to ensure all examination components are documented" — Jason Frischer (clinical) [Ep 107 · 5:27](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=327)
- "To palpate for Swabé cuff, place finger against the sacrum and pull down to feel rubbery tissue outside the pull-through" — Marc Levitt (clinical) [Ep 107 · 14:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=848)
- "If repeat biopsy after pull-through shows no ganglion cells, it is very likely an aganglionic or transition zone pull-through, though sampling error must be considered" — Marc Levitt (clinical) [Ep 107 · 8:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=488)
- "Ganglion cells with hypertrophic nerves on repeat biopsy is more controversial; may represent original pathology error or decompensation over time" — Marc Levitt (opinion) [Ep 107 · 8:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=513)
- "Hypertrophic nerves in the presence of ganglion cells can occur in functional constipation patients" — Marc Levitt (clinical) [Ep 107 · 8:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=532)
- "Patients with significant obstructive symptoms and biopsy showing ganglion cells with hypertrophic nerves may benefit from redo pull-through" — Marc Levitt (opinion) [Ep 107 · 8:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=532)
- "Rectal cuff left at initial pull-through (0.5-1.5 cm in neonate) may grow proportionally as child grows, potentially causing delayed obstruction from lengthened aganglionic segment" — Jason Frischer (opinion) [Ep 107 · 10:27](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=627)
- "Swenson dissection starts 0.5-1 cm above the dentate line" — Jason Frischer (clinical) [Ep 107 · 12:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=721)
- "A good pull-through can overcome the small amount of aganglionosis intentionally left behind to avoid coming too close to the dentate line" — Marc Levitt (opinion) [Ep 107 · 12:18](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=738)
- "Many surgeons performing Swabé have moved toward a mini-cuff approach (approximately 1 cm) that is essentially a Swenson, sometimes called a 'Swabson'" — Marc Levitt (clinical) [Ep 107 · 12:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=750)
- "The original laparoscopic Swabé technique recommended a 5 cm cuff, which is considered too long" — Marc Levitt (opinion) [Ep 107 · 13:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=785)
- "The Swenson was the first Hirschsprung's operation and leaves the least amount of Hirschsprung's tissue behind" — Marc Levitt (clinical) [Ep 107 · 13:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=795)
- "Swabé and Duhamel procedures were developed because surgeons performing Swenson were dissecting in too wide a plane and injuring the nervi erigentes in the mesorectum" — Marc Levitt (clinical) [Ep 107 · 13:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=804)
- "Staying directly on the bowel wall during Swenson dissection avoids nerve injury" — Marc Levitt (clinical) [Ep 107 · 13:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=804)
- "In Swabé procedure, if the cuff is not completely divided or fuses back together, it can create an aganglionic obstructive ring around the pull-through" — Marc Levitt (clinical) [Ep 107 · 13:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=825)
- "For redo pull-through in transition zone cases, the approach is total body prep, transanal dissection in prone position as far as possible, with readiness to proceed to laparoscopy or laparotomy if healthy bowel cannot reach" — Marc Levitt (clinical) [Ep 107 · 15:54](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=954)
- "Redo pull-throughs are easier to perform in prone position" — Marc Levitt (opinion) [Ep 107 · 16:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=967)
- "Initial treatment for obstructed Hirschsprung's patient includes IV antibiotics and colonic irrigation" — Jason Frischer (clinical) [Ep 107 · 17:28](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1048)
- "Rectal irrigation should be done early and every institution should have a protocol for rapid, efficient response" — Jason Frischer (guideline) [Ep 107 · 17:28](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1048)
- "If a child cannot undergo adequate irrigations at bedside, bring them to the operating room for irrigations under anesthesia" (clinical) [Ep 107 · 19:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1151)
- "If unable to evacuate stool despite OR irrigations, diversion with ileostomy is indicated until the mechanical or anatomic problem is identified and corrected" (clinical) [Ep 107 · 19:18](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1158)
- "Knowing the anatomy of the original pull-through (Swabé, Swenson, or Duhamel) is essential for gastroenterologists and surgeons managing complications" — Marc Levitt (clinical) [Ep 107 · 18:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1112)
- "If anatomic causes are excluded, sphincter dysfunction should be considered and may be treated with Botox" — Marc Levitt (clinical) [Ep 107 · 18:44](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1124)
- "The study used a trauma database to track non-accidental trauma patients and examined their hospital course, injuries, consults, discharge instructions, and actual follow-up visits over one year" — Brittany Johnson (clinical) [Ep 110 · 1:44](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=104)
- "Follow-up rates for child physical abuse victims were actually quite high, representing an opportunity since families are trying to make appointments" — Brittany Johnson (clinical) [Ep 110 · 2:19](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=139)
- "Pediatric surgery could adopt the model used for children with complex medical conditions where all appointments are scheduled on one day to decrease burden on families" — Brittany Johnson (opinion) [Ep 110 · 3:18](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=198)
- "85% follow-up rate was observed in the child physical abuse cohort" — Paul Tam (clinical) [Ep 110 · 3:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=238)
- "The UK NEC study was a whole population-based study including all 27 pediatric surgery centers in the UK over one year" — Nigel Hall (clinical) [Ep 110 · 5:15](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=315)
- "Primary outcomes measured were death or parental nutrition requirement at 28 days after surgery" — Nigel Hall (clinical) [Ep 110 · 5:47](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=347)
- "About 130 babies with NEC were included, with approximately half having bowel perforation" — Nigel Hall (clinical) [Ep 110 · 6:57](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=417)
- "Of babies without perforation, one-third were critically ill and proceeded quickly to surgery, while two-thirds eventually had surgery for failed medical treatment" — Nigel Hall (clinical) [Ep 110 · 7:08](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=428)
- "Babies in the failed medical treatment group had the longest time from presentation to operation and the worst outcomes" — Nigel Hall (clinical) [Ep 110 · 7:30](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=450)
- "There are currently no objective clinical markers or novel biomarkers to help make earlier surgical decisions in NEC" — Rod Gerardo (clinical) [Ep 110 · 8:32](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=512)
- "The bowel management program at Nationwide Children's started recording outcomes in a standardized way in 2015 using standardized definitions and patient-reported outcome measures" — Richard Wood (clinical) [Ep 110 · 10:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=637)
- "One-year measurement was chosen instead of one week because it demonstrates sustained changes within the patient's normal environment" — Richard Wood (clinical) [Ep 110 · 11:32](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=692)
- "Children who achieved continence had significantly improved quality of life, while those who remained incontinent showed no quality of life improvement" — Richard Wood (clinical) [Ep 110 · 11:59](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=719)
- "30% of patients in the bowel management program still struggled with fecal incontinence after one year" — Ellen Encisco (clinical) [Ep 110 · 12:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=732)
- "70% of children in bowel management programs do well, requiring focus on the remaining 30% who do not improve" — Richard Wood (clinical) [Ep 110 · 12:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=776)
- "The Italian anorectal malformation study analyzed 350 patients between 1999 and 2019, representing one of the largest series" — Ellen Encisco (clinical) [Ep 110 · 14:59](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=899)
- "The study demonstrated a close relation between spinal cord abnormalities and spinal bone anomalies in anorectal malformation patients" — Ellen Encisco (clinical) [Ep 110 · 15:29](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=929)
- "Patients without sacral or vertebral anomalies can still have spinal cord abnormalities, making MRI necessary for complete evaluation" — Ellen Encisco (clinical) [Ep 110 · 15:44](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=944)
- "Radiographs are not a good substitute for ultrasound or MRI in detecting spinal cord abnormalities" — Paul Tam (clinical) [Ep 110 · 16:34](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=994)
- "Post-pull-through Hirschsprung's patients present in two distinct patterns: obstructed patients with distention, enterocolitis, and failure to thrive versus soiling patients who poop constantly and are never distended" — Marc Levitt (clinical) [Ep 109 · 1:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=101)
- "If the pull-through is done correctly with no anatomic problems and preservation of the sphincter mechanism, most Hirschsprung's patients do extremely well" — Marc Levitt (clinical) [Ep 109 · 4:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=249)
- "There is no reason why any Hirschsprung patient should be obstructed or soiling if properly managed and investigated" — Marc Levitt (opinion) [Ep 109 · 4:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=274)
- "Pathology can change over time; cases exist where ganglion cells were present at pull-through but absent with hypertrophic nerves 7 years later when problems developed" — Jason Frischer (clinical) [Ep 109 · 5:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=307)
- "Pull-throughs can decompensate if patients do not have adequate medical management or sphincter management, potentially leading to nerve hypertrophy" — Marc Levitt (clinical) [Ep 109 · 5:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=347)
- "The most important question for any soiling patient is: what is the patient's potential for bowel control" — Marc Levitt (clinical) [Ep 109 · 6:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=407)
- "All Hirschsprung's patients have the best possible potential for bowel control because they were born with normal sphincters and intact dentate line with anal canal sensation" — Marc Levitt (clinical) [Ep 109 · 7:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=429)
- "Hirschsprung's patients with intact dentate line and intact sphincters have all the potential to have voluntary bowel movements and bowel control" — Marc Levitt (clinical) [Ep 109 · 7:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=458)
- "If the dentate line is lost because dissection was started too low, or sphincters were overstretched and don't contract well, patients may have lost their potential for bowel control" — Marc Levitt (clinical) [Ep 109 · 7:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=472)
- "3D anorectal manometry can visualize whether the sphincter squeeze is concentric; one patient had good squeeze but no squeeze on the anterior side" — Marc Levitt (clinical) [Ep 109 · 9:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=555)
- "Sphincters become overstretched through transanal approach with deep dissection in the wrong plane and retractors placed in the anus" — Marc Levitt (clinical) [Ep 109 · 10:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=648)
- "Patients with poor potential for bowel control due to overstretched sphincters need mechanical emptying programs with enemas or antegrade options" — Marc Levitt (clinical) [Ep 109 · 12:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=740)
- "Mechanical bowel programs can get borderline patients to a point where they are clean and psychologically want to be clean, making them more likely to successfully potty train" — Marc Levitt (clinical) [Ep 109 · 12:39](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=759)
- "Routine practice now includes 3D anorectal manometry in all soiling Hirschsprung's patients to assess sphincter squeeze and determine potential for bowel control" — Marc Levitt (clinical) [Ep 109 · 13:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=791)
- "A new sphincter tightening technique has been developed and published in JPS with great results in multiple patients with disrupted or patulous sphincters" — Marc Levitt (clinical) [Ep 109 · 14:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=842)
- "Rectal prolapse after Hirschsprung's pull-through is iatrogenic and should never occur if sphincters are preserved" — Marc Levitt (clinical) [Ep 109 · 15:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=902)
- "Overstretched sphincters become patulous to the point of prolapse, resembling a spina bifida anus" — Marc Levitt (clinical) [Ep 109 · 15:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=926)
- "During normal bowel movements, sphincters relax and some mucosa comes down, but as soon as sphincters tighten back up, mucosa is retracted back in; prolapse at rest indicates damaged sphincters" — Jason Frischer (clinical) [Ep 109 · 16:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=967)
- "For patients with patulous sphincters, sphincter reconstruction should be offered and can be done at the same time as Malone procedure" — Marc Levitt (clinical) [Ep 109 · 17:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=1033)
- "Malone can serve as a bridge to continence by allowing patients to practice holding in the flush and releasing on command, potentially improving sphincter function to achieve bowel control" — Marc Levitt (clinical) [Ep 109 · 17:53](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=1073)
- "A normal anus requires three qualities: location within the sphincter complex, adequate size, and presence of a perineal body" — Amanda Jensen (clinical) [Ep 114 · 5:12](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=312)
- "Perineal groove is characterized by a mucosal-lined tract between the anterior anus and the vestibule" — Marc Levitt (clinical) [Ep 114 · 5:58](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=358)
- "Visual inspection (eyeballing) is reliable for assessing anal position and presence of perineal body; measurements can be difficult in wriggling babies" — Jonathan Sutcliffe (opinion) [Ep 114 · 8:03](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=483)
- "The anus needs to be supple without narrowing or stenosis; passing an adequately sized Hagar through a stenotic ringed anus does not guarantee functional adequacy" — Marc Levitt (clinical) [Ep 114 · 9:16](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=556)
- "Examination under anesthesia with electrical stimulation can definitively confirm whether the sphincter maps properly and closes around the anal opening" — Marc Levitt (clinical) [Ep 114 · 10:46](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=646)
- "You do not get a morphological abnormality (like cloaca) in association with an endocrinological abnormality (DSD) in the same patient" — Jonathan Sutcliffe (clinical) [Ep 114 · 12:39](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=759)
- "Perineal groove is being seen more often than in the past, though it remains uncommon" — Jonathan Sutcliffe (epidemiological) [Ep 114 · 13:58](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=838)
- "Perineal groove has been misdiagnosed as perianal fissure, perineal trauma, non-accidental injury, dermatitis, or infection" — Jonathan Sutcliffe (clinical) [Ep 114 · 14:25](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=865)
- "Perineal groove is seen fewer than half a dozen times per year even in tertiary colorectal centers" — Jason (epidemiological) [Ep 114 · 15:14](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=914)
- "An anterior anus (normal anus that is anteriorly positioned) does not need surgical correction" — Marc Levitt (clinical) [Ep 114 · 17:03](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1023)
- "A perineal fistula is defined as fistulous tissue that is too small, not distensible, lacks a dentate line, and is anterior to the center of the sphincter" — Marc Levitt (clinical) [Ep 114 · 17:58](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1078)
- "When repairing a perineal fistula associated with perineal groove, the mucosal-lined tract should be excised" — Jonathan Sutcliffe (clinical) [Ep 114 · 18:45](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1125)
- "Over time, the mucosal-lined perineal groove becomes squamous epithelium and is of no consequence" — Marc Levitt (clinical) [Ep 114 · 19:41](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1181)
- "Perineal groove is probably part of the anorectal malformation spectrum, representing one of the most minor forms" — Jonathan Sutcliffe (opinion) [Ep 114 · 21:09](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1269)
- "Perineal groove has been seen in association with perineal fistula or rectovesibular fistula more often than would be expected by random chance" — Jonathan Sutcliffe (clinical) [Ep 114 · 21:20](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1280)
- "Complete VACTERL workup should be performed on any patient with an anorectal malformation to avoid system errors and ensure all screening is documented" — Jonathan Sutcliffe (guideline) [Ep 114 · 21:44](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1304)
- "Spinal ultrasound must be performed within a specific time window; if not done, tethered cord cannot be ruled out later" — Jonathan Sutcliffe (clinical) [Ep 114 · 22:25](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1345)
- "If the perineal groove is secreting significant mucus causing irritation and discomfort, surgical excision may be indicated" — Jason (clinical) [Ep 114 · 23:32](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1412)
- "If a patient has no anus, it is a cloaca with a single perineal opening" — Marc Levitt (clinical) [Ep 114 · 25:11](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1511)
- "If a patient has a patent normal anus and a urogenital sinus, this suggests an endocrine problem rather than cloaca" — Marc Levitt (clinical) [Ep 114 · 25:23](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1523)
- "Perineal fistulas can be associated with tethered cord" — Marc Levitt (clinical) [Ep 114 · 26:09](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1569)
- "Perineal groove typically epithelializes by age 2 years without surgical intervention" — Amanda Jensen (clinical) [Ep 114 · 29:28](https://library.globalcastmd.com/watch/colorectal-quiz-25-perineal-groove-4790?t=1768)
- "Males over age 10 with perianal fistulas have a much higher incidence of Crohn's disease diagnosis" — Jason Frischer (epidemiological) [Ep 115 · 9:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=557)
- "In pediatric patients, the first presenting factor for Crohn's disease can often be perianal disease" — Jason Frischer (clinical) [Ep 115 · 9:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=569)
- "Patients often present with perianal disease because that's what really hurts, then deeper history reveals GI symptoms like diarrhea and abdominal pain" — Jason Frischer (clinical) [Ep 115 · 9:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=580)
- "The highest risk factors for lymphoma with biologics are males, teenagers, and combination with methotrexate" — Jason Frischer (clinical) [Ep 115 · 6:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=412)
- "Mucosa heals first, so if you treat with a biologic and heal the mucosa while an abscess persists, you will get a recurrent abscess" — Jason Frischer (clinical) [Ep 115 · 12:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=751)
- "Making a big cruciate incision and packing a perianal abscess with gauze in a patient who may have Crohn's can result in non-healing and may require colostomy or ileostomy" — Jason Frischer (clinical) [Ep 115 · 13:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=792)
- "The initial Remicade paper from 1998 or 1999 in New England Journal of Medicine was on perianal disease and demonstrated improved healing time and improved length of time between recurrence when combination of seton and infliximab is used versus either separately" — Jason Frischer (guideline) [Ep 115 · 20:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=1255)
- "Remicade has the most literature on healing perianal disease; Humira is also good but has less literature" — Lisa McMahon (guideline) [Ep 115 · 20:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=1227)
- "Stelara and vedolizumab are sometimes used to treat perianal disease but there is less information; there is even less information on JAK inhibitors" — Lisa McMahon (guideline) [Ep 115 · 20:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=1240)
- "Literature shows about a 10% response rate even without biologics if you put a seton in and take it out, and certainly much better with biologics" — Lisa McMahon (clinical) [Ep 115 · 19:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=1152)
- "Typical seton duration is at least 6 months to allow the inflammatory tract to turn into a non-inflammatory tract" — Lisa McMahon (clinical) [Ep 115 · 17:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=1074)
- "Before starting biologics, you want to get rid of the source of infection and make sure the patient is systemically doing OK" — Lisa McMahon (clinical) [Ep 115 · 16:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=1019)
- "If an abscess is not adequately drained, re-imaging should be done before giving biologics or steroids" — Jason Frischer (clinical) [Ep 115 · 17:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=1046)
- "Criteria for seton removal include: bottom looks better, drainage is better, patient is symptom-free, steady state of biologic achieved (loading dose plus at least 3 more doses, typically 2-3 months), and inflammatory markers (fecal calprotectin, ESR, CRP) show systemic disease is under control" — Jason Frischer (clinical) [Ep 115 · 19:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=1163)
- "In recurrent cases, re-imaging is obtained before seton removal" — Lisa McMahon (clinical) [Ep 115 · 18:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=1125)
- "When colonoscopy cannot intubate the terminal ileum, options include capsule endoscopy or fecal calprotectin testing" — Christine Velasco (clinical) [Ep 115 · 3:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=227)
- "If terminal ileum cannot be intubated, the approach is to assume Crohn's disease, treat, and re-scope after a few months of treatment when inflammation has likely gone down" — Jason Frischer (clinical) [Ep 115 · 4:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=276)
- "Infectious complications with biologics include rare risk of tuberculosis, for which quantiferon or PPD testing is done" — Christine Velasco (clinical) [Ep 115 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=389)
- "Hydrogen peroxide is preferred over methylene blue for identifying fistula tracts because it is neater" — Jason Frischer (opinion) [Ep 115 · 14:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=853)
- "Technique for hydrogen peroxide injection: use 3% hydrogen peroxide in a syringe with 16-20 gauge angiocath depending on skin lesion size, place speculum in anus to visualize where fistula would be, then inject to identify the tract" — Jason Frischer (clinical) [Ep 115 · 14:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-26-perianal-crohn-s-disease-4890?t=858)
- "The three components of continence are quality of sphincters, quality of dentate line, and motility" — Levitt (clinical) [Ep 118 · 1:23](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=83)
- "In Hirschsprung disease, two sphincters are of concern: the external sphincter (under voluntary control) and the internal sphincter (which tends not to relax due to absent rectoanal inhibitory reflex)" — Levitt (clinical) [Ep 118 · 1:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=90)
- "Patients who have voluntary bowel movements during the day but accidents at night indicate working external sphincters but non-functioning internal sphincters" — Levitt (clinical) [Ep 118 · 1:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=117)
- "The dentate line represents the transition from squamous epithelium to columnar epithelium, occurring about 2/3 of the way up the anal canal" — Jason Frischer (clinical) [Ep 118 · 3:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=192)
- "The dentate line region contains nerves that provide sensation to distinguish gas, liquid, and solid stool and determine how hard and how long to squeeze" — Jason Frischer (clinical) [Ep 118 · 3:54](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=234)
- "Proprioception from rectal stretch is the signal that stool is accumulating and triggers external sphincter control" — Levitt (clinical) [Ep 118 · 4:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=298)
- "In anorectal malformation patients, giving stool softeners is problematic because patients never feel the stretch and loose stool just flows out" — Levitt (clinical) [Ep 118 · 5:43](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=343)
- "ARM and Hirschsprung patients are better off with bulk stool kicked out by a laxative than stool softener that slowly oozes out" — Levitt (clinical) [Ep 118 · 5:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=358)
- "The ability to sense stool in the rectum or neorectum region is critical for success in children with anorectal malformation, Hirschsprung disease, or spinal conditions" — Jason Frischer (clinical) [Ep 118 · 6:27](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=387)
- "Making stool too soft or loose puts patients on the edge of control over the edge into incontinence" — Jason Frischer (clinical) [Ep 118 · 6:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=405)
- "Loose stool is hard to control even with completely normal continence because you cannot detect it reliably without bulk" — Levitt (clinical) [Ep 118 · 7:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=467)
- "Patients with Hirschsprung disease are dependent on stretch sensation because their rectum has been removed and the sigmoid has taken over that job" — Levitt (clinical) [Ep 118 · 8:19](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=499)
- "Patients with missing dentate line can develop bowel control if their sphincters are working, but they will be very sensitive to loose stool" — Levitt (clinical) [Ep 118 · 10:44](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=644)
- "A missing dentate line scenario is similar to an anorectal malformation anastomosis (rectum or colon mucosa to skin)" — Jason Frischer (clinical) [Ep 118 · 11:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=676)
- "Hirschsprung is an obstruction problem, but getting patients clean afterward is a separate and independent challenge" — Levitt (clinical) [Ep 118 · 19:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1150)
- "The vast majority of Hirschsprung patients get clean on their own and have great success stories" — Levitt (clinical) [Ep 118 · 19:22](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1162)
- "Cyanoacrylate-based barriers are very helpful for skin care in hypermotile patients" — Levitt (clinical) [Ep 118 · 20:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1200)
- "Wound care improvements for perineums in Hirschsprung disease and hypermotile patients have dramatically improved over the last 4-5 years" — Levitt (clinical) [Ep 118 · 20:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1215)
- "Proton pump inhibitors help reduce the acidity of stool in hypermotile patients" — Levitt (clinical) [Ep 118 · 20:27](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1227)
- "Water-soluble fiber produces bulk stool, which is preferred over water-insoluble fiber" — Levitt (clinical) [Ep 118 · 20:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1252)
- "Loperamide dosing is 0.5 to 0.8 mg per kilogram divided daily" — Levitt (clinical) [Ep 118 · 21:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1271)
- "Hyoscyamine (Levsin) is dosed at 0.125 mg tablet every six hours" — Levitt (clinical) [Ep 118 · 21:27](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1287)
- "Diphenoxylate atropine (Lomotil) is almost never used because it has cardiac side effects" — Levitt (clinical) [Ep 118 · 21:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1300)
- "Tincture of opium is useful but difficult to prescribe because it is a controlled substance" — Levitt (clinical) [Ep 118 · 21:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1318)
- "Some Hirschsprung patients with good operations have super strong sphincters that need relaxation to allow stool passage until they learn proper coordination" — Jason Frischer (clinical) [Ep 118 · 22:42](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1362)
- "Anorectal manometry can provide objective data showing resting pressures are usually on the higher end of normal in these patients" — Jason Frischer (clinical) [Ep 118 · 23:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1390)
- "Patients with Hirschsprung disease are very sensitive to some foods, particularly lactose" — Jason Frischer (clinical) [Ep 118 · 23:43](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1423)
- "Of all soiling patient groups (anorectal malformation, Hirschsprung, functional constipation, and spinal), Hirschsprung is the hardest group because the sphincters are so troublesome" — Levitt (opinion) [Ep 118 · 24:49](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1489)
- "Within Hirschsprung patients, hypermotile patients are much harder to manage than hypomotile patients" — Levitt (opinion) [Ep 118 · 25:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1509)
- "With systematic strategies, many Hirschsprung patients who were told they could never be clean can achieve continence" — Levitt (opinion) [Ep 118 · 25:14](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1514)
- "A normal anus must be of appropriate size, in the center of the sphincter, and have a perineal body." — Amanda Jensen (clinical) [Ep 119 · 3:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=182)
- "If the hole is in the center of the sphincter with adequate lumen and a perineal body, the patient does not need to be touched." — Marc Levitt (clinical) [Ep 119 · 3:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=192)
- "If the hole is too small or outside of the sphincter, the patient needs surgery." — Marc Levitt (clinical) [Ep 119 · 3:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=204)
- "There are five management options for perineal fistula: colostomy then repair, primary repair, dilation then repair, colostomy with simultaneous repair, and dilation only." — Marc Levitt (clinical) [Ep 119 · 4:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=260)
- "Diverting with a colostomy does not necessarily prevent wound complications and carries morbidity from both the colostomy and its closure." — Marc Levitt (clinical) [Ep 119 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=323)
- "Diversion of stool is not the reason for colostomy unless the fistula is very tiny and the patient cannot pass stool, which can be managed by dilation." — Marc Levitt (clinical) [Ep 119 · 5:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=354)
- "Dilation alone could be problematic if the distal end is fistulous and will not grow, causing proximal distension." — Marc Levitt (clinical) [Ep 119 · 6:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=367)
- "A vestibular fistula is not a vaginal fistula because the posterior vaginal wall is intact with no fistula to it." — Marc Levitt (clinical) [Ep 119 · 9:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=554)
- "True vaginal fistulas are exceedingly rare." — Marc Levitt (epidemiological) [Ep 119 · 9:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=574)
- "Some perineal fistulas can be managed with posterior wall mobilization without touching the anterior wall." — Marc Levitt (clinical) [Ep 119 · 10:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=652)
- "Anal stenosis with a tiny hole in the middle of the sphincteric ellipse requires screening for Currarino syndrome." — Marc Levitt (clinical) [Ep 119 · 7:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=458)
- "Many children with anorectal malformations have genitourinary anomalies, which is well documented in the literature." — Kathleen Van Leeuwen (epidemiological) [Ep 119 · 12:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=732)
- "Seeing a single cervix on vaginoscopy does not mean there is actually only one; a second cervix may be found later if there is a narrow side." — Kathleen Van Leeuwen (clinical) [Ep 119 · 12:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=768)
- "The incidence of vaginal atresia is quite rare, and vaginal septums are more common at around 3 to 5% of vestibular fistulas." — Marc Levitt (epidemiological) [Ep 119 · 14:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=868)
- "Perineal fistulas can also be associated with distal vaginal atresia." — Marc Levitt (clinical) [Ep 119 · 14:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=876)
- "When neurologic anomalies are found, there is increased likelihood of gynecological anomalies, especially on the same side." — Jason Frischer (clinical) [Ep 119 · 15:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=922)
- "Differential renal function is relevant when considering whether to reimplant an ectopic ureter or remove a non-functional kidney." — Marc Levitt (clinical) [Ep 119 · 16:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=996)
- "Absent kidneys are usually not truly absent but rather non-functional, often multicystic and dysplastic." — Marc Levitt (clinical) [Ep 119 · 17:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1040)
- "Every surgeon caring for an anorectal malformation should know the malformation type, spine status (tethered cord or myelomeningocele, or normal), and sacral status including sacral ratio." — Marc Levitt (guideline) [Ep 119 · 17:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1064)
- "A patient with a low-type malformation but associated spinal problem has a different prognosis for bowel control than a perineal fistula patient with a normal spine." — Marc Levitt (clinical) [Ep 119 · 18:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-28-female-arm-management-perineal-fistula-5115?t=1095)
- "Alberto Pena's original protocol mandated 7 days NPO with central line and hyperalimentation, feeding only on day 7 if healed" — Marc Levitt (clinical) [Ep 120 · 1:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=97)
- "A study comparing NPO for 7 days versus clear liquids for 7 days found the same amount of stool output in both groups" — Marc Levitt (clinical) [Ep 120 · 3:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=190)
- "Hard stool passage, not stool passage itself, is the problem that causes dehiscence" — Marc Levitt (clinical) [Ep 120 · 3:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=210)
- "Current protocol uses regular IV (no PICC line) and clear liquids or breast milk for 5 days, with very low dehiscence rate" — Marc Levitt (clinical) [Ep 120 · 3:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=217)
- "Phoenix group performs early repairs before infants are on anything except breast milk or formula, with early discharge and PO ad lib feeding, reporting very low dehiscence rate" — Kathy (clinical) [Ep 120 · 4:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=272)
- "Perineal body dehiscence usually leads to no perineal body over several months, requiring redo because anterior anoplasty has no sphincter around it" — Marc Levitt (clinical) [Ep 120 · 5:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=345)
- "Patients fed right away and discharged home invariably are the ones seen for redo operations due to perineal body dehiscence" — Marc Levitt (clinical) [Ep 120 · 5:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=359)
- "Families identified dilations as their biggest concern in caring for patients with anorectal malformation" — Marc Levitt (epidemiological) [Ep 120 · 10:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=650)
- "Randomized controlled trial of dilation versus non-dilation for primary PSAP (cloaca excluded) showed 10-15% risk of stricture development in both groups" — Marc Levitt (clinical) [Ep 120 · 9:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=546)
- "Backup plan for stricture in non-dilation group is aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty" — Marc Levitt (clinical) [Ep 120 · 9:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=565)
- "Many anoplasties look absolutely fine 8 weeks later at colostomy closure if never touched with a dilator" — Marc Levitt (clinical) [Ep 120 · 10:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=625)
- "Dilations can drive couples apart, with one family member doing dilations and becoming reluctant to attend follow-up visits" — Kathy (opinion) [Ep 120 · 12:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=736)
- "Jack Langer sees patients weekly in clinic and passes dilator himself rather than having families do it at home" — Marc Levitt (clinical) [Ep 120 · 13:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=825)
- "In the dilation study, 4 patients required redo operations for stricture: 2 in dilation arm and 2 in non-dilation arm" — Jason Frischer (clinical) [Ep 120 · 14:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=860)
- "Approximately 20% of patients in the study required redo operations, either local or total" — Jason Frischer (clinical) [Ep 120 · 14:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=898)
- "Full continence can be restored with a redo operation, with stricture being one indication" — Marc Levitt (clinical) [Ep 120 · 16:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=988)
- "Vast majority of patients needing intervention for stricture are already undergoing surgery for colostomy closure" — Marc Levitt (clinical) [Ep 120 · 17:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1032)
- "No family presented with the non-dilation option has chosen routine dilation" — Marc Levitt (opinion) [Ep 120 · 17:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1041)
- "In developing world practice, anoplasties are made slightly bigger knowing there will be contraction, when patients will not return for follow-up" — Marc Levitt (clinical) [Ep 120 · 19:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1177)
- "For redo operations, anoplasties are made larger knowing there will be contraction; redos are not dilated but examined under anesthesia at one month" — Marc Levitt (clinical) [Ep 120 · 20:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1218)
- "For primary repairs, anoplasty lumen is made to match maximal rectal lumen that fills the sphincter, typically size 13 or 14" — Marc Levitt (clinical) [Ep 120 · 20:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-post-op-management-5181?t=1233)
- "Babies with an anorectal malformation have approximately 25% association with spinal problems" — Levitt (epidemiological) [Ep 121 · 0:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=51)
- "All babies with anorectal malformations need screening in the newborn period with spinal ultrasound" — Levitt (guideline) [Ep 121 · 0:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=51)
- "After 3-4, maybe 5 months of age, the lamina get broad enough that ultrasound waves cannot penetrate for spinal imaging" — John Maceros (clinical) [Ep 121 · 1:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=69)
- "If ultrasound shows conus in normal position, no further imaging is needed" — John Maceros (guideline) [Ep 121 · 1:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=82)
- "If conus is clearly low on ultrasound, MRI should be delayed until after 3 months of age when resolution is better and of surgical quality" — John Maceros (guideline) [Ep 121 · 1:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=87)
- "The conus medullaris is the very end of the spinal cord; below it the filum terminale has no neural tissue, which is why it can be cut" — John Maceros (clinical) [Ep 121 · 1:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=107)
- "In normal development, the spinal cord ascends as the child grows" — John Maceros (clinical) [Ep 121 · 2:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=126)
- "A tethered cord occurs when the cord is low because it became attached or fixed during development, with all tension from growth felt at the bottom of the cord" — John Maceros (clinical) [Ep 121 · 2:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=141)
- "Tension on the spinal cord affects the bottom of the cord, not the cervical cord, because the cord is attached to dura by dentate ligaments" — John Maceros (clinical) [Ep 121 · 2:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=154)
- "The mechanism of tethered cord injury is likely ischemia from occlusion or stenosis of micro vessels in the taut, distorted cord, particularly affecting lower sacral nerve roots to bowel and bladder" — John Maceros (clinical) [Ep 121 · 2:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=173)
- "The conus does not find its final resting spot until about 4 months of age" — John Maceros (clinical) [Ep 121 · 3:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=217)
- "If ultrasound at 1 month shows conus at mid-L3, it may ascend to normal level and should be re-evaluated at 3-4 months rather than proceeding immediately to MRI" — John Maceros (guideline) [Ep 121 · 3:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=221)
- "Urologic manifestations of tethered cord include recurrent febrile UTIs, bladder stones, hematuria, inability to potty train, and urinary incontinence" — Christina Ho (clinical) [Ep 121 · 4:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=267)
- "It is very hard, almost impossible, to pick up subtle neurologic issues in a baby" — John Maceros (clinical) [Ep 121 · 4:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=287)
- "Orthopedic manifestations of tethered cord include leg length discrepancy, foot size asymmetry, reduced leg movement, and hip dislocation" — John Maceros (clinical) [Ep 121 · 4:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=296)
- "In non-walking infants, tethered cord may present with asymmetric reflexes or asymmetric movement" — John Maceros (clinical) [Ep 121 · 5:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=314)
- "Delayed walking or asymmetric gait in toddlers may indicate tethered cord" — John Maceros (clinical) [Ep 121 · 5:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=321)
- "Children should not complain of back pain; back pain in a 4-year-old is concerning for spinal pathology" — John Maceros (clinical) [Ep 121 · 5:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=334)
- "Midline cutaneous manifestations above the gluteal cleft indicate tethered cord" — John Maceros (clinical) [Ep 121 · 6:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=382)
- "Dimples within the gluteal cleft seldom indicate tethered cord; most show coccygeal tracts going caudal, not rostral toward the cord" — John Maceros (clinical) [Ep 121 · 7:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=426)
- "Bladder trabeculation on cystoscopy is a red flag for neurogenic bladder changes" — Christina Ho (clinical) [Ep 121 · 11:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=714)
- "Urodynamics is the gold standard for diagnosing neurogenic bladder when clinical symptoms cannot be relied upon" — Christina Ho (guideline) [Ep 121 · 11:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=719)
- "Normal conus position is between T12-L1 and L2-L3 disc spaces" — John Maceros (clinical) [Ep 121 · 9:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=557)
- "Fat should not be present inside the spinal canal; while some normal children have fat in the filum, children with tethered cords have higher incidence of fatty filum" — John Maceros (clinical) [Ep 121 · 9:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=586)
- "In some tethered cord cases, the actual pathology is a thick, non-flexible, noncompliant filum that does not stretch" — John Maceros (clinical) [Ep 121 · 10:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=635)
- "Approximately 80% of children with radiographically tethered cords will eventually become symptomatic" — John Maceros (epidemiological) [Ep 121 · 13:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=816)
- "The tendency is to untether babies with radiographic tethering upfront to avoid missed symptoms, regardless of anorectal malformation or bladder dysfunction status" — John Maceros (opinion) [Ep 121 · 13:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=816)
- "Conus below L2-3 disc or mid-L3 or lower is considered radiographically tethered" — John Maceros (clinical) [Ep 121 · 14:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=850)
- "For conus at L2-3 level, surgery would not be performed regardless of clinical symptoms" — John Maceros (opinion) [Ep 121 · 14:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=875)
- "For conus below L2-3 disc space with any concerning clinical findings, untethering should be strongly recommended" — John Maceros (opinion) [Ep 121 · 14:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=882)
- "Higher type anorectal malformations are more likely to have associated spinal and sacral problems" — Levitt (clinical) [Ep 121 · 14:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=897)
- "Bladder dysfunction with normal spine in anorectal malformation patients usually represents iatrogenic injury to the bladder neck" — Levitt (clinical) [Ep 121 · 15:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=905)
- "Filum sectioning in a little baby is a 45-minute operation with relative risks close to zero and potential benefits that are huge" — John Maceros (opinion) [Ep 121 · 15:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=935)
- "If neurologic dysfunction, weakness, numbness, prolonged pain, or bladder dysfunction persists for a long period, recovery after untethering is unlikely; surgery may prevent worsening but probably will not restore function" — John Maceros (clinical) [Ep 121 · 15:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=954)
- "Tethered cord repair in infants prevents bladder dysfunction from worsening and protects against future renal dysfunction, though it may not reverse existing damage in older children" — Christina Ho (clinical) [Ep 121 · 16:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=973)
- "Blood and infection during tethered cord surgery increase risk of retethering by causing inflammatory processes that allow nerve roots to clump and cord to retether" — John Maceros (clinical) [Ep 121 · 17:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=1061)
- "The incidence of retethering from sectioning a filum is exceedingly low, pretty close to zero" — John Maceros (clinical) [Ep 121 · 17:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=1077)
- "Taking out the entire lipoma in lipomyelomeningocele is not necessary and not safe because it risks entering the spinal cord" — John Maceros (clinical) [Ep 121 · 18:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=1125)
- "Children with lipomyelomeningocele repairs have larger dorsal scar surface area and the cord falls back against dura during supine positioning, leading to retethering" — John Maceros (clinical) [Ep 121 · 18:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=1131)
- "Essentially all tethered cord patients look radiographically tethered on re-imaging, but not that many are clinically tethered" — John Maceros (clinical) [Ep 121 · 19:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=1145)
- "Clinical retethering rate for complex tethered cords is quoted at 40%, probably between 20-40%; for filum sectioning it is pretty close to zero" — John Maceros (epidemiological) [Ep 121 · 19:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=1158)
- "Repeat urodynamics should be performed 3 months after tethered cord release to allow inflammation to settle and assess bladder effects" — Christina Ho (guideline) [Ep 121 · 19:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=1172)
- "Urodynamic findings indicating neurogenic bladder include decreased functional capacity, incomplete bladder emptying, detrusor overactivity, detrusor sphincter dyskinesia, and impaired compliance with high storage pressures" — Christina Ho (clinical) [Ep 121 · 20:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-30-tethered-cord-5235?t=1225)
- "A single institution prospective randomized control trial found that anal dilations following PSARP may not be needed" — Rebecca Rentia (clinical) [Ep 122 · 1:10](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=70)
- "There is literature suggesting a component of psychosocial, psychologic dissociation in children on later testing related to dilations" — Ellen Encisco (clinical) [Ep 122 · 1:31](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=91)
- "In the dilation study, length of follow-up was 12 months, PSARP had to be performed in a child under 24 months of age, it was primary surgery, and excluded Cloaca as a diagnosis" — Rebecca Rentia (clinical) [Ep 122 · 1:37](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=97)
- "The average PSARP was performed at 5 months in the study" — Rebecca Rentia (clinical) [Ep 122 · 1:50](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=110)
- "A stricture was defined as a Hagar dilator size of less than 10" — Rebecca Rentia (clinical) [Ep 122 · 1:52](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=112)
- "The standard Hagar dilator size for a newborn is about size 12" — Rod (clinical) [Ep 122 · 1:57](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=117)
- "There were 25 children in the dilation study and the types of malformations were evenly distributed" — Rod (clinical) [Ep 122 · 2:16](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=136)
- "Strictures were non-significant between both groups in the dilation study" — Rebecca Rentia (clinical) [Ep 122 · 2:26](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=146)
- "A Heineke-Mikolliz anoplasty is where a longitudinal incision is made toward the anus and then closed transversely to widen the diameter" — Rebecca Rentia (clinical) [Ep 122 · 2:26](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=146)
- "The number of strictures, number who needed anoplasties, and number of redo operations was the same between the dilation and no-dilation groups" — Ellen Encisco (clinical) [Ep 122 · 2:55](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=175)
- "The number of patients who had rectal prolapse is consistent with the literature" — Ellen Encisco (clinical) [Ep 122 · 3:04](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=184)
- "About 5 to 8% of patients require a strictureplasty at the two-month period" — Rebecca Rentia (epidemiological) [Ep 122 · 4:04](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=244)
- "A study looked at 30-day outcomes for patients with ARM with perineal or rectovestibular fistulas who underwent repair, divided between early (before 6 days old) and late repair (6-8 weeks)" — Ellen Encisco (clinical) [Ep 122 · 5:20](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=320)
- "There were 291 patients in the early vs late repair study: 66 underwent early repair and 231 underwent late repair" — Ellen Encisco (clinical) [Ep 122 · 5:31](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=331)
- "30-day complications are not statistically different between early and late repair groups for perineal and rectovestibular fistulas" — Caitlin Smith (clinical) [Ep 122 · 5:40](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=340)
- "For neonates and infants, dilations are really well tolerated for patients up to even several months old" — Caitlin Smith (opinion) [Ep 122 · 6:22](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=382)
- "Formula-fed infants who need caloric concentration have thicker stools, which might push toward earlier repair" — Caitlin Smith (clinical) [Ep 122 · 6:32](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=392)
- "For breastfed infants, repair can be delayed until 2 to 3 months" — Caitlin Smith (opinion) [Ep 122 · 6:39](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=399)
- "You want to get repair done before infants start solids because that can make the dilation strategy at home much more difficult" — Caitlin Smith (opinion) [Ep 122 · 6:47](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=407)
- "Literature shows a shift toward slightly earlier pull-through for Hirschsprung disease" — Rebecca Rentia (clinical) [Ep 122 · 7:11](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=431)
- "Long segment Hirschsprung is defined as any disease proximal to the rectosigmoid colon for the majority of articles reviewed" — Rebecca Rentia (clinical) [Ep 122 · 7:27](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=447)
- "A contrast study itself is very inaccurate for Hirschsprung disease and colonic mapping needs to be performed to determine the level of the transition zone" — Rebecca Rentia (clinical) [Ep 122 · 7:42](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=462)
- "There was no superior operation or more common operation performed for long segment Hirschsprung, although Duhamel and Swenson-Soave were the top operations" — Rebecca Rentia (clinical) [Ep 122 · 7:51](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=471)
- "There are no new novel surgical techniques for Hirschsprung disease over the past several years" — Rod (clinical) [Ep 122 · 8:13](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=493)
- "There is potential for stem cell therapy for Hirschsprung disease but it is still in its infancy" — Rebecca Rentia (clinical) [Ep 122 · 8:21](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=501)
- "An early operation for total colonic Hirschsprung is possible around the age of 5 months old" — Rebecca Rentia (clinical) [Ep 122 · 8:35](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=515)
- "If a child with an ileostomy is adequately prepared and the family can participate in learning to thicken up stool, they can have a pull-through that does not result in complete perineal skin breakdown" — Rebecca Rentia (clinical) [Ep 122 · 8:49](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=529)
- "If you wait way too long to do a pull-through especially for total colonic Hirschsprung, patients will have horrible anal sphincter spasm and potentially horrible pelvic disease that makes keeping a pull-through really challenging" — Rebecca Rentia (clinical) [Ep 122 · 9:34](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=574)
- "A PCPLC study looked at bowel management strategies in children with ARM, examining 624 patients with varying diagnoses of severity" — Caitlin Smith (clinical) [Ep 122 · 10:36](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=636)
- "The majority of ARM patients had constipation as their primary complaint and only 40% were toilet trained" — Caitlin Smith (epidemiological) [Ep 122 · 11:14](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=674)
- "Even mild and moderate ARM patients in the 5 to 12 year old group need to rely on enemas and lots of other bowel management strategies to stay clean when heading into school age" — Caitlin Smith (clinical) [Ep 122 · 10:55](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=655)
- "For Hirschsprung timing study, all infants had to be diagnosed under 1 month of age with primary pull-throughs less than 31 days or greater than 31 days" — Rebecca Rentia (clinical) [Ep 122 · 11:38](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=698)
- "Preoperative enterocolitis was the same between early and late pull-through groups for Hirschsprung" — Rebecca Rentia (clinical) [Ep 122 · 11:46](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=706)
- "Post-operative enterocolitis was the same between early and late pull-through groups and transition zone was the marker if a child needed to be treated for constipation" — Rebecca Rentia (clinical) [Ep 122 · 11:51](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=711)
- "Non-clinical factors including race, ethnicity, and insurance status are associated regardless of clinical variables with outcomes in colorectal patients" — Caitlin Smith (epidemiological) [Ep 122 · 12:05](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=725)
- "A PCPLC consortium study of 525 ARM patients found public insurance was associated with decreased rates of urinary incontinence" — Caitlin Smith (epidemiological) [Ep 122 · 12:21](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=741)
- "The urethral length of about 2.5 centimeters has been measured in a lot of VCUGs of normal females" — Rebecca Rentia (clinical) [Ep 122 · 13:26](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=806)
- "About 1.5 centimeters of urethral length is needed in cloacal reconstruction" — Rebecca Rentia (clinical) [Ep 122 · 13:41](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=821)
- "If a urethra that is too short is pulled past the bladder neck, there is a risk for incontinence" — Rebecca Rentia (clinical) [Ep 122 · 13:44](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=824)
- "A short vagina, even in an otherwise shorter common channel operation, may require a vaginal replacement" — Rebecca Rentia (clinical) [Ep 122 · 13:55](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=835)
- "Rotational fluoroscopy and 3D reconstructions are key to being able to make reliable measurements for anatomy in cloacal cases" — Rebecca Rentia (clinical) [Ep 122 · 14:03](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=843)
- "Motor vehicle collisions and firearm violence represent the leading causes of morbidity and mortality in the pediatric age group" — Richard Kaiser (epidemiological) [Ep 125 · 1:31](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=91)
- "Mortality for pediatric patients with gunshot wounds was 7.5% compared to 1% for motor vehicle collisions" — Richard Kaiser (clinical) [Ep 125 · 1:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=114)
- "After adjusting for confounding factors, children who were shot were 7.8 times more likely to die than those injured in motor vehicle collisions" — Richard Kaiser (clinical) [Ep 125 · 2:04](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=124)
- "The statewide case fatality rate for pediatric firearm injuries was almost 15% overall, twice as high as institutional mortality rate" — Richard Kaiser (epidemiological) [Ep 125 · 2:27](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=147)
- "The statewide case fatality rate for pediatric firearm injuries was 49 times higher than the case fatality rate for motor vehicle collisions" — Richard Kaiser (epidemiological) [Ep 125 · 2:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=157)
- "The case fatality rate for motor vehicle related injuries decreased over time across the state" — Richard Kaiser (epidemiological) [Ep 125 · 2:51](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=171)
- "The case fatality rate for children injured by firearms rose from 13% to almost 17% over the study period" — Richard Kaiser (epidemiological) [Ep 125 · 3:03](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=183)
- "The rate of self-inflicted pediatric gunshot wounds doubled over the study period from 2% to 4.4% of all pediatric firearm injuries" — Richard Kaiser (epidemiological) [Ep 125 · 3:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=193)
- "Self-inflicted pediatric gunshot wounds had a case fatality rate of 77%" — Richard Kaiser (clinical) [Ep 125 · 3:28](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=208)
- "A child getting shot by a gun 10 years ago had less of a chance of dying than a child getting shot by a gun now, suggesting guns became more dangerous" — Richard Kaiser (opinion) [Ep 125 · 4:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=253)
- "Local interventions like community violence intervention programs can help reduce violence in the community" — Richard Kaiser (opinion) [Ep 125 · 5:49](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=349)
- "Policy level changes are needed around the country to reduce access to firearms and increase safety" — Richard Kaiser (opinion) [Ep 125 · 6:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=369)
- "Clinicians can make an individual difference by talking to families about firearm safety and safe storage every time they see an injured child" — Richard Kaiser (opinion) [Ep 125 · 6:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=369)
- "The University of Manitoba study examined 75 patients with Hirschsprung disease" — Richard Kaiser (clinical) [Ep 125 · 7:48](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=468)
- "A 10 to 1 matched control cohort was identified using the Manitoba Center for Health Policy provincial data repository" — Richard Kaiser (clinical) [Ep 125 · 7:52](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=472)
- "Hirschsprung patients performed just as well as the control cohort from grade 3 onwards until grade 12 graduation" — Richard Kaiser (clinical) [Ep 125 · 8:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=534)
- "In preschool age, much closer to their treatment timeline, differences in neurodevelopmental performance can be seen in Hirschsprung patients" — Richard Kaiser (clinical) [Ep 125 · 9:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=545)
- "The early developmental index is one of the more subjective examinations used in the Hirschsprung outcomes study" — Richard Kaiser (opinion) [Ep 125 · 9:16](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=556)
- "Children with Hirschsprung disease going into school may still have challenges around potty training, bowels, and abdominal discomfort" — Richard Kaiser (clinical) [Ep 125 · 9:52](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=592)
- "Most children with isolated Hirschsprung disease do not have developmental delay down the road based on the study data" — Richard Kaiser (clinical) [Ep 125 · 10:25](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=625)
- "The Miami bicycle injury study identified 77 cases over an eight year period from October 2013 to March 2020" — Gareth Gilna (clinical) [Ep 125 · 12:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=732)
- "The average age of bicycle injury patients was 13 years old" — Gareth Gilna (epidemiological) [Ep 125 · 12:55](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=775)
- "Only one of 77 bicycle injury patients was wearing a helmet" — Gareth Gilna (epidemiological) [Ep 125 · 11:32](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=692)
- "The majority of bicycle injuries were happening in low income neighborhoods" — Gareth Gilna (epidemiological) [Ep 125 · 13:02](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=782)
- "Bicycle injuries were happening at high speed areas like interstate on-ramps and off-ramps" — Gareth Gilna (epidemiological) [Ep 125 · 13:10](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=790)
- "About half of the bicycle injuries happened within 1 mile from home" — Gareth Gilna (epidemiological) [Ep 125 · 13:10](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=790)
- "Free helmet programs going through a pediatrician's office is useful but needs to be sustained" — Gareth Gilna (opinion) [Ep 125 · 13:51](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=831)
- "Cities that have been successful with helmet programs implemented multidisciplinary approaches including free helmet programs, changing laws, and public education sustained over several years" — Gareth Gilna (opinion) [Ep 125 · 13:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=838)
- "Colorectal cancer is a leading cause of cancer deaths, particularly in cases of recurrence." — Ryan Morgan (epidemiological) [Ep 127 · 0:45](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=45)
- "Traditional paradigms suggest recurrences are due to either incomplete resection or occult metastases left behind at surgery." — Ryan Morgan (clinical) [Ep 127 · 0:45](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=45)
- "Exfoliated cancer cells in the lumen of the bowel may be a source of recurrence." — Ryan Morgan (clinical) [Ep 127 · 0:58](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=58)
- "In the 1980s, UMLB showed that exfoliated cells are present and viable at the time of surgery." — Ryan Morgan (clinical) [Ep 127 · 1:04](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=64)
- "A subsequent study found that experimental cells could cross a watertight anastomosis in a mouse model." — Ryan Morgan (clinical) [Ep 127 · 1:09](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=69)
- "Clinical data shows that rectal washout decreases rates of local recurrence after rectal cancer resection." — Ryan Morgan (clinical) [Ep 127 · 1:14](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=74)
- "When the primary colorectal tumor is resected, exfoliated cells remain behind within the lumen of the bowel and can interact with the anastomotic microenvironment." — Ryan Morgan (clinical) [Ep 127 · 1:39](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=99)
- "Multiple factors can influence the anastomotic environment, including diet, the microbiome, and the tumor genetic background." — Ryan Morgan (clinical) [Ep 127 · 1:48](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=108)
- "The interaction of diet, microbiome, and genetics in the healing anastomosis promotes migration of exfoliated cells to cause both local and distant recurrences." — Ryan Morgan (clinical) [Ep 127 · 1:55](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=115)
- "AKPT and KPN organoid cell lines demonstrate a wide range of metastatic potential in animal models." — Ryan Morgan (clinical) [Ep 127 · 2:15](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=135)
- "The experimental model involves 6 weeks of high-fat or normal chow diet preoperatively, colonic anastomosis, and enema of organoid cells on postoperative day 2." — Ryan Morgan (clinical) [Ep 127 · 2:42](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=162)
- "Both AKPT and KPN organoids formed tumors in the colon, liver, and lung in the model." — Ryan Morgan (clinical) [Ep 127 · 3:07](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=187)
- "By 56 days, there was a significantly higher rate of AKPT tumor formation with high-fat diet compared to chow diet." — Ryan Morgan (clinical) [Ep 127 · 3:35](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=215)
- "KPN mice showed no significant difference in tumor formation based on diet, with an opposite trend towards higher rates in the chow diet." — Ryan Morgan (clinical) [Ep 127 · 3:46](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=226)
- "AKPT mice given high-fat diet had significantly decreased survival compared to those on chow diet, often dying before planned sacrifice due to large bulky tumors at the anastomosis." — Ryan Morgan (clinical) [Ep 127 · 3:55](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=235)
- "KPN mice showed no similar survival trend, suggesting the response to diet was at least in part based on the organoid genetic background." — Ryan Morgan (clinical) [Ep 127 · 4:14](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=254)
- "In germ-free mice, the high-fat diet-associated microbiome significantly increased the rate of postoperative tumor development to 40%, compared to 10-12% in control and chow FMT groups." — Ryan Morgan (clinical) [Ep 127 · 4:57](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=297)
- "A two-week diet reversal period did not improve survival or tumor rates in mice previously on high-fat diet." — Ryan Morgan (clinical) [Ep 127 · 5:50](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=350)
- "A six-week diet reversal period resulted in significantly increased survival and tumor rates similar to chow-fed mice, suggesting the response was time-dependent." — Ryan Morgan (clinical) [Ep 127 · 6:01](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=361)
- "16S RNA analysis showed derangement of microbiome in high-fat diet mice, with overabundance of Alobaum and bloom of pathogenic bacteria including Proteus, E. coli, and Shigella on postoperative day 7." — Ryan Morgan (clinical) [Ep 127 · 6:22](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=382)
- "The diet reversal group microbiome composition closely mirrored the chow group both at baseline and in response to surgery." — Ryan Morgan (clinical) [Ep 127 · 6:45](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=405)
- "High-fat diet was associated with increased tumor burden and decreased survival for mice given AKPT cells, but not those given KPN cells." — Ryan Morgan (clinical) [Ep 127 · 7:01](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=421)
- "The high-fat diet-associated microbiome was necessary for promoting higher rates of postoperative tumor formation." — Ryan Morgan (clinical) [Ep 127 · 7:13](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=433)
- "Preoperative diet manipulation reduces tumor formation, suggesting a clinically relevant role for diet rehabilitation in colorectal cancer treatment." — Ryan Morgan (opinion) [Ep 127 · 7:23](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=443)
- "Combined mechanical and antibiotic bowel preparation preoperatively decreases rates of colorectal cancer recurrence." — Ryan Morgan (clinical) [Ep 127 · 9:23](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=563)
- "Preliminary in vitro data shows AKPT cells have more proliferative response to secondary bile acids (like deoxycholic acid) than KPN cells." — Ryan Morgan (clinical) [Ep 127 · 11:01](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=661)
- "The differential response between organoids may be related to Wnt signaling, with AKPT cells having knocked out APC signaling." — Ryan Morgan (opinion) [Ep 127 · 11:31](https://library.globalcastmd.com/watch/best-of-the-best-gen-surg-development-of-postoperative-local-tumors-and-distant-metastases-in-diet-genetics-and-microbiome-dependent-in-a-mouse-model-of-colorectal-cancer-recurrence-dr-morgan-5861?t=691)
- "The patient is a 10 year old boy with a prior pull-through for Hirschsprung's disease who suffered from fecal incontinence for many years" (clinical) [Ep 128 · 0:05](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=5)
- "Physical exam showed a patulous anus and an absent dentate line" (clinical) [Ep 128 · 0:11](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=11)
- "These anatomic problems result from an overstretching of the anal sphincters and a dissection started too low during the initial procedure" (clinical) [Ep 128 · 0:25](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=25)
- "A Malone appendicostomy was given for antegrade flushes to manage incontinence" (clinical) [Ep 128 · 0:35](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=35)
- "The patient was able to be clean and socially continent, albeit mechanically, with the Malone" (clinical) [Ep 128 · 0:41](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=41)
- "The novel sphincter reconstruction technique aims to improve the ability to squeeze the anus closed and enable voluntary bowel movements" (clinical) [Ep 128 · 0:47](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=47)
- "Three-dimensional anorectal manometry confirmed objectively the absence of good sphincteric contraction, particularly on the anterior aspect" (clinical) [Ep 128 · 1:19](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=79)
- "The operation is performed in prone position" (clinical) [Ep 128 · 1:37](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=97)
- "Lone star retractor pins are placed just at the skin level, as there is no dentate line to preserve" (clinical) [Ep 128 · 1:40](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=100)
- "The dissection is performed in the plane between the bowel wall and the surrounding sphincter muscle" (clinical) [Ep 128 · 2:08](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=128)
- "The plane between the bowel and the muscle frees up easily, as the muscle is not very adherent to the pull-through" (clinical) [Ep 128 · 2:21](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=141)
- "A nice areolar plane exists between the bowel and muscle, allowing visualization of the external sphincter muscle circumferentially" (clinical) [Ep 128 · 2:29](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=149)
- "The external sphincter muscles need to be more firmly attached to the distal pull-through to provide adequate squeeze to close the anus" (clinical) [Ep 128 · 2:53](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=173)
- "If the patient can detect the presence of stool in the anal canal, they will be able to close the anus in time to avoid an accident" (clinical) [Ep 128 · 3:02](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=182)
- "The patient is planned to practice sphincter control during their antegrade flushes and is anticipated to get better and better at holding in their flush" (clinical) [Ep 128 · 3:11](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=191)
- "The depth of dissection measures 3 to 3.5 centimeters" (clinical) [Ep 128 · 3:18](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=198)
- "Deeper to the dissection location is ischiocrectal fat" (clinical) [Ep 128 · 3:24](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=204)
- "The muscle is tacked to the bowel circumferentially, starting anteriorly, which was the most problematic area noted on the manometry" (clinical) [Ep 128 · 3:33](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=213)
- "Absorbable sutures are used from the seromuscular bowel layer to the muscle" (clinical) [Ep 128 · 3:57](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=237)
- "After tacking is complete, the mucosal edge is sutured back to the skin circumferentially" (clinical) [Ep 128 · 4:15](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=255)
- "Digital exam confirms that the anus is supple and easily distensible, but now compressed by the surrounding external sphincter" (clinical) [Ep 128 · 4:28](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=268)
- "After a period of time with continued antegrade flushes and hopefully improvement in control, the plan is to allow the patient to have their own bowel movements and demonstrate their own capacity for voluntary control" (clinical) [Ep 128 · 4:37](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=277)
- "Repeat three-dimensional anorectal manometry confirmed objectively an improvement in the symmetry of the muscles around the pull-through and in their increased tone" (clinical) [Ep 128 · 4:54](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=294)
- "Hirschsprung disease occurs in about 1 in 5000 live births" — Marc Levitt (epidemiological) [Ep 129 · 3:30](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=210)
- "90% of Hirschsprung patients are diagnosed in the first couple of months of life, the vast majority in the first week" — Marc Levitt (epidemiological) [Ep 129 · 4:42](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=282)
- "Without ganglion cells, the colon cannot relax and therefore stays squeezed, preventing the colon above from emptying through it" — Marc Levitt (clinical) [Ep 129 · 4:53](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=293)
- "In Hirschsprung disease, bacteria can migrate through the abnormal bowel lining into the bloodstream, creating enterocolitis which is life threatening" — Marc Levitt (clinical) [Ep 129 · 6:05](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=365)
- "If Hirschsprung disease is recognized, it is pretty straightforward to intervene, but a few patients die each year from enterocolitis" — Marc Levitt (clinical) [Ep 129 · 6:55](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=415)
- "Medical treatment with proper irrigation can prevent enterocolitis without necessarily requiring surgery" — Marc Levitt (clinical) [Ep 129 · 7:06](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=426)
- "About 5% of Hirschsprung patients present after 1 year of life, the vast majority present as babies" — Marc Levitt (epidemiological) [Ep 129 · 8:10](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=490)
- "Down syndrome is associated with Hirschsprung disease" — Marc Levitt (clinical) [Ep 129 · 9:07](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=547)
- "10% of patients with meconium plug actually have Hirschsprung disease as the underlying cause, while 90% just pass the plug and get better" — Marc Levitt (clinical) [Ep 129 · 10:46](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=646)
- "Milk protein allergy can mimic Hirschsprung disease, and biopsy will find ganglion cells but lots of eosinophils" — Marc Levitt (clinical) [Ep 129 · 11:22](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=682)
- "To diagnose Hirschsprung disease, you need both absence of ganglion cells and confirmation that nerve trunks are hypertrophic (thickened)" — Marc Levitt (clinical) [Ep 129 · 13:40](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=820)
- "Hypertrophic nerve trunks greater than 40 microns is abnormal" — Marc Levitt (clinical) [Ep 129 · 14:31](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=871)
- "A permanent section biopsy takes about 2 or 3 days to analyze and requires evaluation of 100 slices to prove Hirschsprung disease" — Marc Levitt (clinical) [Ep 129 · 16:37](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=997)
- "You cannot diagnose Hirschsprung with a frozen section, but you can rule it out if ganglion cells are present" — Marc Levitt (clinical) [Ep 129 · 16:37](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=997)
- "The vast majority of Hirschsprung cases have the problem in the lower part of the colon, the left colon or below" — Marc Levitt (epidemiological) [Ep 129 · 20:41](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1241)
- "In about 15% of cases, Hirschsprung disease extends higher than the splenic flexure" — Marc Levitt (epidemiological) [Ep 129 · 20:45](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1245)
- "Contrast studies showing the transition zone are accurate about 90% of the time" — Marc Levitt (clinical) [Ep 129 · 22:09](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1329)
- "The dilated colon will shrink down to more normal size once it can successfully empty after the blockade is removed" — Marc Levitt (clinical) [Ep 129 · 22:43](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1363)
- "You really only need about 10% of your colon to function completely normally and have one bowel movement per day" — Marc Levitt (clinical) [Ep 129 · 29:06](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1746)
- "Most Hirschsprung patients only lose about 15 to 20% of their colon because that's where the abnormal segment is" — Marc Levitt (clinical) [Ep 129 · 29:14](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1754)
- "Patients who lose their entire colon and have small bowel brought to the anus tend to have 2 to 6 stools per day" — Marc Levitt (clinical) [Ep 129 · 29:29](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1769)
- "All Hirschsprung patients can maintain bowel control provided the surgeon successfully preserves the anal canal and sphincters during the operation" — Marc Levitt (clinical) [Ep 129 · 29:41](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1781)
- "Sometimes the irrigation tube does not reach high enough into normal bowel and cannot successfully decompress the colon" — Marc Levitt (clinical) [Ep 129 · 30:46](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=1846)
- "In Hirschsprung disease, the internal sphincter tightens at the wrong time instead of relaxing when there is fullness in the rectum" — Marc Levitt (clinical) [Ep 129 · 42:39](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2559)
- "Even after successful Hirschsprung surgery, patients can develop enterocolitis if sphincters don't relax well and slow down flow" — Marc Levitt (clinical) [Ep 129 · 41:43](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2503)
- "Botox injection to the anal sphincters wears off over 3 months, during which time the baby can learn to push and overcome non-relaxing sphincters" — Marc Levitt (clinical) [Ep 129 · 41:59](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2519)
- "The vast majority of Hirschsprung patients recover very uneventfully, stool normally, and successfully potty train by age 3 or 4" — Marc Levitt (clinical) [Ep 129 · 43:59](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2639)
- "Hirschsprung disease is a source of significant morbidity and mortality in the developing world if unrecognized" — Marc Levitt (epidemiological) [Ep 129 · 44:52](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2692)
- "If a family has a baby with Hirschsprung disease, the risk of another baby having it is about 1 in 200, compared to the general population risk of 1 in 5000" — Marc Levitt (epidemiological) [Ep 129 · 38:40](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2320)
- "Hirschsprung-associated enterocolitis is treated with irrigations, metronidazole antibiotic for anaerobic bacteria, and intravenous hydration" — Marc Levitt (clinical) [Ep 129 · 39:29](https://library.globalcastmd.com/watch/drbeen-medical-lectures-dr-marc-levitt-md-discusses-hirschsprung-disease-6227?t=2369)
- "A patient with no anal opening and a single perineal orifice has a cloaca, not ambiguous genitalia or urogenital sinus" — Marc Levitt (clinical) [Ep 130 · 4:06](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=246)
- "Cloacal patients are normal females with typical ovarian anatomy, though various Mullerian anomalies can occur" — Marc Levitt (clinical) [Ep 130 · 4:27](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=267)
- "The common channel in cloaca emanates just below the clitoral hood, not the typical location for female urethra" — Marc Levitt (clinical) [Ep 130 · 4:40](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=280)
- "Leaving the urethral opening in the clitoral location is suboptimal both cosmetically and functionally for intermittent catheterization" — Marc Levitt (opinion) [Ep 130 · 5:04](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=304)
- "In utero ascites in cloaca occurs when urine flows from bladder into vagina, cannot exit the common channel, and backs up through fallopian tubes into peritoneal cavity" — Marc Levitt (clinical) [Ep 130 · 8:08](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=488)
- "The vast majority of hydrocolpos can be drained perineally without abdominal surgery" — Marc Levitt (clinical) [Ep 130 · 9:01](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=541)
- "After hydrocolpos decompression, the bladder will suddenly dilate as distal ureteral obstruction is relieved" — Marc Levitt (clinical) [Ep 130 · 9:33](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=573)
- "A vesicostomy in almost all cloacas is not the correct treatment because it will not solve the distal ureteral obstruction" — Marc Levitt (clinical) [Ep 130 · 9:46](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=586)
- "About 40% of cloacal patients have a bifid vaginal system" — Marc Levitt (epidemiological) [Ep 130 · 10:37](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=637)
- "Hydrocolpos only needs management if it is causing hydronephrosis" — Marc Levitt (clinical) [Ep 130 · 10:46](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=646)
- "Critical measurements for surgical planning are common channel length, native urethral length, and bladder neck location" — Marc Levitt (clinical) [Ep 130 · 12:10](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=730)
- "Cloacas form in two groups: low confluence (common channel ≤3cm) and high confluence (common channel >3cm)" — Marc Levitt (clinical) [Ep 130 · 12:26](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=746)
- "Total urogenital mobilization was historically overused for patients who did not have adequately long urethra" — Marc Levitt (opinion) [Ep 130 · 12:51](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=771)
- "A native urethral length greater than 1.5 centimeters is needed for bladder function" — Marc Levitt (clinical) [Ep 130 · 13:23](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=803)
- "Disrupting the urogenital diaphragm or pulling the bladder neck down out of it will result in urinary leakage" — Marc Levitt (clinical) [Ep 130 · 13:38](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=818)
- "In a patient with 3.5cm common channel and only 1.5cm native urethra, the preferred approach is to repair the back of the common channel and let native urethra plus common channel become a 5cm neourethra" — Marc Levitt (clinical) [Ep 130 · 14:01](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=841)
- "If native urethra cannot be guaranteed to be 1.5cm or greater, a UG separation must be done to let native urethra plus common channel become the neourethra" — Marc Levitt (clinical) [Ep 130 · 16:10](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=970)
- "Normal female urethral length is at least 1.5cm, often greater, based on VCUG studies of patients with UTI" — Marc Levitt (clinical) [Ep 130 · 16:28](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=988)
- "Splitting a long common channel with very little native urethra essentially brings the bladder neck down to the perineum, which must be avoided" — Marc Levitt (clinical) [Ep 130 · 17:23](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1043)
- "For patients with common channel greater than 3cm, 80% (4 out of 5) will need intermittent catheterization" — Marc Levitt (epidemiological) [Ep 130 · 27:24](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1644)
- "For patients with common channel 3cm or less, 20% (1 out of 5) need intermittent catheterization" — Marc Levitt (epidemiological) [Ep 130 · 27:41](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1661)
- "A small posterior incision in the common channel allows recessing of the urethral meatus below the clitoral tissue" — Marc Levitt (clinical) [Ep 130 · 19:33](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1173)
- "Sigmoid colon is the ideal choice for vaginal replacement, with small bowel as second choice" — Marc Levitt (opinion) [Ep 130 · 20:24](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1224)
- "The sigmoid colostomy site itself can be used for vaginal replacement, then the colostomy recreated more proximally" — Marc Levitt (clinical) [Ep 130 · 20:40](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1240)
- "Tissue engineering for vaginal reconstruction using patient stem cells is believed to be achievable in our lifetime" — Marc Levitt (opinion) [Ep 130 · 21:17](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1277)
- "The optimal timing for cloacal repair is between 2 months and 1 year of age, most commonly 6-8 months" — Marc Levitt (clinical) [Ep 130 · 23:13](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1393)
- "Leaving a hypospadiac urethra is acceptable only if the patient will not require catheterization and the introitus reaches without full TUM" — Marc Levitt (clinical) [Ep 130 · 23:53](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1433)
- "If a patient has tethered cord, making a more obvious urethral meatus is preferred over leaving it hypospadiac due to likely need for catheterization" — Marc Levitt (clinical) [Ep 130 · 24:06](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1446)
- "Laparoscopic or robotic UG separation is elegant and beautiful but cases take a long time" — Marc Levitt (opinion) [Ep 130 · 29:43](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1783)
- "Vaginal switch operation is no longer performed due to high stenosis rates" — Marc Levitt (clinical) [Ep 130 · 32:14](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1934)
- "Neovaginal dilatation is not performed; preference is to allow skin-level stenosis and later perform introitoplasty" — Marc Levitt (opinion) [Ep 130 · 32:40](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1960)
- "The perineal sphincter muscle complex is absolutely preserved during posterior sagittal repair" — Marc Levitt (clinical) [Ep 130 · 32:54](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1974)
- "In UG separation, dissection starts on the back of the vagina as it enters the common channel, lifting it off without touching the common channel to avoid spongiosum tissue" — Marc Levitt (clinical) [Ep 130 · 34:12](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2052)
- "For low confluence below peritoneal reflection, always start posterior sagittally; only start abdominally if vagina and rectum are already in the abdomen" — Marc Levitt (opinion) [Ep 130 · 35:25](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2125)
- "A TUM can always be done in prone position; if it doesn't reach, it likely should have been a separation rather than TUM" — Marc Levitt (opinion) [Ep 130 · 36:39](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2199)
- "The key to saving kidneys in cloaca is aggressive bladder management: keep the bladder empty through intermittent catheterization, and vesicostomy for grade 4-5 reflux" — Marc Levitt (clinical) [Ep 130 · 38:10](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2290)
- "Small bowel blood supply is more tenuous and less forgiving than colon for vaginal replacement" — Marc Levitt (clinical) [Ep 130 · 38:53](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2333)
- "C-section is definitely advised for cloacal patients who become pregnant due to extensive perineal dissection" — Marc Levitt (clinical) [Ep 130 · 28:40](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1720)
- "If vaginal orifice is present post-operatively, leave patient alone until puberty then consider introitoplasty rather than early revision" — Marc Levitt (opinion) [Ep 130 · 29:05](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=1745)
- "Bladder neck closure is rarely indicated; most urethras are salvageable if the common channel is kept intact to become neourethra" — Marc Levitt (clinical) [Ep 130 · 40:57](https://library.globalcastmd.com/watch/ern-eurogen-arm-webinar-series-management-of-cloacal-malformations-what-is-new-in-2021-6228?t=2457)
- "The patient is a 6-year-old girl with functional constipation refractory to medical management" (clinical) [Ep 133 · 0:05](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=5)
- "Rectal biopsy and anorectal manometry were both normal" (clinical) [Ep 133 · 0:10](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=10)
- "Colonic manometry identified a 40 centimeter segment of dysmotile colon" (clinical) [Ep 133 · 0:18](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=18)
- "Contrast enema demonstrated a grossly dilated distal colon" (clinical) [Ep 133 · 0:23](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=23)
- "The patient's findings are consistent with Group D in a previously published systematic approach to severe functional constipation" (clinical) [Ep 133 · 0:27](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=27)
- "Initial Malone appendicostomy improved symptoms but after several months the patient developed impactions despite multiple colonic irrigation regimens" (clinical) [Ep 133 · 0:37](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=37)
- "Preoperative bowel preparation was used to ensure decompression of the distal colon at laparoscopy" (clinical) [Ep 133 · 0:53](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=53)
- "A 5 millimeter optical port is placed supraumbilically and to the left to avoid injury to the appendicostomy" (clinical) [Ep 133 · 1:01](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=61)
- "Additional ports are placed under vision in the left upper quadrant and the right lower quadrant" (clinical) [Ep 133 · 1:08](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=68)
- "The left colon demonstrated a grossly dilated redundant sigmoid colon which funnels into a more normal caliber rectum above the peritoneal reflection" (clinical) [Ep 133 · 1:13](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=73)
- "Dissection begins at the pelvic brim using a vessel sealing device to create a mesenteric window, staying close to the bowel" (clinical) [Ep 133 · 1:22](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=82)
- "The position of the ureters is established to ensure they lie away from the dissection plane" (clinical) [Ep 133 · 1:32](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=92)
- "Once normal caliber colon is encountered above the peritoneal reflection, the rectum is transected using an endoGIA stapler" (clinical) [Ep 133 · 1:41](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=101)
- "Several staple fires may be needed depending on the degree of dilatation" (clinical) [Ep 133 · 1:48](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=108)
- "Verification is performed to ensure that the ureter has not been inadvertently caught in the staple line" (clinical) [Ep 133 · 1:52](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=112)
- "In this case, taking down the splenic flexure was not required to achieve sufficient mobility of the normal caliber colon to reach the pelvis" (clinical) [Ep 133 · 2:06](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=126)
- "The right lower quadrant port incision is extended to approximately 2.5 centimeters for specimen extraction" (clinical) [Ep 133 · 2:28](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=148)
- "A wound protector is applied to the right lower quadrant port site during specimen extraction" (clinical) [Ep 133 · 2:40](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=160)
- "The anvil component of an EEA circular stapler is secured in place using a prolene purse string suture" (clinical) [Ep 133 · 2:46](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=166)
- "The colon orientation is examined to ensure there is no twist on the colon as it passes into the pelvis" (clinical) [Ep 133 · 3:11](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=191)
- "The colon should lack redundancy and form a direct path into the pelvis after resection" (clinical) [Ep 133 · 3:17](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=197)
- "The rectum is calibrated using scissors that come with a circular stapling device" (clinical) [Ep 133 · 3:22](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=202)
- "The EEA trocar is deployed adjacent to the rectal staple line until the orange tying area is seen" (clinical) [Ep 133 · 3:26](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=206)
- "A characteristic snap is felt when the anvil is properly engaged into the trocar" (clinical) [Ep 133 · 3:41](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=221)
- "Two complete doughnuts of colonic tissue indicate a satisfactory anastomosis" (clinical) [Ep 133 · 3:55](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=235)
- "Anastomotic integrity is tested by filling the pelvis with saline and insufflating air into the rectum, with no bubbling indicating no leak" (clinical) [Ep 133 · 4:04](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=244)
- "The patient was discharged on the 4th postoperative day following resumption of bowel function and establishment of diet and appendicostomy flushes" (clinical) [Ep 133 · 4:19](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=259)
- "The flush regimen was dramatically improved after resection" (clinical) [Ep 133 · 4:26](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=266)
- "The plan is to attempt to transition the patient to oral laxatives" (clinical) [Ep 133 · 4:26](https://library.globalcastmd.com/watch/laparoscopic-segmental-colectomy-for-functional-constipation-6504?t=266)
- "Surgical site infections are a major cause of perioperative morbidity in children undergoing colorectal surgery" — Alex Halpern (epidemiological) [Ep 134 · 0:00](https://library.globalcastmd.com/watch/standardized-perioperative-care-reduces-colorectal-surgical-site-infection-in-children-6578?t=0)
- "The Western Pediatric Surgery Research Consortium conducted a prospective cohort study on children undergoing colorectal surgery across 10 hospitals in the US" — Alex Halpern (clinical) [Ep 134 · 0:20](https://library.globalcastmd.com/watch/standardized-perioperative-care-reduces-colorectal-surgical-site-infection-in-children-6578?t=20)
- "The study utilized an 8-part perioperative care bundle" — Alex Halpern (clinical) [Ep 134 · 0:32](https://library.globalcastmd.com/watch/standardized-perioperative-care-reduces-colorectal-surgical-site-infection-in-children-6578?t=32)
- "Children were split into either a high or low compliance group based on adherence to the care bundle" — Alex Halpern (clinical) [Ep 134 · 0:32](https://library.globalcastmd.com/watch/standardized-perioperative-care-reduces-colorectal-surgical-site-infection-in-children-6578?t=32)
- "Children in the high compliance group had a statistically significant decrease in rates of superficial surgical site infection when compared to children in the low compliance group" — Alex Halpern (clinical) [Ep 134 · 0:41](https://library.globalcastmd.com/watch/standardized-perioperative-care-reduces-colorectal-surgical-site-infection-in-children-6578?t=41)
- "Standardization of perioperative care may decrease morbidity and improve outcomes in colorectal surgery" — Alex Halpern (opinion) [Ep 134 · 0:41](https://library.globalcastmd.com/watch/standardized-perioperative-care-reduces-colorectal-surgical-site-infection-in-children-6578?t=41)
- "Dr. Patkowski's center in Poland has been performing thoracoscopic esophageal atresia repair exclusively since 2005" — Ellen Encisco (clinical) [Ep 135 · 1:38](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=98)
- "The first thoracoscopic EA procedure took almost 4 hours, but the procedure now takes 1 hour" — Ellen Encisco (clinical) [Ep 135 · 1:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=114)
- "The Polish center has had no conversions from thoracoscopic to open approach since beginning the technique" — Ellen Encisco (clinical) [Ep 135 · 1:59](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=119)
- "All thoracoscopic EA cases at the Polish center have been managed by one team using only the thoracoscopic approach" — Ellen Encisco (clinical) [Ep 135 · 2:06](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=126)
- "Experience in endoscopic surgery and endoscopic suturing is required for thoracoscopic EA repair" — Ellen Encisco (clinical) [Ep 135 · 2:25](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=145)
- "Centralization of EA care is important even if transportation costs are higher, because complication costs are much higher" — Ellen Encisco (opinion) [Ep 135 · 2:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=178)
- "The Polish center handles 15 to 20 EA cases per year, which provides sufficient volume for good experience" — Ellen Encisco (clinical) [Ep 135 · 3:06](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=186)
- "The center in Rocklaw has become the referral center for esophageal atresia and long gap esophageal atresia for all of Poland" — Mark Davenport (clinical) [Ep 135 · 3:38](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=218)
- "Centers of excellence for EA repair are showing better outcomes" — Todd (clinical) [Ep 135 · 4:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=253)
- "Centralization of EA care would be difficult to implement in the United States healthcare system" — Todd (opinion) [Ep 135 · 4:26](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=266)
- "The Sheffield study included 95 Hirschsprung disease patients from January 2004 to August 2021" — Ellen Encisco (epidemiological) [Ep 135 · 5:25](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=325)
- "47% of the Sheffield cohort needed a stoma before primary pull-through" — Govind Murti (clinical) [Ep 135 · 5:35](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=335)
- "In the stoma cohort, 38 patients had ileostomies and the remainder had colostomies" — Ellen Encisco (clinical) [Ep 135 · 5:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=341)
- "The most common indication for initial stoma was washout failure in nearly 40% of cases" — Ellen Encisco (clinical) [Ep 135 · 5:46](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=346)
- "Of 20 patients needing post-pull-through stoma formation, 7 occurred within 30 days and 13 after 30 days" — Govind Murti (clinical) [Ep 135 · 6:19](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=379)
- "Most post-pull-through stomas after 30 days were needed because of constipation or soiling" — Govind Murti (clinical) [Ep 135 · 6:28](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=388)
- "The Sheffield data represents real life surgical reporting and reflects overall Hirschsprung management within the UK" — Mark Davenport (opinion) [Ep 135 · 6:35](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=395)
- "US practice typically involves neonatal pull-through or home irrigations with pull-through in first months of life" — Beth Rymeski (clinical) [Ep 135 · 7:20](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=440)
- "In US practice, pre-pull-through diversion is typically only done for delayed presentation with perforation or complicated cardiac cases" — Beth Rymeski (clinical) [Ep 135 · 7:39](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=459)
- "Sheffield primarily performs Duhamel pull-throughs while Cincinnati primarily performs Swenson procedures" — Ellen Encisco (clinical) [Ep 135 · 8:10](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=490)
- "The Tanzania study was conducted at Mahambile National Hospital and included 252 patients" (epidemiological) [Ep 135 · 8:52](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=532)
- "114 patients received preoperative soap bathing and 11.4% developed surgical site infections" (clinical) [Ep 135 · 9:26](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=566)
- "In the control group without soap bathing, 40.6% of patients developed surgical site infections" (clinical) [Ep 135 · 9:26](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=566)
- "Preoperative soap bathing reduced the odds of surgical site infections by 80%" (clinical) [Ep 135 · 9:43](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=583)
- "Length of stay was reduced from 22 days in the non-interventional group to 12 days in the soap bathing group" — Mark Davenport (clinical) [Ep 135 · 9:53](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=593)
- "Preoperative bathing was not common practice in Tanzania before this study" (clinical) [Ep 135 · 10:04](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=604)
- "A Cincinnati Children's team working in Tanzania had almost every patient develop wound infections in their first year, but near-zero infections after implementing preoperative baths" — Beth Rymeski (clinical) [Ep 135 · 10:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=641)
- "The meta-analysis included 10 studies with 1,298 patients" (epidemiological) [Ep 148 · 0:18](https://library.globalcastmd.com/watch/meta-analysis-of-enhanced-recovery-after-surgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7597?t=18)
- "Patients with ERAS protocols around colorectal surgery had less length of stay" (clinical) [Ep 148 · 0:18](https://library.globalcastmd.com/watch/meta-analysis-of-enhanced-recovery-after-surgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7597?t=18)
- "Patients with ERAS protocols had less opiate use" (clinical) [Ep 148 · 0:18](https://library.globalcastmd.com/watch/meta-analysis-of-enhanced-recovery-after-surgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7597?t=18)
- "Patients with ERAS protocols had less hospital cost" (clinical) [Ep 148 · 0:18](https://library.globalcastmd.com/watch/meta-analysis-of-enhanced-recovery-after-surgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7597?t=18)
- "Complication rates were the same in both groups (ERAS vs standard care)" (clinical) [Ep 148 · 0:18](https://library.globalcastmd.com/watch/meta-analysis-of-enhanced-recovery-after-surgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7597?t=18)
- "Associated malformations in colorectal patients affect airway and cardiac systems, relevant to anesthesia choices" — Mark (clinical) [Ep 147 · 1:05](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=65)
- "Electrical stimulation is used to identify the ideal sphincteric ellipse for anus placement" — Mark (clinical) [Ep 147 · 1:36](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=96)
- "Neuromuscular blockade prevents visualization of muscle contractions during sphincter mapping" — Mark (clinical) [Ep 147 · 1:47](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=107)
- "Neuromuscular blockade should be avoided at the beginning of cases requiring sphincter mapping" — Mark (guideline) [Ep 147 · 1:58](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=118)
- "Neuromuscular blockade can be administered after sphincter marking is complete" — Mark (guideline) [Ep 147 · 2:16](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=136)
- "Patients with existing anus (Hirschsprung's, fecal incontinence with Malone) do not require sphincter mapping, so neuromuscular blockade is acceptable" — Mark (clinical) [Ep 147 · 2:52](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=172)
- "Prone position provides better access to the pelvis for colorectal surgery" — Mark (clinical) [Ep 147 · 3:23](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=203)
- "Alberto Pena introduced the posterior sagittal approach to the rectum in 1980" — Mark (clinical) [Ep 147 · 3:31](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=211)
- "Prone positioning allows three surgeons to visualize the field well, compared to one in supine perineal approach" — Mark (clinical) [Ep 147 · 4:23](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=263)
- "Lower extremity IV access is acceptable with sterile tubing across the drape" — Mark (guideline) [Ep 147 · 4:59](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=299)
- "Baseline hematocrit is important for long cases to monitor for blood loss" — Mark (clinical) [Ep 147 · 5:24](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=324)
- "Transfusion is rare in colorectal cases, occurring approximately once or twice per year" — Mark (epidemiological) [Ep 147 · 5:34](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=334)
- "Hyperviscosity should be avoided because reconstructed tissues are based on single blood vessels" — Mark (clinical) [Ep 147 · 5:45](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=345)
- "Some colorectal reconstructions are analogous to free flap cases, with tissue moved based on a single vessel" — Mark (clinical) [Ep 147 · 6:13](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=373)
- "Bowel prep causes dehydration requiring fluid catch-up" — Mark (clinical) [Ep 147 · 6:38](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=398)
- "When the bladder is open during surgery, urine output cannot be monitored for approximately 6 hours" — Mark (clinical) [Ep 147 · 6:50](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=410)
- "Cloaca repair can range from 3 to 8 hours depending on complexity" — Mark (clinical) [Ep 147 · 7:21](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=441)
- "Regional pain management has significantly reduced ICU utilization at this institution" — Mark (epidemiological) [Ep 147 · 8:05](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=485)
- "Rapid responses for pain and respiratory issues at night were common at previous institution but are rare at current institution" — Mark (epidemiological) [Ep 147 · 8:15](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=495)
- "Leaving patients intubated overnight can prevent midnight pain crises on the floor" — Mark (clinical) [Ep 147 · 8:42](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=522)
- "Vasoconstrictive medications can cause loss of pedicled grafts" — Mark (clinical) [Ep 147 · 9:28](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=568)
- "Dopamine is less vasoconstrictive than norepinephrine" — Mark (clinical) [Ep 147 · 9:25](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=565)
- "Transverse incisions are more painful than vertical incisions" — Mark (clinical) [Ep 147 · 10:35](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=635)
- "Oral narcotics should be delayed until patient is on regular diet to avoid diagnostic confusion from nausea" — Mark (guideline) [Ep 147 · 10:55](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=655)
- "NSAIDs are effective for pain management and avoid narcotics" — Mark (clinical) [Ep 147 · 11:53](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=713)
- "Many colorectal patients have single kidneys but normal renal function" — Mark (clinical) [Ep 147 · 11:44](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=704)
- "Norepinephrine and epinephrine are associated with vasoconstriction of small vessels in pedicled tissue situations" — Mark (clinical) [Ep 147 · 13:24](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=804)
- "At previous institution, cases longer than 6 hours routinely went to ICU" — Mark (epidemiological) [Ep 147 · 15:31](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=931)
- "In the last 6 months, only 1-2 patients required ICU admission" — Mark (epidemiological) [Ep 147 · 16:02](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=962)
- "A 16-hour case required ICU admission for both pain and fluid management" — Mark (clinical) [Ep 147 · 16:25](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=985)
- "Joint cases with urology and robotic cases can take 8-10 hours" — Mark (clinical) [Ep 147 · 16:44](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1004)
- "Better regional care is the major factor in reduced ICU utilization" — Mark (opinion) [Ep 147 · 17:07](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1027)
- "Pain management is the main issue determining ICU need, not blood pressure" — Mark (opinion) [Ep 147 · 17:31](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1051)
- "Patient referral to surgery typically takes 3-4 months for paperwork, insurance, and planning" — Mark (clinical) [Ep 147 · 18:58](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1138)
- "Colorectal reconstructions are not urgent because patients are safe with diverting ostomies" — Mark (clinical) [Ep 147 · 19:12](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1152)
- "Reconstruction can take place anytime within the first year of life as long as colostomy and urinary drainage are functioning" — Mark (guideline) [Ep 147 · 19:42](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1182)
- "Ideal timeline is newborn colostomy, reconstruction at 2-6 months, colostomy closure thereafter, all completed by 1 year" — Mark (guideline) [Ep 147 · 20:07](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1207)
- "Two years after reconstruction allows time for potty training assessment before nursery school" — Mark (clinical) [Ep 147 · 20:24](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1224)
- "Overhydration causes dilated bowel that is difficult to close" — Mark (clinical) [Ep 147 · 23:49](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1429)
- "Current institution has not experienced bowel edema from overhydration" — Mark (epidemiological) [Ep 147 · 23:57](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1437)
- "384 females with anorectal malformations were studied from the Pediatric Colorectal and Pelvic Learning Consortium database" — Ellen Encisco (epidemiological) [Ep 149 · 1:13](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=73)
- "About 27% of patients with anorectal malformations had a gynecologic anomaly" — Ellen Encisco (epidemiological) [Ep 149 · 1:22](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=82)
- "About 46% of females with anorectal malformations had VACTERL association (anorectal malformation plus two of: vertebral, cardiac, tracheoesophageal, renal, or limb anomaly)" — Ellen Encisco (epidemiological) [Ep 149 · 1:22](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=82)
- "Having VACTERL association was associated with more gynecologic anomalies compared to those without VACTERL" — Ellen Encisco (clinical) [Ep 149 · 1:39](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=99)
- "The association between VACTERL and gynecologic anomalies was especially true when renal anomalies were found" — Ellen Encisco (clinical) [Ep 149 · 1:49](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=109)
- "The association between VACTERL and gynecologic anomalies was especially true when patients had recto vestibular or rectal perineal fistulas" — Ellen Encisco (clinical) [Ep 149 · 1:49](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=109)
- "For females with anorectal malformations and VACTERL association, especially renal anomalies, clinicians should look carefully for gynecologic anomalies" — Ellen Encisco (guideline) [Ep 149 · 1:57](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=117)
- "Thoracic epidural and intercostal nerve cryoablation are two options for pain control in patients undergoing Nuss procedure for pectus excavatum" — Alex Halpern (clinical) [Ep 149 · 2:30](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=150)
- "The study was a retrospective chart review of kids who underwent Nuss procedure between 2002 and 2020" — Alex Halpern (epidemiological) [Ep 149 · 2:42](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=162)
- "The intercostal nerve cryoablation group had lower rates of PCA use compared to thoracic epidural" — Alex Halpern (clinical) [Ep 149 · 2:56](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=176)
- "The intercostal nerve cryoablation group had lower total morphine milligram equivalent requirement compared to thoracic epidural" — Alex Halpern (clinical) [Ep 149 · 2:56](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=176)
- "The intercostal nerve cryoablation group had shorter length of stay in the hospital compared to thoracic epidural" — Alex Halpern (clinical) [Ep 149 · 2:56](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=176)
- "The intercostal nerve cryoablation group had longer operative times compared to thoracic epidural" — Alex Halpern (clinical) [Ep 149 · 3:07](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=187)
- "The intercostal nerve cryoablation group had higher total hospitalization cost compared to thoracic epidural" — Alex Halpern (clinical) [Ep 149 · 3:07](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=187)
- "The anal sphincter reconstruction study was a multi-institutional one-year outcome study" — Cecilia Gigena (epidemiological) [Ep 149 · 3:48](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=228)
- "Six patients underwent anal sphincter reconstruction for patulous sphincter after Hirschsprung pull-through" — Cecilia Gigena (epidemiological) [Ep 149 · 3:48](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=228)
- "Two of the six patients had Down syndrome" — Cecilia Gigena (epidemiological) [Ep 149 · 4:00](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=240)
- "Two patients underwent redo pull-through with anal sphincter reconstruction" — Cecilia Gigena (clinical) [Ep 149 · 4:00](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=240)
- "Four patients received only anal sphincter reconstruction without redo pull-through" — Cecilia Gigena (clinical) [Ep 149 · 4:00](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=240)
- "The four patients who received only sphincter reconstruction achieved voluntary bowel movements with higher productivity and confidence" — Cecilia Gigena (clinical) [Ep 149 · 4:12](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=252)
- "Anal sphincter reconstruction is an option for overstretched anal sphincters in patients with Hirschsprung disease after pull-through" — Cecilia Gigena (clinical) [Ep 149 · 4:12](https://library.globalcastmd.com/watch/quick-literature-updates-episode-14-7776?t=252)
- "Hirschsprung's disease is also known as agangliosis of the colon" (clinical) [Ep 153 · 0:07](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=7)
- "Babies with Hirschsprung's disease often display symptoms such as vomiting and a swollen belly" (clinical) [Ep 153 · 0:13](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=13)
- "Babies with Hirschsprung's disease do not pass meconium after birth and subsequent feces" (clinical) [Ep 153 · 0:19](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=19)
- "Meconium is a substance that builds up in a baby's bowel when it's still developing in the womb" (clinical) [Ep 153 · 0:26](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=26)
- "Relief following irrigation can be a sign of Hirschsprung's disease" (clinical) [Ep 153 · 0:49](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=49)
- "No relief of symptoms following irrigation could mean the baby has long segment Hirschsprung's disease or another diagnosis" (clinical) [Ep 153 · 0:58](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=58)
- "Long segment Hirschsprung's disease occurs when ganglion cells are missing from most of the large intestine" (clinical) [Ep 153 · 1:11](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=71)
- "If irrigation does not work sufficiently, surgery is needed to create a stoma for meconium or feces to pass through" (clinical) [Ep 153 · 1:18](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=78)
- "A contrast enema test involves passing special liquid into a baby's bowel through their anus followed by X-ray" (clinical) [Ep 153 · 1:35](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=95)
- "Normally the rectum is wide and the colon smaller and segmented" (clinical) [Ep 153 · 1:54](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=114)
- "A baby with Hirschsprung's disease will have a smaller rectum and part of the colon will be dilated" (clinical) [Ep 153 · 1:59](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=119)
- "To confirm a diagnosis of Hirschsprung's disease, it is essential that tissue samples from the child's colon above the anal canal are taken" (clinical) [Ep 153 · 2:09](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=129)
- "There are two types of rectal biopsy: rectal suction biopsy and full thickness biopsy" (clinical) [Ep 153 · 2:22](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=142)
- "In rectal suction biopsy, tissue is studied under microscope to check for presence of ganglion cells and thickened nerve fibers" (clinical) [Ep 153 · 2:40](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=160)
- "When suction biopsy does not provide enough tissue or the child is older, a full thickness biopsy may be necessary" (clinical) [Ep 153 · 2:48](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=168)
- "Full thickness biopsy is done in an operating room with the child under general anesthetic" (clinical) [Ep 153 · 3:03](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=183)
- "Tissue samples obtained during surgical procedures can show the location of ganglion cells covering the bowel wall because multiple samples from different parts can be taken" (clinical) [Ep 153 · 3:09](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=189)
- "Tissue samples need to be analyzed by a specialized, experienced pathologist" (clinical) [Ep 153 · 3:29](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=209)
- "Before surgery, irrigations can help to relieve the bowel and parents can be trained to perform these at home" (clinical) [Ep 153 · 3:44](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=224)
- "In surgery for Hirschsprung's disease, the affected part of the bowel is removed and the remaining bowel is connected to the anal canal" (clinical) [Ep 153 · 3:51](https://library.globalcastmd.com/watch/how-is-hirschsprung-s-disease-diagnosed-an-ernica-animation-for-parents-and-families-7806?t=231)
- "Hirschsprung's disease is also known as aganglionosis of the colon" (clinical) [Ep 150 · 0:06](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=6)
- "Peristalsis requires ganglion cells in the bowel wall" (clinical) [Ep 150 · 1:02](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=62)
- "Ganglion cells cover the full length of the bowel and form during a baby's development before birth" (clinical) [Ep 150 · 1:09](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=69)
- "Some babies are born with a bowel wall that is not entirely covered by ganglion cells, making peristalsis difficult" (clinical) [Ep 150 · 1:16](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=76)
- "Hirschsprung's disease is classed as a rare birth defect" (epidemiological) [Ep 150 · 1:26](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=86)
- "The cause of Hirschsprung's disease is unknown" (clinical) [Ep 150 · 1:31](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=91)
- "Hirschsprung's disease can be associated with Down syndrome" (clinical) [Ep 150 · 1:31](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=91)
- "Hirschsprung's disease can be associated with genetic defects involving the RET gene" (clinical) [Ep 150 · 1:31](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=91)
- "In Hirschsprung's disease, the absence of ganglion cells always starts at the rectum end of the bowel" (clinical) [Ep 150 · 1:45](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=105)
- "Most of the time, ganglion cells are missing from the end of the colon" (epidemiological) [Ep 150 · 1:52](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=112)
- "Ganglion cells can be missing from more of the colon or the small intestine, but this happens less often" (epidemiological) [Ep 150 · 1:57](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=117)
- "Babies with Hirschsprung's disease may not pass meconium or passage may be delayed" (clinical) [Ep 150 · 2:05](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=125)
- "Meconium is a substance that builds up in a baby's bowel when it is still developing in the womb" (clinical) [Ep 150 · 2:11](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=131)
- "Babies with Hirschsprung's disease may experience vomiting, a swollen belly, and a buildup of feces" (clinical) [Ep 150 · 2:18](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=138)
- "Sometimes babies don't show symptoms straight away after birth; symptoms can present later when the baby starts to eat solid food" (clinical) [Ep 150 · 2:28](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=148)
- "Feces that have built up in the colon can be removed through a rectal cannula in a process called irrigation" (clinical) [Ep 150 · 2:38](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=158)
- "If irrigation is not sufficient to relieve the bowel or other complications arise, it may be necessary to create a stoma" (clinical) [Ep 150 · 2:48](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=168)
- "Diagnosis of Hirschsprung's disease is confirmed after birth by taking a tissue sample from the baby's rectum through the anus, a procedure known as rectal biopsy" (clinical) [Ep 150 · 3:04](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=184)
- "When the length of the affected bowel area is known, surgery can be planned" (clinical) [Ep 150 · 3:17](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=197)
- "Before surgery, irrigations can help to relieve the bowel and parents can be trained to perform these at home" (clinical) [Ep 150 · 3:22](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=202)
- "In surgery, the affected part of the bowel is removed, which helps to bring back bowel movement" (clinical) [Ep 150 · 3:30](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=210)
- "If the child has had a stoma, this can be surgically closed" (clinical) [Ep 150 · 3:37](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=217)
- "Babies with Hirschsprung's disease should be treated at a specialist center by a dedicated team with knowledge and experience of the condition" (guideline) [Ep 150 · 3:42](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=222)
- "Although surgery can help relieve symptoms, babies may experience ongoing difficulties that require different types and levels of care" (clinical) [Ep 150 · 3:54](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=234)
- "Post-operative difficulties may include constipation and lack of control over bowel movements" (clinical) [Ep 150 · 4:06](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=246)
- "Sometimes support with bowel management is necessary after surgery" (clinical) [Ep 150 · 4:16](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=256)
- "Structured regular follow-up care by a multidisciplinary team is essential for babies with Hirschsprung's disease" (guideline) [Ep 150 · 4:20](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=260)
- "Identifying any complications or difficulties early is very important" (guideline) [Ep 150 · 4:32](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=272)
- "Even if a child has symptoms after corrective surgery, these can improve as they grow older" (clinical) [Ep 150 · 4:38](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=278)
- "Peer support can be accessed through patient and family support groups" (guideline) [Ep 150 · 4:45](https://library.globalcastmd.com/watch/what-is-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7805?t=285)
- "Hirschsprung's disease is also known as agangliosis of the colon" (clinical) [Ep 151 · 0:09](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=9)
- "Surgical removal of the affected part is usually performed 2 to 3 months after diagnosis, when the baby is strong enough and growing well" (clinical) [Ep 151 · 0:22](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=22)
- "Surgery is performed when there are no signs of enterocolitis (inflammation of the bowel)" (clinical) [Ep 151 · 0:31](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=31)
- "The surgery is performed under general anesthetic" (clinical) [Ep 151 · 0:37](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=37)
- "The aim of surgery is to remove the aganglionic bowel, which is the affected part with no ganglion cells present" (clinical) [Ep 151 · 0:43](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=43)
- "The transition zone should be removed, which is the area between the aganglionic part and the ganglionic bowel with normal ganglion cells" (clinical) [Ep 151 · 0:52](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=52)
- "The remaining bowel is connected to the anal canal in a pull-through procedure to restore fecal movement" (clinical) [Ep 151 · 1:06](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=66)
- "During the operation, tissue samples can be taken to confirm the presence of ganglion cells" (clinical) [Ep 151 · 1:16](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=76)
- "The procedure used to be done by open surgery with a large incision" (clinical) [Ep 151 · 1:27](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=87)
- "Nowadays, when possible, the procedure is done transanally via the anal canal, sometimes assisted by laparoscopy" (clinical) [Ep 151 · 1:34](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=94)
- "Different pull-through techniques exist including transanal pull-through, Swenson, Duhamel, and Soave procedures" (clinical) [Ep 151 · 1:48](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=108)
- "Surgical technique selection depends on the child, the length of affected bowel, surgeon preference, and hospital resources" (clinical) [Ep 151 · 2:00](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=120)
- "Preservation of the anal canal is crucial to maintain continence" (clinical) [Ep 151 · 2:10](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=130)
- "After surgery, the new connection between bowel and anal canal must be unobstructed and surgical wounds must heal well" (clinical) [Ep 151 · 2:18](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=138)
- "After surgery, patients may experience ongoing difficulties including constipation and lack of control over bowel movements" (clinical) [Ep 151 · 2:27](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=147)
- "Sometimes support with bowel management is necessary after surgery" (clinical) [Ep 151 · 2:50](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=170)
- "After surgery, individuals with Hirschsprung's disease may remain prone to bowel infections known as enterocolitis" (clinical) [Ep 151 · 2:53](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=173)
- "Structured regular follow-up care by a multidisciplinary team is essential for babies with Hirschsprung's disease" (guideline) [Ep 151 · 3:08](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=188)
- "Identifying complications or difficulties early is very important" (clinical) [Ep 151 · 3:21](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=201)
- "Post-operative symptoms can improve as children grow older" (clinical) [Ep 151 · 3:27](https://library.globalcastmd.com/watch/surgical-treatment-for-hirschsprung-s-disease-an-ernica-animation-for-parents-and-families-7807?t=207)
- "Enterocolitis is an inflammation of the intestine that occurs when the body does not get rid of poop quick enough" (clinical) [Ep 152 · 0:11](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=11)
- "A blockage forms in the large intestine, which causes it to swell" (clinical) [Ep 152 · 0:19](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=19)
- "Bacteria grows and enters the blood vessels" (clinical) [Ep 152 · 0:23](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=23)
- "In rare cases, a bowel perforation can occur, which is when a hole develops on the wall of the large intestine due to pressure" (clinical) [Ep 152 · 0:27](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=27)
- "Signs and symptoms of enterocolitis may include smelly explosive poop, which may sometimes contain blood, a swollen and painful belly, nausea and or vomiting, and fever" (clinical) [Ep 152 · 0:35](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=35)
- "An individual may also show signs of dehydration, such as a lack of activity and reduced urination" (clinical) [Ep 152 · 0:50](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=50)
- "Up to 40-50% of children with Hirschsprung's disease experience enterocolitis, either before or after surgical correction" (epidemiological) [Ep 152 · 0:58](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=58)
- "Enterocolitis is more common after surgical correction" (epidemiological) [Ep 152 · 1:08](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=68)
- "For a small number of children, enterocolitis can be persistent and occur repeatedly throughout their life" (clinical) [Ep 152 · 1:12](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=72)
- "Enterocolitis can be triggered by various different factors, such as a virus, bacterial infection, or intestinal dysbiosis" (clinical) [Ep 152 · 1:20](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=80)
- "To treat symptoms of enterocolitis in children, it is very important to remove the blockage of poop in the large intestine" (clinical) [Ep 152 · 1:33](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=93)
- "Irrigation is done using a special tube called a rectal cannula" (clinical) [Ep 152 · 1:42](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=102)
- "If enterocolitis becomes a repeated problem, your child's clinical team may teach you how to carry out irrigation at home" (guideline) [Ep 152 · 1:48](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=108)
- "Symptoms of dehydration can be treated with a drinkable rehydration solution or where necessary, fluid can be given to your child through a vein" (clinical) [Ep 152 · 1:56](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=116)
- "Blood infections must be prevented using antibiotic medication" (guideline) [Ep 152 · 2:06](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=126)
- "When symptoms have improved, it is important for your child's clinical team to investigate possible triggers and underlying causes of the enterocolitis" (guideline) [Ep 152 · 2:11](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=131)
- "Enterocolitis may be caused by obstruction due to bowel dysfunction or by the anatomy of the remaining bowel after the pull-through operation" (clinical) [Ep 152 · 2:21](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=141)
- "Children with Hirshsprung's disease often experience difficulties getting rid of poop because of tight sphincter muscles in the anus" (clinical) [Ep 152 · 2:30](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=150)
- "There can be behavioral and psychological causes of enterocolitis" (clinical) [Ep 152 · 2:39](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=159)
- "Possible treatment includes support with bowel management, internal Botox injections, and in some cases, surgery" (clinical) [Ep 152 · 2:43](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=163)
- "Structured regular follow-up care by a team of different clinical specialists is essential for children with Hirschsprung's disease, ideally by a multidisciplinary team or MDT" (guideline) [Ep 152 · 2:52](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=172)
- "Identifying any complications or difficulties early is very important" (guideline) [Ep 152 · 3:04](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=184)
- "Even if your child has symptoms of enterocolitis after corrective surgery for Hirschprung's disease, these can improve as they grow older" (clinical) [Ep 152 · 3:10](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=190)
- "The meta-analysis was conducted in China" — Cecilia Gigena (epidemiological) [Ep 155 · 0:10](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881?t=10)
- "The meta-analysis included studies with 1,298 patients" — Cecilia Gigena (epidemiological) [Ep 155 · 0:22](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881?t=22)
- "ERAS protocols significantly reduced intraoperative fluid administration in pediatric colorectal surgery" — Cecilia Gigena (clinical) [Ep 155 · 0:27](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881?t=27)
- "ERAS protocols significantly reduced postoperative opioid use in pediatric colorectal surgery" — Cecilia Gigena (clinical) [Ep 155 · 0:27](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881?t=27)
- "ERAS protocols shortened time to bowel function return in pediatric colorectal surgery" — Cecilia Gigena (clinical) [Ep 155 · 0:34](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881?t=34)
- "ERAS protocols shortened time to first enteral nutrition in pediatric colorectal surgery" — Cecilia Gigena (clinical) [Ep 155 · 0:34](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881?t=34)
- "ERAS protocols reduced hospital length of stay in pediatric colorectal surgery" — Cecilia Gigena (clinical) [Ep 155 · 0:39](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881?t=39)
- "ERAS protocols reduced hospital costs in pediatric colorectal surgery" — Cecilia Gigena (clinical) [Ep 155 · 0:39](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881?t=39)
- "ERAS protocols are needed in pediatric colorectal surgery" — Cecilia Gigena (opinion) [Ep 155 · 0:44](https://library.globalcastmd.com/watch/meta-analysis-of-enhaced-recovery-after-ssurgery-protocols-for-the-perioperative-management-of-pediatric-colorectal-surgery-7881?t=44)
- "Two variations of perineal body-sparing PSARP have been published in the last 6 months, one from Boston and one from DC." — Steven Lee (clinical) [Ep 154 · 1:08](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=68)
- "One study has 6 patients and the other has 4 patients." — Em Gootee (epidemiological) [Ep 154 · 1:17](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=77)
- "The techniques are similar but slightly different." — Em Gootee (clinical) [Ep 154 · 1:20](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=80)
- "The Boston technique includes a slight posterior sagittal extension of the incision." — Steven Lee (clinical) [Ep 154 · 1:26](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=86)
- "These techniques aim to spare the perineal body and preserve long-term gynecologic function for female patients." — Steven Lee (clinical) [Ep 154 · 1:30](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=90)
- "The perineal body is important for sexual function and obstetric outcomes in the future." (clinical) [Ep 154 · 1:38](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=98)
- "The DC technique uses an incision just through the sphincter alone, preserving the perineal body skin in its entirety." — Steven Lee (clinical) [Ep 154 · 1:49](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=109)
- "For non-diverted patients undergoing dilations, the perineal body seeing stool right away creates a setup for postoperative infection." (clinical) [Ep 154 · 2:00](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=120)
- "Perineal body-sparing techniques can reduce postoperative infection risks in patients undergoing dilations." — Em Gootee (clinical) [Ep 154 · 2:29](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=149)
- "The Hirschsprung-associated IBD study was retrospective, gathering patients from 2000 to 2021 at 17 institutions" — Cecilia Gigena (epidemiological) [Ep 156 · 0:59](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=59)
- "The study identified 55 Hirschsprung patients, with 50% having long segment disease" — Cecilia Gigena (epidemiological) [Ep 156 · 1:14](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=74)
- "68% of the Hirschsprung patients had Hirschsprung-associated enterocolitis" — Cecilia Gigena (epidemiological) [Ep 156 · 1:19](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=79)
- "10% of the Hirschsprung patients had trisomy 21" — Cecilia Gigena (epidemiological) [Ep 156 · 1:19](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=79)
- "Long segment disease, Hirschsprung-associated enterocolitis, and trisomy 21 are potential risk factors for IBD-like symptoms in Hirschsprung patients after pull through" — Cecilia Gigena (clinical) [Ep 156 · 1:19](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=79)
- "The choledochal cyst study used the nationwide readmissions database and identified 577 children who underwent choledochal cyst resection between 2016 and 2018" — Ellen Encisco (epidemiological) [Ep 156 · 2:11](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=131)
- "The majority of choledochal cyst patients underwent open resection" — Ellen Encisco (epidemiological) [Ep 156 · 2:21](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=141)
- "Patients who underwent open choledochal cyst resection were more likely to have a Roux-en-Y hepaticojejunostomy" — Ellen Encisco (clinical) [Ep 156 · 2:21](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=141)
- "Patients who underwent laparoscopic choledochal cyst resection were more likely to have a hepaticoduodenostomy" — Ellen Encisco (clinical) [Ep 156 · 2:21](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=141)
- "Patients who underwent open choledochal cyst resection had longer length of hospital stay compared to laparoscopic resection" — Ellen Encisco (clinical) [Ep 156 · 2:36](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=156)
- "Patients who underwent open choledochal cyst resection had more complications compared to laparoscopic resection" — Ellen Encisco (clinical) [Ep 156 · 2:36](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=156)
- "Patients who underwent open choledochal cyst resection had higher total costs compared to laparoscopic resection" — Ellen Encisco (clinical) [Ep 156 · 2:36](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=156)
- "The solid organ injury study was retrospective and conducted in South Carolina" — Cecilia Gigena (epidemiological) [Ep 156 · 3:09](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=189)
- "The study gathered 262 patients with isolated solid organ injuries, grades 1 to 3" — Cecilia Gigena (epidemiological) [Ep 156 · 3:19](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=199)
- "148 patients had solid organ injuries grades 1 or 2, and none required acute intervention" — Cecilia Gigena (clinical) [Ep 156 · 3:26](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=206)
- "Of 114 patients with grade 3 solid organ injuries, only 3 required acute intervention" — Cecilia Gigena (clinical) [Ep 156 · 3:34](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=214)
- "Isolated solid organ injuries after blunt abdominal trauma, grades 1 or 2, can be discharged from the emergency department" — Cecilia Gigena (clinical) [Ep 156 · 3:44](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=224)
- "Every baby with Hirschsprung disease has a poorly functioning sphincter by nature of the disease" — Caitlin Smith (clinical) [Ep 157 · 1:14](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=74)
- "In order to maintain continence, you want to preserve the dentate line, and you have to leave a tiny bit of aganglionic internal sphincter" — Caitlin Smith (clinical) [Ep 157 · 2:17](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=137)
- "Babies outgrow enterocolitis because their external sphincter is able to overcome their internal sphincter, and that takes time for their body to mature" — Caitlin Smith (opinion) [Ep 157 · 2:23](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=143)
- "The Hirschsprung physiology sets up the colon to act like a pond with poor emptying and motility issues, allowing bacteria to overgrow if the colon is not cleared diligently" — Steven Lee or Doctor Julia Grabowski (clinical) [Ep 157 · 2:37](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=157)
- "There is a significantly higher rate of enterocolitis in Hirschsprung disease after pull-through when you take out the entire colon compared to babies with shorter segment disease" — Caitlin Smith (epidemiological) [Ep 157 · 3:06](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=186)
- "There is a much higher rate of enterocolitis in children with trisomy 21" — Caitlin Smith (epidemiological) [Ep 157 · 3:21](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=201)
- "You can still get enterocolitis even if you're doing rectal irrigations at home; there are times when it's just not enough to empty that colon" — I'm Goddy (clinical) [Ep 157 · 3:25](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=205)
- "There is discussion of whether when you make the diagnosis of total colon Hirschsprung, you should do the colectomy at that time because of the risk of enterocolitis" — Caitlin Smith (opinion) [Ep 157 · 3:35](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=215)
- "There is so much phenotypic variance in Hirschsprung disease that studying the use of Botox in post-pull-through enterocolitis yields imperfect data" — Caitlin Smith (opinion) [Ep 157 · 3:49](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=229)
- "Prophylactic Botox has not been shown to decrease the risk of enterocolitis" — Caitlin Smith (clinical) [Ep 157 · 4:14](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=254)
- "Botox has been shown to decrease the length of stay in patients who have been admitted for enterocolitis" — Caitlin Smith (clinical) [Ep 157 · 4:14](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=254)
- "Botox has been shown to potentially decrease hospitalizations in patients who present with recurrent episodes of obstruction or enterocolitis" — Caitlin Smith (clinical) [Ep 157 · 4:26](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=266)
- "Maybe not everyone needs Botox at the time of pull-through, but there is a subset of patients who have predisposition to enterocolitis for whom Botox as part of treatment strategy would be beneficial" — Caitlin Smith (opinion) [Ep 157 · 4:34](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=274)
- "Botox is often administered as 100 units in 1 mL of saline" — Caitlin Smith (clinical) [Ep 157 · 1:45](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=105)
- "Botox injection technique typically involves 3-4 injections in the dentate line" — Caitlin Smith (clinical) [Ep 157 · 1:48](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=108)
- "People are doing any amount of Botox in any aliquots in any number of locations (technique varies widely in the literature)" — Caitlin Smith (clinical) [Ep 157 · 1:33](https://library.globalcastmd.com/watch/update-course-rewind-botox-in-hirschsprung-disease-2023-7941?t=93)
- "Pectus arcuatum is a bony deformity caused by a premature obliteration of the sternal sutures, resulting in a short sternum bent on itself" — Sahab Delaville (clinical) [Ep 159 · 2:07](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=127)
- "47% of pectus arcuatum patients required X-ray or CT scan for diagnosis" — Cecilia Gigena (clinical) [Ep 159 · 1:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=116)
- "35% of pectus arcuatum cases had associated malformations like Noonan syndrome, scoliosis, or cardiopathy" — Sahab Delaville (epidemiological) [Ep 159 · 2:40](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=160)
- "25% of pectus arcuatum patients had skeletal malformation in their family" — Sahab Delaville (epidemiological) [Ep 159 · 2:55](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=175)
- "Bracing does not work for pectus arcuatum treatment" — Sahab Delaville (clinical) [Ep 159 · 3:02](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=182)
- "Pectus arcuatum treatment requires surgery that includes a sternotomy" — Cecilia Gigena (clinical) [Ep 159 · 3:07](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=187)
- "Patients diagnosed with pectus arcuatum need cardiac ultrasound to look for cardiac malformation and evaluation for scoliosis" — Sahab Delaville (guideline) [Ep 159 · 3:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=193)
- "Early CDH repair on ECMO was defined as during the first 48 hours after ECMO cannulation" — Red Holcomb (clinical) [Ep 159 · 4:40](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=280)
- "Bleeding risk for CDH repair on ECMO was approximately 1% if operated in less than 24 hours" — Jason Smithers (clinical) [Ep 159 · 4:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=298)
- "Bleeding risk for CDH repair on ECMO was 5-6% at 48 hours" — Jason Smithers (clinical) [Ep 159 · 5:08](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=308)
- "Bleeding risk for CDH repair on ECMO jumped to approximately 15% after 48 hours" — Jason Smithers (clinical) [Ep 159 · 5:11](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=311)
- "Duration of ECMO support was shorter in the early CDH repair group" — Em Gootee (clinical) [Ep 159 · 5:17](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=317)
- "Survival was not statistically different between early and delayed CDH repair groups on ECMO" — Em Gootee (clinical) [Ep 159 · 5:17](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=317)
- "Some patients who only get CDH repair off ECMO die because they never came off ECMO" — Jason Smithers (clinical) [Ep 159 · 6:46](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=406)
- "The key after CDH repair is to get lung growth in such a way that the contralateral lung grows the most and not the ipsilateral lung" — Jason Smithers (clinical) [Ep 159 · 6:53](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=413)
- "ERAS protocols significantly reduce intraoperative fluids needed by pediatric colorectal surgery patients" — Cecilia Gigena (clinical) [Ep 159 · 7:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=461)
- "ERAS protocols significantly reduce postoperative opiate use in pediatric colorectal surgery" — Cecilia Gigena (clinical) [Ep 159 · 7:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=461)
- "Time to first oral intake was less in pediatric colorectal surgery patients with ERAS protocols" — Cecilia Gigena (clinical) [Ep 159 · 7:55](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=475)
- "Time for complete nutrition was less in pediatric colorectal surgery patients with ERAS protocols" — Cecilia Gigena (clinical) [Ep 159 · 7:55](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=475)
- "ERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization" — Red Holcomb (clinical) [Ep 159 · 8:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=493)
- "Physician suicide is characterized by tragically high rates of suicide among doctors compared to the general population" — Em Gootee (epidemiological) [Ep 159 · 9:32](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=572)
- "Every surgeon will have adversity in practice with patients where despite best efforts there is not a good result" — Red Holcomb (opinion) [Ep 159 · 9:47](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=587)
- "High levels of stress, emotional and physical burnout, demanding work schedules, and pressure to maintain successful careers contribute to physician suicide" — Em Gootee (clinical) [Ep 159 · 10:17](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=617)
- "Stigma associated with mental health issues within the medical profession discourages physicians from seeking help, leading to untreated depression, anxiety, and other mental health disorders" — Em Gootee (clinical) [Ep 159 · 10:33](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=633)
- "Physician mental health and suicide is discussed more now versus 10 years ago, but still should be discussed more openly" — Red Holcomb (opinion) [Ep 159 · 11:30](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-september-2023-8057?t=690)
- "The most common type of urogenital sinus has a long urethra and a short common channel" (clinical) [Ep 160 · 0:05](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=5)
- "For urogenital sinus with long urethra and short common channel, a transperineal total urogenital mobilization is appropriate" (clinical) [Ep 160 · 0:13](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=13)
- "An astra approach involves incising the anterior wall of the rectum to gain more exposure" (clinical) [Ep 160 · 0:23](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=23)
- "A trans anorectal approach can be performed with extension to include the posterior sagittal incision" (clinical) [Ep 160 · 0:32](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=32)
- "For urogenital sinus with normal anus, there are two surgical options: total urogenital mobilization for short common channel and long urethra, and urogenital separation for long common channel and short urethra" (clinical) [Ep 160 · 0:47](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=47)
- "Cystoscopy revealed a long common channel and a short urethra in this case" (clinical) [Ep 160 · 1:37](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=97)
- "When there is a long common channel and short urethra, the surgical plan is to separate the vagina from the common channel and allow the common channel plus the native urethra to become the neourethra" (clinical) [Ep 160 · 1:43](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=103)
- "The patient is placed prone for the trans anorectal approach" (clinical) [Ep 160 · 2:03](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=123)
- "The anal canal is marked with silk sutures to facilitate its reconstruction after it has been split" (clinical) [Ep 160 · 2:12](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=132)
- "The trans anorectal approach is an extension of the astra concept, which is incision of the anterior anus only" (clinical) [Ep 160 · 2:30](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=150)
- "The vaginal-common channel fistula is identified after opening the vagina in the midline" (clinical) [Ep 160 · 3:21](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=201)
- "Silk sutures are used to help mobilize the anterior wall of the vagina off of the urinary tract anterior to it" (clinical) [Ep 160 · 3:36](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=216)
- "The posterior urethra is repaired in two layers" (clinical) [Ep 160 · 4:03](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=243)
- "An ischiorectal fat pad is used to cover the posterior urethral repair" (clinical) [Ep 160 · 4:08](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=248)
- "The vagina is mobilized so that it comfortably reaches the introitus" (clinical) [Ep 160 · 4:12](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=252)
- "The vagina is sutured first to the posterior urethral meatus before completing the introitoplasty" (clinical) [Ep 160 · 4:17](https://library.globalcastmd.com/watch/a-complex-urogenital-malformation-urogenital-sinus-with-normal-anus-8078?t=257)
- "Patient is 27-year-old female born with rectal vestibular fistula, repaired as newborn, with lifelong fecal incontinence" — Mark Malota (clinical) [Ep 158 · 1:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=85)
- "Patient was told incontinence was normal and unavoidable after initial surgery" — Mark Malota (clinical) [Ep 158 · 1:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=90)
- "Daily irrigations introduced at puberty allowed patient to regain social life" — Mark Malota (clinical) [Ep 158 · 1:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=114)
- "Patient had rectal prolapse 2–3 years prior, repaired by adult proctologist" — Mark Malota (clinical) [Ep 158 · 2:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=142)
- "Original operation reports from early 1990s were incomplete" — Mark Malota (clinical) [Ep 158 · 2:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=165)
- "Physical exam revealed anus not in correct anatomic position" — Mark Malota (clinical) [Ep 158 · 3:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=183)
- "Examination under anesthesia is valuable for ARM patients with previous surgery to assess anoplasty position, prolapse, stricture, and use electrical stimulation" — Marc Levitt (clinical) [Ep 158 · 3:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=217)
- "MRI with specific protocols can show whether anoplasty is within muscle complex" — Jason Frischer (clinical) [Ep 158 · 4:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=242)
- "Endorectal ultrasound can help assess anoplasty position within sphincter" — Jason Frischer (clinical) [Ep 158 · 4:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=250)
- "In males, cystoscopy should be added to rule out fistula remnant and assess bladder emptying" — Marc Levitt (clinical) [Ep 158 · 4:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=255)
- "Anus was too ventrally located; posterior dimple visible showing where anus should be positioned" — Stuart Jose (clinical) [Ep 158 · 4:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=292)
- "Electrical stimulation of external sphincter shows muscle limits and correct anatomic position for anus" — Stuart Jose (clinical) [Ep 158 · 5:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=318)
- "Anterior malposition means no sphincter muscle anterior to anoplasty, preventing complete closure and causing incontinence" — Marc Levitt (clinical) [Ep 158 · 5:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=328)
- "Anterior malposition is the most common problem requiring redo surgery in females" — Marc Levitt (clinical) [Ep 158 · 5:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=354)
- "Dehiscence of perineal body leaves C-shaped rather than O-shaped sphincter around anus" — Marc Levitt (clinical) [Ep 158 · 6:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=379)
- "Electrical stimulation confirmed C-shaped sphincter with anterior opening not surrounded by muscle" — Mark Malota (clinical) [Ep 158 · 6:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=402)
- "Anal ultrasound confirmed electrical stimulation findings of C-shaped sphincter" — Mark Malota (clinical) [Ep 158 · 7:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=427)
- "Rectal prolapse was sign of missing/non-functioning sphincter complex" — Mark Malota (clinical) [Ep 158 · 7:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=439)
- "Redo PSARP was chosen as treatment for anteriorly malpositioned anus" — Mark Malota (clinical) [Ep 158 · 7:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=457)
- "Patient learned to manage daily life despite incontinence and felt quality of life was not bad, but recognized situation could improve" — Stuart Jose (clinical) [Ep 158 · 7:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=478)
- "Formal colon prep performed preoperatively with antibiotics continued for several days postoperatively" — Stuart Jose (clinical) [Ep 158 · 8:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=516)
- "Patient was not diverted for redo PSARP" — Stuart Jose (clinical) [Ep 158 · 8:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=530)
- "Adult surgeons assisted with redo PSARP and had never seen such a procedure before" — Stuart Jose (clinical) [Ep 158 · 9:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=541)
- "Rectum was placed in correct anatomic position and excess length was shortened" — Stuart Jose (clinical) [Ep 158 · 9:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=558)
- "Patient kept NPO for 5 days postoperatively then started feeding" — Stuart Jose (clinical) [Ep 158 · 9:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=579)
- "Clear liquid diet produces soft, watery stool that does not traumatize perineal repair, unlike hard stool from regular food" — Marc Levitt (clinical) [Ep 158 · 10:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=622)
- "Clear liquids avoid need for PICC line, TPN, and NPO, making patients and families happier" — Marc Levitt (opinion) [Ep 158 · 10:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=643)
- "At 5 days, if perineal healing looks good, diet is advanced with laxatives to keep stool liquidy" — Marc Levitt (clinical) [Ep 158 · 10:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=655)
- "Hard stool going through repair is the problem, not stool itself, as long as wound is kept clean" — Marc Levitt (clinical) [Ep 158 · 11:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=672)
- "Non-diversion strategy has not caused problems in redo PSARP cases" — Marc Levitt (clinical) [Ep 158 · 11:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=677)
- "In Germany, pediatric surgeons are not allowed to treat patients over age 18" — Mark Malota (guideline) [Ep 158 · 12:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=720)
- "Transition discussion begins at age 12, informing parents that patient cannot stay in pediatric surgery department forever" — Mark Malota (clinical) [Ep 158 · 12:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=720)
- "Network built with adult colorectal surgeons interested in pediatric procedures to facilitate transition" — Mark Malota (clinical) [Ep 158 · 12:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=750)
- "Patients connected to adult physiotherapists, urologists, and gynecologists as needed" — Mark Malota (clinical) [Ep 158 · 12:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=762)
- "During annual visits, adult surgeon is present so patient and surgeon get to know each other" — Mark Malota (clinical) [Ep 158 · 13:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=784)
- "Soft transition lasts 3–4 years with goal that patient eventually sees only adult colorectal surgeon" — Mark Malota (clinical) [Ep 158 · 13:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=806)
- "Collaborative operating during transition is a key component" — Jason Frischer (opinion) [Ep 158 · 14:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=845)
- "This case was performed in adult operating theater with adult surgeons, and patient stayed in adult surgical ward" — Stuart Jose (clinical) [Ep 158 · 14:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=868)
- "Freestanding children's hospitals face more challenges than integrated adult-pediatric systems due to physical and financial separation" — Jason Frischer (opinion) [Ep 158 · 15:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=904)
- "In Cincinnati, ARM patients continue to come to colorectal center at children's hospital regardless of age, partnering with adult colorectal surgeon" — Jason Frischer (clinical) [Ep 158 · 15:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=921)
- "In United States, age line for pediatric vs. adult care is blurry, creating problems" — Marc Levitt (clinical) [Ep 158 · 18:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1093)
- "Pediatric nurse practitioners cannot write orders on patients over age 21 due to licensing restrictions" — Marc Levitt (guideline) [Ep 158 · 18:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1113)
- "If 40-year-old needs ICU in children's hospital, intensivists are pediatric-trained, not adult-trained" — Marc Levitt (clinical) [Ep 158 · 18:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1126)
- "Pulmonary embolism or myocardial infarction in children's hospital creates safety concerns and potential for poor outcomes" — Jason Frischer (clinical) [Ep 158 · 18:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1138)
- "Adult hospitals are more skilled at managing perioperative complications like PE and MI" — Jason Frischer (opinion) [Ep 158 · 19:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1150)
- "Surgeons are making progress on transition, but struggle remains with intensive bowel management training for adult patients" — Jason Frischer (opinion) [Ep 158 · 19:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1173)
- "Pediatric centers are adept at bowel management for patients of all ages, but adult patients requiring intensive outpatient bowel management are still being seen at children's hospitals" — Jason Frischer (clinical) [Ep 158 · 19:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1197)
- "Bowel management expertise needs to be passed from nurse to nurse and advanced practice provider to advanced practice provider, not just doctor to doctor" — Marc Levitt (opinion) [Ep 158 · 20:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1211)
- "Malone appendicostomy is a valuable operation many adult surgeons have never heard of" — Marc Levitt (clinical) [Ep 158 · 20:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1223)
- "Peristeen system allows self-controlled enema administration in adults" — Marc Levitt (clinical) [Ep 158 · 20:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1240)
- "One week of bowel management can convert a patient with decades of soiling to clean continence" — Marc Levitt (clinical) [Ep 158 · 20:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1258)
- "In United States, financial incentives favor operations over medical management, which can be problematic for transition" — Marc Levitt (opinion) [Ep 158 · 20:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1246)
- "Over 100 adult ARM patients presenting to outpatient clinic represents failure of transition, as problems should be addressed before they appear" — Stuart Jose (opinion) [Ep 158 · 21:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1305)
- "Patient and parent associations in Germany, US, France, and Italy play important role in transition" — Stuart Jose (clinical) [Ep 158 · 22:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1349)
- "Patient passport booklet documents all information from newborn period through follow-up, including surgeries, malformations, and examinations" — Stuart Jose (clinical) [Ep 158 · 22:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-38-transitional-care-in-colorectal-surgery-8049?t=1368)
- "The location of the intended anoplasty is obvious in males with anorectal malformation, with a discoloration in the area of the sphincteric ellipse" (clinical) [Ep 175 · 0:18](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=18)
- "A fistula entering the deltoid or shoulder region of the urethra is classified as a bladder neck fistula" (clinical) [Ep 175 · 0:39](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=39)
- "A fistula entering the triceps or humerus area of the urethra is classified as a prostatic fistula" (clinical) [Ep 175 · 0:46](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=46)
- "A fistula entering at the elbow of the urethra is classified as a bulbar fistula" (clinical) [Ep 175 · 0:52](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=52)
- "Rectal prostatic fistulas and rectal bladder neck fistulas are cases where one could consider whether to perform laparoscopy or posterior sagittal repair" (clinical) [Ep 175 · 0:58](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=58)
- "A properly done distal colostogram is key to determining the best surgical approach" (clinical) [Ep 175 · 1:18](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=78)
- "A high rectum with a narrow fistula at the low prostatic level is amenable to a laparoscopic approach when the rectum is above the PC or puococcygeal line" (clinical) [Ep 175 · 1:26](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=86)
- "A lower rectum with a fistula to the bulbar urethra is best treated with a posterior sagittal anorectoplasty" (clinical) [Ep 175 · 1:46](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=106)
- "When the rectum is relatively high but reachable through a posterior sagittal approach, placing a catheter in the mucous fistula allows the distal rectum to be inflated through injection so the bulge can be seen and dissected" (clinical) [Ep 175 · 2:02](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=122)
- "It is important that the anesthesia team has not given muscle relaxant, as this will interfere with the electrical stimulation" (clinical) [Ep 175 · 2:25](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=145)
- "The posterior sagittal incision should incise the center of the sphincter and stay perfectly in the midline" (clinical) [Ep 175 · 2:40](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=160)
- "In some cases, removal of the coccyx improves the exposure" (clinical) [Ep 175 · 2:55](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=175)
- "The bulge of the distal rectum is facilitated by injection using saline through the mucous fistula" (clinical) [Ep 175 · 3:03](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=183)
- "The anterior lip of the rectal lumen is a key anatomic finding" (clinical) [Ep 175 · 3:51](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=231)
- "Dissection should be performed within the whitish fascia that envelops the rectum" (clinical) [Ep 175 · 4:15](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=255)
- "It is vital to find the plane within the whitish fascia, which allows for the rectum to be mobilized" (clinical) [Ep 175 · 4:19](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=259)
- "The lateral dissection defines the anterior dissection" (clinical) [Ep 175 · 4:24](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=264)
- "If you see fat during rectal mobilization, you can get closer to the rectal wall" (clinical) [Ep 175 · 4:56](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=296)
- "The initial fistula stitch is important for exposure during urethral fistula closure" (clinical) [Ep 175 · 5:14](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=314)
- "The urethral fistula is closed using long term absorbable suture with a second layer of closure added" (clinical) [Ep 175 · 5:23](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=323)
- "The wheat lander retractor needs to be relaxed before tying the sutures that tack the posterior edge of the muscle complex to the posterior rectal wall" (clinical) [Ep 175 · 5:45](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=345)
- "Anoplasty sutures should be left under a little bit of tension, so that when cut, the anoplasty retracts in slightly" (clinical) [Ep 175 · 6:01](https://library.globalcastmd.com/watch/posterior-sagittal-anorectoplasty-10130?t=361)
- "The systematic review and meta-analysis compared clinical outcomes of loop colostomies versus divided colostomies in neonates with anorectal malformations" — Lizzie Lee (clinical) [Ep 176 · 0:10](https://library.globalcastmd.com/watch/comparing-loop-and-divided-colostomy-for-anorectal-malformation-a-systematic-review-and-meta-analysis-10428?t=10)
- "The review included 11 retrospective cohort studies" — Lizzie Lee (epidemiological) [Ep 176 · 0:19](https://library.globalcastmd.com/watch/comparing-loop-and-divided-colostomy-for-anorectal-malformation-a-systematic-review-and-meta-analysis-10428?t=19)
- "There were no significant differences between the two colostomy types in terms of complications such as stoma prolapse, urinary tract infections, and wound infections" — Lizzie Lee (clinical) [Ep 176 · 0:23](https://library.globalcastmd.com/watch/comparing-loop-and-divided-colostomy-for-anorectal-malformation-a-systematic-review-and-meta-analysis-10428?t=23)
- "Both colostomies are good options for fecal diversion, with the choice depending on individual patient factors and surgical expertise" — Lizzie Lee (opinion) [Ep 176 · 0:31](https://library.globalcastmd.com/watch/comparing-loop-and-divided-colostomy-for-anorectal-malformation-a-systematic-review-and-meta-analysis-10428?t=31)
- "The rate of Hirschsprung disease and anorectal malformation occurring together is less than 2%" — Jill Knepprath (epidemiological) [Ep 200 · 0:34](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=34)
- "The co-occurrence of Hirschsprung disease and ARM is something to keep in mind for patients with trisomy 21" — Jill Knepprath (clinical) [Ep 200 · 0:37](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=37)
- "A single-center study examined rectal fistula specimens obtained during posterior sagittal anorectoplasty (PSARP) procedures" (clinical) [Ep 200 · 0:41](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=41)
- "Rectal fistula tissue is not physiologic tissue" (clinical) [Ep 200 · 0:52](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=52)
- "Ganglion cells were found in 91% of rectal fistula specimens" — Jill Knepprath (clinical) [Ep 200 · 0:58](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=58)
- "Hypo or absent ganglion cells were found in the remaining specimens (9%)" — Jill Knepprath (clinical) [Ep 200 · 0:58](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=58)
- "Absent ganglion cells in fistula tissue does not necessarily mean the patient has Hirschsprung disease" — Jill Knepprath (clinical) [Ep 200 · 1:05](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=65)
- "Three patients (4% of the cohort) had both Hirschsprung disease and an anorectal malformation" — Jill Knepprath (epidemiological) [Ep 200 · 1:11](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=71)
- "Two of the three patients with both conditions also had trisomy 21" — Jill Knepprath (epidemiological) [Ep 200 · 1:15](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=75)
- "Patients who have both Hirschsprung disease and ARM tend to have chromosomal anomalies" (clinical) [Ep 200 · 1:22](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=82)
- "Chromosomal anomalies associated with both conditions include trisomy 21, Pallister-Killian syndrome, and others" (clinical) [Ep 200 · 1:27](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=87)
- "Complex anorectal malformation patients with chromosomal anomalies who do not respond to laxatives or enemas should be worked up for Hirschsprung disease" — Jill Knepprath (guideline) [Ep 200 · 1:31](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12083?t=91)
- "The rate of Hirschsprung disease and anorectal malformation occurring together is less than 2%" — Jill Knepprath (epidemiological) [Ep 201 · 0:34](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=34)
- "The co-occurrence of Hirschsprung disease and ARM is something to keep in mind for patients with trisomy 21" — Jill Knepprath (clinical) [Ep 201 · 0:37](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=37)
- "A single-center study examined rectal fistula specimens obtained during posterior sagittal anorectoplasty (PSARP) procedures" (clinical) [Ep 201 · 0:41](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=41)
- "Rectal fistula tissue is not physiologic tissue" (clinical) [Ep 201 · 0:52](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=52)
- "Ganglion cells were found in 91% of rectal fistula specimens" — Jill Knepprath (clinical) [Ep 201 · 0:58](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=58)
- "Hypo or absent ganglion cells were found in the remaining rectal fistula specimens" — Jill Knepprath (clinical) [Ep 201 · 0:58](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=58)
- "Absent ganglion cells in fistula tissue does not necessarily mean the patient has Hirschsprung disease" — Jill Knepprath (clinical) [Ep 201 · 1:05](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=65)
- "Three patients (4% of the study cohort) had both Hirschsprung disease and anorectal malformation" — Jill Knepprath (epidemiological) [Ep 201 · 1:11](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=71)
- "Two of the three patients with both conditions had trisomy 21" — Jill Knepprath (epidemiological) [Ep 201 · 1:15](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=75)
- "Patients with both Hirschsprung disease and ARM tend to have chromosomal anomalies" (clinical) [Ep 201 · 1:22](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=82)
- "Chromosomal anomalies associated with both conditions include trisomy 21 and Pallister-Killian syndrome" (clinical) [Ep 201 · 1:27](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=87)
- "Complex anorectal malformation patients with chromosomal anomalies who do not respond to laxatives or enemas should be worked up for Hirschsprung disease" — Jill Knepprath (guideline) [Ep 201 · 1:31](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=91)
- "The study was a single institution retrospective study of 208 patients with neurogenic bladder, anorectal malformations, myelomeningocele, and other spinal cord pathology who underwent urinary reconstruction between 2014 and 2021" — Megan Reedy Vituri (epidemiological) [Ep 203 · 0:11](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168?t=11)
- "About 74% of patients underwent continent reconstruction and 26% underwent incontinent reconstruction" — Megan Reedy Vituri (epidemiological) [Ep 203 · 0:32](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168?t=32)
- "There was no difference in reconstruction type based on insurance type" — Megan Reedy Vituri (epidemiological) [Ep 203 · 0:38](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168?t=38)
- "There was no difference in reconstruction type based on childhood opportunity index" — Megan Reedy Vituri (epidemiological) [Ep 203 · 0:38](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168?t=38)
- "Patients who had incontinent reconstruction were more likely to have food insecurity" — Megan Reedy Vituri (epidemiological) [Ep 203 · 0:38](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168?t=38)
- "Patients who had incontinent reconstruction were more likely to have missed appointments" — Megan Reedy Vituri (epidemiological) [Ep 203 · 0:38](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168?t=38)
- "Patients who had incontinent reconstruction were more likely to have unmarried parents" — Megan Reedy Vituri (epidemiological) [Ep 203 · 0:38](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168?t=38)
- "Patients who traveled from out of state were more likely to have a continent diversion" — Megan Reedy Vituri (epidemiological) [Ep 203 · 0:49](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168?t=49)
- "Social stability and the ability to engage with follow-up may be influencing what surgeons offer families as well as what families can realistically manage" — Megan Reedy Vituri (opinion) [Ep 203 · 0:57](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168?t=57)
- "The best reconstruction isn't just one that's technically feasible, it also needs to be sustainable for patients and their families" — Megan Reedy Vituri (opinion) [Ep 203 · 1:08](https://library.globalcastmd.com/watch/association-between-social-determinants-of-health-and-choice-of-urinary-reconstruction-in-children-12168?t=68)
- "The study was a single institution retrospective study of 40 patients with cloacal malformations who underwent bowel neovagina creation during reconstruction" — Megan Reed Evatori (clinical) [Ep 205 · 0:11](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=11)
- "Overall outcomes were similar between small bowel and colonic neovaginas" — Megan Reed Evatori (clinical) [Ep 205 · 0:25](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=25)
- "Major complications were uncommon but not negligible" — Megan Reed Evatori (clinical) [Ep 205 · 0:29](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=29)
- "Enterroidal stenosis was more common with colonic grafts" — Megan Reed Evatori (clinical) [Ep 205 · 0:32](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=32)
- "A subset of patients required roidoplasty" — Megan Reed Evatori (clinical) [Ep 205 · 0:32](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=32)
- "Vaginal prolapse was rare" — Megan Reed Evatori (clinical) [Ep 205 · 0:38](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=38)
- "Menstrual obstruction occurred in only a few patients" — Megan Reed Evatori (clinical) [Ep 205 · 0:40](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=40)
- "About 25% of patients reported bothersome discharge" — Megan Reed Evatori (clinical) [Ep 205 · 0:43](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=43)
- "Among the small number who were sexually active, dyspareunia was reported" — Megan Reed Evatori (clinical) [Ep 205 · 0:46](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=46)
- "Bowel neovaginas are a reasonable and durable option" — Megan Reed Evatori (opinion) [Ep 205 · 0:52](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=52)
- "Patients with bowel neovaginas need long term follow up with attention to function, stenosis and quality of life" — Megan Reed Evatori (guideline) [Ep 205 · 0:57](https://library.globalcastmd.com/watch/complications-and-long-term-outcomes-of-patients-with-cloacal-malformation-after-bowel-neovagina-12170?t=57)
- "The patient is a female infant born with an anorectal malformation and a rectovesibular fistula." (clinical) [Ep 202 · 0:05](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=5)
- "Examination reveals a normal introitus with the rectum ending as a fistula in the vestibule and a pink sphincteric ellipse." (clinical) [Ep 202 · 0:12](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=12)
- "For females with anorectal malformation, anatomic options include rectovesibular fistula, rectocloacal fistula, rectoperitoneal fistula in the center of the perineal body, rectoperitoneal fistula within the sphincteric complex at its anteriormost extent, anal stenosis, and slightly anteriorly located but otherwise normal anus." (clinical) [Ep 202 · 0:22](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=22)
- "With all anorectal malformations, it is vital to inspect for any associated anomalies." (guideline) [Ep 202 · 1:03](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=63)
- "In females with anorectal malformation, vaginoscopy is performed to look for associated Mullerian anomalies such as vaginal septum, distal vaginal atresia, and uterine anomalies." (guideline) [Ep 202 · 1:10](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=70)
- "In this case, vaginoscopy showed a normal vagina and a single cervix." (clinical) [Ep 202 · 1:10](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=70)
- "The traditional PSARP is done in prone position with cutting of the perineal body down to the vestibular fistula, including a long posterior sagittal incision from the coccyx, mobilizing the rectum off the posterior vaginal wall, repairing the perineal body, completing the anoplasty, and closing the posterior sagittal incision." (clinical) [Ep 202 · 1:31](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=91)
- "The perineal body preserving technique (PPP) is an alternative to traditional PSARP." (clinical) [Ep 202 · 1:58](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=118)
- "An electrical stimulator (the same one used by anesthesia for train of four) can define the extent of the sphincter complex." (clinical) [Ep 202 · 2:11](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=131)
- "For the electrical stimulator to work well, muscle relaxation must be avoided." (clinical) [Ep 202 · 2:26](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=146)
- "In the PPP technique, the entire incision need only be the extent of the sphincter; no posterior and no anterior incision is needed." (clinical) [Ep 202 · 2:35](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=155)
- "Care must be taken that retractors do not split the perineal body inadvertently." (clinical) [Ep 202 · 2:45](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=165)
- "A suture is placed at the anteriormost extent of the intended anoplasty to help avoid inadvertent splitting of the perineal body." (clinical) [Ep 202 · 2:50](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=170)
- "In the PPP, the perineal body is not incised." (clinical) [Ep 202 · 3:13](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=193)
- "The lateral aspects of the rectum are intimately attached to the vaginal wall and must be dissected with great care to avoid injury." (clinical) [Ep 202 · 3:33](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=213)
- "A helpful concept is to think of the PPP like a bulbar fistula repair in a male with anorectal malformation." (opinion) [Ep 202 · 3:43](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=223)
- "A stitch is placed in the fistula, analogous to the approach for a bulbar fistula." (clinical) [Ep 202 · 3:59](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=239)
- "Placement of multiple sutures across the anterior lip of the rectal wall is a vitally important step because it facilitates lifting of the rectal wall and separation from the posterior vaginal wall." (clinical) [Ep 202 · 4:20](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=260)
- "The rectum is mobilized and dissected within the whitish fascia that envelops it." (clinical) [Ep 202 · 8:32](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=512)
- "A Hagar dilator in the vagina facilitates dissection of the rectum from the vagina." (clinical) [Ep 202 · 8:41](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=521)
- "The stitch on the fistula is passed into the introitus and the fistula tissue is managed at the end of the case." (clinical) [Ep 202 · 8:50](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=530)
- "The perineal body muscles are sutured together where the fistula used to be, forming the sphincter anterior to the new anoplasty." (clinical) [Ep 202 · 9:00](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=540)
- "The anoplasty is placed within the initial incision, which is the center of the sphincters." (clinical) [Ep 202 · 9:09](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=549)
- "In the PPP technique, no sutures are needed in the perineal body's skin; the perineal body skin is untouched." (clinical) [Ep 202 · 9:15](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=555)
- "The rectum is split on its anterior and posterior wall." (clinical) [Ep 202 · 9:23](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=563)
- "The anoplasty is completed with 16 absorbable sutures placed full thickness, rectal wall to anal skin." (clinical) [Ep 202 · 9:27](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=567)
- "After completion of the anoplasty, the patient is turned supine and the introitus is exposed." (clinical) [Ep 202 · 10:08](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=608)
- "The fistula tissue is excised and the mucosa of the vestibule is repaired where the fistula had been." (clinical) [Ep 202 · 10:27](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=627)
- "The study was published in 2026 in the Journal of Pediatric Surgery" — Megan Reed Evaurri (clinical) [Ep 204 · 0:15](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=15)
- "The study examined institutional experience from 2018 to 2024" — Megan Reed Evaurri (clinical) [Ep 204 · 0:28](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=28)
- "50 patients developed post-operative anastomotic stricture: 30 with anorectal malformations and 20 with Hirschsprung disease" — Megan Reed Evaurri (epidemiological) [Ep 204 · 0:40](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=40)
- "70% of patients with anorectal malformations achieved stricture resolution with TAC injections" — Megan Reed Evaurri (clinical) [Ep 204 · 0:46](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=46)
- "85% of patients with Hirschsprung disease achieved stricture resolution with TAC injections" — Megan Reed Evaurri (clinical) [Ep 204 · 0:50](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=50)
- "The median number of TAC injections needed to achieve stricture resolution was 1 in both groups" — Megan Reed Evaurri (clinical) [Ep 204 · 0:55](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=55)
- "30% of anorectal malformation patients required surgery despite TAC injections" — Megan Reed Evaurri (clinical) [Ep 204 · 1:00](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=60)
- "10% of Hirschsprung disease patients required surgery despite TAC injections" — Megan Reed Evaurri (clinical) [Ep 204 · 1:00](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=60)
- "There were no intraoperative complications from TAC injections" — Megan Reed Evaurri (clinical) [Ep 204 · 1:06](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=66)
- "The 30-day complication rate was 2.2%" — Megan Reed Evaurri (clinical) [Ep 204 · 1:06](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=66)
- "TAC injections may be a safe, minimally invasive adjunct to traditional dilations with promising rates of stricture resolution and low short-term morbidity" — Megan Reed Evaurri (opinion) [Ep 204 · 1:14](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=74)
- "This is a retrospective single center study" — Megan Reed Evaurri (clinical) [Ep 204 · 1:27](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=87)
- "TAC injections may be a useful treatment option before moving on to another operation" — Megan Reed Evaurri (opinion) [Ep 204 · 1:27](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=87)
- "Notebook LM is a free offering of Google that can create realistic-sounding podcasts between two people from uploaded content" — Todd Ponsky (clinical) [Ep 177 · 2:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=136)
- "Notebook LM uses the same two voices (one man and one woman) for all generated podcasts" — Todd Ponsky (clinical) [Ep 177 · 4:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=262)
- "The beta version of Notebook LM allows users to join the conversation and interact with the AI hosts" — Todd Ponsky (clinical) [Ep 177 · 5:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=303)
- "When content is uploaded to Notebook LM, it creates an expert based only on the provided documents, not external sources" — Em Gootee (clinical) [Ep 177 · 5:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=356)
- "A review article that took two weeks to write five years ago can now be produced in minutes using Notebook LM with the same source articles" — Marc Levitt (clinical) [Ep 177 · 6:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=399)
- "AI can identify gaps in knowledge from a collection of research articles" — Marc Levitt (clinical) [Ep 177 · 7:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=424)
- "Colorectal and pelvic disorders in children are intricate and can have lifelong effects" (clinical) [Ep 177 · 11:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=705)
- "These conditions frequently involve a network of connected issues affecting digestive, urinary, reproductive systems, and sometimes bones and muscles of spine and hips" (clinical) [Ep 177 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=713)
- "Collaborative programs lead to better treatment plans, improved communication between specialists, fewer complications, and better overall health outcomes" (clinical) [Ep 177 · 13:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=802)
- "A dedicated physician leader, most often a pediatric surgeon, is necessary to champion the program" (clinical) [Ep 177 · 14:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=874)
- "Key initial specialties needed are general surgery, urology, gynecology, GI motility specialist, and a dedicated nursing team" (clinical) [Ep 177 · 15:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=958)
- "A dedicated and passionate nurse who specializes in managing bowel issues is the backbone of the program" (clinical) [Ep 177 · 16:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=976)
- "Finding a pediatric gynecologist can be a challenge in some areas" (clinical) [Ep 177 · 17:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1038)
- "A GI colleague with interest in motility and performing manometry studies is needed" (clinical) [Ep 177 · 17:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1078)
- "Manometry involves inserting a thin flexible tube into the digestive tract to measure muscle contractions" (clinical) [Ep 177 · 18:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1087)
- "Access to anal and colonic motility studies and pelvic floor physical therapy is key" (clinical) [Ep 177 · 18:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1111)
- "Radiologists need education on colorectal diseases and how to properly perform and interpret contrast enemas, colostograms, and cloicograms" (clinical) [Ep 177 · 19:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1144)
- "Active participation from surgeons in imaging studies is important, especially initially" (clinical) [Ep 177 · 19:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1171)
- "Regular multidisciplinary meetings, ideally once or twice a week, are essential for reviewing patient needs and developing coordinated care plans" (clinical) [Ep 177 · 20:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1230)
- "A dedicated multidisciplinary outpatient clinic is the ideal scenario, but practical limitations may require coordinating same-day appointments in different locations" (clinical) [Ep 177 · 20:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1245)
- "Continuous learning strategies include visiting established centers, staying current with research, watching surgical videos, and visiting other multidisciplinary programs" (clinical) [Ep 177 · 21:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1292)
- "Surgical videos are helpful but not a substitute for actual hands-on surgical experience" (clinical) [Ep 177 · 23:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1400)
- "The colorectal nurse needs skills in preoperative and postoperative care including bowel irrigations, enemas, catheter management, and teaching families anal dilations" (clinical) [Ep 177 · 24:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1477)
- "Essential supplies include Hagar dilators, various catheters, gravity bags for enemas, and specialized surgical retractors like the Lone Star retractor" (clinical) [Ep 177 · 25:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1545)
- "Key data to track includes patient referrals, visits, new patients, out-of-region patients, surgical cases, length of stay, revenues, expenses, and complication rates" (clinical) [Ep 177 · 26:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1616)
- "Telephone encounters with patients and families should be documented to justify nursing staff needs" (clinical) [Ep 177 · 27:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1646)
- "Children with colorectal and pelvic conditions often need long-term chronic care and don't follow typical surgical recovery paths" (clinical) [Ep 177 · 27:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1672)
- "In private hospitals, the business case focuses on attracting patients and downstream revenue; in public hospitals, on cost savings through reduced complications and shorter stays" (clinical) [Ep 177 · 29:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1760)
- "Building trust with referring physicians takes time and requires demonstrating value through successful management of referred patients" (clinical) [Ep 177 · 30:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1802)
- "A significant portion of patients referred for management issues will likely need further surgical intervention later" (clinical) [Ep 177 · 30:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1844)
- "A dedicated care coordinator or scheduler is a top priority for resource allocation" (clinical) [Ep 177 · 31:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1895)
- "Building bench strength by initially sharing resources from existing hospital departments can be cost-effective" (clinical) [Ep 177 · 32:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=1930)
- "For new patients, dedicated intake meetings involve nursing gathering medical records, developing initial care plans, and addressing psychosocial, nutritional, or anesthesia concerns" (clinical) [Ep 177 · 36:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=2217)
- "The multidisciplinary team including colorectal surgery, urology, gynecology, GI motility, nursing, and social work reviews the nurse's proposed plan collaboratively" (clinical) [Ep 177 · 37:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=2251)
- "For families traveling significant distances, programs try to consolidate appointments into a single visit" (clinical) [Ep 177 · 37:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=2277)
- "In the previous technique, the urethra and vagina were brought up to the introitus and separately anastomosed, resulting in poor definition of the vaginal vestibule and labia, often with skin separation between the urethra and vagina." (clinical) [Ep 179 · 0:14](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=14)
- "In the new technique, the urethral meatus is positioned slightly recessed and posterior to the clitoris in a more orthotopic position, which rebuilds the vaginal vestibule." (clinical) [Ep 179 · 0:30](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=30)
- "Key components include careful dissection and reconfiguration of the anterior and posterior urethra to form a patent orthotopic meatus that is slightly recessed, in addition to creating well-defined labia minora." (clinical) [Ep 179 · 0:41](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=41)
- "In cloacal repair patients who underwent urogenital sinus separation and vaginal and anorectal pull-through, the common channel becomes the urethra." (clinical) [Ep 179 · 0:56](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=56)
- "The first step is to recess the urethromeatus to a more orthotopic location by opening the urethromeatus and performing a urethromeattoplasty if necessary." (clinical) [Ep 179 · 1:10](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=70)
- "To recreate and build the vaginal vestibule, the vagina is slightly tubularized and then re-approximated to the neourethral meatus at its inferior aspect." (clinical) [Ep 179 · 1:28](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=88)
- "A retrospective case series included 50 patients with cloacal anomalies who underwent primary cloacal repair between 2020 and 2024." (epidemiological) [Ep 179 · 3:38](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=218)
- "Of the 50 patients, 24 underwent urogenital sinus separation with vaginal and anorectal pull-through, and 17 underwent total urogenital mobilization." (epidemiological) [Ep 179 · 3:48](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=228)
- "The urethromiattoplasty technique was applied to 6 patients who underwent UG separation and 5 patients who underwent TUM." (epidemiological) [Ep 179 · 3:58](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=238)
- "On follow-up, all patients had satisfactory cosmetic results and successful neoatus creation with minimal scarring and a well-positioned urethral meatus." (clinical) [Ep 179 · 4:07](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=247)
- "There were no instances of stenosis or fistula in the case series." (clinical) [Ep 179 · 4:17](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=257)
- "1 patient required clean intermittent catheterization." (clinical) [Ep 179 · 4:20](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=260)
- "3 patients underwent vesicostomy for bladder management." (clinical) [Ep 179 · 4:23](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=263)
- "7 patients did not require assisted bladder emptying." (clinical) [Ep 179 · 4:23](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10864?t=263)
- "In the previous technique, the urethra and vagina were brought up to the introitus and separately anastomosed, resulting in poor definition of the vaginal vestibule and labia, often with skin separation between the urethra and vagina." (clinical) [Ep 178 · 0:14](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=14)
- "In the new technique, the urethral meatus is positioned slightly recessed and posterior to the clitoris in a more orthotopic position, which rebuilds the vaginal vestibule." (clinical) [Ep 178 · 0:30](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=30)
- "Key components include careful dissection and reconfiguration of the anterior and posterior urethra to form a patent orthotopic meatus that is slightly recessed, in addition to creating well-defined labia minora." (clinical) [Ep 178 · 0:41](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=41)
- "In cloacal repair patients who underwent urogenital sinus separation and vaginal and anorectal pull-through, the common channel becomes the urethra." (clinical) [Ep 178 · 0:56](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=56)
- "The first step is to recess the urethromeatus to a more orthotopic location by opening the urethromeatus and performing a urethromeattoplasty if necessary." (clinical) [Ep 178 · 1:10](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=70)
- "To recreate and build the vaginal vestibule, the vagina is slightly tubularized and then re-approximated to the neourethral meatus at its inferior aspect." (clinical) [Ep 178 · 1:28](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=88)
- "A retrospective case series included 50 patients with cloacal anomalies who underwent primary cloacal repair between 2020 and 2024." (epidemiological) [Ep 178 · 3:38](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=218)
- "Of the 50 patients, 24 underwent urogenital sinus separation with vaginal and anorectal pull-through, and 17 underwent total urogenital mobilization." (epidemiological) [Ep 178 · 3:48](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=228)
- "The urethromiattoplasty technique was applied to 6 patients who underwent UG separation and 5 patients who underwent TUM." (epidemiological) [Ep 178 · 3:58](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=238)
- "On follow-up, all patients had satisfactory cosmetic results and successful neoatus creation with minimal scarring and a well-positioned urethral meatus." (clinical) [Ep 178 · 4:07](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=247)
- "There were no instances of stenosis or fistula in the case series." (clinical) [Ep 178 · 4:17](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=257)
- "1 patient required clean intermittent catheterization." (clinical) [Ep 178 · 4:20](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=260)
- "3 patients underwent vesicostomy for bladder management." (clinical) [Ep 178 · 4:23](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=263)
- "7 patients did not require assisted bladder emptying." (clinical) [Ep 178 · 4:23](https://library.globalcastmd.com/watch/enhancing-urethral-meatus-creation-in-cloacal-malformations-a-new-technique-10865?t=263)
- "A study examined 85 children treated for rectal prolapse after anorectal malformation surgery" — Lizzie Lee (epidemiological) [Ep 181 · 0:11](https://library.globalcastmd.com/watch/morbidity-of-rectal-prolapse-repair-after-surgery-for-anorectal-malformation-10942?t=11)
- "Approximately 30% of children had recurrence of prolapse requiring another repair" — Lizzie Lee (epidemiological) [Ep 181 · 0:16](https://library.globalcastmd.com/watch/morbidity-of-rectal-prolapse-repair-after-surgery-for-anorectal-malformation-10942?t=16)
- "Children without symptoms from prolapse at initial presentation were more likely to develop stricture later" — Lizzie Lee (clinical) [Ep 181 · 0:20](https://library.globalcastmd.com/watch/morbidity-of-rectal-prolapse-repair-after-surgery-for-anorectal-malformation-10942?t=20)
- "Surgical repair of asymptomatic rectal prolapse may not be indicated because the treatment itself carries risks" — Lizzie Lee (opinion) [Ep 181 · 0:26](https://library.globalcastmd.com/watch/morbidity-of-rectal-prolapse-repair-after-surgery-for-anorectal-malformation-10942?t=26)
- "Routine anal dilatations after surgery for anorectal malformations have been standard since the 1980s" — Lizzie Lee (clinical) [Ep 182 · 0:11](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-children-with-anorectal-malformation-a-systematic-review-11031?t=11)
- "Stricture rates after anorectal malformation surgery range from 0 to almost 40%, even with the classic Pena protocol" — Lizzie Lee (epidemiological) [Ep 182 · 0:18](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-children-with-anorectal-malformation-a-systematic-review-11031?t=18)
- "Alternative methods like weekly dilatations or skipping dilatations altogether showed similar outcomes to standard protocols" — Lizzie Lee (clinical) [Ep 182 · 0:25](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-children-with-anorectal-malformation-a-systematic-review-11031?t=25)
- "There is insufficient high quality evidence proving that dilatations after anorectal malformation surgery are actually necessary" — Lizzie Lee (opinion) [Ep 182 · 0:32](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-children-with-anorectal-malformation-a-systematic-review-11031?t=32)
- "More randomized trials are needed to determine whether post-operative anal dilatations are necessary" — Lizzie Lee (opinion) [Ep 182 · 0:37](https://library.globalcastmd.com/watch/post-operative-anal-dilatations-for-the-prevention-of-anal-strictures-in-children-with-anorectal-malformation-a-systematic-review-11031?t=37)
- "Two studies in 2021 found no difference in wound complications, re-operations, or readmissions between early (less than 7-14 days) and delayed (6 weeks to 8 months) PSARP for vestibular fistulas" — Jamie Harris (clinical) [Ep 180 · 5:14](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=314)
- "Wound breakdown and dehiscence was the most common complication in both neonatal and delayed PSARP groups, occurring in approximately 5-6% with no significant difference between groups" — Jamie Harris (clinical) [Ep 180 · 6:00](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=360)
- "For vestibular fistula dilations, recommend only dilating to 7 Hegar to decrease potential scarring along the tract for future PSARP" — Jamie Harris (clinical) [Ep 180 · 2:33](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=153)
- "Perineal body-preserving PSARP showed no dehiscence, no prolapse, and only 13% required revision of anal stenosis at one-year follow-up in 2023 publication" (clinical) [Ep 180 · 10:22](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=622)
- "Two-thirds of patients undergoing perineal body-preserving PSARP went home on postoperative day one" (clinical) [Ep 180 · 10:36](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=636)
- "Perineal body-preserving PSARP does not add operative time compared to standard PSARP" — Jamie Harris (clinical) [Ep 180 · 14:03](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=843)
- "Anal dilations are associated with parental anxiety, PTSD for both patients and caregivers, and post-traumatic stress symptoms in families" (clinical) [Ep 180 · 16:31](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=991)
- "Preoperative dilations appear to be more tolerated than postoperative dilations" (opinion) [Ep 180 · 17:00](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1020)
- "In Spanish study, children adequately sized at initial post-PSARP appointment did not receive dilations, while undersized children received dilations" (clinical) [Ep 180 · 17:19](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1039)
- "Single institution review showed 2 children in each group (dilations vs no dilations) required re-operation for neoanal stricture, and approximately 15% required Heineke-Mikulicz stricturoplasty" (clinical) [Ep 180 · 18:01](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1081)
- "PCPLC retrospective study of Hirschsprung disease found no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days)" — Nelson Rosen (clinical) [Ep 180 · 20:25](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1225)
- "Multi-center retrospective study found 24% of Hirschsprung patients received at least one Botox injection" — Nelson Rosen (epidemiological) [Ep 180 · 23:40](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1420)
- "Cincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients receiving Botox (30% vs 50%)" — Nelson Rosen (clinical) [Ep 180 · 23:58](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1438)
- "Patients receiving Botox at time of pull-through had higher risk of diaper rash (60%)" — Nelson Rosen (clinical) [Ep 180 · 24:23](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1463)
- "Early work from Boston used per-kilogram Botox dosing up to maximum of 100 units" — Nelson Rosen (clinical) [Ep 180 · 24:58](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1498)
- "Rate of concurrent Hirschsprung disease and anorectal malformation is approximately 2% based on Pena's series" (epidemiological) [Ep 180 · 27:03](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1623)
- "Some papers show rate of concurrent Hirschsprung and ARM as high as 3-4%, while recent paper showed less than 1%" (epidemiological) [Ep 180 · 27:14](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1634)
- "Single center study found ganglion cells in 90% of rectal fistula specimens taken during PSARP, with hypoganglionosis or absent ganglion cells in the rest" (clinical) [Ep 180 · 27:39](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1659)
- "Patients with both Hirschsprung disease and anorectal malformation tend to have chromosomal anomalies, particularly trisomy 21" (clinical) [Ep 180 · 28:24](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1704)
- "Fistula dilations represent controlled tears when starting from pinhole size, not true stretching" — Nelson Rosen (clinical) [Ep 180 · 8:41](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=521)
- "Goal of fistula dilation is to maintain patency just large enough for soft, mustardy stool to pass through" — Nelson Rosen (clinical) [Ep 180 · 4:17](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=257)
- "Perineal body-preserving PSARP is essentially the same technique used for bulbar fistula applied to vestibular fistula" — Nelson Rosen (clinical) [Ep 180 · 11:04](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=664)
- "Key technical principle for perineal body-preserving PSARP is to mobilize lateral planes and back wall thoroughly before coming around the anterior common plane" — Nelson Rosen (clinical) [Ep 180 · 11:32](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=692)
- "Perineal body-preserving PSARP can be converted to standard PSARP by extending the incision if visualization is inadequate" — Jamie Harris (clinical) [Ep 180 · 13:09](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=789)
- "Families competent with irrigations will start treatment for enterocolitis before calling the surgeon" (opinion) [Ep 180 · 21:36](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1296)
- "Patients with longer aganglionic segments who cannot be adequately decompressed at home may require earlier pull-through to prevent enterocolitis or perforation" (clinical) [Ep 180 · 22:07](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1327)
- "Some data suggests possibly better continence in delayed Hirschsprung pull-through group, but studies have been underpowered" (clinical) [Ep 180 · 22:39](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1359)
- "Ultrasound guidance for Botox injection allows visualization of needle placement, internal and external anal sphincter layers, superficial external anal sphincter, and sometimes puborectalis" (clinical) [Ep 180 · 25:48](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1548)
- "Absence of ganglion cells in fistula tissue does not necessarily mean Hirschsprung disease, as fistula tissue is not physiologic tissue" (clinical) [Ep 180 · 27:54](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1674)
- "A narrow anal opening in normal sphincter position can represent either anal stenosis or rectal atresia" (clinical) [Ep 183 · 0:11](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=11)
- "In cases of narrow anal opening, one must screen for Currarino triad" (guideline) [Ep 183 · 0:29](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=29)
- "In cases of narrow anal opening, one must ensure there is no associated presacral mass" (guideline) [Ep 183 · 0:29](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=29)
- "Presacral masses associated with anorectal malformations are usually teratoma or meningocele" (clinical) [Ep 183 · 0:39](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=39)
- "Rectal atresia should now be treated like Hirschsprung's disease" (opinion) [Ep 183 · 1:31](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=91)
- "If the rectum is high in rectal atresia, laparoscopy can be used to mobilize it" (clinical) [Ep 183 · 1:36](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=96)
- "If the rectum is low in rectal atresia, it can be approached transanally only" (clinical) [Ep 183 · 1:40](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=100)
- "The transanal approach to rectal atresia is very different from the previously described posterior sagittal approach" (clinical) [Ep 183 · 1:45](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=105)
- "The surgeon can avoid a posterior sagittal incision and reach the rectum transanally using a Swenson technique" (clinical) [Ep 183 · 1:52](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=112)
- "Transanal dissection for rectal atresia begins with incision 0.5 centimeters proximal to the dentate line" (clinical) [Ep 183 · 2:14](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=134)
- "The mobilized distal rectum is anastomosed to the anal canal, just like in a case for Hirschsprung's disease" (clinical) [Ep 183 · 2:25](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=145)
- "The dissection must find the typical whitish fascia that surrounds the rectum, just like for all PARPs, for a Swenson plane mobilization" (clinical) [Ep 183 · 3:48](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=228)
- "On the anterior side of the dissection, the surgeon must be careful not to hurt the urethra by staying right against the rectal wall" (clinical) [Ep 183 · 4:05](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=245)
- "Sutures placed at 12, 3, 6, and 9 o'clock help manage size discrepancy between the rectal lumen and anal canal during anastomosis" (clinical) [Ep 183 · 4:40](https://library.globalcastmd.com/watch/rectal-atresia-a-unique-anorectal-malformation-11105?t=280)
- "Suction rectal biopsy is diagnostic for Hirschsprung's disease" (clinical) [Ep 198 · 0:27](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=27)
- "There is not really evidence in the literature of good timing to perform a pull-through procedure" (clinical) [Ep 198 · 0:44](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=44)
- "A 2021 PCPLC retrospective study compared outcomes of neonatal pull-through versus delayed primary pull-through" (epidemiological) [Ep 198 · 0:50](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=50)
- "The median age of the neonatal group was 11 days at time of surgery" — Jill Knepprath (epidemiological) [Ep 198 · 0:59](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=59)
- "The median age of the delayed group was 98 days at time of surgery" — Jill Knepprath (epidemiological) [Ep 198 · 1:02](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=62)
- "The study found no difference in preoperative and postoperative enterocolitis between neonatal and delayed pull-through groups" — Jill Knepprath (epidemiological) [Ep 198 · 1:06](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=66)
- "The study found no difference in fecal incontinence at follow-up between neonatal and delayed pull-through groups" — Jill Knepprath (epidemiological) [Ep 198 · 1:06](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=66)
- "Family ability to perform irrigations at home is an important skill" (opinion) [Ep 198 · 1:13](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=73)
- "A family who is really good at irrigations will save a baby's life" (opinion) [Ep 198 · 1:23](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=83)
- "Kids whose families cannot perform adequate washouts may not be able to go home" (clinical) [Ep 198 · 1:29](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=89)
- "Inadequate decompression can lead to hospitalization with colitis or perforation" (clinical) [Ep 198 · 1:29](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=89)
- "Studies show no difference in complications between neonatal and delayed pull-through procedures for Hirschsprung patients" — Jill Knepprath (epidemiological) [Ep 198 · 1:42](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=102)
- "Decisions on timing should factor in the family's ability to perform irrigations" — Jill Knepprath (opinion) [Ep 198 · 1:50](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-s-pull-through-why-family-training-may-save-lives-12009?t=110)
- "50% of polled surgeons would not inject Botox at the same time as pull-through procedure" — Lei Wen (epidemiological) [Ep 199 · 0:33](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=33)
- "The Cincinnati Children's group injects Botox at the same time of surgery" — Lei Wen (opinion) [Ep 199 · 0:42](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=42)
- "A 2022 multi-center study found that 24% of patients undergoing pull-through procedure also received Botox" — Jill Knepprath (epidemiological) [Ep 199 · 0:45](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=45)
- "Cincinnati Children's study from 2020 to 2024 found decreased risk of enterocolitis within 31 days after pull-through procedure: 0% versus 30%" — Lei Wen (clinical) [Ep 199 · 0:55](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=55)
- "Patients that received Botox had a higher chance of diaper rash" — Jill Knepprath (clinical) [Ep 199 · 1:09](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=69)
- "There is no evidence on the number of units of Botox to use" (clinical) [Ep 199 · 1:20](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=80)
- "Better data is needed on Botox dosing" (opinion) [Ep 199 · 1:23](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=83)
- "Ultrasound guidance allows visualization of every layer, needle position, injection amount and location, and diffusion pattern" (clinical) [Ep 199 · 1:25](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=85)
- "Injecting Botox during pull-through procedure for Hirschsprung's disease has been shown to reduce enterocolitis risk" — Jill Knepprath (clinical) [Ep 199 · 1:37](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=97)
- "Dosing and guidance for Botox injection varies widely" — Jill Knepprath (epidemiological) [Ep 199 · 1:41](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=101)
- "The START trial randomized 140 infants with biliary atresia to high-dose steroids (13-week course) versus placebo after Kasai portoenterostomy" — Daniel von Allmen (clinical) [Ep 76 · 2:56](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=176)
- "High-dose steroid therapy following Kasai did not result in statistically significant treatment difference in bile drainage at 6 months: 58.6% treatment group versus 48.6% placebo" — Daniel von Allmen (clinical) [Ep 76 · 4:01](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=241)
- "Survival without liver transplant at 24 months was not statistically different: 58.7% steroid group versus 49.4% placebo group" — Daniel von Allmen (clinical) [Ep 76 · 4:39](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=279)
- "Adverse events occurred in near 80% of patients in both steroid and placebo groups, attributed largely to severe underlying liver dysfunction" — Daniel von Allmen (clinical) [Ep 76 · 4:55](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=295)
- "Steroid treatment was associated with earlier onset of serious adverse events in children with biliary atresia" — Daniel von Allmen (clinical) [Ep 76 · 5:10](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=310)
- "The study was powered to detect a 25% absolute treatment difference in outcomes" — Daniel von Allmen (clinical) [Ep 76 · 3:46](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=226)
- "Steroids are proposed to work through two mechanisms: reducing ongoing inflammation to preserve bile ductules, and acting as a choleretic to maintain bile flow" — Daniel von Allmen (clinical) [Ep 76 · 8:59](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=539)
- "Washington State registry study included over 50 hospitals and analyzed clean-contaminated operations over 18 months beginning January 2011" — Whit Holcomb (clinical) [Ep 76 · 12:02](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=722)
- "Overall surgical site infection rate was 4.6%, varying by procedure: 6.6% colorectal, 1.4% bariatric, 1.5% other" — Whit Holcomb (epidemiological) [Ep 76 · 13:05](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=785)
- "No single antiseptic agent was associated with lower risk of surgical site infection than any other agent" — Whit Holcomb (clinical) [Ep 76 · 13:39](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=819)
- "Isopropyl alcohol provided no benefit: 4.5% SSI rate without alcohol versus 4.6% with alcohol" — Whit Holcomb (clinical) [Ep 76 · 13:49](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=829)
- "Registry data could not identify surgical site infections diagnosed after discharge, likely underestimating true SSI rate" — Whit Holcomb (clinical) [Ep 76 · 14:20](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=860)
- "Recent reports show 50% or more surgical site infections are diagnosed after discharge" — Whit Holcomb (epidemiological) [Ep 76 · 14:40](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=880)
- "Most surgical site infections occur 3 to 10 days after operation" — Whit Holcomb (clinical) [Ep 76 · 14:48](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=888)
- "Chlorhexidine prep dries faster than betadine, allowing cases to start sooner" — Whit Holcomb (clinical) [Ep 76 · 18:33](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1113)
- "Appendicitis pilot RCT enrolled 50 patients aged 5-15 years with non-perforated appendicitis: 26 randomized to operation, 24 to antibiotics" — Whit Holcomb (clinical) [Ep 76 · 22:58](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1378)
- "Of 24 patients randomized to non-operative treatment, 2 underwent appendectomy during primary treatment course and 1 had appendectomy at 9 months for recurrent appendicitis" — Whit Holcomb (clinical) [Ep 76 · 23:14](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1394)
- "An additional 6 patients in the non-operative group underwent appendectomy for recurrent abdominal pain or parental desire during 1-year follow-up, with no appendicitis found on histology" — Whit Holcomb (clinical) [Ep 76 · 23:32](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1412)
- "Total of 9 of 24 patients (38%) initially randomized to antibiotic therapy underwent appendectomy within first year, making success rate 62%" — Whit Holcomb (clinical) [Ep 76 · 24:10](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1450)
- "Median time to discharge was significantly shorter in surgical group than non-operative group, possibly due to stipulated 48-hour minimum hospitalization for non-operative patients" — Whit Holcomb (clinical) [Ep 76 · 24:35](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1475)
- "Cost for initial inpatient stay was significantly lower in non-operative treatment group despite longer hospitalizations" — Whit Holcomb (clinical) [Ep 76 · 24:55](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1495)
- "Immunosuppressed cancer patients with typhlitis are sometimes treated non-operatively and most resolve with antibiotics" — Whit Holcomb (clinical) [Ep 76 · 27:00](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1620)
- "PIFCON study included 272 patients from 14 multidisciplinary intestinal rehab programs with median 33-month follow-up" — Aaron Lipskar (clinical) [Ep 76 · 32:32](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1952)
- "Enteral autonomy was achieved in 43% of intestinal failure cohort, 13% remained PN-dependent, and 43% died or underwent transplantation" — Aaron Lipskar (epidemiological) [Ep 76 · 32:40](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1960)
- "Necrotizing enterocolitis diagnosis, care at intestinal rehab facility without transplant center, and presence of ileocecal valve were associated with statistically significant higher rates of enteral autonomy" — Aaron Lipskar (clinical) [Ep 76 · 32:58](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1978)
- "Residual small bowel length was a statistically significant but less impressive predictor of enteral autonomy" — Aaron Lipskar (clinical) [Ep 76 · 33:19](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1999)
- "The protective effect of necrotizing enterocolitis on enteral autonomy goes against understanding of that inflammatory illness" — Aaron Lipskar (opinion) [Ep 76 · 33:55](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2035)
- "A companion paper in same journal showed necrotizing enterocolitis was a poor predictor of growth outcome in infants with short bowel syndrome" — Aaron Lipskar (clinical) [Ep 76 · 35:12](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2112)
- "FDA established SmartTots partnership with International Anesthesia Research Society in 2009 to study anesthesia-related neurotoxicity" — Aaron Lipskar (guideline) [Ep 76 · 37:19](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2239)
- "SmartTots 2012 consensus statement recommended avoiding elective surgical procedures under anesthesia in children less than 3 years when possible" — Aaron Lipskar (guideline) [Ep 76 · 37:34](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2254)
- "Commonly used anesthetics including propofol, etomidate, sevoflurane, isoflurane, and ketamine produce profound neurotoxic effects in laboratory animals from nematodes to nonhuman primates" — Aaron Lipskar (clinical) [Ep 76 · 38:09](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2289)
- "Observational studies in children undergoing early anesthesia offer conflicting results but suggest some children may have deficits, though causation difficult to establish" — Aaron Lipskar (clinical) [Ep 76 · 38:43](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2323)
- "June 2014 SmartTots statement concluded animal data sufficiently convincing that large-scale clinical studies are warranted" — Aaron Lipskar (guideline) [Ep 76 · 39:06](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2346)
- "Updated recommendation is to avoid surgical procedures under anesthesia in children under 3 years unless situation is urgent or potentially harmful if not attended to" — Aaron Lipskar (guideline) [Ep 76 · 39:14](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2354)
- "Regional anesthesia blocks can diminish amount of potentially neurotoxic medications in almost every laparoscopic, thoracoscopic, or open operation" — Aaron Lipskar (clinical) [Ep 76 · 42:00](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2520)
- "Rule of two suggested: defer elective operations until after age 2 and try not to have two anesthetics in one year" — Todd Ponsky (opinion) [Ep 76 · 42:16](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2536)
- "Survey of 150 parents in primary care pediatrics office found vast majority did not know anesthetic neurotoxicity was a major issue" — Aaron Lipskar (epidemiological) [Ep 76 · 43:17](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2597)
- "Cloacal exstrophy affects the gastrointestinal/colorectal area, urogenital tract, spine and cord, and sometimes motion of lower extremities" — Alberto Peña (clinical) [Ep 80 · 1:31](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=91)
- "Babies are born with omphalocele, bladder exstrophy with two hemibladders, open cecum between the hemibladders, and separated pubic bones" — Alberto Peña (clinical) [Ep 80 · 2:09](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=129)
- "The small bowel can become exstrophic through the ileocecal valve creating an 'elephant trunk' appearance" — Alberto Peña (clinical) [Ep 80 · 3:08](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=188)
- "Males have two separated hemiphalluses with normal gonads; females have two hemivaginas below the exstrophic bladder leading to two hemi-uteri" — Alberto Peña (clinical) [Ep 80 · 3:32](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=212)
- "Colonic anatomy exists on a spectrum from normal colon to almost absent colon or no colon at all, sometimes with two ceca or two appendices and bizarre blood supply" — Alberto Peña (clinical) [Ep 80 · 4:20](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=260)
- "The amount of colon present at birth has very important implications for the patient and surgeon" — Alberto Peña (clinical) [Ep 80 · 4:57](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=297)
- "A variant exists where babies have intact abdominal skin without omphalocele or bladder exstrophy externally, but have completely open bladder and all internal malformations" — Alberto Peña (clinical) [Ep 80 · 5:44](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=344)
- "We have progressed in safer surgical techniques, intensive care, and parenteral nutrition, but cannot claim much progress in functional sequelae" — Alberto Peña (opinion) [Ep 80 · 7:02](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=422)
- "Patients suffer lifelong serious limitations in bowel control, urinary control, sexual function, and spinal abnormalities that can be managed but not made normal" — Alberto Peña (clinical) [Ep 80 · 7:34](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=454)
- "Historical practice was bilateral gonadectomy, hemiphallus removal, vaginal creation with bowel, and female gender assignment for XY patients" — Alberto Peña (clinical) [Ep 80 · 8:31](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=511)
- "Patients raised as females despite XY chromosomes showed male attitudes and behavior, and became upset when learning of their chromosomal sex and surgical reassignment" — Alberto Peña (clinical) [Ep 80 · 9:16](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=556)
- "Patients argued that sex is not the most important thing, they wanted their gonads back, and with modern techniques can fertilize and have children" — Alberto Peña (clinical) [Ep 80 · 9:59](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=599)
- "Current consensus is that XY patients should be raised as male, with urologists and plastic surgeons working on phallic reconstruction" — Alberto Peña (guideline) [Ep 80 · 10:34](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=634)
- "When prominent pediatric urologists dominated surgical departments, patients received good urologic attention but poor gastrointestinal attention, and vice versa when pediatric surgeons led" — Alberto Peña (clinical) [Ep 80 · 12:13](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=733)
- "The pediatric surgeon must separate the urothelium of the bladder from intestinal mucosa by placing multiple stitches at the edges and making an incision" — Alberto Peña (clinical) [Ep 80 · 13:31](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=811)
- "It is very common and very bad for pediatric surgeons to simply create an ileostomy, leaving all colon distally attached to the urinary tract" — Alberto Peña (opinion) [Ep 80 · 14:55](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=895)
- "Leaving colon attached to the urinary tract creates a natural congenital bladder augmentation that urologists may appreciate" — Alberto Peña (clinical) [Ep 80 · 15:31](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=931)
- "Babies with ileostomy and colon left attached to bladder absorb urine from the newborn period causing hyperchloremic acidosis that interferes with growth and development" — Alberto Peña (clinical) [Ep 80 · 15:43](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=943)
- "Defunctionalized colon left distally will not grow and remain tiny; colon requires passing fecal matter through its lumen to grow" — Alberto Peña (clinical) [Ep 80 · 16:03](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=963)
- "The rescue operation involves taking down the ileostomy, finding colonic tissue, performing end-to-end anastomosis, and creating an end colostomy, which makes acidosis disappear the next day" — Alberto Peña (clinical) [Ep 80 · 17:03](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1023)
- "Surgeons must accept they are dealing with a spectrum and sometimes the colonic component is so complex they prefer to avoid it and simply open an ileostomy" — Alberto Peña (opinion) [Ep 80 · 19:13](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1153)
- "The surgeon must not leave gastrointestinal tract inside defunctionalized—this is the main principle" — Alberto Peña (guideline) [Ep 80 · 20:07](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1207)
- "Orthopedic surgeons in some institutions routinely perform pelvic osteotomy at initial operation, which facilitates bladder and omphalocele reconstruction" — Alberto Peña (clinical) [Ep 80 · 21:00](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1260)
- "Even technically correct colostomies sometimes don't work well due to poor motility of the incorporated colon" — Alberto Peña (clinical) [Ep 80 · 22:00](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1320)
- "Babies with poor colonic motility may have bacterial overgrowth similar to Hirschsprung disease and require colostomy irrigation" — Alberto Peña (clinical) [Ep 80 · 22:20](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1340)
- "Babies below 3 years of age are in diapers at home and don't care about them, but around age 3 when starting school is when the second phase of management begins" — Alberto Peña (clinical) [Ep 80 · 23:18](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1398)
- "Most patients require bladder augmentation using gastrointestinal tract, and the pediatric surgeon is the defender of the gastrointestinal tract" — Alberto Peña (opinion) [Ep 80 · 23:54](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1434)
- "Patients born with no colon are candidates for colostomy for life and should never have terminal ileum pulled through even if sphincter evidence exists, because they will never have bowel control" — Alberto Peña (guideline) [Ep 80 · 24:42](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1482)
- "Only patients with capacity to form solid stool should be considered for pull-through, as bowel management only works with solid stool" — Alberto Peña (guideline) [Ep 80 · 25:04](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1504)
- "Surgeons should not underestimate the capacity of tiny pieces of colon to grow and should incorporate everything rather than discarding it" — Alberto Peña (guideline) [Ep 80 · 25:47](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1547)
- "Trial of bowel management through the colostomy simulates the colostomy as the new anus; if enema keeps patient clean for 24 hours with no stool in bag, pull-through may work" — Alberto Peña (clinical) [Ep 80 · 26:41](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1601)
- "If patient has very little colon and cannot form solid stool, the urologist can freely use bowel for augmentation since pull-through is not an option" — Alberto Peña (clinical) [Ep 80 · 28:07](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1687)
- "The colon to be pulled through is the most posterior structure in the pelvis with bladder augmentation in front, so augmentation should not be done before deciding on pull-through or it becomes a nightmare to access" — Alberto Peña (clinical) [Ep 80 · 28:54](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1734)
- "Pull-through and bladder augmentation should ideally be done together in approximately a 12-hour operation" — Alberto Peña (clinical) [Ep 80 · 31:04](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1864)
- "Pediatric surgeon goes first because the colon goes in the back, and separated pubic bones make things easier" — Alberto Peña (clinical) [Ep 80 · 31:16](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1876)
- "Appendix stays up in abdomen when colon is pulled down and can be used for Malone procedure to administer enemas" — Alberto Peña (clinical) [Ep 80 · 31:28](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1888)
- "Urologists almost never use colon for augmentation because colon is needed to form solid stool" — Alberto Peña (clinical) [Ep 80 · 31:57](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1917)
- "Giant colonic pouches with poor motility are good for bowel management because lack of peristalsis means once-daily irrigation keeps patient clean" — Alberto Peña (clinical) [Ep 80 · 32:26](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1946)
- "Midline abdominal incisions are always used in colorectal pediatric surgery to keep flanks and quadrants available for potential stomas" — Alberto Peña (clinical) [Ep 80 · 33:13](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1993)
- "The blood supply in cloacal exstrophy is very bizarre with aberrant abnormal vessels, requiring careful study to avoid ligating crucial vessels and losing the colon" — Alberto Peña (clinical) [Ep 80 · 34:20](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2060)
- "Patients don't need prone positioning because the exstrophy makes everything anterior; frog-leg supine position provides access to entire perineum" — Alberto Peña (clinical) [Ep 80 · 35:53](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2153)
- "Patients have orthopedic problems for life, and some teenagers are unhappy about persistent pubic bone separation" — Alberto Peña (clinical) [Ep 80 · 37:33](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2253)
- "Separated pubic bones cause walking with feet separated and pointing laterally, which looks ugly and patients complain about" — Alberto Peña (clinical) [Ep 80 · 37:55](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2275)
- "Patients with severe spinal problems need ongoing follow-up by pediatric orthopedics and neurosurgeon for tethered cord, sometimes requiring cord release" — Alberto Peña (clinical) [Ep 80 · 38:21](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2301)
- "During pull-through, vaginas are approximated as much as possible; degree of separation varies on the spectrum" — Alberto Peña (clinical) [Ep 80 · 38:50](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2330)
- "When vaginas run in completely different directions and cannot be brought together due to blood supply, one vagina may be removed leaving the one with better-looking cervix" — Alberto Peña (clinical) [Ep 80 · 39:20](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2360)
- "Patients with functional hemi-uterus may become pregnant but it is high-risk and should be followed by specialized pediatric gynecologist" — Alberto Peña (clinical) [Ep 80 · 39:53](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2393)
- "General advice is not to become pregnant, but some patients want to and may deliver by cesarean section" — Alberto Peña (opinion) [Ep 80 · 40:10](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2410)
- "Hemi-uterus has great tendency to produce miscarriages and premature labors" — Alberto Peña (clinical) [Ep 80 · 40:30](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2430)
- "Augmented bladder produces a lot of mucus; if mucus stays it forms stones, requiring family teaching on bladder irrigation and mucus removal" — Alberto Peña (clinical) [Ep 80 · 41:07](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2467)
- "Mitrofanoff may stop working or leak urine and need revision or valve tightening, similar to Malone" — Alberto Peña (clinical) [Ep 80 · 42:04](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2524)
- "When patients transition to adult hospitals they don't feel well because adult specialists lack experience with these malformations" — Alberto Peña (clinical) [Ep 80 · 42:29](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2549)
- "Patients with cloacal exstrophy when they grow up are particularly charming, intelligent, charismatic, and beautiful" — Alberto Peña (opinion) [Ep 80 · 42:57](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2577)
- "Colorectal and urogenital problems have been left behind in terms of scientific approach and research funds because they are not elegant problems related to stool, urine, and sex" — Alberto Peña (opinion) [Ep 80 · 44:48](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2688)
- "Prenatal diagnosis of anorectal and urogenital malformations is easier in the most complex defects because they have visible spinal problems and absent bladder" — Alberto Peña (clinical) [Ep 80 · 47:58](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2878)
- "No bladder visible on ultrasound from week 20 of pregnancy is a bad sign" — Alberto Peña (clinical) [Ep 80 · 49:00](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2940)
- "Prenatal diagnosis allows families to make decisions about pregnancy interruption or to deliver in a place with a specialized team" — Alberto Peña (clinical) [Ep 80 · 49:38](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2978)
- "Certain malformations require centers of excellence with dedicated focused teams, otherwise after 20 years there will be many damaged children and nobody properly trained" — Alberto Peña (opinion) [Ep 80 · 50:30](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=3030)
- "Patients with deformed sacrums have lower likelihood of being successful with bowel management using medication alone, not on an enema program" — Jason Frischer (clinical) [Ep 2 · 7:27](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=447)
- "Malone procedure typically performed starting at around age 5 years and older, most commonly between ages 5 and 10 or 12" — Jason Frischer (clinical) [Ep 2 · 8:17](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=497)
- "Vomiting from enemas can be caused by high volume enemas with irritants stretching the colon and causing discomfort" — Jason Frischer (clinical) [Ep 2 · 8:53](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=533)
- "Enemas should be given either prior to meals or about an hour after a meal to prevent nausea from gastric and bowel distention" — Monica Holder (clinical) [Ep 2 · 9:14](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=554)
- "Sacral nerve stimulators are not FDA approved for children under 18 in the United States but are performed off-label" — Jason Frischer (guideline) [Ep 2 · 10:42](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=642)
- "Manufacturer indication for sacral nerve stimulator requires 50% improvement on symptoms" — Jason Frischer (guideline) [Ep 2 · 10:59](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=659)
- "Maximum enema volume typically around 500 mL for rectal enemas and cecostomy/Malone enemas, occasionally slightly higher" — Monica Holder (clinical) [Ep 2 · 13:03](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=783)
- "When portion of colon is removed, stool becomes softer or less water is absorbed; as more colon removed, stool becomes softer and looser" — Jason Frischer (clinical) [Ep 2 · 17:33](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1053)
- "The large intestine or colon can absorb up to 1 liter of water per day in adults" — Jason Frischer (clinical) [Ep 2 · 17:28](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1048)
- "No proven surgery absolutely works for constipation; surgery may lessen the amount of treatment needed but is not definitively curative" — Jason Frischer (clinical) [Ep 2 · 19:53](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1193)
- "Colon resection is a big surgery requiring anastomosis with associated risks and is used as last-resort option" — Jason Frischer (clinical) [Ep 2 · 22:31](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1351)
- "There is no research leading to scary outcomes of Senna laxative use" — Monica Holder (clinical) [Ep 2 · 24:02](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1442)
- "Patients on long-term Senna use may show melanosis coli (freckling of colon) on colonoscopy but no other long-term side effects" — Jason Frischer (clinical) [Ep 2 · 25:04](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1504)
- "Stimulant laxatives (Senna, Dulcolax) make the colon squeeze and push stool forward, and stool moves quicker through colon with less time to absorb water" — Jason Frischer (clinical) [Ep 2 · 26:59](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1619)
- "MiraLax allows colon to absorb water so water stays in colon and is not absorbed, making stool softer" — Jason Frischer (clinical) [Ep 2 · 27:41](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1661)
- "Patients with colostomy can still suffer from constipation and may need stool softener or laxative" — Monica Holder (clinical) [Ep 2 · 29:04](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1744)
- "Peristeen device designed originally for spina bifida patients, meant for patients with dexterity problems or limited use of extremities" — Monica Holder (clinical) [Ep 2 · 33:32](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2012)
- "Peristeen has more success in patients age 8 or older; younger patients had difficulty with balloon device staying in rectum" — Monica Holder (clinical) [Ep 2 · 34:13](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2053)
- "Sacral nerve stimulator initially designed for urinary incontinence; during testing in postpartum women, found to also help with fecal constipation and incontinence" — Jason Frischer (clinical) [Ep 2 · 37:10](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2230)
- "Sacral nerve stimulator works well in patients with urinary and stool issues in combination" — Jason Frischer (clinical) [Ep 2 · 38:03](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2283)
- "No published pediatric literature details which patients sacral nerve stimulator works in and which it does not due to many variables in patient population" — Jason Frischer (clinical) [Ep 2 · 38:30](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2310)
- "Constipation or fecal impaction puts pressure on urinary tract and can cause urinary infections, improper emptying, urgency, and other symptoms" — Jason Frischer (clinical) [Ep 2 · 40:57](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2457)
- "All patients with anorectal malformations should be followed by urologist long-term to ensure kidney function and proper urinary tract emptying" — Jason Frischer (guideline) [Ep 2 · 41:58](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2518)
- "Long-term use of fleet phosphate enemas can make colon irritated and stiff like a lead pipe, losing mobility and pliability" — Jason Frischer (clinical) [Ep 2 · 46:28](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2788)
- "Celesta is hyaluronic acid polymer used as filler in patulous anus to help with fecal incontinence by making anal canal smaller" — Jason Frischer (clinical) [Ep 2 · 47:27](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2847)
- "Celesta has little side effect with small risk of infection" — Jason Frischer (clinical) [Ep 2 · 48:21](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2901)
- "Sacral nerve stimulator results in spina bifida patients are mixed; some respond positively, others do not" — Jason Frischer (clinical) [Ep 2 · 49:18](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2958)
- "Sacral nerve stimulator requires 3rd sacral foramina or opening where 3rd sacral nerve exits sacrum and innervates pelvis" — Jason Frischer (clinical) [Ep 2 · 50:25](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3025)
- "Botox is muscle relaxant that relaxes anal sphincter, typically used in Hirschsprung disease patients with higher resting anal pressures" — Jason Frischer (clinical) [Ep 2 · 51:57](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3117)
- "Children with normal anatomy typically potty train between 2.5 to 3.5 years, sometimes even 4 years; boys tend to potty train later than girls" — Monica Holder (clinical) [Ep 2 · 53:15](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3195)
- "Anorectal malformation is abnormal development of where colon or rectum ends up during development, with wide spectrum in male and female patients" — Jason Frischer (clinical) [Ep 2 · 56:58](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3418)
- "Dissection of the fistula up to the red line is necessary to prevent residual fistula without injuring nerves, prostate, urethra, and sphincters" — Yamataka (clinical) [Ep 7 · 0:21](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=21)
- "29 male patients with imperforate anus: 1 vesical fistula, 14 prostatic fistula, 9 bulbar fistula, 5 no fistula; 23 with rectourethral fistula were studied" — Yamataka (clinical) [Ep 7 · 0:51](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=51)
- "Fine flexible colonoscope inserted into anterior rectal wall allows both the fistula orifice and level of laparoscopic dissection to be observed intraluminally" — Yamataka (clinical) [Ep 7 · 1:52](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=112)
- "Fine catheter with calibration inserted through opening by lap surgeon while another surgeon performing cystoscopy observes how far it emerges at or near the verumontanum" — Yamataka (clinical) [Ep 7 · 2:37](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=157)
- "Lap surgeon can measure inside length of fistula between fistula opening and urethral side orifice, thus calculating actual length of residual fistula" — Yamataka (clinical) [Ep 7 · 2:52](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=172)
- "If length of residual fistula longer than 5 millimeters, rectal end is further dissected toward urethra using mucosectomy" — Yamataka (clinical) [Ep 7 · 4:27](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=267)
- "Mucosectomy technique used to prevent injury of prostate and urethra" — Yamataka (clinical) [Ep 7 · 4:44](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=284)
- "Procedure repeated until length of residual fistula is shorter than or equal to 5 millimeters, then fistula is ligated, tied, and excised" — Yamataka (clinical) [Ep 7 · 4:57](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=297)
- "For bulbar fistula, suprapubic tube cystostomy is very important to decompress bladder and open up clear view of deep pelvic floor" — Yamataka (clinical) [Ep 7 · 6:16](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=376)
- "Trocar position for bulbar fistula differs from prostatic fistula: right and left trocars placed much closer to telescope" — Yamataka (clinical) [Ep 7 · 6:49](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=409)
- "Adjustable telescope (0 to 120 degrees) allows surgeon freedom to choose best view without disrupting dissection" — Yamataka (clinical) [Ep 7 · 7:10](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=430)
- "Despite increased difficulty in handling forceps, closer trocar position allows forceps tips to reach deeper and reach bulbar urethra located deep in pelvis" — Yamataka (clinical) [Ep 7 · 7:32](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=452)
- "After fistula is tied, catheter is again inserted until it gently probes tied fistula, allowing surgeon to reconfirm residual fistula length is ≤5 millimeters" — Yamataka (clinical) [Ep 7 · 8:30](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=510)
- "First 8 cases: initial measurements from rectal to urethral orifice were 13, 15, 12, 10, 15, 21, 10, 5 millimeters respectively" — Yamataka (clinical) [Ep 7 · 9:25](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=565)
- "7 of 8 cases required further dissection until fistula ≤5mm; case 8 did not require further dissection" — Yamataka (clinical) [Ep 7 · 9:39](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=579)
- "During cystoscopy, normal saline refluxed into pelvic floor through fistula in 6 cases (indicating large fistula), but no reflux in 2 cases (indicating very narrow fistula)" — Yamataka (clinical) [Ep 7 · 9:48](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=588)
- "All patients well after mean follow-up of 2 years with no evidence of diverticular formation due to residual fistula on voiding cystourethrography or MRI in all 23 cases" — Yamataka (clinical) [Ep 7 · 10:10](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=610)
- "All dissections were uncomplicated and postoperative courses were unremarkable" — Yamataka (clinical) [Ep 7 · 10:20](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=620)
- "Residual fistula from rectal site to urethral side is much longer than expected" — Yamataka (clinical) [Ep 7 · 10:28](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=628)
- "Measuring exact length of fistula facilitates safe and complete excision, reducing risk of postoperative diverticulum formation due to incomplete fistula excision" — Yamataka (clinical) [Ep 7 · 10:37](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=637)
- "For prostatic fistula, if lap surgeon has training for gallbladder removal or other fundamental techniques, they can perform the procedure" — Yamataka (opinion) [Ep 7 · 13:10](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=790)
- "Key for dissection of fistula is decompression of bladder" — Yamataka (clinical) [Ep 7 · 13:31](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=811)
- "If lap surgeon technique is not good enough, recommend inserting suprapubic catheter first for complete decompression to provide good view of pelvic floor" — Yamataka (opinion) [Ep 7 · 13:53](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=833)
- "For bulbar fistula dissection, lap surgeon needs 5 to 10 cases of prostatic fistula experience before attempting" — Yamataka (opinion) [Ep 7 · 14:32](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=872)
- "Trocar position must be very close to telescope for bulbar fistula, otherwise instrument tip cannot reach deep side of pelvis or bulbar fistula" — Yamataka (clinical) [Ep 7 · 14:43](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=883)
- "2-3 traction sutures used to bring bladder up during dissection" — Yamataka (clinical) [Ep 7 · 15:58](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=958)
- "Right transverse colostomy preferred because sigmoid colostomy can fix rectum and colon, requiring takedown of sigmoid colostomy to achieve adequate length for pull-through" — Yamataka (opinion) [Ep 7 · 16:52](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1012)
- "If sigmoid colostomy done very proximal at descending colon-sigmoid junction, will have enough length for pull-through even for high fistula" (opinion) [Ep 7 · 17:19](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1039)
- "Transverse colostomy has too many problems including urine absorption, infection, and prolapse" — Sherif Emil (opinion) [Ep 7 · 18:37](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1117)
- "With sigmoid colostomy on left side and ports placed more midline for bulbar fistula, colostomy location becomes less of an obstacle" — Jose (opinion) [Ep 7 · 19:42](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1182)
- "Can place ports in left upper quadrant and go lateral to sigmoid colostomy; it is not an issue" (opinion) [Ep 7 · 20:10](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1210)
- "For prostatic or bladder neck fistula, can do dissection without this measurement technique and get very close to end of fistula" (opinion) [Ep 7 · 20:21](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1221)
- "Laparoscopic approach for bulbar fistula is far more difficult and more dangerous; technique described is extremely complicated for average pediatric surgeon" (opinion) [Ep 7 · 21:06](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1266)
- "PSARP technique is easy for bulbar fistula patients" (opinion) [Ep 7 · 21:20](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1280)
- "No convincing data that laparoscopic approach results in better outcomes for bulbar fistulas than PSARP" (opinion) [Ep 7 · 21:25](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1285)
- "Reason for sticking to laparoscopic procedure even for bulbar fistula is to avoid cutting anal sphincter and damaging muscle and nerves for sphincters" — Yamataka (opinion) [Ep 7 · 21:32](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1292)
- "Getting good distal colostogram at beginning is critical; if cannot get good view of fistula, repeat it" — Yamataka (clinical) [Ep 7 · 22:13](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1333)
- "Sometimes do colonoscopy before operation through transverse colostomy if doubt whether patient has fistula; can combine colonoscopy and cystoscopy if colostogram does not show nice anatomy" — Yamataka (clinical) [Ep 7 · 22:49](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1369)
- "Combining VCUG and colostogram at same time by putting dye in from both sides usually allows clear visualization of fistula" (clinical) [Ep 7 · 23:41](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1421)
- "Empty bladder is critically important when doing laparoscopic anorectal malformation repair" (clinical) [Ep 7 · 23:51](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1431)
- "Sometimes Foley catheter placed at beginning goes into fistula and rectum instead of bladder, may not be discovered until middle of operation" (clinical) [Ep 7 · 24:04](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1444)
- "Probably good idea to cystoscope all these patients at beginning of case to ensure catheter is actually in bladder before starting" (opinion) [Ep 7 · 24:22](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1462)
- "When doing cystoscopy, must inject saline for visualization; bladder decompression via suprapubic catheter needed, otherwise bladder fills with saline and pelvic floor cannot be seen" — Yamataka (clinical) [Ep 7 · 24:33](https://library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1473)
- "Genitourinary anomalies and anorectal malformations represent a broad spectrum, with more severe malformations having higher chances of abnormal amniotic fluid volume" — Maria Calvos (clinical) [Ep 17 · 11:29](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=689)
- "Ultrasound can accurately define amniotic fluid volume and cystic structures, with bladder outlined by umbilical arteries on axial plane from abdominal cord insertion" — Maria Calvos (clinical) [Ep 17 · 12:18](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=738)
- "Echogenic concretions or meconium in hydrocolpos or bladder are clues for rectourinary fistula in anorectal malformation" — Maria Calvos (clinical) [Ep 17 · 13:45](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=825)
- "Ultrasound has technical limitations in settings of poor amniotic fluid and cannot detect early stages of cystic renal dysplasia" — Maria Calvos (clinical) [Ep 17 · 14:36](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=876)
- "Fetal bowel contains natural contrast media: proximal bowel has bright fluid content on T2-weighted MRI, while meconium appears dark on T2 and bright on T1-weighted imaging" — Maria Calvos (clinical) [Ep 17 · 15:22](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=922)
- "Meconium does not reach the rectum until 20 weeks gestation and fills the entire colon by 26 weeks" — Maria Calvos (clinical) [Ep 17 · 16:23](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=983)
- "Normal fetal rectum measures at least 10 millimeters from bladder base to most distal segment on sagittal MRI view" — Maria Calvos (clinical) [Ep 17 · 16:44](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1004)
- "Long common channel cloaca presents with high position of rectum and dilation on prenatal MRI" — Maria Calvos (clinical) [Ep 17 · 18:02](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1082)
- "Cloacas and imperforate anus with rectourinary fistula can have fluid distention of rectum and enterolith, with bright T2 signal indicating increased fluid content" — Maria Calvos (clinical) [Ep 17 · 19:02](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1142)
- "Urogenital sinus shows normal rectum course posterior to bladder then to hydrocolpos, distinguishing it from cloaca where rectum is abnormally positioned" — Maria Calvos (clinical) [Ep 17 · 20:49](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1249)
- "Cloacal exstrophy typically presents with persistent absent bladder visualization, normal amniotic fluid, low omphalocele, and skin-covered spinal defects" — Maria Calvos (clinical) [Ep 17 · 22:14](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1334)
- "The 'elephant trunk sign' refers to prolapsed terminal ileum protruding and floating in amniotic fluid, characteristic of cloacal exstrophy" — Maria Calvos (clinical) [Ep 17 · 23:05](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1385)
- "Cloacal exstrophy can be misdiagnosed as gastroschisis on ultrasound, but is distinguished by absent bladder and low position of protruding structure below umbilical cord insertion" — Maria Calvos (clinical) [Ep 17 · 23:50](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1430)
- "Fetuses with cloacal exstrophy show no meconium signal in expected rectum distribution on MRI, distinguishing it from bladder exstrophy which has normal rectum" — Maria Calvos (clinical) [Ep 17 · 24:54](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1494)
- "Many cloacal malformations are missed prenatally and misdiagnosed as urethroceles, double bladders, ovarian cysts, or bladder diverticula by non-specialized radiologists" — Alberto Peña (epidemiological) [Ep 17 · 30:26](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1826)
- "Hydrocolpos is not well described in radiology literature, leading many non-specialized radiologists to miss or misinterpret this finding" — Alberto Peña (epidemiological) [Ep 17 · 32:15](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1935)
- "Prenatal diagnosis allows transfer to specialized centers for proper colostomy and hydrocolpos drainage, and gives families time to prepare" — Andrea Bischoff (clinical) [Ep 17 · 32:46](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=1966)
- "Current prenatal imaging cannot reliably predict common channel length or sacral anatomy, limiting ability to counsel parents about future bowel control, urinary control, and sexual function" — Andrea Bischoff (clinical) [Ep 17 · 33:30](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=2010)
- "At Sick Kids Toronto, increasing numbers of cloacal patients have prenatal diagnosis, but the majority still do not" — Jack Langer (epidemiological) [Ep 17 · 34:52](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=2092)
- "Findings of cloacal malformations on routine 20-week ultrasound may be very subtle, requiring high index of suspicion that most community obstetricians lack" — Jack Langer (opinion) [Ep 17 · 35:00](https://library.globalcastmd.com/watch/cloaca-prental-imaging-diagnosis-counseling-682?t=2100)
- "Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period" — Marc Levitt (clinical) [Ep 31 · 2:57](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=177)
- "Males with perineal fistula may pass meconium and the malformation goes unnoticed, typically presenting in the first year of life with severe constipation" — Marc Levitt (clinical) [Ep 31 · 3:06](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=186)
- "A newborn anus should accept a size 12 Hagar dilator and a one-year-old should accept size 15" — Marc Levitt (clinical) [Ep 31 · 6:16](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=376)
- "Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation" — Marc Levitt (clinical) [Ep 31 · 4:54](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=294)
- "Patients with uncorrected perineal fistula will soil with loose stool or athletic activity because they cannot completely close the hole when squeezing sphincters" — Marc Levitt (clinical) [Ep 31 · 5:40](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=340)
- "A bucket handle skin tag is consistent with a perineal fistula even if the fistula itself is not visible" — Marc Levitt (clinical) [Ep 31 · 6:42](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=402)
- "Perineal fistula in females is probably the most confounding diagnostic challenge in pediatric colorectal surgery, with both missed diagnoses and overdiagnosis occurring" — Marc Levitt (opinion) [Ep 31 · 7:33](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=453)
- "If the anal opening in a female is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed as the perineal body will lengthen with growth" — Marc Levitt (clinical) [Ep 31 · 8:47](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=527)
- "Commercial muscle stimulators costing $15,000 can be replaced by anesthesia nerve stimulators costing $150 with appropriate needle attachments" — Marc Levitt (clinical) [Ep 31 · 10:52](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=652)
- "In rectourethral fistula, the rectum could be at bladder neck, prostatic, or bulbar level, and attempting to find it without knowing the level risks finding urinary tract structures instead" — Marc Levitt (clinical) [Ep 31 · 12:45](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=765)
- "Rectourethral fistulas should be managed with colostomy and distal colostogram rather than primary repair, except in exceedingly rare cases where cross-table lateral at 20 hours shows very low rectum" — Marc Levitt (guideline) [Ep 31 · 13:20](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=800)
- "The standard of not checking rectal temperature in newborns makes it easier to miss anorectal malformations" — Marc Levitt (opinion) [Ep 31 · 4:25](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=265)
- "Cloaca is distinguished from urogenital sinus with virilization by the absence of a normal anus; cloaca patients have no anus while urogenital sinus patients have completely normal anus" — Marc Levitt (clinical) [Ep 31 · 15:49](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=949)
- "The most common colostomy error is opening too distal in the sigmoid, which restricts the ultimate pull-through" — Marc Levitt (clinical) [Ep 31 · 17:18](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1038)
- "Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections" — Marc Levitt (clinical) [Ep 31 · 17:45](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1065)
- "Transverse colostomies can cause acidosis when large rectourethral fistulas allow the left colon to absorb urine" — Marc Levitt (clinical) [Ep 31 · 18:38](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1118)
- "Prolapse risk depends on colostomy location: mid-transverse can prolapse both sides, hepatic flexure only distal, proximal sigmoid only distal because left colon is fixed to retroperitoneum" — Marc Levitt (clinical) [Ep 31 · 19:58](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1198)
- "Marking the anoplasty location on the skin surface before making the incision prevents getting lost when looking at stimulated jumping muscles" — Marc Levitt (clinical) [Ep 31 · 21:30](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1290)
- "A properly done distal colostogram requires enough contrast and pressure to overcome the PC line (puborectalis compression), otherwise it gives false impression of high rectum or absent fistula" — Marc Levitt (clinical) [Ep 31 · 24:11](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1451)
- "The urethra can be visualized as a reverse C or elbow; fistula at or below the elbow is bulbar, above the elbow is prostatic, at bladder neck is bladder neck fistula" — Marc Levitt (clinical) [Ep 31 · 25:23](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1523)
- "Bulbous rectums are more easily approached posterior sagittally while tapered rectums are better suited for laparoscopy" — Marc Levitt (clinical) [Ep 31 · 25:55](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1555)
- "Opening posterior sagittally without knowing rectum location risks finding and potentially mobilizing bladder neck instead of rectum" — Marc Levitt (clinical) [Ep 31 · 27:00](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1620)
- "Bulbar and low prostatic fistulas are found right under or distal to the coccyx; bladder neck fistulas are not reachable through posterior sagittal approach" — Marc Levitt (clinical) [Ep 31 · 27:36](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1656)
- "Laparoscopy replaces laparotomy, not PSARP; a mini-PSARP should still be done with laparoscopy for safe entry and prolapse prevention" — Marc Levitt (opinion) [Ep 31 · 31:48](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1908)
- "Rectal prolapse occurs in about 3% of cases, particularly in patients without great muscles" — Marc Levitt (epidemiological) [Ep 31 · 33:33](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2013)
- "Rectal prolapse greater than 3 millimeters should be treated because it causes bleeding, mucus, and can inhibit bowel control even in patients with good muscles" — Marc Levitt (clinical) [Ep 31 · 34:14](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2054)
- "Circumferential prolapse can be repaired in two stages (half circumference each) in ambulatory settings, avoiding hospitalization and eliminating need for dilation since half remains untouched" — Marc Levitt (clinical) [Ep 31 · 34:48](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2088)
- "Perineal body dehiscence is the most common cause of reoperation in female ARM repairs" — Marc Levitt (epidemiological) [Ep 31 · 36:03](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2163)
- "Proper anterior rectal wall mobilization to the areolar plane between rectum and vagina is essential to prevent tension and subsequent perineal body dehiscence" — Marc Levitt (clinical) [Ep 31 · 35:41](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2141)
- "Clear liquids only for one week postoperatively prevents hard stool formation while allowing more stool volume, showing good perineal body healing results" — Marc Levitt (clinical) [Ep 31 · 36:45](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2205)
- "Early perineal body dehiscence detected on days 5-8 can be salvaged by taking patient back to OR for re-suturing" — Marc Levitt (clinical) [Ep 31 · 37:48](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2268)
- "Attempting laparoscopic dissection of rectum that is too low risks leaving behind remnant of original fistula (distal rectum) or getting too close to urinary tract" — Marc Levitt (clinical) [Ep 31 · 38:36](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2316)
- "For high rectums, especially bladder neck fistulas, the IMA must be preserved because prior colostomy may have disrupted collaterals down the left colic, making rectum completely dependent on IMA" — Marc Levitt (clinical) [Ep 31 · 39:33](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2373)
- "The ARM continence index uses three factors to predict continence potential: original malformation type, sacral ratio, and spine quality" — Marc Levitt (clinical) [Ep 31 · 42:23](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2543)
- "A bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control" — Marc Levitt (clinical) [Ep 31 · 43:19](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2599)
- "A bladder neck fistula with sacral ratio of 0.4 and tethered cord or myelomeningocele has no real chance of good bowel control" — Marc Levitt (clinical) [Ep 31 · 43:29](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2609)
- "The unique challenge of ARM surgery is that technical errors may not become apparent for several years, unlike most surgical procedures where problems are immediately evident" — Marc Levitt (opinion) [Ep 31 · 46:25](https://library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2785)
- "The incidence of enterocolitis is significantly higher in children with trisomy 21, as much as double the incidence in genetically normal kids" (epidemiological) [Ep 46 · 36:05](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=2165)
- "False positive contrast enemas occur in newborns showing a transition zone that looks like Hirschsprung's but is not" — Langer (clinical) [Ep 46 · 4:58](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=298)
- "In older kids, if they have a normal recto-anal inhibitory reflex on manometry, they don't have Hirschsprung's and don't need biopsy" — Langer (clinical) [Ep 46 · 14:19](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=859)
- "Manometry can have false absence of the reflex, so if reflex is absent you still have to biopsy" — Langer (clinical) [Ep 46 · 14:37](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=877)
- "There are two definitions for ultra-short segment Hirschsprung's: absence of recto-anal inhibitory reflex with normal ganglion cells (internal sphincter achalasia), versus very short segment of true aganglionosis" — Langer (clinical) [Ep 46 · 15:15](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=915)
- "Internal sphincter achalasia is not Hirschsprung's disease, it's a different entity" — Langer (opinion) [Ep 46 · 15:54](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=954)
- "The incidence of long segment Hirschsprung's in girls is fifty-fifty, so odds are much higher than in boys" (epidemiological) [Ep 46 · 8:49](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=529)
- "In Mana Proctor's paper, 8% of cases that looked like short transition zone had pathological transition zone significantly higher (long transition zone)" — Langer (clinical) [Ep 46 · 8:02](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=482)
- "Most cecal perforations from Hirschsprung's disease are not total colonic disease, they are shorter segment disease where the cecum gets distended and perforates like with a rectal cancer" — Langer (clinical) [Ep 46 · 20:55](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1255)
- "In long segment disease, wait longer before pull-through (6 to 12 months) because patients have terrible perianal excoriation if pulled through too early, need to wait till stoma output thickens" — Langer (clinical) [Ep 46 · 22:40](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1360)
- "Experience with very short pull-through using just the cecum has not been good, patients end up with stasis and enterocolitis from the big pouch reservoir" — Langer (opinion) [Ep 46 · 23:37](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1417)
- "For ascending colon or cecal transition zones, treat like total colon disease and do ileal Duhamel rather than preserving the short colonic segment" — Langer (opinion) [Ep 46 · 23:48](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1428)
- "If transition zone is at hepatic flexure, preserve the colon and bring it down, but if just cecum, sacrifice it" — Langer (opinion) [Ep 46 · 24:23](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1463)
- "In older children with massive dilation, distal bowel can shrink in size with a stoma for 6 or 8 months at age 3, making pull-through easier" — Langer (clinical) [Ep 46 · 32:26](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1946)
- "The older the kid, the less likely the dilated bowel will shrink down in size with diversion" — Langer (clinical) [Ep 46 · 32:42](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1962)
- "The anal canal in an adult is 3 to 4 centimeters long, versus 1 centimeter in an infant, so biopsies at 3 cm in an adolescent may actually be from the anal canal where there are normally no ganglion cells" (clinical) [Ep 46 · 17:13](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1033)
- "In the anal canal there are no ganglion cells normally, but you should not see hypertrophic nerves" (clinical) [Ep 46 · 17:25](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1045)
- "Biopsies from anal canal should show transitional epithelium, not normal rectum mucosa" — Langer (clinical) [Ep 46 · 17:39](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1059)
- "Botox injection decreased the number of hospitalizations for enterocolitis in children post-pull-through" — Langer (clinical) [Ep 46 · 37:48](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=2268)
- "Botox doesn't always work for enterocolitis, sometimes it works and sometimes it doesn't" — Langer (clinical) [Ep 46 · 37:58](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=2278)
- "Many kids need chronic metronidazole for enterocolitis, can be on it for three months, and when you try taking them off they start getting symptoms again, some need it for a long time" — Langer (clinical) [Ep 46 · 37:33](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=2253)
- "There is an occasional patient really sick from enterocolitis where you may not want to wait for tissue diagnosis and might have to operate and divert because it's long segment, can't decompress with irrigation, and pathology won't be back for days" (clinical) [Ep 46 · 5:16](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=316)
- "In older children trying to resect dilated colon transanally, the stretch put on the sphincter is enormous and continence postoperatively definitely suffers" — Garrison (clinical) [Ep 46 · 31:50](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1910)
- "For older children with dilated colon, go all the way down with laparoscopic dissection and do very little resection transanally to minimize sphincter stretch" — Garrison (opinion) [Ep 46 · 32:04](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=1924)
- "Biopsies done by colonoscopy in older children can miss Hirschsprung's disease, rectal biopsy is more reliable" — Garrison (clinical) [Ep 46 · 33:33](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1056?t=2013)
- "Common channel less than 3 cm with urethral length 1.5 cm or greater allows total urogenital mobilization" — Marc Levitt (clinical) [Ep 117 · 8:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=482)
- "Common channel greater than 3 cm almost always requires urogenital separation" — Marc Levitt (clinical) [Ep 117 · 8:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=494)
- "About 30 to 50% of children with cloaca develop long-term renal dysfunction" — Richard Wood (epidemiological) [Ep 117 · 3:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=227)
- "Vaginal voiding persists after isolated rectal repair, maintaining UTI risk" — Richard Wood (clinical) [Ep 117 · 3:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=219)
- "The protocol has led to a significant reduction in need for redo operations" — Marc Levitt (opinion) [Ep 117 · 4:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=297)
- "PC line (pubis to coccyx) is the reference for determining rectal height" — Richard Wood (clinical) [Ep 117 · 6:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=416)
- "High rectum in cloaca may be reachable posterior sagittally when doing TUM, unlike in males" — Marc Levitt (clinical) [Ep 117 · 9:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=575)
- "Full rectal mobilization to peritoneum is required to visualize lateral and posterior vaginal attachments and blood supply" — Richard Wood (clinical) [Ep 117 · 14:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=882)
- "In TUM, the common channel is opened widely until urethral and vaginal openings are clearly visible" — Richard Wood (clinical) [Ep 117 · 12:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=772)
- "In separation, the common channel is left intact and not opened" — Richard Wood (clinical) [Ep 117 · 13:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=793)
- "Remeasuring common channel intraoperatively before TUM allows conversion to separation if measurements were incorrect" — Richard Wood (clinical) [Ep 117 · 13:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=829)
- "Full-thickness lateral dissection is essential in TUM to avoid tissue breakdown and ensure good tissue for suturing" — Richard Wood (clinical) [Ep 117 · 17:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1038)
- "Division of common channel should be 0.5 cm behind clitoral tissue to preserve nerve supply" — Richard Wood (clinical) [Ep 117 · 17:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1063)
- "Suspensory ligaments should be released until retropubic fat is visible, gaining approximately 2 to 2.5 cm of length" — Marc Levitt (clinical) [Ep 117 · 19:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1187)
- "There is no demonstrated functional benefit of partial TUM over complete TUM" — Richard Wood (clinical) [Ep 117 · 18:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1108)
- "Vaginal length less than 4 cm predicts higher likelihood of needing vaginal replacement" — Richard Wood (clinical) [Ep 117 · 31:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1906)
- "Vaginal length greater than 6 cm predicts lower likelihood of needing vaginal replacement" — Richard Wood (clinical) [Ep 117 · 32:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1923)
- "When vaginas are posterior to rectum, they are often adherent to presacral fascia and more difficult to mobilize than rectum" — Richard Wood (clinical) [Ep 117 · 23:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1423)
- "In separation, ureters approach from lateral, requiring strict midline dissection initially" — Marc Levitt (clinical) [Ep 117 · 26:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1592)
- "Urethral length can be calculated intraoperatively: 1 cm above visible urethral opening in common channel equals bladder neck location" — Richard Wood (clinical) [Ep 117 · 28:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1707)
- "Posterior sagittal dissection should stop within 0.5 cm of ureteral insertion or at bladder neck level to avoid ureteral injury" — Richard Wood (clinical) [Ep 117 · 29:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1747)
- "Ureteric stents placed cystoscopically before surgery provide reassurance during laparoscopic separation" — Richard Wood (clinical) [Ep 117 · 29:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1785)
- "Laparoscopic separation uses scissors with minimal or no cautery to avoid ureteral injury" — Richard Wood (clinical) [Ep 117 · 30:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1858)
- "Laparoscopic approach may reduce need for vaginal replacement compared to open approach" — Richard Wood (opinion) [Ep 117 · 31:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1880)
- "Vagina tends to envelop bladder neck rather than staying in a distinct plane like rectum in males" — Richard Wood (clinical) [Ep 117 · 34:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2052)
- "Double-layer urethral repair with SIS and fat pad eliminated urethrovaginal fistulas over 5.5 years" — Richard Wood (clinical) [Ep 117 · 32:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1973)
- "Leaving adequate vaginal cuff tissue allows tension-free urethral closure and is critical for fistula prevention" — Marc Levitt (clinical) [Ep 117 · 26:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=1619)
- "97% of patients repaired using the protocol maintain a catheterizable urethra" — Richard Wood (clinical) [Ep 117 · 37:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2244)
- "Perineal urethral access is valuable even if patient later requires Mitrofanoff, as it provides a pop-off for bladder emptying" — Richard Wood (opinion) [Ep 117 · 37:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2260)
- "Attempting TUM that fails and then converting to separation can devascularize the urethra, leaving patient with no functional urethra" — Marc Levitt (clinical) [Ep 117 · 41:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2486)
- "Since implementing measurement protocol, surgical plans have matched intraoperative findings in every case" — Marc Levitt (opinion) [Ep 117 · 42:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=2533)
- "Surgeons who do not specialize in cloaca often repair the rectum but leave the urogenital sinus for later, creating a reoperative field" — Marc Levitt (clinical) [Ep 117 · 2:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=161)
- "The two sides of the split common channel in TUM become the labia minora" — Marc Levitt (clinical) [Ep 117 · 16:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-24-cloaca-part-3-5055?t=977)
- "A single-center prospective RCT showed routine anal dilations may not be needed following PSARP, with equivalent stricture rates between dilation and non-dilation groups (3 strictures in dilation arm, 8 in non-dilation arm, non-significant difference)." — Rebecca Rentia (clinical) [Ep 123 · 3:35](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=215)
- "Heineke-Mikulicz anoplasty can be performed for post-PSARP strictures, sometimes at the time of colostomy takedown, avoiding the need for routine dilations." — Rebecca Rentia (clinical) [Ep 123 · 5:33](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=333)
- "Literature shows a component of psychological dissociation in children on later testing related to anal dilation protocols." — Rebecca Rentia (clinical) [Ep 123 · 4:00](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=240)
- "A stricture is defined as a Hagar dilator size of less than 10, which is 2 standard deviations below the newborn norm of Hagar size 12." — Rebecca Rentia (clinical) [Ep 123 · 4:36](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=276)
- "The PCPLC (Pediatric Colorectal and Pelvic Learning Consortium) is a multi-institutional consortium across 17 US institutions collecting intensive longitudinal data on pediatric colorectal patients." — Rebecca Rentia (clinical) [Ep 123 · 11:07](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=667)
- "NSQIP-P data (291 patients) showed no statistical difference in 30-day complications between early repair (under 6 days) and late repair (6 weeks to 8 months) of perineal and rectovesibular fistulas." — Caitlin Smith (clinical) [Ep 123 · 14:55](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=895)
- "PCPLC data (164 patients) showed no difference in 30-day outcomes between early repair (under 14 days) and late repair (after 14 days) of perineal and rectovesibular fistulas." — Caitlin Smith (clinical) [Ep 123 · 15:53](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=953)
- "Neonates and infants under about 3 months tolerate anal dilations well, but dilations are more psychologically stressful for older children and parents." — Caitlin Smith (opinion) [Ep 123 · 17:39](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1059)
- "Repair of low anorectal malformations is typically performed around 2 to 3 months of age to balance keeping the fistula open while avoiding massive constipation before repair." — Caitlin Smith (clinical) [Ep 123 · 18:17](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1097)
- "Formula-fed infants requiring caloric concentration may need earlier repair due to thicker stools, while breastfed infants can safely delay repair until 2-3 months." — Caitlin Smith (clinical) [Ep 123 · 18:54](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1134)
- "Repair should be completed before infants start solid foods, as this makes home dilation strategy much more difficult." — Caitlin Smith (clinical) [Ep 123 · 19:17](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1157)
- "Long-segment Hirschsprung disease is defined as any disease proximal to the rectosigmoid colon in the majority of reviewed articles." — Rebecca Rentia (clinical) [Ep 123 · 22:57](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1377)
- "Contrast studies are very inaccurate for determining transition zone level in Hirschsprung disease; colonic mapping with biopsies is needed." — Rebecca Rentia (clinical) [Ep 123 · 23:38](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1418)
- "Early pull-through for total colonic Hirschsprung (around 5 months) is possible if ileostomy effluent is adequately prepared using water-soluble fiber and Imodium to thicken and slow stool." — Rebecca Rentia (clinical) [Ep 123 · 24:45](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1485)
- "Delaying total colonic Hirschsprung pull-through too long (waiting for toilet training) can result in horrible anal sphincter spasm and pelvic disease that makes maintaining the pull-through challenging." — Rebecca Rentia (clinical) [Ep 123 · 26:23](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1583)
- "PCPLC bowel management study of 624 ARM patients showed the majority (418, or 2/3) were enrolled in bowel management programs, with constipation as the primary complaint." — Caitlin Smith (epidemiological) [Ep 123 · 27:53](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1673)
- "In the PCPLC ARM cohort, only 40% were toilet-trained and about half reported daytime stool accidents." — Caitlin Smith (epidemiological) [Ep 123 · 29:18](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1758)
- "Even mild and moderate ARM patients in the 5-12 year age group frequently require enemas and intensive bowel management strategies to stay clean for school." — Caitlin Smith (clinical) [Ep 123 · 28:24](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1704)
- "PCPLC Hirschsprung timing study showed preoperative enterocolitis rates were the same (about 2 cases each) between early (under 31 days) and late (over 31 days) pull-through groups." — Rebecca Rentia (clinical) [Ep 123 · 30:19](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1819)
- "Post-operative enterocolitis rates were similar (40-50%) in both early and late Hirschsprung pull-through groups, with at least one episode occurring in each." — Rebecca Rentia (clinical) [Ep 123 · 30:37](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1837)
- "Constipation and incontinence outcomes tracked to 3.5 years were the same for early and late Hirschsprung pull-through groups." — Rebecca Rentia (clinical) [Ep 123 · 30:46](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1846)
- "Transition zone level (not timing of surgery) was the marker predicting whether a Hirschsprung patient would need treatment for constipation." — Rebecca Rentia (clinical) [Ep 123 · 30:55](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1855)
- "Delayed Hirschsprung pull-through with home irrigation is a safe alternative to neonatal operation if there is adequate family support system." — Rebecca Rentia (clinical) [Ep 123 · 31:12](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1872)
- "PCPLC study of 525 ARM patients showed public insurance was associated with decreased rates of urinary continence." — Caitlin Smith (epidemiological) [Ep 123 · 32:26](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1946)
- "Clinical factors (type of ARM, spine and sacrum characteristics) were also related to continence outcomes in ARM patients." — Caitlin Smith (clinical) [Ep 123 · 32:55](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1975)
- "Normal female urethral length is about 2.5 cm; a minimum of 1.5 cm is needed to avoid incontinence risk when mobilizing the urethra in cloacal reconstruction." — Rebecca Rentia (clinical) [Ep 123 · 35:19](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=2119)
- "If the urethra is pulled past the bladder neck during cloacal reconstruction, there is a risk for incontinence." — Rebecca Rentia (clinical) [Ep 123 · 35:45](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=2145)
- "A short vagina, even in an otherwise short common channel cloaca, may require vaginal replacement." — Rebecca Rentia (clinical) [Ep 123 · 35:57](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=2157)
- "Rotational fluoroscopy and 3D reconstructions are key to making reliable anatomic measurements for cloacal reconstruction planning." — Rebecca Rentia (clinical) [Ep 123 · 36:05](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=2165)
- "About 5-8% of patients require strictureplasty at 2 months post-PSARP when dilations are not routinely performed." — Rebecca Rentia (epidemiological) [Ep 123 · 10:33](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=633)
- "A no fistula defect is very similar to a bulbar fistula in terms of surgical approach" — Marc Levitt (clinical) [Ep 8 · 0:20](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=20)
- "The key to starting any anorectal malformation case is a good imaging study" — Marc Levitt (clinical) [Ep 8 · 0:45](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=45)
- "A bladder neck fistula is at the deltoid level, rectoprostatic fistula at the triceps level, and rectobulbar fistula at the elbow of the urethral curve or distal" — Marc Levitt (clinical) [Ep 8 · 1:05](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=65)
- "Patient positioning requires prone position with buttocks elevated, good axillary support, and feet supported so toes don't touch the bed" — Marc Levitt (clinical) [Ep 8 · 1:31](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=91)
- "The sphincter ellipse should be marked before the posterior sagittal incision because it becomes hard to identify afterward" — Marc Levitt (clinical) [Ep 8 · 1:50](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=110)
- "The sphincters must be cut perfectly in the midline so they can be easily reconstructed" — Marc Levitt (clinical) [Ep 8 · 2:28](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=148)
- "Without a good distal colostogram, the midline whitish structure could be urinary tract rather than rectum" — Marc Levitt (clinical) [Ep 8 · 2:42](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=162)
- "The anterior dissection should continue until running out of rectum, which is the point where a fistula would normally be" — Marc Levitt (clinical) [Ep 8 · 3:09](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=189)
- "Lateral dissection should be performed before turning attention anteriorly" — Marc Levitt (clinical) [Ep 8 · 3:21](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=201)
- "The initial anterior dissection for the first few millimeters is a submucosal dissection" — Marc Levitt (clinical) [Ep 8 · 3:35](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=215)
- "The lateral dissection defines the anterior dissection; when unsure, go lateral" — Marc Levitt (clinical) [Ep 8 · 4:07](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=247)
- "When lateral, any fat seen means you can get closer to the rectum" — Marc Levitt (clinical) [Ep 8 · 4:14](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=254)
- "The lower the rectum, the longer the common wall between rectum and urinary tract" — Marc Levitt (clinical) [Ep 8 · 4:23](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=263)
- "Lower rectum is easier in that it is lower, but harder because there is a longer dissection adjacent to the urethra" — Marc Levitt (clinical) [Ep 8 · 4:29](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=269)
- "A rectobulbar fistula is too low to approach laparoscopically and is much safer to approach posterior sagittally" — Marc Levitt (opinion) [Ep 8 · 4:38](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=278)
- "Laparoscopic approach to low rectum risks leaving behind distal rectum, a remnant of the urethral fistula, or a roof" — Marc Levitt (clinical) [Ep 8 · 4:51](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=291)
- "If you see fat during dissection, you can get closer to the rectum" — Marc Levitt (clinical) [Ep 8 · 5:13](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=313)
- "You must be in the correct plane for the rectum to mobilize" — Marc Levitt (clinical) [Ep 8 · 5:16](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=316)
- "For muscle complex bites, taking a bite of the rectum helps to avoid prolapse" — Marc Levitt (clinical) [Ep 8 · 5:44](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=344)
- "The rectum should lie adjacent to, not constricted by, the muscle complex" — Marc Levitt (clinical) [Ep 8 · 5:54](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=354)
- "Very little rectum should be trimmed; preserve as much rectum as possible" — Marc Levitt (clinical) [Ep 8 · 6:15](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=375)
- "The anoplasty uses 16 sutures" — Marc Levitt (clinical) [Ep 8 · 6:32](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=392)
- "The anoplasty should be under slight tension so that when stitches are cut, the rectum will gently retract in" — Marc Levitt (clinical) [Ep 8 · 6:36](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=396)
- "Dilations will begin at 2 weeks postoperatively" — Marc Levitt (clinical) [Ep 8 · 6:52](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=412)
- "Colostomy closure can take place 2 to 3 months after surgery once the anus has reached its desired size" — Marc Levitt (clinical) [Ep 8 · 6:52](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=412)
- "In newborns, you cannot distinguish between colon and small bowel on plain radiographs; all you can say is there are multiple dilated loops suggesting distal bowel obstruction" — Steven Kraus (clinical) [Ep 10 · 3:23](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=203)
- "The five most common causes of distal bowel obstruction in neonates are Hirschsprung disease, small left colon syndrome, anorectal malformation, meconium ileus, and ileal atresia, making up about 99% of cases" — Steven Kraus (epidemiological) [Ep 10 · 4:00](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=240)
- "Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise" — Steven Kraus (clinical) [Ep 10 · 8:14](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=494)
- "The false negative rate for contrast enema in diagnosing Hirschsprung disease is between 20% and 25%" — Steven Kraus (clinical) [Ep 10 · 10:33](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=633)
- "The false positive transition zone rate in contrast enemas is up to 43%" — Steven Kraus (clinical) [Ep 10 · 11:20](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=680)
- "Radiologist agreement on transition zone location is fairly high at 90%" — Steven Kraus (clinical) [Ep 10 · 11:35](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=695)
- "The concordance rate between radiology and pathology for transition zone location is only about 62% overall" — Steven Kraus (clinical) [Ep 10 · 13:00](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=780)
- "For short segment disease (rectosigmoid), the concordance between radiologic and pathologic transition zones is about 75%" — Steven Kraus (clinical) [Ep 10 · 13:27](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=807)
- "For long segment disease (descending colon or more proximal), the concordance between radiologic and pathologic transition zones is only about 25%" — Steven Kraus (clinical) [Ep 10 · 13:54](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=834)
- "Repeat enemas in children with long segment disease are futile and will not give better knowledge of transition zone location" — Steven Kraus (opinion) [Ep 10 · 14:29](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=869)
- "Never use a Foley catheter inside the rectum for contrast enemas in suspected Hirschsprung disease" — Rodrigo Ocelami (clinical) [Ep 10 · 16:42](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1002)
- "Contrast should be injected very slowly and gently, otherwise you can miss or distend the aganglionic segment" — Rodrigo Ocelami (clinical) [Ep 10 · 17:16](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1036)
- "Water soluble contrast used for enemas is hyperosmotic (about 400 mOsm) and can cause dehydration in neonates if it stays in the colon" — Steven Kraus (clinical) [Ep 10 · 21:44](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1304)
- "Early maximal distention is the best time to see the transition zone because waiting too long can cause distention of the distal aganglionic segment" — Steven Kraus (clinical) [Ep 10 · 23:01](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1381)
- "Contrast enemas in premature infants (less than 35-36 weeks) do not follow the normal rules and may not have diagnostic accuracy" — Steven Kraus (clinical) [Ep 10 · 25:47](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1547)
- "If you use a Foley catheter with the balloon inflated in the rectum, you will miss short segment Hirschsprung disease every single time" — Steven Kraus (clinical) [Ep 10 · 24:40](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1480)
- "In Soave procedures, a widened presacral space is seen on lateral view due to the cuff of tissue left behind from partial thickness dissection" — Steven Kraus (clinical) [Ep 10 · 34:18](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2058)
- "In Duhamel procedures, an anterior pouch is seen that can fill with stool and cause obstruction by compressing the ganglionic bowel" — Steven Kraus (clinical) [Ep 10 · 35:56](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2156)
- "In untreated Hirschsprung disease, the aganglionic rectum never becomes dilated even after 10-15 years" — Pena (clinical) [Ep 10 · 37:07](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2227)
- "The exact length of the normal physiologic aganglionic segment at the anal canal has never been accurately determined at different ages" — Pena (clinical) [Ep 10 · 41:32](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2492)
- "The internal anal sphincter has been defined as a thickening of the circular muscle layer, but this thickening has never been consistently demonstrated anatomically" — Pena (opinion) [Ep 10 · 42:14](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2534)
- "Internal anal sphincter achalasia is a manometric concept, not an anatomic concept" — Pena (opinion) [Ep 10 · 43:07](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2587)
- "3D cloacograms are performed in interventional radiology using angiography equipment with rotational imaging capabilities." — Manish Patel (clinical) [Ep 16 · 0:00](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=0)
- "Endoscopy by surgeons, gynecologists, and urologists is now combined with 3D cloacogram imaging in a single session." — Manish Patel (clinical) [Ep 16 · 0:22](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=22)
- "The 3D imaging technology is the same as that used for 3D angiography, with contrast injected into hollow structures and rotational image acquisition." — Manish Patel (clinical) [Ep 16 · 0:42](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=42)
- "Conventional cloacograms in main radiology typically produce only AP and lateral views with overlapping structures that are difficult to decipher." — Manish Patel (clinical) [Ep 16 · 1:11](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=71)
- "Catheters can be placed into the mucous fistula, bladder, and vaginostomy to opacify structures during rotational imaging." — Manish Patel (clinical) [Ep 16 · 1:49](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=109)
- "3D reconstructed images allow visualization of the cloaca level, measurement of common channel length, and assessment of vaginal anatomy." — Manish Patel (clinical) [Ep 16 · 2:19](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=139)
- "The 3D workstation allows viewing of images in any plane, including with or without bony landmarks." — Manish Patel (clinical) [Ep 16 · 2:14](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=134)
- "Real-time clips can be saved to show which structures fill during contrast injection of the mucous fistula." — Manish Patel (clinical) [Ep 16 · 2:52](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=172)
- "Modern technology allows precise measurement of the common channel using digital calipers on reconstructed images, eliminating foreshortening from external rulers." — Manish Patel (clinical) [Ep 16 · 4:11](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=251)
- "The radiation dose from a 3D rotational cloacogram is similar to that of a conventional cloacogram because fewer static images are required." — Manish Patel (clinical) [Ep 16 · 6:51](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=411)
- "MRI cloacograms lose the real-time capability of seeing what is being injected and filled, and significantly increase anesthesia time." — Manish Patel (opinion) [Ep 16 · 7:17](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=437)
- "Nationwide Children's Hospital has the same 3D imaging system with endoscopy in the interventional radiology suite." — Richard (clinical) [Ep 16 · 5:32](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=332)
- "3D reconstruction allows comparison of endoscopic measurements with three-dimensional imaging, aiding complex decision-making." — Richard (opinion) [Ep 16 · 5:39](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=339)
- "3D imaging provides useful information for deciding whether the vagina will reach and whether to approach the repair laparoscopically or from below." — Richard (opinion) [Ep 16 · 6:16](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=376)
- "The 3D cloacogram studies represent a significant advance in prenatal diagnosis, providing accurate and efficient imaging with no remaining mystery about internal anatomy." — Pena (opinion) [Ep 16 · 7:49](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=469)
- "Radiologic measurements of common channel length have become accurate to within millimeters and match intraoperative findings." — Pena (clinical) [Ep 16 · 8:46](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=526)
- "The majority of cloacas diagnosed prenatally are complex cases." (epidemiological) [Ep 16 · 10:53](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=653)
- "Prenatal imaging is now sufficiently detailed and reliable to counsel families well about cloacal malformations." (opinion) [Ep 16 · 11:39](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=699)
- "Baseline renal-bladder ultrasound is the preferred initial urologic imaging modality to identify upper and lower tract abnormalities in newborns with cloaca." (guideline) [Ep 16 · 12:23](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=743)
- "Pelvic ultrasound in cloacal malformations should assess for fluid accumulation in the vagina or vaginas and evaluate ovarian anatomy." (guideline) [Ep 16 · 13:15](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=795)
- "Vaginal fluid accumulation on ultrasound guides the timing of therapy and whether acute drainage is needed." (clinical) [Ep 16 · 13:30](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=810)
- "Sacral X-ray (AP and lateral) is needed to assess prognosis for bowel control and to evaluate for presacral masses." (guideline) [Ep 16 · 13:41](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=821)
- "Spinal ultrasound is performed to rule out tethered cord in cloacal malformation workup." (guideline) [Ep 16 · 13:58](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=838)
- "Echocardiogram or thorough cardiac physical exam is needed to rule out associated cardiac anomalies (VACTERL association)." (guideline) [Ep 16 · 13:58](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=838)
- "Placement of a catheter into the common channel for VCUG is challenging because it may enter any of three organ systems (bladder, vagina, or rectum)." (clinical) [Ep 16 · 16:02](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=962)
- "VCUG is not favored as a separate study; cystography is performed under endoscopic guidance during collaborative rotational imaging." (opinion) [Ep 16 · 16:12](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=972)
- "High-grade vesicoureteral reflux is not commonly identified in cloacal malformation patients; most reflux is mild and warrants observation rather than mandatory preoperative intervention." (clinical) [Ep 16 · 16:54](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1014)
- "Attempting very precise anatomic diagnosis of cloacal anatomy in the neonatal period is not useful and may harm the baby." — Pena (opinion) [Ep 16 · 17:26](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1046)
- "The critical neonatal imaging goals are to identify hydronephrosis, megaureters, and hydrocolpos that may compress the ureters." — Pena (guideline) [Ep 16 · 17:29](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1049)
- "Neonatal endoscopy in cloacal malformations does not add crucial information and should not be forced into tiny structures due to risk of injury." — Pena (opinion) [Ep 16 · 18:09](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1089)
- "Nephrostomy, ureterostomy, and vesicostomy are not indicated in most neonatal cloacal malformations." — Pena (guideline) [Ep 16 · 19:04](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1144)
- "The recommended neonatal management is hydrocolpos drainage and colostomy, with urologic re-evaluation 48 hours later to determine if vesicostomy is needed." — Pena (guideline) [Ep 16 · 19:14](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1154)
- "Vesicostomy may be needed in patients with obstruction in the common channel, but many do not require it after hydrocolpos decompression." — Pena (clinical) [Ep 16 · 19:25](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1165)
- "Neonatal endoscopy of cloacal malformations often does not yield accurate information and can traumatize the common channel, potentially causing harm." (opinion) [Ep 16 · 19:43](https://library.globalcastmd.com/watch/cloaca-workup-evaluation-683?t=1183)
- "In the 1970s fluoroscopy was done by everybody and done very well, but with advent of MRI, CT, and ultrasound, fluoroscopy has become almost a lost art" — Steven Kraus (opinion) [Ep 18 · 1:02](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=62)
- "In a newborn on plain radiograph you cannot tell the difference between colon and small bowel" — Steven Kraus (clinical) [Ep 18 · 3:23](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=203)
- "The five main causes of distal bowel obstruction appearance in neonates are Hirschsprung disease, small left colon syndrome, anorectal malformation, meconium ileus, and ileal atresia, making up about 99% of cases" — Steven Kraus (clinical) [Ep 18 · 3:57](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=237)
- "Seeing air in the rectum does not rule out Hirschsprung disease" — Steven Kraus (clinical) [Ep 18 · 5:32](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=332)
- "Air-fluid levels in the colon on cross-table or decubitus views are a sign of inflammatory process or enterocolitis" — Steven Kraus (clinical) [Ep 18 · 6:58](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=418)
- "Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise" — Steven Kraus (clinical) [Ep 18 · 8:14](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=494)
- "The false negative rate of contrast enema for Hirschsprung disease is between 20% and 25%" — Steven Kraus (clinical) [Ep 18 · 10:33](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=633)
- "The false positive transition zone rate in contrast enemas is up to 43%" — Steven Kraus (clinical) [Ep 18 · 11:20](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=680)
- "Radiologist agreement on transition zone location is fairly high at about 90%" — Steven Kraus (clinical) [Ep 18 · 11:35](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=695)
- "Concordance between radiologic and pathologic transition zone is only about 62% overall" — Steven Kraus (clinical) [Ep 18 · 13:10](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=790)
- "For short segment rectosigmoid disease, concordance between radiology and pathology is about 75%" — Steven Kraus (clinical) [Ep 18 · 13:35](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=815)
- "For long segment disease with transition in descending colon or more proximal, concordance between radiology and pathology is only about 25%" — Steven Kraus (clinical) [Ep 18 · 13:54](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=834)
- "Repeat enemas in children with long segment disease are futile and will not give better knowledge of transition zone location" — Steven Kraus (opinion) [Ep 18 · 14:16](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=856)
- "Never use a Foley catheter inside the rectum for contrast enema" — Rodrigo Ocelami (clinical) [Ep 18 · 16:42](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1002)
- "Contrast should be injected very slowly and gently, otherwise you can miss or distend the aganglionic segment" — Rodrigo Ocelami (clinical) [Ep 18 · 17:16](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1036)
- "After neonatal period, only fill colon up to transverse colon if the studied segment appears normal" — Rodrigo Ocelami (clinical) [Ep 18 · 17:41](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1061)
- "The iodinated water-soluble contrast used has osmolality of about 400, similar to colon prep agents, and can cause dehydration in neonates if it stays in the colon" — Steven Kraus (clinical) [Ep 18 · 21:44](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1304)
- "Early maximal distention is best to see the transition zone because waiting too long can cause distention of the distal aganglionic segment" — Steven Kraus (clinical) [Ep 18 · 23:01](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1381)
- "If you use a Foley catheter blown up in the rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time" — Steven Kraus (clinical) [Ep 18 · 24:40](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1480)
- "Rectosigmoid transition zone cases are usually concordant between radiology and pathology" — Steven Kraus (clinical) [Ep 18 · 25:09](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1509)
- "Contrast enemas in premature infants do not follow the rules and cannot reliably distinguish between immaturity and Hirschsprung disease" — Steven Kraus (clinical) [Ep 18 · 25:47](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1547)
- "Contrast enemas can be performed in premature infants greater than 35 to 36 weeks gestational age with reasonable diagnostic accuracy" — Steven Kraus (clinical) [Ep 18 · 26:06](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1566)
- "In Soave procedure, partial thickness dissection leaves a cuff of tissue that causes widening of the presacral space visible on lateral radiographs" — Steven Kraus (clinical) [Ep 18 · 34:18](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2058)
- "In Duhamel procedure, the pouch is a chimera of aganglionic segment distally with ganglionic segment proximally, creating an anterior pouch that can fill with stool" — Steven Kraus (clinical) [Ep 18 · 35:56](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2156)
- "Patients with untreated Hirschsprung disease for 10-15 years never develop dilated rectum, yet Duhamel pouches show dilated aganglionic rectum, suggesting these patients may not have had true Hirschsprung disease" — Pena (opinion) [Ep 18 · 36:59](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2219)
- "The length of the normal physiologic aganglionic segment has never been accurately determined at different ages in humans" — Pena (clinical) [Ep 18 · 41:32](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2492)
- "The internal sphincter has been defined as a thickening of the circular muscle layer, but this thickening has not been consistently observed anatomically and its exact limits at different ages have never been determined" — Pena (opinion) [Ep 18 · 42:14](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2534)
- "Internal sphincter achalasia is a manometric concept, not an anatomic concept" — Pena (opinion) [Ep 18 · 43:16](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2596)
- "In every single female redo, undissected areolar tissue is found that had never been dissected by the original surgeon" — Mark (clinical) [Ep 22 · 6:38](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=398)
- "If anterior rectal wall is not free enough it can pull back and disrupt the perineal body" — Mark (clinical) [Ep 22 · 7:09](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=429)
- "Many female redos were done without colostomy in the newborn period" — Mark (clinical) [Ep 22 · 7:51](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=471)
- "The vast majority of common perineal grooves, if observed, will become normal skin over time" — Mark (clinical) [Ep 22 · 11:35](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=695)
- "Rectal blood supply is intramural, so injuring the rectal wall hurts its blood supply" — Mark (clinical) [Ep 22 · 14:12](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=852)
- "Coming in from lateral to anterior is key; the lateral defines the anterior plane" — Mark (clinical) [Ep 22 · 14:36](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=876)
- "The more proximal you are, the easier rectum and vagina are to separate" — Mark (clinical) [Ep 22 · 15:25](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=925)
- "Mark keeps patients NPO until perineal body is healed, usually around day 6 or 7" — Mark (clinical) [Ep 22 · 17:27](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1047)
- "Can use 10% dextrose for NPO period instead of hyperalimentation in healthy robust children" — Mark (clinical) [Ep 22 · 18:17](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1097)
- "Systematic review shows early enteral nutrition seems better than later nutrition, but all studies are retrospective and poor quality" — Mark (epidemiological) [Ep 22 · 19:54](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1194)
- "Women with longitudinal vaginal septa often learn to use one side more than the other and are not really bothered with intercourse" — Mark (clinical) [Ep 22 · 30:15](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1815)
- "Women with vaginal septa often have tampon difficulties - can't use them, need one in each side, or need tampon plus pad" — Mark (clinical) [Ep 22 · 30:53](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1853)
- "Resecting vaginal septum in adolescent is not hard; use electricity and get as close to cervix as possible without damaging it" — Mark (clinical) [Ep 22 · 31:29](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1889)
- "About 2-5% of vestibular fistulas have a vaginal septum" — Mark (epidemiological) [Ep 22 · 27:40](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=1660)
- "Of 33 patients with absent vagina, 75% had urologic problems including neurogenic bladder" — Shamel (epidemiological) [Ep 22 · 37:13](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2233)
- "Of patients with absent vagina, 50% had CKD stage 3 or greater" — Shamel (epidemiological) [Ep 22 · 37:26](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2246)
- "Solitary kidneys, reflux, hydronephrosis, neurogenic bladder, and UTIs are long-term sequelae in absent vagina cohort" — Shamel (clinical) [Ep 22 · 37:31](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2251)
- "Rectum separates very nicely from urethra in absent vagina cases - thick fibrous tissue, not as adherent as rectum to posterior vagina" — Mark (clinical) [Ep 22 · 38:17](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2297)
- "Ideal time to fix vagina is when fixing rectum because perineal body is open" — Mark (opinion) [Ep 22 · 39:35](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2375)
- "Neovagina pedicle reaches much easier when child is young and doesn't have as long a pelvis" — Mark (clinical) [Ep 22 · 39:42](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2382)
- "For newborn cloaca with hydrocolpos, do open divided colostomy and decompress vagina with pigtail catheter rather than formal vaginostomy" — Mark (clinical) [Ep 22 · 46:09](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2769)
- "Doing cystoscopy at time of colostomy creation in cloaca patient makes colostomy creation very difficult" — Mark (clinical) [Ep 22 · 46:48](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2808)
- "No rush to scope vagina in newborn period; better to wait until 2-3 months for better visualization" — Mark (opinion) [Ep 22 · 47:20](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=2840)
- "With hydrocolpos, straight tubes fall out at about 2 months when inflammation recedes; use curled tube instead" — Mark (clinical) [Ep 22 · 50:02](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3002)
- "Much of hydrocolpos fluid can be urine refluxing up, not just vaginal secretions" — Mark (clinical) [Ep 22 · 50:28](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3028)
- "As vagina distends it obstructs urethra, resulting in more urine going into vagina - cycle perpetuates itself" — Mark (clinical) [Ep 22 · 51:37](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3097)
- "Catheter can go into right vagina, left vagina, bladder, or rectum - need ultrasound guidance to ensure draining correct structure" — Mark (clinical) [Ep 22 · 52:08](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3128)
- "Once hydrocolpos is drained, bladder fills beautifully, demonstrating that hydrocolpos compresses ureters" — Mark (clinical) [Ep 22 · 53:50](https://library.globalcastmd.com/watch/surgical-management-of-female-anorectal-malformation-patients-including-741?t=3230)
- "Between 75 and 80% of Hirschsprung cases can be reached transanally; in the remaining 20%, abdominal approach is added if biopsies remain aganglionotic" — Pena (clinical) [Ep 23 · 3:42](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=222)
- "Concordance between pathology and radiology is 75% in rectosigmoid Hirschsprung patients, meaning 25% discordance" (clinical) [Ep 23 · 5:30](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=330)
- "Concordance is only 25% for long-segment disease" (clinical) [Ep 23 · 5:39](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=339)
- "Leaving 1-2 centimeters of aganglionotic bowel does not explain poor outcomes in most patients" — Pena (opinion) [Ep 23 · 18:30](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1110)
- "Majority of patients with retention symptoms after pull-through do not have residual aganglionotic bowel" — Pena (clinical) [Ep 23 · 21:41](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1301)
- "Removing the rectum affects bowel control mechanisms even with perfect technique because the natural reservoir is removed" — Pena (clinical) [Ep 23 · 22:39](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1359)
- "Fecal incontinence is much more common than believed and not discussed enough in pediatric surgical meetings" — Pena (opinion) [Ep 23 · 23:44](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1424)
- "The main problems in Hirschsprung disease are related to inexperience and technical incapacity of the surgeon, not the approach used" — Pena (opinion) [Ep 23 · 11:10](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=670)
- "Patients complain about fecal incontinence, not scar size" — Pena (opinion) [Ep 23 · 12:17](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=737)
- "Stretching the anus too much during transanal dissection damages the sphincter mechanism and causes fecal incontinence" — Pena (clinical) [Ep 23 · 15:06](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=906)
- "Rectal irrigations are mandatory before any surgical procedure for Hirschsprung disease" — Luis de la Torre (guideline) [Ep 23 · 34:05](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2045)
- "Long-segment Hirschsprung patients do not improve with irrigation, unlike rectosigmoid cases" — Luis de la Torre (clinical) [Ep 23 · 60:03](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3603)
- "More than 80% of Hirschsprung patients have rectosigmoid aganglionosis" — Luis de la Torre (epidemiological) [Ep 23 · 60:31](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3631)
- "Patients with chronic dilation and massive megacolon are not good candidates for primary transanal pull-through" — Luis de la Torre (clinical) [Ep 23 · 62:01](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3721)
- "The anal canal consists of three zones: anoderm (squamous epithelium), pectinate line area, and columnar zone" — Luis de la Torre (clinical) [Ep 23 · 64:05](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3845)
- "Anastomosis below the columnar zone results in fecal incontinence" — Luis de la Torre (clinical) [Ep 23 · 66:20](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3980)
- "Total colonic aganglionosis ileostomy should only be closed when child is toilet-trained for urine and accepts rectal irrigations" — Andrea (guideline) [Ep 23 · 72:01](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4321)
- "Closing ileostomy early in total colonic aganglionosis leads to severe unmanageable diaper rash" — Andrea (clinical) [Ep 23 · 76:14](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4574)
- "Patients with total colonic aganglionosis have high incidence of enterocolitis and will likely need rectal irrigations" — Pena (clinical) [Ep 23 · 80:29](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4829)
- "There are two types of Hirschsprung disease: benign type without enterocolitis that can go years with huge megacolon, and bad type with newborn manifestations and enterocolitis tendency" — Pena (clinical) [Ep 23 · 120:20](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7220)
- "PHOX2B mutation is associated with congenital central hypoventilation syndrome, neuroblastoma, and Hirschsprung disease" — Andrea (clinical) [Ep 23 · 121:58](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7318)
- "Anorectal malformation combined with Hirschsprung disease results in guaranteed fecal incontinence because patient has no anal canal and loses natural reservoir" — Andrea (clinical) [Ep 23 · 126:31](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7591)
- "Post-evacuation films are not reliable for diagnosing Hirschsprung disease because aganglionotic segments can be spastic and expel contrast" — Krauss (clinical) [Ep 23 · 128:06](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7686)
- "The JRS 3 millimeter sealer is used as the primary mode of dissection for laparoscopic assisted pull-through in Hirschsprung's disease" (clinical) [Ep 24 · 0:00](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=0)
- "The patient is a newborn weighing 3.2 kg" (clinical) [Ep 24 · 0:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=32)
- "A super umbilical ring incision is used to place the Veress needle and 4mm trocar for the camera port in small newborns" (clinical) [Ep 24 · 0:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=36)
- "The trocar is placed just to the left of midline to avoid the umbilical vein" (clinical) [Ep 24 · 0:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=45)
- "A full thickness biopsy is obtained from the muscular wall approximately 5 centimeters above the transition zone" (clinical) [Ep 24 · 0:53](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=53)
- "The key to mesenteric dissection is staying exactly adjacent to the colon wall to prevent injury to surrounding structures" (clinical) [Ep 24 · 1:21](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=81)
- "All heat and energy remains between the jaws of the sealer, preventing injury to surrounding structures" (clinical) [Ep 24 · 1:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=92)
- "The 3 millimeter sealer has no risk of pass pointing compared to the 3 millimeter hook which was previously the preferred mode of dissection" (clinical) [Ep 24 · 2:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=152)
- "There is no need to perform instrument changes with the right hand throughout the case when using the 3mm sealer" (clinical) [Ep 24 · 2:55](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=175)
- "Carrying dissection down to the pelvic floor limits the amount of transanal dissection necessary and decreases the risk of injury to the external sphincter" (clinical) [Ep 24 · 3:24](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=204)
- "There is no energy spread from the tips of the 3mm sealer instrument, making it safe to be adjacent to the bladder, vagina, prostate, and other surrounding structures" (clinical) [Ep 24 · 3:42](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=222)
- "Energy only between the jaws of the instrument diminishes the risk of injury to the ureters and other vital structures such as the vas deferens" (clinical) [Ep 24 · 4:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=245)
- "The operation is preferred in the newborn period prior to discharge to home" (opinion) [Ep 24 · 4:35](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=275)
- "It is acceptable if the child tolerates rectal irrigations to let them grow before surgery" (clinical) [Ep 24 · 4:40](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=280)
- "With current technology, the operation is extremely safe in the newborn period" (opinion) [Ep 24 · 4:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=285)
- "A mucosal incision is made 2 to 3 millimeters proximal to the dentate line" (clinical) [Ep 24 · 5:53](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=353)
- "The transanal dissection should all take place externally to the anus" (clinical) [Ep 24 · 6:28](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=388)
- "Laparoscopic dissection down to the pelvic floor allows the dissection to be carried out outside of the anus so no retractors are placed within the external sphincter" (clinical) [Ep 24 · 6:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=396)
- "Placing retractors within the external sphincter may cause these muscles to be damaged" (clinical) [Ep 24 · 6:46](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=406)
- "Sharp dissection is preferred to mobilize the submucosal space, although blunt dissection can also be used" (opinion) [Ep 24 · 7:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=425)
- "Performing dissection external to the anus protects the external sphincter muscles and improves the chance of good continence" (clinical) [Ep 24 · 7:31](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=451)
- "The colon is divided 5 to 6 centimeters above the biopsy site, which is 5 centimeters above the obvious transition zone" (clinical) [Ep 24 · 8:57](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=537)
- "A total of 12 to 16 sutures are placed for the coloanal anastomosis, with 3 to 4 additional sutures in each quadrant after 4 quadrant stay sutures" (clinical) [Ep 24 · 9:19](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=559)
- "Vicryl suture is used for the anastomosis in newborns" (clinical) [Ep 24 · 9:44](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=584)
- "This operation took 70 minutes" (clinical) [Ep 24 · 9:57](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=597)
- "The child was left without a nasogastric tube and started stooling the morning following surgery" (clinical) [Ep 24 · 10:00](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=600)
- "The patient was started on feeds less than 24 hours after the procedure" (clinical) [Ep 24 · 10:07](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=607)
- "The anastomosis is calibrated with a number 12 Hegar dilator at the end of the procedure" (clinical) [Ep 24 · 10:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=636)
- "Gauze packing is placed in the anus at the end of the procedure" (clinical) [Ep 24 · 10:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=645)
- "The procedure uses three trocars: one umbilical for the scope, and 3mm and 5mm trocars in the right and left mid-quadrants just below the umbilicus" (clinical) [Ep 25 · 0:10](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=10)
- "The technique uses fine dissection just on the serosa of the bowel wall" (clinical) [Ep 25 · 0:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=32)
- "Small vessels are individually isolated, grasped with the sealer, sealed, and then retracted away from the bowel" (clinical) [Ep 25 · 0:38](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=38)
- "This is a very safe and efficient technique for mobilizing the distal bowel without devascularizing it" (opinion) [Ep 25 · 0:50](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=50)
- "This technique is much safer than using electrocautery in this area which could spread to surrounding structures causing injury to the vas deferens, the bladder, the ureter, and other structures" (opinion) [Ep 25 · 0:57](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=57)
- "Electrocautery could also damage the surrounding nerves" (clinical) [Ep 25 · 1:10](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=70)
- "The 3 millimeter sealer has very limited heat spread" (clinical) [Ep 25 · 1:13](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=73)
- "Using the sealer in the right hand allows the surgeon to dissect with both hands, providing traction with the left hand and doing fine dissection with the right" (clinical) [Ep 25 · 1:25](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=85)
- "In this case, the fistula is a high fistula at the level of the bladder neck" (clinical) [Ep 25 · 2:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=125)
- "There is no bleeding because each of the vessels is sealed" (clinical) [Ep 25 · 2:26](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=146)
- "The most difficult portion of the dissection is always anteriorly, where the fistula comes up into the bladder" (clinical) [Ep 25 · 2:49](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=169)
- "In the anterior area, one needs to be very careful to prevent injury to the prostate or the seminal vesicles or the vas deferens" (clinical) [Ep 25 · 2:56](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=176)
- "A hitch stitch is placed through the anterior abdominal wall down to the peritoneal reflection to retract the bladder up and out of the way" (clinical) [Ep 25 · 3:12](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=192)
- "The anterior dissection can be difficult as the tissue planes can be very dense and difficult to differentiate between the rectum and surrounding structures" (clinical) [Ep 25 · 3:26](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=206)
- "The colon tapers relatively quickly as it enters down into the bladder neck" (clinical) [Ep 25 · 4:07](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=247)
- "This is a relatively high fistula; most of the fistulas dealt with in this procedure are closer to the level of the prostate" (clinical) [Ep 25 · 4:15](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=255)
- "The fistula is taken using the 5 millimeter stapler almost completely flush with the bladder neck" (clinical) [Ep 25 · 5:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=305)
- "This technique removes any residual fistula so that there is no chance of a diverticulum" (clinical) [Ep 25 · 5:43](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=343)
- "In most cases, it is not necessary to mobilize the rectosigmoid much above the pelvic reflection" (clinical) [Ep 25 · 6:09](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=369)
- "Staying relatively close to the bowel wall prevents devascularization of the colon and injury to surrounding structures" (clinical) [Ep 25 · 6:26](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=386)
- "This technique prevents the need for changing to scissors in order to cut the tissue" (clinical) [Ep 25 · 7:00](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=420)
- "This technique prevents the heat spread seen with monopolar hook cautery" (clinical) [Ep 25 · 7:10](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=430)
- "The baby's feet and legs are prepped at the beginning of the procedure and retracted up towards the baby's head exposing the area of the external sphincter" (clinical) [Ep 25 · 7:29](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=449)
- "The nerve stimulator is used to identify the center of the sphincter" (clinical) [Ep 25 · 7:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=465)
- "The stimulator is used throughout the perineal portion to ensure that dissection does not wander off to the right or left and stays in the center as close as possible" (clinical) [Ep 25 · 8:19](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=499)
- "A Veress needle is inserted through the center of the external sphincter and into the center of the pelvic floor under direct visualization" (clinical) [Ep 25 · 8:53](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=533)
- "It is important that the needle insertion be visualized as it is possible to injure the urethra or the bladder if not careful" (clinical) [Ep 25 · 9:07](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=547)
- "A sheath is inserted over the Veress needle and a series of radially expandable trocars are used to go from 5mm up to 10mm to create the anal canal" (clinical) [Ep 25 · 9:24](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=564)
- "Because of the staple line, there is no spillage during the pull-through portion of the procedure" (clinical) [Ep 25 · 10:02](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=602)
- "Care should be taken to make sure that the orientation of the bowel is correct and that it does not get twisted or the mesentery kinked" (clinical) [Ep 25 · 10:10](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=610)
- "Because the patient has a diverting colostomy, it is only necessary to place about 12 to 16 sutures as the anastomosis does not need to be airtight" (clinical) [Ep 25 · 11:54](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=714)
- "Too many sutures could make the anastomosis ischemic" (clinical) [Ep 25 · 12:02](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=722)
- "Calibration and anal dilations are started at approximately 2 weeks of age" (clinical) [Ep 25 · 12:57](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=777)
- "Anal dilations are often only necessary for a few weeks" (clinical) [Ep 25 · 13:06](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=786)
- "Hitch stitches are placed in the colon, attaching the distal or mid rectum to the presacral fascia to help prevent prolapse later on" (clinical) [Ep 25 · 14:17](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=857)
- "Usually 2 stitches, one on each side, is sufficient for presacral fixation" (clinical) [Ep 25 · 14:37](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-imperforate-anus-759?t=877)
- "For the average pediatric surgeon doing transanal pull-through without prior biopsy, approximately 1 in 10 to 1 in 15 cases will have aganglionosis higher than expected or involve total colon" — Holcomb (clinical) [Ep 33 · 1:47](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=107)
- "Putting three abdominal incisions may be less invasive than prolonged transanal dissection with torquing in the anal canal" (opinion) [Ep 33 · 3:50](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=230)
- "Laparoscopic mobilization with three 3-millimeter ports can be completed in approximately 45 minutes" — Jason (clinical) [Ep 33 · 4:57](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=297)
- "Standard rectosigmoid Hirschsprung disease 6 to 10 centimeters up can be done transanally in approximately 2 hours" — Jason (clinical) [Ep 33 · 5:06](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=306)
- "Post-Hirschsprung complications divide into obstructive symptoms (enterocolitis, failure to thrive, abdominal distention) and soiling issues (true incontinence versus pseudo-incontinence)" — Jason (clinical) [Ep 33 · 5:53](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=353)
- "Obstructive symptoms after Hirschsprung surgery require determining whether the cause is anatomic or pathologic" — Jason (clinical) [Ep 33 · 6:13](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=373)
- "True fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line" — Jason (clinical) [Ep 33 · 6:20](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=380)
- "Workup for post-Hirschsprung problems includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twist" — Jason (clinical) [Ep 33 · 6:53](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=413)
- "If no anatomic cause is found on exam under anesthesia, biopsy should be performed" — Jason (clinical) [Ep 33 · 6:53](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=413)
- "A stretched sphincter is determined by observation of a patulous anus, whereas Hirschsprung anus should appear normal with a normal anal canal" — Jason (clinical) [Ep 33 · 7:20](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=440)
- "MRI utility for Hirschsprung complications is uncertain because unlike anorectal malformations where anus placement within sphincters is assessed, Hirschsprung dissection goes through the sphincter and anal canal without anus repositioning" — Jason (opinion) [Ep 33 · 7:33](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=453)
- "Starting dissection approximately 1 centimeter above the dentate line in a newborn may result in 2.5 to 3 centimeters of retained aganglionic segment when the child reaches 7 years old" — Jason (clinical) [Ep 33 · 8:33](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=513)
- "If dissection starts too high and subsequent biopsy is not taken high enough, the biopsy may show transition zone rather than definitive aganglionosis" — Jason (clinical) [Ep 33 · 8:59](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=539)
- "Injury to the dentate line can render patients fecally incontinent, which is a devastating injury" — Jason (clinical) [Ep 33 · 9:11](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=551)
- "The dentate line is defined as the transition from squamous epithelium to columnar epithelium, located somewhere within the anal columns" — Jason (clinical) [Ep 33 · 9:37](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=577)
- "In J-pouch surgery for ulcerative colitis or FAP, dissection is performed right at the top of the columns or slightly lower if polyps are present in that region" — Jason (clinical) [Ep 33 · 10:07](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=607)
- "Ultra-short segment aganglionosis can be overcome with laxatives, whereas fecal incontinence cannot be overcome" — Belinda (clinical) [Ep 33 · 11:50](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=710)
- "The surgical approach hedges on the side of leaving ultra-short segment Hirschsprung disease rather than injuring the anal canal" — Jason (opinion) [Ep 33 · 12:04](https://library.globalcastmd.com/watch/hirschsprung-disease-rapid-fire-update-course-2015-985?t=724)
- "A patulous anus can be determined by observation" — Jason (clinical) [Ep 35 · 0:06](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=6)
- "Hirschsprung anus should be a normal appearing anus with a normal anal canal" — Jason (clinical) [Ep 35 · 0:10](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=10)
- "In anorectal malformations surgeons look at placement of the anus within the sphincters and split the sphincters during the procedure" — Jason (clinical) [Ep 35 · 0:22](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=22)
- "In Hirschsprung disease the dissection goes right through the sphincter and anal canal without placing the anus" — Jason (clinical) [Ep 35 · 0:25](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=25)
- "Starting the dissection approximately 1 centimeter above the dentate line is one approach" — Jason (clinical) [Ep 35 · 1:10](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=70)
- "A 1 centimeter distance in a newborn might become 2.5 or 3 centimeters when the child is 7 years old" — Jason (clinical) [Ep 35 · 1:19](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=79)
- "Leaving too much tissue can result in what some call short segment or ultra short segment Hirschsprung disease" — Jason (clinical) [Ep 35 · 1:38](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=98)
- "If biopsy is not taken high enough, it might show transition zone" — Jason (clinical) [Ep 35 · 1:45](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=105)
- "Injury to the dentate line can render patients fecally incontinent, which is a devastating injury" — Jason (clinical) [Ep 35 · 1:57](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=117)
- "The dentate line is defined as the transition from squamous epithelium to columnar epithelium" — Jason (clinical) [Ep 35 · 2:23](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=143)
- "In J pouch procedures for ulcerative colitis or FAP, the dissection goes right at the top of the columns or even slightly lower if polyps are present" — Jason (clinical) [Ep 35 · 2:53](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=173)
- "The distance from anoderm to the top of the columns grows with the patient" — Jason (clinical) [Ep 35 · 3:17](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=197)
- "The dentate line location is variably pointed to in anatomic literature and illustrations" — Jason (clinical) [Ep 35 · 3:44](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=224)
- "The top of the anal columns serves as a standard landmark for dissection" — Belinda (clinical) [Ep 35 · 4:22](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=262)
- "Surgeons may deliberately leave a zone of aganglionosis because it can be overcome with laxatives" (clinical) [Ep 35 · 4:34](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=274)
- "Fecal incontinence cannot be overcome, unlike residual aganglionosis" (opinion) [Ep 35 · 4:48](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=288)
- "Surgeons hedge on the side of leaving ultra short segment Hirschsprung disease versus injuring the anal canal" — Jason (opinion) [Ep 35 · 4:50](https://library.globalcastmd.com/watch/enterocolitis-in-hirschsprung-disease-update-course-2015-1001?t=290)
- "Iodinated water-soluble contrast with osmolality approximately 400 is used, similar to colon prep agents" (clinical) [Ep 44 · 0:03](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=3)
- "Hypertonic contrast helps make the diagnosis and attempts to clean the colon" (clinical) [Ep 44 · 0:21](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=21)
- "Neonates can become dehydrated if contrast remains in the colon due to hyperosmotic effect" (clinical) [Ep 44 · 0:26](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=26)
- "Gravity infusion from a bag with large-bore tubing is used rather than injection" (clinical) [Ep 44 · 0:41](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=41)
- "Moderate-pace infusion (not slow) allows rapid visualization of distal and proximal segments to identify transition zone" (clinical) [Ep 44 · 1:03](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=63)
- "Lateral rectosigmoid imaging is performed" (clinical) [Ep 44 · 1:24](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=84)
- "Early maximal distention is best for seeing transition zone; delayed imaging can distend the aganglionic distal segment and obscure the transition" (clinical) [Ep 44 · 1:31](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=91)
- "AP rectosigmoid image is obtained; if colon appears small in neonate, entire colon is filled with attempt to reflux into terminal ileum to identify other diagnoses" (clinical) [Ep 44 · 1:51](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=111)
- "12-14 French Foley catheter is used in full-term neonates; smaller size in premature infants" (clinical) [Ep 44 · 2:08](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=128)
- "Normal rectum is larger than proximal colon (toward splenic flexure)" (clinical) [Ep 44 · 2:43](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=163)
- "Inflated Foley balloon positioned in distal rectum will miss ultra-short segment Hirschsprung every time" (clinical) [Ep 44 · 3:01](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=181)
- "Tube without balloon should be used, or balloon should be pushed further proximally to avoid obscuring distal colon" (clinical) [Ep 44 · 3:15](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=195)
- "Rectosigmoid transition Hirschsprung cases are usually concordant pathologically and radiologically" (clinical) [Ep 44 · 3:30](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=210)
- "Rectosigmoid transition is located at approximately S2 vertebral level" (clinical) [Ep 44 · 5:51](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=351)
- "Distal rectal Hirschsprung is distal to S1-S2; more proximal is typical rectosigmoid transition" (clinical) [Ep 44 · 5:55](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=355)
- "Small left colon syndrome typically has transition at splenic flexure that is very abrupt" (clinical) [Ep 44 · 6:20](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=380)
- "Rectosigmoid index (rectum larger than sigmoid) is a useful principle but insufficient—must image to splenic flexure" (clinical) [Ep 44 · 7:54](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=474)
- "Proximal transition zones on contrast enema cannot accurately predict histologic transition location" (clinical) [Ep 44 · 9:10](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=550)
- "Uncertain proximal transition should prompt more invasive surgical approach (laparoscopic or open) rather than transanal" (opinion) [Ep 44 · 9:28](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=568)
- "Contrast enema is reliable for diagnosis at gestational age 35-36 weeks and above" (clinical) [Ep 44 · 4:30](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=270)
- "Below 35-36 weeks gestational age, enema does not follow diagnostic rules due to colonic immaturity and overlap with necrotizing enterocolitis" (clinical) [Ep 44 · 4:08](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=248)
- "Rectal biopsy should be performed in almost any patient requiring contrast enema for distal obstruction, including meconium plug and small left colon" (opinion) [Ep 44 · 10:18](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=618)
- "Rectal biopsy may be omitted in clear meconium ileus with reflux into terminal ileum and clinical improvement" (opinion) [Ep 44 · 10:44](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=644)
- "Rectal biopsy would not be performed if diagnosis is clearly meconium (ileus)" — Pena (opinion) [Ep 44 · 10:58](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=658)
- "Rectal biopsy should be performed for small left colon appearance because it cannot be reliably distinguished from Hirschsprung" — Pena (opinion) [Ep 44 · 11:03](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=663)
- "Between 75 and 80% of the time transanal dissection reaches normal ganglionic bowel; in the other 20% the surgeon converts to abdominal approach" — Alberto Peña (clinical) [Ep 37 · 3:42](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=222)
- "Concordance between pathology and radiology is 75% in rectosigmoid Hirschsprung patients, leaving 25% discordant" — Belinda Dickey (clinical) [Ep 37 · 5:30](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=330)
- "Concordance is only 25% for long segment disease" — Belinda Dickey (clinical) [Ep 37 · 5:39](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=339)
- "The consequence of starting transanal and not reaching normal ganglionic bowel is opening the abdomen, which is what would be done anyway with laparoscopic approach" — Alberto Peña (opinion) [Ep 37 · 6:36](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=396)
- "When starting transanally and breaking through peritoneum, it becomes difficult to maintain pneumoperitoneum if converting to laparoscopy" — Belinda Dickey (clinical) [Ep 37 · 7:57](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=477)
- "Laparoscopic dissection is easy and gives a head start when doing transanal portion" — Belinda Dickey (opinion) [Ep 37 · 8:18](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=498)
- "Pure transanal approach results in absolutely no scar and minimal postoperative pain" — Andrea (clinical) [Ep 37 · 8:59](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=539)
- "The main problems in Hirschsprung disease are related to inexperience and technical incapacity of the surgeon, not the approach used" — Alberto Peña (opinion) [Ep 37 · 11:10](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=670)
- "Patients complain about fecal incontinence, not about scar size" — Alberto Peña (opinion) [Ep 37 · 12:09](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=729)
- "Long segment Hirschsprung patients do not improve with rectal irrigation, unlike rectosigmoid cases" — Luis de la Torre (clinical) [Ep 37 · 60:03](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3603)
- "More than 80% of Hirschsprung patients have rectosigmoid aganglionosis" — Luis de la Torre (epidemiological) [Ep 37 · 60:31](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3631)
- "When removing the rectum, the natural reservoir is removed, affecting bowel control mechanisms even with perfect technique" — Alberto Peña (clinical) [Ep 37 · 22:39](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1359)
- "Even adult ulcerative colitis patients with perfect ileoanal anastomosis have accidents at night due to loss of rectal reservoir" — Alberto Peña (clinical) [Ep 37 · 22:50](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1370)
- "The rectum in natural circumstances is resting all the time and only starts moving when it wants to empty" — Alberto Peña (clinical) [Ep 37 · 23:09](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1389)
- "Leaving 1-2 centimeters of aganglionic bowel does not explain why patients don't behave well" — Alberto Peña (opinion) [Ep 37 · 18:30](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1110)
- "Some patients with exactly the same technique do beautifully while others have enterocolitis symptoms, and we don't know why" — Alberto Peña (clinical) [Ep 37 · 18:52](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1132)
- "Patients live normal lives with remaining pieces of aganglionic bowel" — Alberto Peña (clinical) [Ep 37 · 19:07](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1147)
- "The majority of patients with retention symptoms after pull-through do not have residual aganglionic bowel" — Alberto Peña (clinical) [Ep 37 · 21:41](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1301)
- "When residual aganglionic bowel is present, it is usually much more than 2 centimeters" — Alberto Peña (clinical) [Ep 37 · 21:57](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1317)
- "The 2 centimeters left above the pectinate line are already damaged by the end of the operation" — Alberto Peña (clinical) [Ep 37 · 22:06](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1326)
- "Fecal incontinence is a much more common problem than we discuss in pediatric surgical meetings" — Alberto Peña (opinion) [Ep 37 · 23:44](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1424)
- "Most enterocolitis and constipation after pull-through is not due to residual aganglionosis" — Alberto Peña (opinion) [Ep 37 · 23:53](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1433)
- "Ileostomy should not be closed until the child is toilet-trained for urine and accepts rectal irrigation" — Andrea (guideline) [Ep 37 · 72:01](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4321)
- "Closing ileostomy early in total colonic aganglionosis leads to severe unmanageable diaper rash" — Andrea (clinical) [Ep 37 · 76:14](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4574)
- "Babies are happy with ileostomy; only others are unhappy" — Alberto Peña (opinion) [Ep 37 · 79:52](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4792)
- "When ileostomy is closed around 3 years after toilet training for urine, babies become toilet trained for stool quickly" — Alberto Peña (clinical) [Ep 37 · 80:07](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4807)
- "Total colonic aganglionosis patients have high incidence of enterocolitis requiring rectal irrigation capability" — Alberto Peña (clinical) [Ep 37 · 80:29](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4829)
- "Patients with anorectal malformation and Hirschsprung disease will be fecally incontinent by definition" — Andrea (clinical) [Ep 37 · 126:22](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=7582)
- "There are two types of Hirschsprung disease: benign type without enterocolitis that can go years, and bad type with newborn manifestations and enterocolitis tendency" — Alberto Peña (clinical) [Ep 37 · 120:08](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=7208)
- "Laparoscopy decreases stretch on anal sphincters compared to high transanal dissection" — Belinda Dickey (clinical) [Ep 37 · 94:53](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=5693)
- "With laparoscopic mobilization to pelvic floor, transanal dissection becomes very short with limited sphincter stretch" — Belinda Dickey (clinical) [Ep 37 · 95:11](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=5711)
- "Rectal irrigation is the best treatment for enterocolitis" — Andrea (guideline) [Ep 37 · 72:13](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4333)
- "Ganglion cells must be present 45 centimeters proximal to ileocecal valve in total colonic aganglionosis case" — Andrea (clinical) [Ep 37 · 72:49](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4369)
- "Unused colon in total colonic aganglionosis patients is at risk for enterocolitis" — Andrea (clinical) [Ep 37 · 74:33](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4473)
- "Urinary sodium should be checked in total colonic aganglionosis; if less than 20 mmol/L, start oral sodium replacement" — Andrea (guideline) [Ep 37 · 74:45](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4485)
- "Dissection of the fistula up to the red line is necessary to prevent residual fistula without injuring nerves, prostate, urethra, and sphincters" — Yamataka (clinical) [Ep 47 · 0:21](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=21)
- "The novel technique allows measurement of fistula length, enabling surgeons to know exactly how far to safely dissect distally for complete cystic excision" — Yamataka (clinical) [Ep 47 · 0:33](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=33)
- "A fine flexible colonoscope inserted into the anterior rectal wall allows observation of both the fistula orifice and the level of laparoscopic dissection intraluminally" — Yamataka (clinical) [Ep 47 · 1:52](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=112)
- "A fine catheter with calibration is inserted through the opening by the laparoscopic surgeon while another surgeon performing cystoscopy observes how far it emerges at or near the verumontanum" — Yamataka (clinical) [Ep 47 · 2:37](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=157)
- "The laparoscopic surgeon can measure the inside length of the fistula between the fistula opening and the urethral side orifice, allowing calculation of the actual length of the residual fistula" — Yamataka (clinical) [Ep 47 · 2:52](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=172)
- "If the length of the residual fistula is longer than 5 millimeters, the rectal end is further dissected toward the urethra using mucosectomy" — Yamataka (clinical) [Ep 47 · 4:28](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=268)
- "The procedure is repeated until the length of the residual fistula is shorter than or equal to 5 millimeters before the fistula is ligated, tied, and excised" — Yamataka (clinical) [Ep 47 · 4:57](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=297)
- "For bulbar fistula, it is very important to obtain as clear a surgical field of the deep pelvic floor as possible through use of suprapubic cystostomy which decompresses the bladder and opens up a clear view" — Yamataka (clinical) [Ep 47 · 6:16](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=376)
- "Trocar position for bulbar fistula differs from prostatic fistula in that right and left trocars are placed much closer to the telescope" — Yamataka (clinical) [Ep 47 · 6:49](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=409)
- "An adjustable telescope device allows adjustment from 0 to 120 degrees intraoperatively, giving the surgeon freedom to choose the best view without disrupting dissection" — Yamataka (clinical) [Ep 47 · 7:10](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=430)
- "The trocar positioning allows the tips of the forceps to reach deeper and to reach the bulbar urethra which is located deep in the pelvis" — Yamataka (clinical) [Ep 47 · 7:32](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=452)
- "After the fistula is tied, a catheter is again inserted until it gently probes the tied fistula, allowing the surgeon to reconfirm that the residual fistula length is shorter than or equal to 5 millimeters" — Yamataka (clinical) [Ep 47 · 8:30](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=510)
- "In the first eight cases, initial measurements of the rectal to urethral orifice fistula were 13, 15, 12, 10, 15, 21, 10, and 5 millimeters respectively" — Yamataka (clinical) [Ep 47 · 9:25](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=565)
- "Seven cases required further dissection until the fistula was shorter than or equal to 5 millimeters, but case 8 did not require further dissection" — Yamataka (clinical) [Ep 47 · 9:39](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=579)
- "During cystoscopy, normal saline refluxed into the pelvic floor through the fistula in 6 cases indicating the fistula is large, but there was no reflux in 2 cases indicating the fistula is very narrow" — Yamataka (clinical) [Ep 47 · 9:48](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=588)
- "All patients are well after mean follow-up of 2 years with no evidence of diverticular formation owing to residual fistula on voiding cystourethrography or MRI in all 23 cases" — Yamataka (clinical) [Ep 47 · 10:10](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=610)
- "The residual fistula from rectal site to urethral side is much longer than expected" — Yamataka (clinical) [Ep 47 · 10:28](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=628)
- "The new technique measuring the exact length of the fistula facilitates safe and complete excision of the fistula, reducing the risk of postoperative diverticulum formation due to incomplete fistula excision" — Yamataka (clinical) [Ep 47 · 10:37](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=637)
- "For prostatic fistula dissection, if the laparoscopic surgeon has training for gallbladder removal or other fundamental techniques, they can perform the procedure" — Yamataka (opinion) [Ep 47 · 12:54](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=774)
- "The key for dissection of the fistula is decompression of the bladder" — Yamataka (clinical) [Ep 47 · 13:31](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=811)
- "For bulbar fistula dissection, laparoscopic surgeons need 5 to 10 cases of prostatic fistula experience before they can attempt bulbar fistula" — Yamataka (opinion) [Ep 47 · 14:33](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=873)
- "Trocar position must be very close to the telescope for bulbar fistula, otherwise the tip of the instrument cannot reach the deep side of the pelvis" — Yamataka (clinical) [Ep 47 · 14:43](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=883)
- "Traction sutures (2 to 3) are used to bring the bladder up during the procedure" — Yamataka (clinical) [Ep 47 · 15:49](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=949)
- "Right transverse colostomy is preferred because sigmoid colostomy can fix the rectum and colon, requiring takedown of the sigmoid colostomy to achieve adequate length for pull-through" — Yamataka (opinion) [Ep 47 · 16:52](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1012)
- "If sigmoid colostomy is done very proximal in the sigmoid or at the descending colon-sigmoid junction, there will be enough length to do a pull-through even for a high fistula" (opinion) [Ep 47 · 17:19](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1039)
- "Transverse colostomy has too many problems including urine absorption, infection, and prolapse" — Sherif Emil (opinion) [Ep 47 · 18:37](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1117)
- "With sigmoid colostomy on the left side, ports can be placed to work around the stoma without having to take it down for deep pelvic dissection" — Jose (opinion) [Ep 47 · 19:17](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1157)
- "Sigmoid colostomy on the left side can be an obstacle for inserting trocars" — Yamataka (opinion) [Ep 47 · 19:57](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1197)
- "For sigmoid colostomy, you can go in the left upper quadrant and go around lateral to the colostomy, which is not an issue" (opinion) [Ep 47 · 20:11](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1211)
- "For prostatic or bladder neck fistula, the dissection can be done without this measurement technique and still get very close to the end of the fistula" (opinion) [Ep 47 · 20:21](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1221)
- "The laparoscopic approach for bulbar fistula is far more difficult and more dangerous, and the technique is extremely complicated for the average pediatric surgeon" (opinion) [Ep 47 · 21:07](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1267)
- "The PSARP technique is easy for bulbar fistula patients" (opinion) [Ep 47 · 21:20](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1280)
- "There is no convincing data that the laparoscopic approach results in any better outcomes for bulbar fistulas than PSARP" (opinion) [Ep 47 · 21:25](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1285)
- "The reason for using laparoscopic procedure even for bulbar fistula is to avoid cutting the anal sphincter and damaging the muscle and nerves for sphincters" — Yamataka (opinion) [Ep 47 · 21:32](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1292)
- "Colostogram is very important for planning laparoscopic dissection, and if good views of the fistula cannot be obtained, it should be repeated" — Yamataka (clinical) [Ep 47 · 22:32](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1352)
- "Colonoscopy can be performed through the transverse colostomy before operation if there is doubt whether the patient has a fistula or if the colostogram did not show nice anatomy" — Yamataka (clinical) [Ep 47 · 22:49](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1369)
- "Combining VCUG and colostogram at the same time by putting dye in from both sides usually allows clear visualization of the fistula" (clinical) [Ep 47 · 23:41](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1421)
- "It is important to have an empty bladder when doing laparoscopic anorectal malformation repair" (clinical) [Ep 47 · 23:51](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1431)
- "Sometimes when the Foley catheter is placed at the beginning of the case, it goes into the fistula and into the rectum rather than the bladder, which may not be discovered until mid-operation" (clinical) [Ep 47 · 24:04](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1444)
- "It is a good idea to cystoscope all anorectal malformation patients at the beginning of the case to make sure the catheter is actually in the bladder before starting" (opinion) [Ep 47 · 24:22](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1462)
- "When doing cystoscopy, saline is injected, so bladder decompression via suprapubic catheter is needed; otherwise the bladder will be filled with saline and the pelvic floor cannot be visualized" — Yamataka (clinical) [Ep 47 · 24:33](https://library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1473)
- "Since 1980, approximately 75% of operated anorectal malformation patients achieve acceptable bowel control, while 25% suffer permanent fecal incontinence" — Pena (clinical) [Ep 50 · 0:36](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=36)
- "Functional prognosis for anorectal malformations can be determined in the first few days of life through long-term follow-up data" — Pena (clinical) [Ep 50 · 2:12](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=132)
- "Perineal fistula patients have 100% bowel control by age 3 when they have a normal sacrum" — Pena (clinical) [Ep 50 · 4:19](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=259)
- "Perineal fistula, despite being the most benign malformation, suffers from the worst constipation" — Pena (clinical) [Ep 50 · 4:24](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=264)
- "Constipation produces fecal incontinence" — Pena (clinical) [Ep 50 · 4:42](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=282)
- "Presacral masses are more common in perineal fistula defects and change the prognosis completely" — Pena (clinical) [Ep 50 · 5:08](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=308)
- "Constipation in perineal fistula patients is incurable but manageable" — Pena (clinical) [Ep 50 · 5:36](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=336)
- "Rectal vestibular fistula is by far the most common defect in females" — Pena (epidemiological) [Ep 50 · 7:48](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=468)
- "95% of rectal vestibular fistula patients with good sacrum and no tethered cord achieve bowel control" — Pena (clinical) [Ep 50 · 7:55](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=475)
- "70% of rectal vestibular fistula patients have constipation" — Pena (clinical) [Ep 50 · 8:06](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=486)
- "Anorectal malformation without fistula occurs in only 5% of all cases" — Pena (epidemiological) [Ep 50 · 9:13](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=553)
- "Half of anorectal malformation without fistula patients have Down syndrome" — Pena (epidemiological) [Ep 50 · 9:23](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=563)
- "95% of Down syndrome babies with anorectal malformations have the no-fistula type defect" — Pena (epidemiological) [Ep 50 · 9:35](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=575)
- "80% of Down syndrome patients with anorectal malformations achieve bowel control" — Pena (clinical) [Ep 50 · 9:41](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=581)
- "90% of non-Down syndrome patients with anorectal malformation without fistula achieve bowel control" — Pena (clinical) [Ep 50 · 9:48](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=588)
- "All anorectal malformation patients have two enemies: constipation and diarrhea" — Pena (clinical) [Ep 50 · 10:03](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=603)
- "Rectal urethral bulbar fistula is the most common defect in male patients" — Pena (epidemiological) [Ep 50 · 10:41](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=641)
- "85% of rectal urethral bulbar fistula patients achieve bowel control with good operation, good sacrum, and no tethered cord" — Pena (clinical) [Ep 50 · 11:15](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=675)
- "Laparoscopy is contraindicated in rectal urethral bulbar fistula due to increasing posterior urethral diverticulums from inability to reach the low pelvis" — Pena (opinion) [Ep 50 · 11:23](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=683)
- "60% of rectoprostatic fistula patients have voluntary bowel movements by age 3" — Pena (clinical) [Ep 50 · 12:08](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=728)
- "Rectal bladder neck fistula occurs in only about 10% of all cases" — Pena (epidemiological) [Ep 50 · 13:25](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=805)
- "Only 20% of rectal bladder neck fistula patients have voluntary bowel movements by age 3" — Pena (clinical) [Ep 50 · 13:37](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=817)
- "Bladder neck fistula is the ideal case for laparoscopy because it is easy to reach from above, avoids laparotomy, and the rectum-bladder neck connection has no common wall allowing direct ligation" — Pena (clinical) [Ep 50 · 13:52](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=832)
- "The percentage of associated defects runs mathematically with defect severity: perineal fistula 15%, bladder neck fistula 90%" — Pena (epidemiological) [Ep 50 · 14:56](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=896)
- "In cloaca, bowel control depends on sacral quality while urinary control depends on common channel length" — Pena (clinical) [Ep 50 · 16:37](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=997)
- "Common channel shorter than 3 centimeters: 70% of patients have urinary control" — Pena (clinical) [Ep 50 · 17:04](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1024)
- "Common channel over 3 centimeters: 20% have urinary control, 80% need intermittent catheterization" — Pena (clinical) [Ep 50 · 17:15](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1035)
- "Cloacas with common channel shorter than 3 centimeters can be repaired by general pediatric surgeons because the operation is reproducible" — Pena (opinion) [Ep 50 · 17:26](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1046)
- "Cloacas with common channel longer than 3 centimeters require extensive experience in both pediatric surgery and pediatric urology due to complexity" — Pena (opinion) [Ep 50 · 17:50](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1070)
- "Cloacal exstrophy patients have 15-20% chance of voluntary bowel movements" — Pena (clinical) [Ep 50 · 20:14](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1214)
- "Bowel management cannot be done with liquid stool; patients incapable of forming solid stool cannot have bowel management" — Pena (clinical) [Ep 50 · 21:05](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1265)
- "The most important formal contraindication for pull-through is incapacity to form solid stool" — Pena (clinical) [Ep 50 · 21:10](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1270)
- "Meningocele, bladder neck fistula, and tethered cord are not contraindications for pull-through" — Pena (opinion) [Ep 50 · 21:26](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1286)
- "If a patient is capable of forming solid stool, by definition they are a good candidate for bowel management" — Pena (clinical) [Ep 50 · 21:42](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1302)
- "Even with good sphincter, if a patient has no colon, they should never have a pull-through because bowel management doesn't work" — Pena (clinical) [Ep 50 · 21:50](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1310)
- "It is contraindicated to do a pull-through in anorectal malformation if the patient is incapable of forming solid stool, unlike in Hirschsprung total colonic aganglionosis or ulcerative colitis where patients have normal sphincter and anal canal" — Pena (clinical) [Ep 50 · 22:01](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1321)
- "The most common error in cloacal exstrophy neonatal period is opening an ileostomy and leaving a piece of colon attached to the urinary tract" — Pena (clinical) [Ep 50 · 23:04](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1384)
- "Colon left attached to urinary tract will not grow, will not develop water absorption capacity, will absorb urine, and will provoke hyperchloremic acidosis interfering with growth and development" — Pena (clinical) [Ep 50 · 23:13](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1393)
- "Do not resect any piece of colon in anorectal malformations; every piece of gastrointestinal tissue is extremely valuable for bladder reconstruction, vaginal reconstruction, and water absorption" — Pena (guideline) [Ep 50 · 24:30](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1470)
- "In cloacal exstrophy, determining whether the patient has enough GI tissue for pull-through is the priority before allowing urologists to use GI tissue for reconstructions" — Pena (guideline) [Ep 50 · 24:51](https://library.globalcastmd.com/watch/anorectal-malformations-introduction-and-overview-for-bowel-management-1071?t=1491)
- "Perineal fistula is distinguished from vestibular fistula by location relative to the fourchette" (clinical) [Ep 60 · 1:40](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=100)
- "Adequate mobilization is achieved when the rectum reaches the perineal skin with a little bit of tension" — Don (opinion) [Ep 60 · 2:27](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=147)
- "Complete separation from vagina is necessary because incomplete separation leads to retraction and wound problems" — Ivo (opinion) [Ep 60 · 2:51](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=171)
- "Complete separation results in loss of rudimentary internal sphincter tissue" — Ivo (clinical) [Ep 60 · 3:43](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=223)
- "Starting dissection more proximally makes separation easier than starting at the perineum" — Don (clinical) [Ep 60 · 14:26](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=866)
- "Dissecting too far from the rectal wall risks entering the posterior vagina" — Michael (clinical) [Ep 60 · 4:22](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=262)
- "In every female redo case, areolar tissue is found that was never dissected by the original surgeon" (clinical) [Ep 60 · 5:40](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=340)
- "Inadequate anterior rectal wall mobilization leads to perineal body disruption" (opinion) [Ep 60 · 6:10](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=370)
- "Many redo cases were done without colostomy in the newborn period" — Don (clinical) [Ep 60 · 6:52](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=412)
- "Common perineal groove is not symptomatic in most patients" — Jonathan (clinical) [Ep 60 · 8:06](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=486)
- "A hole in the center of the sphincter accepting Hagar 11-12 in a neonate can be observed" (clinical) [Ep 60 · 8:22](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=502)
- "Perineal groove typically becomes normal skin over time with observation" (clinical) [Ep 60 · 10:36](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=636)
- "If a hole must be made during dissection, vaginal injury is preferable to rectal injury" — Ivo (clinical) [Ep 60 · 12:53](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=773)
- "Rectal blood supply is intramural, making rectal wall injury particularly problematic" (clinical) [Ep 60 · 13:14](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=794)
- "Starting laterally is key to avoiding injury when separating common wall" — Michael (clinical) [Ep 60 · 13:34](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=814)
- "Vestibular fistula patients are continent based on having normal skeletal muscle" (clinical) [Ep 60 · 14:09](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=849)
- "Vestibular fistula can be repaired primarily without colostomy in newborn or at 3-4 months" (opinion) [Ep 60 · 15:00](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=900)
- "Primary repair can be done with simultaneous diversion followed by colostomy closure" (opinion) [Ep 60 · 15:21](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=921)
- "Waiting until perineal body is healed (day 6-7) before feeding prevents dehiscence" (opinion) [Ep 60 · 16:27](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=987)
- "Monitoring perineal body allows intervention with re-suturing before complete dehiscence" (clinical) [Ep 60 · 16:50](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1010)
- "Patients fed early and sent home may have undetected perineal body dehiscence" (opinion) [Ep 60 · 17:09](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1029)
- "10% dextrose can be used instead of hyperalimentation for NPO periods under 7 days" (clinical) [Ep 60 · 17:22](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1042)
- "Systematic review shows early enteral nutrition appears better than later nutrition" — Ivo (epidemiological) [Ep 60 · 18:56](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1136)
- "All existing studies on perioperative nutrition are retrospective and poor quality" — Ivo (epidemiological) [Ep 60 · 19:02](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1142)
- "Rapid learning healthcare systems allow real-time statistical modeling for rare diseases" — Kate (clinical) [Ep 60 · 22:24](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1344)
- "Newborns do not require bowel prep; delayed repairs receive full GoLYTELY prep with oral antibiotics" (clinical) [Ep 60 · 23:04](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1384)
- "Perineal body is examined on day 7 post-repair; if separated, patient returns to OR for reinforcing sutures" (clinical) [Ep 60 · 23:57](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1437)
- "Alkaline urine on fresh wound is a theoretical concern for using Foley catheter" — Jonathan (opinion) [Ep 60 · 26:15](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1575)
- "In the surgeon's personal series of 8 patients with rectovestibular fistula and no vagina, only one had an imperforate hymen with actual vagina present; the others had no uterus or fallopian tubes" — Don (clinical) [Ep 55 · 1:41](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=101)
- "Sigmoid colon pulled down to function as rectum does not have the same storage qualities and physiologic properties as native rectum" — Don (clinical) [Ep 55 · 0:47](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=47)
- "The areolar dissection plane between rectum and urethra is much thicker when vagina is absent" — Mark (clinical) [Ep 55 · 3:57](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=237)
- "98% of 51 surveyed participants recommended using sigmoid rather than rectum for neovagina construction" (opinion) [Ep 55 · 6:23](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=383)
- "The rudimentary vagina ended blindly at the back of the bladder with no connection to urinary system, explaining absence of hydrocolpos" — Mark (clinical) [Ep 55 · 14:00](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=840)
- "This anatomic variant (rectovestibular fistula with absent vagina) occurs approximately once per 500 cases" — Mark (epidemiological) [Ep 55 · 14:43](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=883)
- "In the surgeon's experience of approximately 40 cases of absent vagina, 3 had usable vagina for pull-through: one extremely low requiring only introitoplasty, two others that delivered up and reached perineum" — Mark (clinical) [Ep 55 · 15:18](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=918)
- "For congenital cervical agenesis, there is no evidence that retaining the uterus and connecting to vagina is helpful; there have been no successful live births and the problem has been pyometra and ascending infection" — Jerry (clinical) [Ep 55 · 15:55](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=955)
- "In the absence of a cervix, there is no evidence as of 2014 that retaining uterine cavity is beneficial for reproduction and there is evidence it can be harmful due to pyometra" — Jerry (clinical) [Ep 55 · 16:51](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=1011)
- "Creating an outflow tract from a uterus without cervix sets up risk for ascending PID without reproductive benefit" — Jerry (clinical) [Ep 55 · 17:53](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=1073)
- "The ideal time to create neovagina is when rectum has been mobilized; waiting creates a scarred perineum that makes subsequent neovagina placement more difficult" — Mark (opinion) [Ep 55 · 20:10](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=1210)
- "Staplers may be used for bowel division but staple lines should be removed to avoid leaving staples on any anastomosis" — Mark (clinical) [Ep 55 · 21:46](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=1306)
- "75% of 32 respondents voted to leave the uterus intact rather than remove it" (opinion) [Ep 55 · 23:25](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=1405)
- "Tactile feedback suggesting cervical presence included inability to pass forceps through the back of uterus and feeling firmness as if encountering upper vaginal surface" — Mark (clinical) [Ep 55 · 25:03](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=1503)
- "The neovaginal pedicle passes through the space where the bowel will be reanastomosed, between the rectum and sigmoid" — Mark (clinical) [Ep 55 · 29:09](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-ii-pediatric-colorectal-1093?t=1749)
- "Total body prep from nipples to toes is performed in supine position for these patients" (clinical) [Ep 62 · 2:06](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=126)
- "Foley catheter is typically placed in supine position before flipping patient prone over bump" (clinical) [Ep 62 · 2:21](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=141)
- "In a baby this small, MRI pelvis has difficulty delineating uterus and ovaries" — Mark (clinical) [Ep 62 · 3:46](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=226)
- "Neonatal ultrasound was performed and was normal but did not specifically show vagina" (clinical) [Ep 62 · 4:29](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=269)
- "Cost-effective nerve stimulation uses anesthesia train-of-four box instead of dedicated pena stimulator" (clinical) [Ep 62 · 8:08](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=488)
- "With train-of-four stimulator, one probe must be grounded on wet skin while touching with the other probe" (clinical) [Ep 62 · 8:35](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=515)
- "Lateral dissection defines the anterior plane in posterior sagittal approach" — Mark (clinical) [Ep 62 · 15:24](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=924)
- "In absent vagina situations, the urethra is always found to be quite big" — Mark (clinical) [Ep 62 · 19:29](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1169)
- "There is typically a thick wall between rectum and urethra in absent vagina situations" — Mark (clinical) [Ep 62 · 20:53](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1253)
- "The distal rectum has value for continence in patients with good potential for bowel control" — Mark (clinical) [Ep 62 · 26:26](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1586)
- "Neovaginal reconstruction timing depends on presence of uterus - if present, connection to outside needed before menstruation" — Tony Khoury (clinical) [Ep 62 · 23:30](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1410)
- "Imaging may not be extremely helpful at this age due to very small structures" — Mark (clinical) [Ep 62 · 24:39](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1479)
- "Upper vagina is unlikely to be present when lower vagina is absent, though possible" — Mark (clinical) [Ep 62 · 25:09](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1509)
- "Would not perform separate EUA in newborn primary anorectal malformation case - would do EUA at time of repair" — Mark (opinion) [Ep 62 · 27:22](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1642)
- "Renal workup for this patient was normal" (clinical) [Ep 62 · 12:18](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=738)
- "Patient has good quality sacrum" — Mark (clinical) [Ep 62 · 12:37](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=757)
- "In girls without vagina, must be more careful about bladder and urethra during dissection" (clinical) [Ep 62 · 14:05](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=845)
- "63% of respondents favored protective colostomy, 36% did not" (opinion) [Ep 59 · 0:14](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=14)
- "Colon is preferred over small bowel for neovagina due to more robust blood supply; small bowel mesentery is tenuous" — Marc Levitt (clinical) [Ep 59 · 2:12](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=132)
- "Small bowel does not produce less mucus than colon for vaginoplasty" — Marc Levitt (clinical) [Ep 59 · 2:07](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=127)
- "Purpose of neovagina is for long-term sexual function and menstruation, potentially for conception if cervix is competent" — Raj (clinical) [Ep 59 · 6:20](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=380)
- "7-8 centimeters is used for bowel segment length because that approximates normal vaginal length in a baby" — Marc Levitt (clinical) [Ep 59 · 7:56](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=476)
- "There is no science behind the 7-8 cm vaginal length measurement" — Marc Levitt (opinion) [Ep 59 · 8:06](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=486)
- "Family agreed to leave structures that did not need to be removed, given uncertainty about future reproductive potential" — Marc Levitt (clinical) [Ep 59 · 10:09](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=609)
- "Uterine transplantation is now a successful procedure (referenced as recent development)" — Marc Levitt (clinical) [Ep 59 · 10:37](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=637)
- "Neovagina should be tacked to pelvic fascia or posterior bladder to allow it to grow and lengthen into pelvis" — Marc Levitt (clinical) [Ep 59 · 11:06](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=666)
- "Vaginal dilation is not performed post-operatively; some patients will need introitoplasty later" — Marc Levitt (clinical) [Ep 59 · 11:58](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=718)
- "Pelvic ultrasound and examination under anesthesia with vaginoscopy should be performed 6 months after breast budding" — Marc Levitt (guideline) [Ep 59 · 12:24](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=744)
- "If no cervix is found, decision must be made whether to empirically remove uterus or wait for trouble" — Marc Levitt (clinical) [Ep 59 · 13:55](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=835)
- "Surgeon has patients without cervix: one had two episodes of pelvic inflammatory disease requiring removal, another has been asymptomatic" — Marc Levitt (clinical) [Ep 59 · 14:17](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=857)
- "Pelvic MRI in infants has limited utility for identifying vaginal lumen unless there is hematocolpos or hydrocolpos" — Marc Levitt (clinical) [Ep 59 · 24:51](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1491)
- "MRI can frequently identify fallopian tubes, ovaries, and uterine anatomy but has low confidence for vaginal lumen assessment in young patients" — Marc Levitt (clinical) [Ep 59 · 25:32](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1532)
- "Preoperative workup would not have been changed; imaging did not hint at Müllerian anomaly and office exam appeared gynecologically normal" — Marc Levitt (opinion) [Ep 59 · 27:31](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1651)
- "Independent examination under anesthesia would not be performed; patient should be examined at time of PSARP" — Marc Levitt (guideline) [Ep 59 · 27:39](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1659)
- "Neovagina is already tethered to patient's proximal vagina, eliminating need for separate tacking to bladder" — Marc Levitt (clinical) [Ep 59 · 29:20](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1760)
- "Papers by Pastor et al and Gosain et al outline frameworks and clinical guidelines for management of enterocolitis" — Meera Kotagal (guideline) [Ep 67 · 0:21](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=21)
- "The guideline is most appropriate for patients with either known or suspected Hirschsprung's who present with GI symptoms and/or fever" — Meera Kotagal (guideline) [Ep 67 · 0:21](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=21)
- "GI symptoms in HAEC include abdominal distension, vomiting, no or minimal stool, foul smelling stool, or explosive diarrhea" — Meera Kotagal (clinical) [Ep 67 · 0:21](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=21)
- "Systemic signs of concern include fever, lethargy, age-adjusted tachycardia, tachypnea, hypotension, or oliguria" — Meera Kotagal (clinical) [Ep 67 · 0:21](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=21)
- "Patients should be seen and evaluated as soon as possible, ideally within one hour by someone with clinical expertise such as a surgical fellow or attending" — Meera Kotagal (guideline) [Ep 67 · 2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120)
- "The exam should include a rectal exam" — Meera Kotagal (guideline) [Ep 67 · 2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120)
- "If the patient is less than four weeks out from surgery, fellows should discuss the rectal exam with an attending surgeon prior to performing it" — Meera Kotagal (guideline) [Ep 67 · 2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120)
- "Irrigations should not be delayed for patients to get an x-ray" — Meera Kotagal (guideline) [Ep 67 · 2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120)
- "Irrigations should be repeated as frequently as every eight hours, but even every six or four hours as needed for sicker patients" — Meera Kotagal (guideline) [Ep 67 · 2:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=120)
- "Abdominal films should be obtained upon arrival and then repeated again after an irrigation to demonstrate adequate decompression" — Meera Kotagal (guideline) [Ep 67 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "Abdominal films can be repeated throughout the course of the hospitalization as clinically necessary" — Meera Kotagal (guideline) [Ep 67 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "Patients should be NPO and started on IV fluids to assist with resuscitation and hydration" — Meera Kotagal (guideline) [Ep 67 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "Patients without systemic signs who are mostly clinically well can be maintained on either IV or oral flagyl during hospitalization" — Meera Kotagal (guideline) [Ep 67 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "All patients who are vomiting should be on IV antibiotics" — Meera Kotagal (guideline) [Ep 67 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "Patients with systemic signs who are sicker need broad spectrum antibiotics, specifically Zosyn and flagyl at Cincinnati Children's" — Meera Kotagal (guideline) [Ep 67 · 3:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=180)
- "All patients should get a CBC and a basic metabolic panel" — Meera Kotagal (guideline) [Ep 67 · 4:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=240)
- "A venous blood gas should be obtained for sicker patients to help evaluate resuscitation needs" — Meera Kotagal (guideline) [Ep 67 · 4:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=240)
- "Patients with systemic signs should be evaluated for potential admission to the ICU" — Meera Kotagal (guideline) [Ep 67 · 4:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=240)
- "After an admission for enterocolitis, patients are continued on metronidazole and irrigations for a few weeks and then slowly tapered" — Meera Kotagal (guideline) [Ep 67 · 5:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=300)
- "Underlying anatomic issues such as a stricture or a transition zone pull through must be addressed to prevent recurrent enterocolitis" — Meera Kotagal (clinical) [Ep 67 · 5:00](https://library.globalcastmd.com/watch/suspected-hirschsprung-s-associated-enterocolitis-treatment-guideline-1540?t=300)
- "Many errors still happen in patients with Hirschsprung, resulting in complications and mortality" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "The most common error in these patients are the false diagnosis of Hirschsprung because of an inadequate biopsy" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "Incorrect performance of rectal irrigations during medical treatment is a common error" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "Failure to demonstrate the transitional zone in the contrast enema is a common error" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "Problematic intraoperative diagnosis of transitional zone is a common error" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "Damage of the anal canal during mapping the colon with multiple biopsies is a common error" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "Missing the rectal biopsy to confirm Hirschsprung disease in patients with low intestinal obstruction is a common error" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "These errors are the source of pull-throughs in patients with idiopathic constipation" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "These errors result in multiple bowel resection with loss of significant amount of colon" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "These errors result in fecal incontinence" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "These errors result in the necessity of colostomy or ileostomies" — Louis Delatorre (clinical) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "Avoiding these errors can improve the outcome and quality of life of these patients" — Louis Delatorre (opinion) [Ep 69 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "The Stay Current app is viewed by 6,000 pediatric surgeons" (epidemiological) [Ep 72 · 0:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=0)
- "Stay Current Pediatric Surgery was released in February of 2019" (clinical) [Ep 72 · 0:43](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=43)
- "Users have shared over 450 pieces of content approximately 1400 times" (epidemiological) [Ep 72 · 1:08](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=68)
- "Digital anal dilation is safe if the digits are appropriately sized and if the families follow a strict protocol of dilations" (clinical) [Ep 72 · 1:27](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=87)
- "Techniques for laparoscopic CDH treatment include utilizing a needle to decompress bowel laparoscopically" (clinical) [Ep 72 · 2:30](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=150)
- "Creating a pneumothorax allows easier retraction of the hernia sac in laparoscopic CDH repair" (clinical) [Ep 72 · 2:30](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=150)
- "A laparoscopic detectable magnet can be utilized for greater maneuverability of the hernia sac" (clinical) [Ep 72 · 2:30](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=150)
- "The evidence supporting best practices for long gap esophageal atresia is currently low quality" (clinical) [Ep 72 · 4:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=240)
- "Patients with long gap esophageal atresia should receive appropriate long-term follow-up" (guideline) [Ep 72 · 4:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=240)
- "Workup, diagnosis, and treatment of GERD patients is complex" (opinion) [Ep 72 · 5:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=300)
- "The latest recommendation for Nissen fundoplication involves minimal dissection at the GE junction" (guideline) [Ep 72 · 5:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=300)
- "The Nissen wrap should be performed above the left gastric artery" (guideline) [Ep 72 · 5:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=300)
- "Multiple randomized control trials have shown that ad lib feeds are superior or equivalent to protocolized feeds for pyloric stenosis" (clinical) [Ep 72 · 6:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=360)
- "All infants less than 50 weeks post-conceptual age at the time of surgery need some level of observation for apnea monitoring" (guideline) [Ep 72 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- "NPO guidelines include clears up to two hours preop and breast milk up to four hours preop" (guideline) [Ep 72 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- "Clinicians tend to be too restrictive with NPO guidelines" (opinion) [Ep 72 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- "Pre-op antibiotic prophylaxis must be administered within 60 minutes before incision" (guideline) [Ep 72 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- "Redosing of antibiotics is needed for the duration of the operation" (guideline) [Ep 72 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- "Generally, antibiotics are not needed after surgery unless the case determines otherwise" (guideline) [Ep 72 · 7:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=420)
- "Hirschsprung's disease is the number one search topic on the app overall" (epidemiological) [Ep 72 · 8:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=480)
- "The transition zone can vary widely depending on the extent of disease with numbers as high as 22 centimeters for total colonic Hirschsprung's disease" (clinical) [Ep 72 · 8:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=480)
- "Coyle et al recommend resecting greater than 5 cm proximally to the normal biopsy to avoid transition zone pull through" (guideline) [Ep 72 · 8:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=480)
- "Management of suspected Hirschsprung's associated enterocolitis includes prompt evaluation of the patient, rectal irrigations with normal saline, NPO, IV fluids, antibiotics and continuous monitoring" (guideline) [Ep 72 · 8:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=480)
- "Patients with intussusception should go to the operating room if they have peritoneal signs or if they fail reduction after three attempts" (guideline) [Ep 72 · 10:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=600)
- "Patients can be safely discharged home after four hours of observation after a successful intussusception reduction" (clinical) [Ep 72 · 10:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=600)
- "Patients with intussusception can have the air enema repeated every hour up to three times as long as there are no signs of peritonitis before operative exploration" (guideline) [Ep 72 · 10:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=600)
- "Patients who are asymptomatic for four hours after a successful intussusception reduction can be discharged from the emergency department" (guideline) [Ep 72 · 10:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=600)
- "Non-operative management should be primarily considered in hemodynamically stable patients with blunt solid organ injuries" (guideline) [Ep 72 · 12:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=720)
- "Angioembolization should be considered for ongoing or delayed bleeding, high grade injuries and early hemodynamic compromise before proceeding to the operating room" (guideline) [Ep 72 · 12:00](https://library.globalcastmd.com/watch/top-themes-from-the-stay-current-app-2999?t=720)
- "Hirschsprung disease is a loss of innervation to a section of bowel" — Michael Koep (clinical) [Ep 124 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "Hirschsprung disease is sometimes associated with genetic syndromes such as Down syndrome" — Michael Koep (clinical) [Ep 124 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "Hirschsprung disease can be fixed but requires surgery that involves cutting that section of bowel out" — Michael Koep (clinical) [Ep 124 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "Children with Hirschsprung disease may have ongoing issues with constipation, incontinence, and occasional abdominal pain after surgery" — Michael Koep (clinical) [Ep 124 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "The study compared children with Hirschsprung disease to their peers in real-world assessments" — Michael Koep (clinical) [Ep 124 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "While there may be some delay in the beginning in the preschool assessment, once children with Hirschsprung start school, there does not appear to be a significant difference between them and their peers in assessments that include reading and number skills" — Michael Koep (clinical) [Ep 124 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "There is not a significant difference in graduation from grade 12 between children with Hirschsprung disease and their peers" — Michael Koep (clinical) [Ep 124 · 0:27](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=27)
- "Neurodevelopmental outcomes are just as important to parents as what surgeons do directly in the operating room" — Pam Choi (opinion) [Ep 124 · 3:34](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=214)
- "Data was only specifically from Manitoba and using a Manitoba health repository" — Michael Koep (clinical) [Ep 124 · 5:02](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=302)
- "The standardized tests are standardized within each province" — Pam Choi (clinical) [Ep 124 · 5:29](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=329)
- "The data includes public school, private school and homeschooling" — Michael Koep (clinical) [Ep 124 · 5:35](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=335)
- "First Nations and indigenous schools were not included in the repository" — Michael Koep (clinical) [Ep 124 · 5:35](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=335)
- "The study did not account for how the disease is affecting each child individually" — Michael Koep (clinical) [Ep 124 · 6:21](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=381)
- "Patients were matched based on being male and socioeconomic status" — Michael Koep (clinical) [Ep 124 · 6:21](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=381)
- "The data was from 1997 to 2012" — Michael Koep (clinical) [Ep 124 · 7:16](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=436)
- "The study did not include a subset analysis of long segment Hirschsprung disease" — Michael Koep (clinical) [Ep 124 · 7:44](https://library.globalcastmd.com/watch/caps-educational-outcomes-in-school-age-children-with-a-history-of-hirschsprung-s-disease-michael-cowap-5420?t=464)
- "The study examined 277 children with Hirschsprung's disease, with about half receiving Soave procedure, a third Duhamel, and the rest Swenson" — Britney Levy (clinical) [Ep 138 · 0:47](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=47)
- "217 of the 277 children had long-term outcome data available" — Britney Levy (clinical) [Ep 138 · 1:10](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=70)
- "Duhamel procedure has the lowest risk of incontinence but the highest risk of constipation in school age children with Hirschsprung's disease" — Britney Levy (clinical) [Ep 138 · 1:15](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=75)
- "The Peters et al. study examined 55 pediatric patients with short bowel syndrome" — Rod Gerardo (clinical) [Ep 138 · 1:35](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=95)
- "Infants with an ileocecal valve had significantly shorter duration on parenteral nutrition" — Rod Gerardo (clinical) [Ep 138 · 1:50](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=110)
- "Patients with less than 50% of their colon had significantly less time on parenteral nutrition as long as they had their ileocecal valve" — Rod Gerardo (clinical) [Ep 138 · 2:05](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=125)
- "The Olsen et al. systematic review analyzed 10 studies with 6,430 patients" — Cecilia Gigena (epidemiological) [Ep 138 · 2:43](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=163)
- "The definition of a high volume surgeon varies widely from 9 thyroidectomies per year to over 200 thyroidectomies with at least 30 being in pediatric patients" — Cecilia Gigena (clinical) [Ep 138 · 3:00](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=180)
- "Thyroidectomies performed by high volume surgeons show shorter length of stays" — Cecilia Gigena (clinical) [Ep 138 · 3:20](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=200)
- "The Tendon et al. study was a prospective randomized control trial conducted between 2017 and 2018" — Ellen Encisco (clinical) [Ep 138 · 3:35](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=215)
- "The study compared three skin closure groups: sutures with tissue adhesive, sutures with adhesive tape, and sutures alone" — Ellen Encisco (clinical) [Ep 138 · 3:55](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=235)
- "Wounds were assessed at two weeks, six weeks, and more than six months after operation by surveying clinicians and parents" — Ellen Encisco (clinical) [Ep 138 · 4:10](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=250)
- "Wounds with tissue adhesive had poorer cosmesis at six weeks" — Em Tombash (clinical) [Ep 138 · 4:17](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=257)
- "The cosmesis difference between tissue adhesive and other closure methods was gone by six months" — Em Tombash (clinical) [Ep 138 · 4:25](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=265)
- "There was no difference between the three closure groups at six months for clinicians or for parents" — Em Tombash (clinical) [Ep 138 · 4:35](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=275)
- "The life-threatening bleeding study was a prospective observational study of children presenting with life threatening bleeding events across 24 centers between the US, Canada, and Italy" (clinical) [Ep 143 · 0:20](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=20)
- "Children were eligible for the bleeding study if they received more than 40 ccs per kilo of total blood products over six hours, or if they were transfused under massive transfusion protocol" (clinical) [Ep 143 · 0:20](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=20)
- "The bleeding study compared patients presenting with traumatic bleeding, operative bleeding, and medical bleeding" — Em Tombash (clinical) [Ep 143 · 1:21](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=81)
- "The Western Pediatric Surgery Research Consortium conducted a prospective cohort study on children undergoing colorectal surgery across 10 hospitals in the US" (clinical) [Ep 143 · 1:43](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=103)
- "The colorectal surgery study utilized an eight-part perioperative care bundle and split children into either a high or low compliance group" (clinical) [Ep 143 · 1:43](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=103)
- "Children in the high compliance group had a statistically significant decrease in rates of superficial surgical site infection when compared to children in the low compliance group" — Em Tombash (clinical) [Ep 143 · 2:16](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=136)
- "Standardization of perioperative care may decrease morbidity and improve outcomes in colorectal surgery" — Em Tombash (opinion) [Ep 143 · 2:16](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=136)
- "The contrast enema study was a retrospective study done in Netherlands between 1998 and 2018" (clinical) [Ep 143 · 2:39](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "The contrast enema study looked at patients under three years old that got a stoma reversal to see if they had contrast enema prior to it and if they were able to detect strictures" (clinical) [Ep 143 · 2:39](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "The contrast enema study gathered 244 patients" (clinical) [Ep 143 · 2:39](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "Of the 244 patients in the contrast enema study, 10% got strictures" (clinical) [Ep 143 · 2:39](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "95% of patients with strictures had necrotizing enterocolitis" (clinical) [Ep 143 · 2:39](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "Only 68% of all patients had a contrast enema prior to the stoma reversal" (clinical) [Ep 143 · 2:39](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "Contrast enema was able to detect 92% of the strictures" (clinical) [Ep 143 · 2:39](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "Contrast enema prior to stoma reversal is only useful if patients had necrotizing enterocolitis" — Em Tombash (opinion) [Ep 143 · 3:29](https://library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=209)
- "Vaginal agenesis in perineal fistula occurs approximately once per 500 cases" — Marc Levitt (epidemiological) [Ep 63 · 44:03](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2643)
- "Urethra is typically enlarged in anorectal malformations with absent vagina" — Marc Levitt (clinical) [Ep 63 · 5:49](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=349)
- "Total body prep from nipples to toes is standard for posterior sagittal anorectoplasty" (clinical) [Ep 63 · 2:10](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=130)
- "MRI has limited utility for visualizing vaginal lumen in infants unless hydrocolpos or hematocolpos present" — Marc Levitt (clinical) [Ep 63 · 82:15](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4935)
- "In congenital cervical agenesis, retaining uterus without cervix has no proven benefit for fertility and risks pyometra" — Don (clinical) [Ep 63 · 44:03](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2643)
- "There have been no successful live births from uteri with congenital cervical agenesis connected to neovagina" — Don (clinical) [Ep 63 · 44:03](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2643)
- "Optimal timing for neovagina creation is during initial rectal mobilization to avoid operating through scarred perineum later" — Marc Levitt (opinion) [Ep 63 · 48:12](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2892)
- "Sigmoid colon is preferred over small bowel for neovagina due to more robust blood supply" — Marc Levitt (opinion) [Ep 63 · 59:42](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=3582)
- "Normal vaginal length in infant is approximately 7-8 centimeters" — Marc Levitt (clinical) [Ep 63 · 65:08](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=3908)
- "Vaginal dilation is not routinely performed postoperatively; some patients require minor revision for introital stenosis" — Marc Levitt (clinical) [Ep 63 · 69:37](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4177)
- "Pelvic ultrasound and examination under anesthesia with vaginoscopy should be performed after breast budding to assess Müllerian structures" — Marc Levitt (guideline) [Ep 63 · 70:40](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4240)
- "Electrical nerve stimulator from anesthesia (train-of-four) is cost-effective alternative to dedicated perineal stimulator" — Marc Levitt (clinical) [Ep 63 · 7:47](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=467)
- "Lateral dissection plane defines anterior plane in posterior sagittal approach" — Marc Levitt (clinical) [Ep 63 · 15:16](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=916)
- "Presence of fat in dissection plane indicates surgeon can dissect closer to rectal wall" — Marc Levitt (clinical) [Ep 63 · 35:07](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2107)
- "Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse" — Marc Levitt (clinical) [Ep 63 · 68:53](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4133)
- "In absent vagina cases, thick wall typically exists between rectum and urethra" — Marc Levitt (clinical) [Ep 63 · 20:28](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1228)
- "Sigmoid colon does not have same storage capacity and physiologic properties as rectum" — Don (clinical) [Ep 63 · 28:50](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1730)
- "In series of eight recto-vestibular fistulas with absent vagina, only one had imperforate hymen; remainder had no uterus or fallopian tubes" — Don (epidemiological) [Ep 63 · 28:50](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1730)
- "Neonatal pelvic ultrasound did not show hydrocolpos in this case" — Marc Levitt (clinical) [Ep 63 · 4:25](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=265)
- "Renal and urologic workup was normal preoperatively" — Marc Levitt (clinical) [Ep 63 · 12:11](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=731)
- "Separate examination under anesthesia would not be performed for straightforward primary perineal fistula repair in newborn" — Marc Levitt (opinion) [Ep 63 · 26:53](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1613)
- "Staple line should be removed from neovagina segment to avoid leaving foreign material" — Marc Levitt (clinical) [Ep 63 · 49:17](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2957)
- "Patient-controlled analgesia is planned postoperative pain management" — Marc Levitt (clinical) [Ep 63 · 86:40](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=5200)
- "Parasympathetic nerve fibers are at risk during dissection in female patients without vagina" — Marc Levitt (clinical) [Ep 63 · 13:53](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=833)
- "This patient has good potential for bowel control based on sacral anatomy" — Marc Levitt (clinical) [Ep 63 · 25:36](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1536)
- "True fecal incontinence patients lack the ability to have bowel control, either congenital or acquired." (clinical) [Ep 51 · 0:22](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=22)
- "Congenital true fecal incontinence includes myelomeningocele, large sacrococcygeal tumors, absent sacrum, and anorectal malformation with bad prognosis (bladder neck fistula, complex cloaca, sacral ratio <0.4, presacral mass, tethered cord)." (clinical) [Ep 51 · 0:39](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=39)
- "Acquired true fecal incontinence includes patients operated for Hirschsprung disease with damaged anal canal or anorectal malformation with good prognosis who had complications (dehiscence, reoperation) changing prognosis to bad." (clinical) [Ep 51 · 2:24](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=144)
- "Treatment for true fecal incontinence is enema—an artificial way to clean the colon and avoid bowel movements for 24 hours." (clinical) [Ep 51 · 3:37](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=217)
- "Pseudo fecal incontinence patients have the ability to have bowel control but suffer from constipation." (clinical) [Ep 51 · 3:49](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=229)
- "Pseudo fecal incontinence includes anorectal malformation with good prognosis and good operation, severe idiopathic constipation, and some Hirschsprung patients with good operation and intact anal canal." (clinical) [Ep 51 · 4:01](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=241)
- "Pseudo fecal incontinence is treated by addressing constipation with laxatives; once adequate laxative dose is achieved, patients empty daily and are clean." (clinical) [Ep 51 · 4:23](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=263)
- "Sacral ratio less than 0.4 indicates true fecal incontinence." (clinical) [Ep 51 · 5:20](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=320)
- "Removal of presacral mass does not improve continence because continence is related to sacral nerve damage, not the mass itself." (clinical) [Ep 51 · 7:39](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=459)
- "Presacral mass must be resected to prevent infection (severe meningitis) and because some masses are malignant; MRI is needed to check for dural connection requiring neurosurgeon involvement." (clinical) [Ep 51 · 8:55](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=535)
- "Tethered cord release does not improve bowel control; practice varies by institution and country, with no scientific consensus." (opinion) [Ep 51 · 9:57](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=597)
- "Some neurosurgeons believe tethered cord release may help bladder function more than anorectal function." (opinion) [Ep 51 · 11:03](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=663)
- "Tethered cord is a controversial issue with no scientific approach; some patients with tethered cord are never operated and have normal bowel and urinary control." (opinion) [Ep 51 · 12:47](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=767)
- "Contrast enema without bowel prep divides fecal incontinence patients into two groups: dilated colon (slow-moving) and non-dilated colon (fast-moving, hypermotile)." (clinical) [Ep 51 · 33:36](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2016)
- "Dilated colon patients need large volume, concentrated enema; once cleaned, the colon stays quiet for 23 hours." (clinical) [Ep 51 · 34:23](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2063)
- "Non-dilated colon patients need small saline enema plus constipating diet, limited snacks (3 meals/day to avoid gastrocolic reflex), loperamide, and fiber to keep colon quiet." (clinical) [Ep 51 · 34:55](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2095)
- "Enema base is saline solution 200–1000 mL; irritants are liquid glycerin 10–30 mL, Castile soap 9–36 mL, and fleet phosphate (last resort due to colitis risk)." (clinical) [Ep 51 · 35:57](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2157)
- "Fleet enema is last resort because long-term use can cause narrow spastic colon (inflammatory reaction); dose must be respected to avoid electrolyte disturbances." (clinical) [Ep 51 · 36:30](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2190)
- "Fleet dosing: 3–4 years half pediatric fleet (33 mL), 4–10 years one pediatric fleet (66 mL), >10 years adult fleet (133 mL)." (clinical) [Ep 51 · 37:04](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2224)
- "Enema titration is a one-week trial-and-error program; no weight/height formula exists; each child's colon behaves differently." (clinical) [Ep 51 · 37:28](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2248)
- "Daily abdominal X-ray is the only way to know if the enema is working; goal is clear left colon and rectum (stool in right colon will take 23 hours to reach rectum)." (clinical) [Ep 51 · 37:54](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2274)
- "Never give laxatives and enemas simultaneously in fecal incontinence patients; laxatives cause unpredictable bowel movements after enema, worsening incontinence." (clinical) [Ep 51 · 39:27](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2367)
- "If enema takes >1 hour to produce bowel movement, increase concentration (enema not irritant enough)." (clinical) [Ep 51 · 41:24](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2484)
- "If patient has pain, nausea, vomiting during enema with clean X-ray, decrease concentration; if X-ray not clean, slow administration and warm solution to body temperature." (clinical) [Ep 51 · 41:59](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2519)
- "If colon is completely clean but patient has accidents, colon is moving too fast; add loperamide and constipating diet." (clinical) [Ep 51 · 43:46](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2626)
- "Bowel management through stoma is an option for cloacal exstrophy patients; if successful (empty bag 23 hours), pull-through can be offered; some patients prefer to continue stoma management." (clinical) [Ep 51 · 44:20](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2660)
- "Bowel management is a matter of quality of life determined by the patient, not the doctor." (opinion) [Ep 51 · 45:06](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2706)
- "Initial enema volume can be estimated by asking radiologist how much volume was needed to reach splenic flexure during contrast enema." (clinical) [Ep 51 · 47:20](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2840)
- "Typical enema volumes range from 200–250 mL in small children to 1–1.5 L in large patients with huge colon." (clinical) [Ep 51 · 48:04](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2884)
- "Glycerin dosing: start 10 mL, maximum 40 mL; Castile soap: start 9 mL, maximum 27–36 mL." (clinical) [Ep 51 · 48:29](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=2909)
- "Malone procedure should only be offered after demonstrating that enema works; doing Malone without prior bowel management trial is incorrect." (opinion) [Ep 51 · 50:53](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=3053)
- "Tap water enema risks water absorption by colon (colon's function is to absorb water) and electrolyte disturbances; saline solution is preferred." (clinical) [Ep 51 · 61:51](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=3711)
- "Saline solution alone often does not produce bowel movement; irritants (glycerin, soap) are needed to provoke colonic contraction." (clinical) [Ep 51 · 62:13](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=3733)
- "For fecal impaction, disimpaction uses 3 enemas/day with maximum concentration, not saline only." (clinical) [Ep 51 · 62:40](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=3760)
- "When evaluating enema X-rays, focus on left colon and rectum; stool in transverse/right colon takes 24 hours to reach rectum." (clinical) [Ep 51 · 63:20](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=3800)
- "Myelomeningocele patients typically do not have dilated colon even with severe dysmotility and fecal incontinence; colon may be redundant but not dilated." (clinical) [Ep 51 · 20:23](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=1223)
- "Achalasia of anal sphincter is a manometric concept (lack of internal sphincter relaxation); internal sphincter is a functional, not anatomic, structure." (opinion) [Ep 51 · 30:44](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=1844)
- "Neuronal intestinal dysplasia (NID) lacks topographic studies defining which bowel segment is abnormal; no standard treatment exists; diagnosis is controversial." (opinion) [Ep 51 · 22:34](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=1354)
- "Duhamel pouch patients with giant pouch and staple line visible on contrast enema typically suffer from constipation, treated with laxatives." (clinical) [Ep 51 · 27:47](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=1667)
- "For severe idiopathic constipation with megarectum, 85% respond to laxative protocol; 15% non-responders may be offered sigmoid resection as last resort with variable results (50% improve)." (clinical) [Ep 51 · 25:26](https://library.globalcastmd.com/watch/fecal-incontinence-bowel-management-pediatric-bowel-management-2013-1067?t=1526)
- "Prenatal diagnosis of anorectal malformation in boys is not very good; it is often a surprise at birth" (clinical) [Ep 61 · 0:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=0)
- "In females with cloaca, prenatal ultrasound findings include bilateral hydronephrosis, dilated bladder, and hydrocolpos" — Greg Bates (clinical) [Ep 61 · 2:12](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=132)
- "Fetal MRI is used when level 2 ultrasounds are abnormal, especially for prognostication and genetic counseling" (clinical) [Ep 61 · 6:03](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=363)
- "Calcified meconium in the GI tract on KUB indicates urine mixing with meconium and suggests a rectourinary fistula" — Greg Bates (clinical) [Ep 61 · 7:14](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=434)
- "Patients with hydrocolpos can have significant urinary compromise with creatinine elevation into the 2–3 range if not managed urgently" — Greg Bates (clinical) [Ep 61 · 9:14](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=554)
- "Hemisacrum is associated with presacral masses such as teratoma or anterior meningocele (Currarino triad)" (clinical) [Ep 61 · 12:38](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=758)
- "Sacral ratio measurement requires a true AP pelvis view, not an angled sacral view, to avoid measurement error" — Greg Bates (clinical) [Ep 61 · 15:35](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=935)
- "The lateral view is the most accurate for measuring sacral ratio because it minimizes angulation artifacts" — Greg Bates (clinical) [Ep 61 · 21:48](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1308)
- "A sacral ratio below 0.3 is associated with very low likelihood of continence" (clinical) [Ep 61 · 24:42](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1482)
- "Sacral ratio between 0.3 and 0.5 has intermediate prognosis; above 0.6–0.7 most patients do fine in terms of continence" (clinical) [Ep 61 · 24:42](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1482)
- "There is inter-observer variability in sacral ratio measurement, particularly in abnormal sacrums" (clinical) [Ep 61 · 30:35](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1835)
- "Sacral ratio has not been shown to be predictive of long-term continence in robust multicenter studies" (epidemiological) [Ep 61 · 32:10](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1930)
- "Cross-table lateral radiograph (invertogram) should be done after 24–36 hours to allow adequate air distension of the distal rectum" — Greg Bates (clinical) [Ep 61 · 36:40](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=2200)
- "If invertogram is done too early (e.g., a few hours after birth), it can erroneously suggest a high rectal pouch when the fistula is actually perineal" — Greg Bates (clinical) [Ep 61 · 48:27](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=2907)
- "Waiting longer than 48 hours for invertogram is associated with increased risk of perforation" — Keith Jorgensen (clinical) [Ep 61 · 48:27](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=2907)
- "Perineal ultrasound may be more accurate than invertogram because it does not depend on BB positioning or air distension" (opinion) [Ep 61 · 40:30](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=2430)
- "In Down syndrome patients without a perineal fistula, invertogram and ultrasound can help avoid unnecessary colostomy" (clinical) [Ep 61 · 50:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3000)
- "Approximately 95% of boys with ARM have a fistula (outside of Down syndrome)" (epidemiological) [Ep 61 · 52:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3120)
- "During distal colostography, adequate pressurization is essential to demonstrate the fistula; a spherical distal rectum without a beak suggests no fistula" (clinical) [Ep 61 · 52:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3120)
- "Rectobladder-neck fistulas fill the bladder almost immediately with minimal resistance during colostography" (clinical) [Ep 61 · 52:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3120)
- "Patients with very dilated distal colonic segments are at higher risk of perforation during colostography due to Laplace's Law" — Greg Bates (clinical) [Ep 61 · 56:56](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3416)
- "Perforation during colostography with hyperosmotic contrast can cause rapid fluid shifts and peritonitis requiring immediate IV fluids and surgical consultation" — Keith Jorgensen (clinical) [Ep 61 · 58:21](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3501)
- "Use of iso-osmotic contrast for colostography reduces the risk of fluid shifts if perforation occurs" — Greg Bates (clinical) [Ep 61 · 59:58](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3598)
- "On fetal MRI, T1 hyperintensity of meconium in the colon is visible after 20–24 weeks; loss of T1 hyperintensity and bright T2 signal suggests urine mixing" — Greg Bates (clinical) [Ep 61 · 9:14](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=554)
- "The distal rectum should extend at least 10 mm below the bladder neck on fetal MRI; less than this suggests a high rectal position" — Greg Bates (clinical) [Ep 61 · 9:14](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=554)
- "Normal sacral ratio ranges from 0.6 to 1.0" (clinical) [Ep 61 · 29:40](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1780)
- "When measuring sacral ratio on lateral view, use the midpoint between the two inferior SI joints (which are not perfectly superimposed) as the second reference line" — Greg Bates (clinical) [Ep 61 · 29:40](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1780)
- "Spine ultrasound in the newborn can count sacral segments and is a good predictor of sacral ratio abnormality" (clinical) [Ep 61 · 30:35](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=1835)
- "If there is no meconium on the perineum and the clinical picture is unclear, it is never wrong to do a colostomy" — Keith Jorgensen (opinion) [Ep 61 · 49:51](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=2991)
- "Incidence of complications doubles in patients who undergo colostomy" (epidemiological) [Ep 61 · 50:00](https://library.globalcastmd.com/watch/anorectal-malformation-radiology-pediatric-colorectal-controversies-2014-1097?t=3000)
- "Mismanagement decisions in ARM are often based on an incorrect newborn exam." — Mark (opinion) [Ep 65 · 0:00](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=0)
- "A flat bottom in a newborn suggests high fistula and usually poor continence prognosis." — Jeff (clinical) [Ep 65 · 1:35](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=95)
- "There is no rush to operate on a newborn ARM on the day of birth if the abdomen is soft and not distended." — Paola (clinical) [Ep 65 · 3:27](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=207)
- "Approximately 95% of Down syndrome patients with ARM have no fistula." (epidemiological) [Ep 65 · 5:54](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=354)
- "In a male newborn anoplasty for perineal fistula, the urethra is incredibly close and anterior dissection risks urethral injury." — Jack (clinical) [Ep 65 · 32:13](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1933)
- "A cutback technique (unroofing the fistula posteriorly without circumferential mobilization) avoids dangerous anterior dissection in male perineal fistula." — Jack (clinical) [Ep 65 · 35:02](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=2102)
- "If the anal opening is left outside the sphincter, patients may have anterior leakage during athletics or with loose stool when they try to close the sphincter." — Mark (clinical) [Ep 65 · 42:04](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=2524)
- "The transition from breast milk or formula to solid food (around six months) causes a change in stool character that leads to rectal dilation in untreated ARM." — Jack (clinical) [Ep 65 · 25:40](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1540)
- "Dilating a one-year-old postoperatively is much more challenging than dilating a four-month-old." — Mark (clinical) [Ep 65 · 25:40](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1540)
- "An anus is defined as a properly sized hole in the center of the sphincter that is mucosal lined." — Mark (clinical) [Ep 65 · 28:08](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1688)
- "Trans-scrotal fistulas are generally low-type malformations (over 90%) with rectum very low, suitable for primary neonatal repair." — Ivo (clinical) [Ep 65 · 30:24](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1824)
- "Cross-table lateral x-ray is most useful when it shows a very short distance between skin and rectum; a long distance may be falsely elevated by meconium blocking air." — Jack (clinical) [Ep 65 · 93:40](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5620)
- "Perineal body in females grows and lengthens over time; what appears short in the newborn period often becomes adequate." — Mark (clinical) [Ep 65 · 49:54](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=2994)
- "From a gynecological standpoint, building as good a perineal body as possible is important for separation of reproductive and GI tracts, sexual function, and potential vaginal delivery." — Jonathan (clinical) [Ep 65 · 50:49](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3049)
- "Cloaca patients (single perineal opening, no anus) do not need endocrine evaluation; their electrolytes will be normal." — Mark (clinical) [Ep 65 · 54:39](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3279)
- "If a female has a normal anus and a urogenital sinus, that is consistent with disorder of sexual development and requires workup for congenital adrenal hyperplasia." — Jonathan (clinical) [Ep 65 · 55:50](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3350)
- "The incidence of congenital adrenal hyperplasia in the ARM population is almost zero." — Mark (epidemiological) [Ep 65 · 55:50](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3350)
- "A vestibular fistula is distinguished from a perineal fistula by the absence of perineal body." — Jack (clinical) [Ep 65 · 57:24](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3444)
- "Undiverted repair of vestibular fistula is feasible but will have fewer perineal complications if diverted; the trade-off is colostomy complications." — Mark (opinion) [Ep 65 · 59:40](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3580)
- "Anal stenosis patients must be evaluated for presacral mass with plain x-ray of sacrum and ultrasound." — Mark (clinical) [Ep 65 · 74:45](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4485)
- "Rectal atresia is a hole in the right place that does not communicate with the rectum and requires surgery." — Mark (clinical) [Ep 65 · 75:58](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4558)
- "H-type rectovaginal fistula (normal urethra, vagina, and anus with fistulous communication) is a real congenital entity, more common in Asia." — Mark (clinical) [Ep 65 · 80:10](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4810)
- "Esophageal atresia must be ruled out in every ARM patient before starting feeds." — Mark (clinical) [Ep 65 · 83:01](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4981)
- "If a newborn has normal physical exam, normal chest x-ray, and normal ECG, significant cardiac problems that would interfere with anesthesia are not found." — Jack (clinical) [Ep 65 · 84:41](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5081)
- "Approximately 30% of perineal fistula patients have associated anomalies across the board." — Jonathan (epidemiological) [Ep 65 · 87:33](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5253)
- "Three factors predict continence in ARM: type of malformation, quality of sacrum, and quality of spine." — Mark (clinical) [Ep 65 · 88:10](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5290)
- "Perineal ultrasound to assess rectal position requires a quiet baby and no compression; if the baby is valsalving, the rectum may appear falsely low." — Jonathan (clinical) [Ep 65 · 32:13](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1933)
- "It is exceedingly rare to have perineal meconium and a long fistula; almost uniformly those patients have a very reachable rectum." — Mark (clinical) [Ep 65 · 91:51](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5511)
- "Colostomy should be created at the very proximal sigmoid (where sigmoid begins at left retroperitoneal attachments) to prevent prolapse." — Mark (clinical) [Ep 65 · 97:28](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5848)
- "Loop stomas theoretically allow distal spillage and prolapse, but recent data show no difference in urinary tract infection rates compared to divided stomas." — Jonathan (clinical) [Ep 65 · 101:15](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=6075)
- "Urinary tract infection rate in ARM is affected by vesicoureteral reflux or neurogenic bladder, not stoma type." — Jonathan (clinical) [Ep 65 · 101:15](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=6075)
- "If ARM repair is done early (within 3 months), there is less time for urinary and stoma complications." — Jonathan (clinical) [Ep 65 · 102:35](https://library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=6155)
- "Hirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction" — Aaron Garrison (clinical) [Ep 73 · 0:07](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=7)
- "More than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease" — Jason Frischer (clinical) [Ep 73 · 0:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=35)
- "Some infants with Hirschsprung's disease do pass meconium" — Jason Frischer (clinical) [Ep 73 · 0:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=35)
- "Hirschsprung disease has an incidence of about 1 in 5,000 children" — Aaron Garrison (epidemiological) [Ep 73 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "About 10% of children with Hirschsprung disease will have a positive family history" — Aaron Garrison (epidemiological) [Ep 73 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "The RET gene is a predisposing genetic condition associated with Hirschsprung disease" — Aaron Garrison (clinical) [Ep 73 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "Up to 10% of children with Hirschsprung's disease will have trisomy 21" — Aaron Garrison (epidemiological) [Ep 73 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "Only 1 to 2% of patients with trisomy 21 have Hirschsprung disease" — Aaron Garrison (epidemiological) [Ep 73 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "Hirschsprung disease is associated with Waardenburg syndrome and congenital central hypoventilation (Ondine's curse)" — Aaron Garrison (clinical) [Ep 73 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "The classic finding on contrast enema is a transition zone in the rectosigmoid" — Jason Frischer (clinical) [Ep 73 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "A rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease" — Jason Frischer (clinical) [Ep 73 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema" — Jason Frischer (clinical) [Ep 73 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Rectal biopsy is the true definitive diagnosis for Hirschsprung disease" — Jason Frischer (clinical) [Ep 73 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Typical biopsy features include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining" — Jason Frischer (clinical) [Ep 73 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "An adequate biopsy must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers" — Jason Frischer (guideline) [Ep 73 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR)" — Jason Frischer (clinical) [Ep 73 · 4:23](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=263)
- "Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis" — Jason Frischer (guideline) [Ep 73 · 4:23](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=263)
- "Enterocolitis is the life-threatening part of Hirschsprung's disease" — Aaron Garrison (clinical) [Ep 73 · 5:12](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=312)
- "There are three goals to the surgical management of Hirschsprung's disease: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity" — Jason Frischer (guideline) [Ep 73 · 6:42](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=402)
- "The contrast enema can be used as a roadmap for surgery but is not always accurate to where the level is" — Aaron Garrison (clinical) [Ep 73 · 6:59](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=419)
- "The Swenson procedure involves pulling down the aganglionic bowel and performing a full thickness anastomosis one to two centimeters above the dentate line" — Jason Frischer (clinical) [Ep 73 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel" — Jason Frischer (clinical) [Ep 73 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "In the Suave procedure, the aganglionic cuff can become stiff enough to cause an obstruction or an outlet obstruction" — Jason Frischer (clinical) [Ep 73 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "The Duhamel procedure intentionally leaves a portion of the aganglionic rectum behind and brings the normally ganglionated bowel posterior to that rectum" — Aaron Garrison (clinical) [Ep 73 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "Children with Duhamel procedure may have higher risks of having constipation and stool withholding" — Aaron Garrison (clinical) [Ep 73 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "All three surgical techniques (Swenson, Suave, and Duhamel) are equally effective" — Aaron Garrison (opinion) [Ep 73 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth" — Jason Frischer (clinical) [Ep 73 · 12:34](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=754)
- "A child with enterocolitis presents with abdominal distension, vomiting, fever, and change in bowel habits that could be either diarrhea or not passing stool at all" — Jason Frischer (clinical) [Ep 73 · 12:34](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=754)
- "Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations" — Jason Frischer (guideline) [Ep 73 · 12:34](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=754)
- "About 80% of kids with Hirschsprung's disease are constipated and will need some kind of management" — Aaron Garrison (epidemiological) [Ep 73 · 13:54](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=834)
- "Most patients with rectosigmoid type Hirschsprung disease should be continent by the time they enter kindergarten" — Aaron Garrison (clinical) [Ep 73 · 13:54](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=834)
- "If you're getting past the splenic flexure during surgery for Hirschsprung's disease, stop and await permanent sections and then do a diversion with an ileostomy" — Aaron Garrison (guideline) [Ep 73 · 17:10](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=1030)
- "Patients tend to outgrow episodes of enterocolitis early in life" — Aaron Garrison (clinical) [Ep 73 · 17:10](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=1030)
- "All patients should be able to perform irrigations before they get their pull-through and go home" — Jason Frischer (guideline) [Ep 73 · 18:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=1115)
- "The case involves a one-day-old full-term baby weighing 3.9 kilograms presenting with significant abdominal distension and bilious emesis" — Todd Ponsky (clinical) [Ep 87 · 0:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=40)
- "The patient is 41 weeks gestation, just under 4 kilograms" — Rod Gerardo (clinical) [Ep 87 · 2:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=120)
- "If the child is sick, resuscitation should be the first step before diagnostic workup" — Rod Gerardo (clinical) [Ep 87 · 2:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=150)
- "It is hard on a newborn film to really discern small and large bowel, and you can get fooled" — Frischer (clinical) [Ep 87 · 3:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=228)
- "A baby with bilious emesis and non-classic abdominal x-ray could have had distal air and then had a volvulus, requiring urgent upper GI to rule out the dangerous thing before contrast enema" — Todd Ponsky (clinical) [Ep 87 · 4:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=245)
- "An upper GI was performed and ruled out malrotation in this child" — Frischer (clinical) [Ep 87 · 4:43](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=283)
- "The contrast enema shows a transition zone somewhere in the transverse colon" — Levitt (clinical) [Ep 87 · 5:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=301)
- "The patient was lucky not to show up with a perforation, which usually occurs in the cecum" — Frischer (clinical) [Ep 87 · 5:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=320)
- "To get a perforation, you need distension, and if you have a transition zone at the hepatic flexure, then all the pressure is in the right colon" — Frischer (clinical) [Ep 87 · 5:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=335)
- "A competent ileosecal valve contributes to perforation risk, while an incompetent ileosecal valve might save the baby from perforation" — Levitt (clinical) [Ep 87 · 5:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=341)
- "You are obligated at some point, maybe after resuscitation, to get a rectal biopsy" — Frischer (clinical) [Ep 87 · 5:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=357)
- "If the transition zone is in the hepatic flexure, it builds up enough pressure in the right colon to have the cecum perforate" — Levitt (clinical) [Ep 87 · 6:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=364)
- "You rarely get a perforation in a more standard sigmoid level transition" — Levitt (clinical) [Ep 87 · 6:25](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=385)
- "A rectal biopsy confirmed the diagnosis of Hirschsprung disease" — Levitt (clinical) [Ep 87 · 6:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=418)
- "Proximal Hirschsprung disease requires a different operative approach than distal Hirschsprung disease" — Frischer (clinical) [Ep 87 · 7:14](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=434)
- "If you don't get anorectoplasty perfect, you might not have the best outcomes, which separates it from other surgical procedures" — Rod Gerardo (opinion) [Ep 85 · 0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=0)
- "A lot of surgeons agree that oftentimes your first shot might be your only shot to give this patient a good outcome and the right anatomy" — Rod Gerardo (opinion) [Ep 85 · 0:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=50)
- "The original malformation was a prostatic fistula and the patient has a tethered cord and a sacral ratio of 0.66" — Marc Levitt (clinical) [Ep 85 · 4:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=270)
- "The family doesn't really care how technically elegant is your anaplasty. What they care about is whether that anaplasty that you make is going to work" — Rod Gerardo (opinion) [Ep 85 · 5:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=350)
- "The higher the malformation is, the worse the prognosis" — Rod Gerardo (clinical) [Ep 85 · 6:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=375)
- "Sacrum ratio 0.7 or greater usually means normal or close to normal sphincters and good muscle tone and spine innervation" — Rod Gerardo (clinical) [Ep 85 · 6:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=390)
- "The most common associated spinal anomaly is tethered cord, but the worst is myelomeningocele" — Rod Gerardo (clinical) [Ep 85 · 6:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=415)
- "Patients with myelomeningocele have much more trouble with continence" — Rod Gerardo (clinical) [Ep 85 · 6:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=415)
- "It's amazingly common to have a mislocated anus" — Rod Gerardo (clinical) [Ep 85 · 7:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=464)
- "A key pitfall is opening the PSARP incision first; you should mark the sphincters first, then open the PSARP so you don't get confused when placing the anoplasty" — Rod Gerardo (clinical) [Ep 85 · 7:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=475)
- "The patient was born with a vestibular fistula, the spine is normal and has an excellent sacrum, so this is a much better prognosis bowel control patient" — Marc Levitt (clinical) [Ep 85 · 8:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=520)
- "The stimulator is the same electrical stimulator that anesthesia uses for their train of four" — Marc Levitt (clinical) [Ep 85 · 9:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=590)
- "You have to tell your anesthesiologist not to give skeletal muscle relaxant because the stimulator is a little bit weaker than the traditional stimulator" — Marc Levitt (clinical) [Ep 85 · 10:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=605)
- "In higher malformations like bladder neck fistula in a boy, the sphincter complex isn't always where you think it's going to be; sometimes those sphincter complexes are more anterior than anticipated" — Rod Gerardo (clinical) [Ep 85 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=640)
- "The vast majority of redo operations were for mislocation, then came stricture, and less common reasons included remnant of original fistula (roof), rectal prolapse, and others" — Marc Levitt (clinical) [Ep 85 · 12:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=720)
- "Quality of life improved with a redo operation" — Marc Levitt (clinical) [Ep 85 · 12:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=750)
- "Patients had an improved ability to achieve continence after redo" — Marc Levitt (clinical) [Ep 85 · 12:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=760)
- "20% of patients with a poor sacrum or poor spine actually developed bowel control after their redo" — Marc Levitt (clinical) [Ep 85 · 12:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=770)
- "Patients with good potential—a good sacrum and good spine—did extremely well after redo" — Marc Levitt (clinical) [Ep 85 · 13:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=785)
- "Patients who did not develop voluntary bowel movements were still able to be clean with a bowel management program with enemas or antegrade using a Malone" — Marc Levitt (clinical) [Ep 85 · 13:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=795)
- "The average age of patients in the study is about three and a half years" — Marc Levitt (epidemiological) [Ep 85 · 13:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=801)
- "If you know the anatomy is off, you should do the redo" — Marc Levitt (opinion) [Ep 85 · 13:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=808)
- "There's an advantage to getting the anatomy right the younger the child is" — Marc Levitt (opinion) [Ep 85 · 13:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=820)
- "Many patients present after the age of potty training because they're incontinent, and evaluation reveals the reason is they don't have the best operation" — Marc Levitt (clinical) [Ep 85 · 14:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=850)
- "When doing redo at older age, usually add a Malone at the same time so patients can learn how to get control with their new anatomy before trying voluntary bowel movements" — Marc Levitt (clinical) [Ep 85 · 14:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=870)
- "The process of learning control with new anatomy after redo may take 6 to 12 months" — Marc Levitt (clinical) [Ep 85 · 14:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-when-to-redo-a-psarp-3580?t=883)
- "Babies with abdominal distention can have both anatomic and physiologic causes beyond Hirschsprung disease" — Levitt (clinical) [Ep 86 · 1:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=104)
- "Maternal magnesium sulfate used to slow delivery can cause neonatal abdominal distention that mimics Hirschsprung disease" — Levitt (clinical) [Ep 86 · 2:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=163)
- "Maternal opiates can cause neonatal abdominal distention mimicking Hirschsprung disease" — Levitt (clinical) [Ep 86 · 2:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=163)
- "Hypothyroidism can present with abdominal distention similar to Hirschsprung disease" — Levitt (clinical) [Ep 86 · 2:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=163)
- "Small left colon syndrome associated with maternal diabetes can mimic Hirschsprung disease" — Levitt (clinical) [Ep 86 · 2:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=163)
- "Contrast enema should not be performed in the presence of enterocolitis because it may perforate the baby" — Levitt (clinical) [Ep 86 · 6:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=404)
- "Rectal irrigations before contrast enema do not change the result of the contrast study" — Levitt (opinion) [Ep 86 · 7:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=453)
- "Rectal exam should be performed to rule out anal stenosis or rectal atresia" — Levitt (clinical) [Ep 86 · 7:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=453)
- "The contrast study serves as a map for surgery rather than definitive diagnosis" — Levitt (opinion) [Ep 86 · 7:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=453)
- "Some institutions go directly to rectal biopsy without contrast study" — Levitt (clinical) [Ep 86 · 8:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=519)
- "The recto-sigmoid ratio reflects that the aganglionic rectum is in spasm with diminished circumference compared to dilated ganglionated bowel above" — Frischer (clinical) [Ep 86 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=592)
- "Tortuosity and hyperperistalsis in the rectum is a classic finding in Hirschsprung disease due to hypercontractility from absence of ganglion cells" — Levitt (clinical) [Ep 86 · 10:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=630)
- "The exact transition zone location cannot be determined precisely on contrast study" — Levitt (clinical) [Ep 86 · 10:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=630)
- "A neonate does not need an open biopsy in the OR and can have suction rectal biopsy done at bedside" — Levitt (opinion) [Ep 86 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=766)
- "Three good biopsy specimens should be obtained for pathology review" — Frischer (clinical) [Ep 86 · 13:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=783)
- "Quick diff staining highlights ganglion cells better than standard H&E staining" — Frischer (clinical) [Ep 86 · 13:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=783)
- "Diagnostic criteria require examining 100 histologic levels for absence of ganglion cells" — Levitt (clinical) [Ep 86 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Finding even one ganglion cell rules out Hirschsprung disease regardless of overall ganglion cell density" — Levitt (clinical) [Ep 86 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Nerve hypertrophy is defined as nerve trunks greater than 40 microns" — Levitt (clinical) [Ep 86 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Pathologists need to measure nerve trunks and report on nerve hypertrophy, not just absence of ganglion cells" — Levitt (opinion) [Ep 86 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Patients have been incorrectly operated on for Hirschsprung disease when pathology reported no ganglion cells without commenting on nerves" — Levitt (clinical) [Ep 86 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Everyone is aganglionic in the zone of the anal canal, but hypertrophic nerves are not found there" — Levitt (clinical) [Ep 86 · 15:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=951)
- "Finding squamous epithelium confirms the biopsy was taken too low in the anal canal" — Levitt (clinical) [Ep 86 · 15:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=951)
- "The optimal biopsy location is 0.5 to 1 cm above the crypts to ensure sampling columnar epithelium" — Levitt (clinical) [Ep 86 · 15:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=951)
- "The crypts are above the dentate line, so proper biopsy location is at least 1-2 cm above the dentate line" — Frischer (clinical) [Ep 86 · 16:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=1005)
- "Babies presenting like Hirschsprung disease with ganglion cells present but numerous eosinophils may have allergic etiology" — Levitt (clinical) [Ep 86 · 16:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=1015)
- "Anorectal malformations occur in 1 in 5,000 live births" — Rod Gerardo (epidemiological) [Ep 97 · 0:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=22)
- "Anorectal malformations occur when the anus, rectum, and nerves do not develop properly during fetal growth" — Rod Gerardo (clinical) [Ep 97 · 0:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=42)
- "More than 90% of anorectal malformation patients have their actual anatomy ascertained on physical exam alone" — Frischer (clinical) [Ep 97 · 2:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=145)
- "95% of boys with anorectal malformations have a fistula somewhere" — Levitt (epidemiological) [Ep 97 · 4:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=275)
- "The vast majority of male anorectal malformations enter into the urinary tract" — Levitt (clinical) [Ep 97 · 4:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=285)
- "The presence of a flat bottom, meaning absence of a normal midline groove, is usually associated with a very high located rectum and usually associated with a bad prognosis" — Levitt (clinical) [Ep 97 · 5:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=358)
- "With bucket handle malformation, you can be very confident that you have a perineal fistula" — Levitt (clinical) [Ep 97 · 7:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=428)
- "You can gently dilate a perineal fistula under a bucket handle to get meconium out and spare the baby a trip to the OR if they are too ill" — Levitt (clinical) [Ep 97 · 7:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=442)
- "In black ribbon malformation, the fistula parallels the urethra for a long distance with potential for urethral injury" — Levitt (clinical) [Ep 97 · 8:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=500)
- "In male patients with perineal fistula, the fistula is always located anterior to the center of the sphincter" — Frischer (clinical) [Ep 97 · 9:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=570)
- "No surgical repair should be done before the first 24 hours because a patient may pass meconium through the tiny orifice and the perineal fistula should be identified" — Frischer (clinical) [Ep 97 · 9:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=590)
- "The no fistula defect is quite rare, only about 5% of cases" — Levitt (epidemiological) [Ep 97 · 10:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=616)
- "The no fistula defect is not surprising if you had a trisomy 21 patient" — Levitt (clinical) [Ep 97 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=628)
- "The no fistula defect is almost uniformly at the same level as a bulbar urethra" — Levitt (clinical) [Ep 97 · 10:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=636)
- "Rectal-urethral fistulas are categorized by location on the urethra: bulbar, prostatic, or bladder neck" — Frischer (clinical) [Ep 97 · 3:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=220)
- "It is nice to put a little gauze to check the urine for particulate matter to detect rectal-urethral fistula" — Levitt (clinical) [Ep 97 · 5:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=316)
- "Newborns with rectal-urethral fistulas will need colostomies and then ultimately distal colostograms and then definitive surgery" — Frischer (clinical) [Ep 97 · 5:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-12-newborn-arm-part-1-4121?t=341)
- "The target part of the colon to create the stoma is in the most proximal part of the sigmoid colon, as high as possible close to the descending colon" — Tamer Ashraf Wafa (clinical) [Ep 96 · 0:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=0)
- "Targeting the proximal sigmoid colon as high as possible is done to avoid future stoma prolapse" — Tamer Ashraf Wafa (clinical) [Ep 96 · 0:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=0)
- "The site of the proximal stoma is in the center of a triangle between the anterior superior iliac spine, costal margin, and the umbilicus" — Tamer Ashraf Wafa (clinical) [Ep 96 · 0:40](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=40)
- "The distal colon is brought out at the medial end of the incision as a mucous fistula that is made as narrow as possible" — Tamer Ashraf Wafa (clinical) [Ep 96 · 1:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=60)
- "The incision is oblique and about 5 to 6 centimeters in length" — Tamer Ashraf Wafa (clinical) [Ep 96 · 1:15](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=75)
- "The layers are carefully opened to avoid bowel injury due to the colonic distension" — Tamer Ashraf Wafa (clinical) [Ep 96 · 1:25](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=85)
- "The distal and proximal limbs must be carefully identified to avoid stoma reversal" — Tamer Ashraf Wafa (clinical) [Ep 96 · 1:40](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=100)
- "A purse-string suture is applied around the stoma site using a 4-0 suture" — Tamer Ashraf Wafa (clinical) [Ep 96 · 1:55](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=115)
- "A small puncture is made to allow the introduction of a 12-French catheter" — Tamer Ashraf Wafa (clinical) [Ep 96 · 2:10](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=130)
- "The catheter is used for suction of meconium and emptying the distal colon" — Tamer Ashraf Wafa (clinical) [Ep 96 · 2:25](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=145)
- "Saline is used to help liquefy the thick meconium" — Tamer Ashraf Wafa (clinical) [Ep 96 · 2:40](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=160)
- "Washing and suction continues until the colon is completely cleaned out" — Tamer Ashraf Wafa (clinical) [Ep 96 · 2:50](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=170)
- "A window in the mesentery is created with preservation of the marginal vessels" — Tamer Ashraf Wafa (clinical) [Ep 96 · 3:00](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=180)
- "Bipolar diathermy is applied to the vessels distal to the marginal vessels" — Tamer Ashraf Wafa (clinical) [Ep 96 · 3:15](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=195)
- "Coagulation is kept close to the colonic wall and a 2 cm window is created" — Tamer Ashraf Wafa (clinical) [Ep 96 · 3:25](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=205)
- "Two fine bulldogs are applied to occlude the colonic lumen before the colon is divided" — Tamer Ashraf Wafa (clinical) [Ep 96 · 3:40](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=220)
- "Another division of the mesenteric vessels is done to ensure adequate placement of the two stomas at the two ends of the wound" — Tamer Ashraf Wafa (clinical) [Ep 96 · 3:55](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=235)
- "The colon is fixed to the peritoneum using 4-0 absorbable sutures starting on both ends" — Tamer Ashraf Wafa (clinical) [Ep 96 · 4:10](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=250)
- "The peritoneum in between is then approximated with interrupted sutures" — Tamer Ashraf Wafa (clinical) [Ep 96 · 4:25](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=265)
- "The distal stoma is made as narrow as possible" — Tamer Ashraf Wafa (clinical) [Ep 96 · 4:35](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=275)
- "The muscles are approximated using interrupted sutures, followed by closure of the skin with interrupted subcuticular sutures" — Tamer Ashraf Wafa (clinical) [Ep 96 · 4:42](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=282)
- "The stoma edges are fixed to the skin with few simple sutures using 5-0 sutures" — Tamer Ashraf Wafa (clinical) [Ep 96 · 4:55](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=295)
- "The stoma bag shall be applied to the proximal stoma only" — Tamer Ashraf Wafa (clinical) [Ep 96 · 5:05](https://library.globalcastmd.com/watch/descending-colostomy-for-anorectal-malformations-dr-tamer-ashraf-wafa-4002?t=305)
- "Perineal fistula requires surgery when the hole is too small, not in the center of the sphincter, and there is an inadequate perineal body" — Marc Levitt (clinical) [Ep 98 · 2:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=154)
- "Surgical indications for anorectal malformation include: locating the perineal fistula, determining if it is in the correct location, assessing if it is too big or too small, confirming it is within the sphincter, and evaluating the size of the perineal body" — Rod Gerardo (clinical) [Ep 98 · 2:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=174)
- "Perineal groove typically does not require surgical intervention and will keratinize to look like a normal perineal body over time" — Jason Frischer (clinical) [Ep 98 · 4:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=285)
- "Surgical indication for perineal groove exists only if it is secreting mucus, causing irritation, or developing ulcers, where mucosal lining could be excised" — Jason Frischer (clinical) [Ep 98 · 5:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=300)
- "Congenital perineal groove has a normal anal opening and is an exposed wet sulcus of non-keratinized mucous membrane that usually epithelializes on its own by age two" — Amanda Jensen (clinical) [Ep 98 · 6:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=370)
- "An adequately sized hole that appears surrounded by sphincter with a peroneal body, albeit short, requires no surgery" — Marc Levitt (clinical) [Ep 98 · 7:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=434)
- "The peroneal body will grow over time and there is nothing to do about a short peroneal body when other anatomical features are correct" — Marc Levitt (clinical) [Ep 98 · 8:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=481)
- "If half the fistula is within the sphincter complex and half is outside, the patient will leak stool because they cannot close the hole, making surgery worthy to relocate the hole" — Marc Levitt (clinical) [Ep 98 · 8:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=519)
- "Three qualities to assess in anal location are: anal size, location (whether surrounded by sphincter muscle complex), and the peroneal body that separates it from the introitus or urinary structures" — Amanda Jensen (clinical) [Ep 98 · 9:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=551)
- "Vestibular fistula is very common in females and needs a formal repair with the hole transposed to the center of the sphincter" — Jason Frischer (clinical) [Ep 98 · 9:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=575)
- "For vestibular fistula diagnosed in the newborn period, primary repair can be done if the baby is well, or the baby can stool through the fistula for a couple of months followed by elective operation without a stoma after bowel prep" — Jason Frischer (clinical) [Ep 98 · 10:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=622)
- "Patients diagnosed with vestibular fistula at 6, 8, or 12 months of life who have dilated their rectosigmoid need diversion as the first step, then repair" — Jason Frischer (clinical) [Ep 98 · 10:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=622)
- "Diversion in vestibular fistula repair is to try to avoid perineal body dehiscence" — Jason Frischer (clinical) [Ep 98 · 10:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=622)
- "Recto vestibular fistula has three openings: the urethra, the vagina, and a fistula within the vestibule" — Amanda Jensen (clinical) [Ep 98 · 11:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=672)
- "A baby with no anal opening and a single perineal orifice has a cloaca" — Marc Levitt (clinical) [Ep 98 · 11:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=685)
- "The hypertrophied area around the clitoral hood in cloaca is fairly typical and is not ambiguous genitalia" — Marc Levitt (clinical) [Ep 98 · 11:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=685)
- "Cloaca patients have no endocrine problem, do not need steroids, and do not need an endocrinologic workup" — Marc Levitt (clinical) [Ep 98 · 11:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=685)
- "There is no question of gender assignment in cloaca - it is a female" — Marc Levitt (clinical) [Ep 98 · 11:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=685)
- "Cloaca patients are still being misdiagnosed as ambiguous genitalia, with some babies not having proper gender assignment for a week or two" — Marc Levitt (clinical) [Ep 98 · 11:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=685)
- "Urogenital sinus plus a normal anus is an endocrine problem, but no anus and a urogenital sinus is a cloaca" — Amanda Jensen (clinical) [Ep 98 · 12:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=742)
- "Good lighting and good visualization are needed for perineal exam in newborn females, with magnification tools like loops helpful for seeing small holes" — Jason Frischer (clinical) [Ep 98 · 12:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=763)
- "The key to perineal examination is to push down and flatten the perineal body to see if it is normal or not" — Marc Levitt (clinical) [Ep 98 · 13:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=806)
- "Hagar dilators should be used to check anal size, starting low and working up for accurate measurement, rather than using fingers because every surgeon has a different size glove" — Rod Gerardo (clinical) [Ep 98 · 13:38](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=818)
- "To evaluate for vestibular fistula, use both hands on the right and left labia, pulling the labia toward you and opening them to visualize the vaginal opening and look for the urethra" — Jason Frischer (clinical) [Ep 98 · 14:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=851)
- "The biggest question with female anorectal malformation exam is how many perineal orifices are there" — Amanda Jensen (clinical) [Ep 98 · 15:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=903)
- "If there are three orifices, the question is whether it is a perineal fistula or a vestibular fistula" — Amanda Jensen (clinical) [Ep 98 · 15:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=903)
- "If there are two orifices, it is important to know if there is a fistula at all, vaginal atresia, or a rectal vaginal fistula" — Amanda Jensen (clinical) [Ep 98 · 15:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=903)
- "If there is only one orifice, this is a cloaca" — Amanda Jensen (clinical) [Ep 98 · 15:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-13-newborn-arm-part-2-4142?t=903)
- "A single perineal orifice in a newborn should clue you into a cloaca, where the vagina, urethra, and rectum are fused together inside, creating a single common channel." — Richard Wood (clinical) [Ep 102 · 2:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=125)
- "Hydrocolpos is the distension of the vagina caused by the accumulation of fluid." — Richard Wood (clinical) [Ep 102 · 2:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=145)
- "A cloaca or anorectal malformation is associated with VACTERL and needs to be worked up as such." — Amanda Jensen (guideline) [Ep 102 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=178)
- "VACTERL association requires three or more anomalies: vertebral, imperforate anus, cardiovascular, tracheoesophageal fistula, esophageal atresia, renal/radial, and limb defects." — Amanda Jensen (guideline) [Ep 102 · 3:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=190)
- "The diagnostic yield for cloacal malformations in utero is still much lower than desired." — Richard Wood (epidemiological) [Ep 102 · 3:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=224)
- "Hydrocolpos on perinatal ultrasound should alert to the possibility of a cloaca." — Richard Wood (clinical) [Ep 102 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=235)
- "Abnormal kidneys, a single kidney, or a two-vessel cord can alert perinatologists to a possible VACTERL situation." — Richard Wood (clinical) [Ep 102 · 4:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=250)
- "In a large majority of patients with cloaca, the diagnosis is made at birth." — Marc Levitt (epidemiological) [Ep 102 · 5:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=341)
- "Children with cloacal malformations who do not have an anus do not need investigation for ambiguous genitalia or disorders of sexual differentiation, because these children are female." — Richard Wood (guideline) [Ep 102 · 7:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=436)
- "Initial workup should consist of an NG tube and chest X-ray, cardiac echo, and pelvic and renal ultrasound to assess for TEF, cardiac anomalies, hydrocolpos, and hydronephrosis." — Amanda Jensen (guideline) [Ep 102 · 8:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=525)
- "If a patient has bilateral hydronephrosis and hydrocolpos, the hydrocolpos needs to be managed as part of initial treatment." — Amanda Jensen (guideline) [Ep 102 · 9:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=550)
- "Traditionally hydrocolpos was managed with vaginostomy, but practice has moved heavily toward clean intermittent catheterization through the common channel." — Richard Wood (clinical) [Ep 102 · 9:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=562)
- "When catheterizing for hydrocolpos, pass a tube through the common channel, drain fluid, confirm tube placement in the hydrocolpos with ultrasound, then perform recurrent catheterization." — Richard Wood (clinical) [Ep 102 · 9:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=564)
- "A lot of hydrocolpos cases can be drained perineally; you are more likely to get into the vagina than the bladder when catheterizing, given the anatomy of the urethral takeoff." — Marc Levitt (clinical) [Ep 102 · 11:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=668)
- "When draining hydrocolpos by perineal catheterization, pass the tube initially, leave it in, get a bedside ultrasound to confirm placement in the hydrocolpos and confirm decompression." — Richard Wood (clinical) [Ep 102 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=753)
- "When you drain the hydrocolpos with a catheter, the bladder fills immediately, demonstrating the physiology: the hydrocolpos obstructs the ureters." — Marc Levitt (clinical) [Ep 102 · 13:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=781)
- "A vesicostomy is the wrong move in almost every cloaca; the hydrocolpos needs to be drained, not the bladder." — Marc Levitt (opinion) [Ep 102 · 13:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=820)
- "Once the hydrocolpos is drained, the ureters are no longer compressed at the trigone and can empty into the bladder, which then empties out the common channel or back into the hydrocolpos for sequential perineal catheterization." — Marc Levitt (clinical) [Ep 102 · 13:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=839)
- "The most important goal is decompressing the kidneys; if a hydrocolpos exists with completely normal kidneys, it does not matter." — Richard Wood (clinical) [Ep 102 · 15:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=901)
- "After initial drainage with bedside ultrasound confirmation, catheterize three times daily initially, then reduce to twice daily when the family takes over, and follow with serial ultrasounds every 2–3 days initially, then weekly." — Richard Wood (guideline) [Ep 102 · 15:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=919)
- "After discharge, perform monthly ultrasounds to ensure continued renal decompression, stretching to every six weeks if the patient is doing well." — Richard Wood (guideline) [Ep 102 · 16:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=970)
- "Even with a vaginostomy tube, you must keep checking that the kidneys remain decompressed; the tube does not guarantee effective drainage." — Richard Wood (clinical) [Ep 102 · 16:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1000)
- "Newborn management bullet points: good exam with good light to make the diagnosis, no endocrine workup for cloaca, renal and pelvic ultrasounds plus tests for anesthesia safety, drain hydrocolpos via clean intermittent catheterization, and colostomy within 24–48 hours." — Richard Wood (guideline) [Ep 102 · 17:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1022)
- "Perform the colostomy as proximally as possible, at the descending-sigmoid junction, to ensure enough length for distal work." — Richard Wood (clinical) [Ep 102 · 17:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1075)
- "Laparoscopy for newborn colostomy formation provides a good view of pelvic anatomy, allows precise colostomy site selection, and avoids a wound between the two stomas if using a divided stoma." — Richard Wood (clinical) [Ep 102 · 18:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1122)
- "For laparoscopic colostomy, bring the bowel up through the mucus fistula site, staple it, wash out the distal limb, then make a separate incision for the proximal stoma with no incision around it, leaving clean skin for easy healing and bagging." — Richard Wood (clinical) [Ep 102 · 19:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1180)
- "Before creating a vaginostomy, check if the patient has a vaginal septum; if present, open the anterior wall of the hydrocolpos and remove a small portion of the septum to drain both sides through one hole." — Richard Wood (clinical) [Ep 102 · 20:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1213)
- "For vaginostomy, you can use a laparoscope and pass a tube or bring up a single hole for a tubeless setup; tubeless has the advantage of avoiding tube encrustation and colonization." — Richard Wood (clinical) [Ep 102 · 21:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1260)
- "If a massive hydrocolpos is present and you are doing an open technique, use a lower midline incision to get above the hydrocolpos, which is very adherent to the anterior abdominal wall and inflamed." — Marc Levitt (clinical) [Ep 102 · 21:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1297)
- "For a large hydrocolpos, open into the dome, take out a bit of the septum, close it, put in a tube to drain both sides, or suture it to the abdominal wall like a vesicostomy or gastrostomy to avoid an indwelling tube as a nidus for infection." — Marc Levitt (clinical) [Ep 102 · 22:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1340)
- "A single perineal orifice with no anal opening is a cloaca and does not need an endocrine workup, whereas a perineal opening with a normal anus is a urogenital sinus and does need an endocrine workup." — Marc Levitt (guideline) [Ep 102 · 23:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1388)
- "Urogenital sinus patients can also have hydrocolpos and hydronephrosis, requiring similar management but no colostomy." — Marc Levitt (clinical) [Ep 102 · 23:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1420)
- "After discharge, follow the patient carefully to ensure kidneys are well decompressed, the patient is growing well, and parents are managing the stoma; once stable, plan definitive imaging and reconstruction." — Richard Wood (guideline) [Ep 102 · 24:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-4322?t=1476)
- "Hirschsprung disease is a congenital condition affecting the lowermost aspect of the intestine, typically the rectum or sigmoid" — Nelson Rosen (clinical) [Ep 106 · 1:05](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=65)
- "In Hirschsprung disease, the system of nerves that allows the intestine to relax (ganglion cells in the submucosal and myenteric plexus) is missing" — Nelson Rosen (clinical) [Ep 106 · 1:25](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=85)
- "In Hirschsprung disease, the affected area always ends right above the anus, but where it begins is variable" — Nelson Rosen (clinical) [Ep 106 · 2:00](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=120)
- "About 85% of Hirschsprung cases begin in the very end part of the sigmoid colon or the beginning of the rectum" — Nelson Rosen (epidemiological) [Ep 106 · 2:20](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=140)
- "In about 10% of Hirschsprung cases, the entire colon is affected" — Nelson Rosen (epidemiological) [Ep 106 · 2:35](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=155)
- "90 to 95% of Hirschsprung cases are recognized in the newborn period" — Patty Curran (epidemiological) [Ep 106 · 2:52](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=172)
- "The first sign of Hirschsprung disease is usually failure to pass stool (meconium) within the first 24 to 48 hours" — Patty Curran (clinical) [Ep 106 · 3:00](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=180)
- "After failure to pass meconium, clinical symptoms include bloating, not passing stool, and vomiting" — Patty Curran (clinical) [Ep 106 · 3:15](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=195)
- "Initial workup for suspected Hirschsprung disease includes a water-soluble contrast enema looking for a narrow distal segment with dilation above" — Nelson Rosen (clinical) [Ep 106 · 3:30](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=210)
- "If there is real concern for Hirschsprung disease on contrast enema, a suction rectal biopsy is performed to examine for nerves" — Nelson Rosen (clinical) [Ep 106 · 4:10](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=250)
- "In older children, Hirschsprung disease can be missed and these children are often small for their age group with significant constipation" — Nelson Rosen (clinical) [Ep 106 · 4:46](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=286)
- "Children with Hirschsprung disease very rarely thrive and develop normally" — Nelson Rosen (clinical) [Ep 106 · 5:10](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=310)
- "In older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess constipation severity, followed by contrast enema, and potentially biopsy" — Nelson Rosen (clinical) [Ep 106 · 5:20](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=320)
- "In low-risk situations where constipation developed after the first couple years of life, biopsy should usually be done after routine management measures are tried" — Nelson Rosen (guideline) [Ep 106 · 5:45](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=345)
- "Anorectal manometry uses a balloon catheter to measure pressures in the anus and rectum" — Nelson Rosen (clinical) [Ep 106 · 6:25](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=385)
- "The recto-anal inhibitory reflex is present when stretching the rectum with a balloon causes the sphincter to relax, which is normal" — Nelson Rosen (clinical) [Ep 106 · 7:05](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=425)
- "In Hirschsprung disease, the recto-anal inhibitory reflex is absent" — Nelson Rosen (clinical) [Ep 106 · 7:25](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=445)
- "Anorectal manometry is not very sensitive for Hirschsprung disease; a normal manometry does not completely rule out the disease" — Nelson Rosen (clinical) [Ep 106 · 7:33](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=453)
- "Nobody would operate on manometry findings alone; if manometry is suggestive, a biopsy will still be done" — Rod Gerardo (guideline) [Ep 106 · 7:50](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=470)
- "The gold standard for diagnosing Hirschsprung disease is biopsy" — Rod Gerardo (guideline) [Ep 106 · 8:10](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=490)
- "Suction rectal biopsy can be done at the bedside for newborns and children up to one year old" — Patty Curran (clinical) [Ep 106 · 8:20](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=500)
- "After one year of age, biopsy should be done in the operating room under anesthesia to sample higher in the rectum" — Patty Curran (guideline) [Ep 106 · 8:35](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=515)
- "Normal individuals without Hirschsprung disease have no ganglion cells in the very first part of the rectum" — Rod Gerardo (clinical) [Ep 106 · 8:41](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=521)
- "In older children after one year of age, tissue is thicker and suction biopsy cannot obtain adequate tissue depth to reach the level where ganglion cells would be present" — Rod Gerardo (clinical) [Ep 106 · 9:30](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=570)
- "Surgical biopsy in the operating room is a simple procedure taking about 20 minutes with same-day discharge" — Rod Gerardo (clinical) [Ep 106 · 9:55](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=595)
- "Three components of continence are quality of sphincters, quality of dentate line, and motility" — Lovett (clinical) [Ep 111 · 1:14](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=74)
- "In Hirschsprung disease, two sphincters are of concern: external sphincter (under voluntary control) and internal sphincter (which tends not to relax due to absent recto-anal inhibitory reflex)" — Lovett (clinical) [Ep 111 · 1:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=90)
- "Patient with voluntary bowel movements during day but accidents at night indicates working external sphincter but non-working internal sphincter" — Hira Ahmad (clinical) [Ep 111 · 2:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=132)
- "Nighttime soiling with daytime control can occur if dentate line is lost with some preservation of external sphincter" — Amanda Jensen (clinical) [Ep 111 · 2:29](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=149)
- "Dentate line represents transition from squamous epithelium to columnar epithelium, occurring about two-thirds up the anal canal" (clinical) [Ep 111 · 2:44](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=164)
- "Blood supply changes occur at dentate line: splenic versus systemic" (clinical) [Ep 111 · 3:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=210)
- "Nerves in dentate line region provide sensation for gas/liquid/solid discrimination and information about squeeze intensity and duration needed" (clinical) [Ep 111 · 3:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=220)
- "Rectum (not anal canal) provides proprioception through stretch detection, signaling when stool is accumulating" (clinical) [Ep 111 · 4:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=298)
- "In anorectal malformation patients, stool softeners are problematic because patients never feel stretch; they do better with bulk plus laxative than with stool softener that slowly oozes" (clinical) [Ep 111 · 5:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=330)
- "Ability to sense stool in rectum or neorectum is highly sensitive to stool consistency and bulk; making stool too soft or loose can eliminate control in borderline continent patients" — Lovett (clinical) [Ep 111 · 6:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=370)
- "Loose stool is difficult to control even with normal continence because stretch detection is impaired without bulk" (clinical) [Ep 111 · 7:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=432)
- "Hirschsprung patients are particularly vulnerable to loose stool because rectum has been removed and sigmoid has taken over that function" (clinical) [Ep 111 · 8:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=480)
- "Dentate line is visible as color change from unkeratinized squamous epithelium to columnar epithelium" — Lovett (clinical) [Ep 111 · 8:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=515)
- "Patient with missing dentate line can develop bowel control if sphincters are working, but will be very sensitive to loose stool and require bulk for detection" — Lovett (clinical) [Ep 111 · 10:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=640)
- "Missing dentate line is similar to anorectal malformation anastomosis: rectum or colon mucosa to skin" (clinical) [Ep 111 · 11:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=676)
- "Patients with no dentate line and poor sphincters show severe perineal excoriation from chronic soiling and require temporary or permanent stomas" — Lovett (clinical) [Ep 111 · 12:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=732)
- "For soiling patient with intact sphincters and dentate line but hypomotile colon (dilated, few haustrations), treatment is bowel management program; mechanical enemas if sphincters deficient, laxatives if sphincters intact" — Hira Ahmad (clinical) [Ep 111 · 15:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=941)
- "For patient with hypermotile colon (decompressed, many haustrations) stooling 7-8 times daily, treatment includes constipating diet, bulking agents, and PPIs; may need small volume enemas if sphincters deficient" — Hira Ahmad (clinical) [Ep 111 · 17:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1065)
- "For hypermotile patients, treatment strategy is to constipate them first, then help them empty in time-controlled fashion either spontaneously or mechanically depending on sphincter function" (clinical) [Ep 111 · 18:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1096)
- "Hirschsprung disease is an obstruction problem; getting patient clean afterward is a separate independent challenge" — Lovett (clinical) [Ep 111 · 19:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1148)
- "Treatment ladder for hypermotility: skin care with cyanoacrylate barrier, proton pump inhibitor, water-soluble fiber for bulk, loperamide (0.5-0.8 mg/kg divided daily), cholestyramine, hyoscyamine 0.125 mg every 6 hours, diphenoxylate-atropine (rarely used due to cardiac side effects)" — Lovett (clinical) [Ep 111 · 19:53](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1193)
- "Tincture of opium is useful for hypermotility but is a controlled substance and difficult to prescribe" (clinical) [Ep 111 · 21:54](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1314)
- "Some Hirschsprung patients with good operations have super-strong sphincters that need Botox for relaxation to allow stool passage until sphincters learn to coordinate properly" (clinical) [Ep 111 · 22:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1354)
- "Anorectal manometry shows Hirschsprung patients often have resting pressures on higher end of normal" (clinical) [Ep 111 · 23:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1400)
- "Hirschsprung patients are very sensitive to certain foods, particularly lactose" (clinical) [Ep 111 · 23:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1420)
- "Of all soiling patient groups (anorectal malformation, Hirschsprung, functional constipation, spinal), Hirschsprung is the hardest due to troublesome sphincters" — Lovett (opinion) [Ep 111 · 24:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1476)
- "Within Hirschsprung soilers, hypermotile patients are much harder to manage than hypomotile patients" — Lovett (opinion) [Ep 111 · 25:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1510)
- "The first reports of Hirschsprung disease date back to the 17th century" — Rod Gerardo (epidemiological) [Ep 116 · 0:00](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=0)
- "Treatment, workup, management, including operative surgical approach has changed dramatically since the 1940s" — Rod Gerardo (epidemiological) [Ep 116 · 0:00](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=0)
- "Hirschsprung disease is a congenital anomaly of the GI tract that results in a functional bowel obstruction" — Jason Frischer (clinical) [Ep 116 · 0:33](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=33)
- "The ganglion cells don't make it all the way down distally and the colon ends up not being able to contract" — Aaron Garrison (clinical) [Ep 116 · 0:48](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=48)
- "More than 95% of neonates pass meconium within the first 48 hours of life" — Jason Frischer (clinical) [Ep 116 · 1:11](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=71)
- "Failure to pass meconium is typical of Hirschsprung's disease" — Jason Frischer (clinical) [Ep 116 · 1:11](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=71)
- "If an infant who has not passed meconium in the first 48 hours of life presents to your clinic, the possibility of Hirschsprung's disease should be entertained" — Jason Frischer (guideline) [Ep 116 · 1:11](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=71)
- "Hirschsprung disease has an incidence of about 1 in 5,000 children" — Aaron Garrison (epidemiological) [Ep 116 · 1:32](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=92)
- "About 10% of children with Hirschsprung disease will have a positive family history" — Jason Frischer (epidemiological) [Ep 116 · 1:43](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=103)
- "There are predisposing genetic conditions such as the RET gene" — Jason Frischer (clinical) [Ep 116 · 1:43](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=103)
- "Up to 10% of children with Hirschsprung's disease will have trisomy 21" — Jason Frischer (epidemiological) [Ep 116 · 1:43](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=103)
- "Only 1 to 2% of patients with trisomy 21 have Hirschsprung's disease" — Jason Frischer (epidemiological) [Ep 116 · 1:43](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=103)
- "Hirschsprung's disease is associated with Wordenberg syndrome, congenital central hyperventilation (Andine's curse), and some other syndromes" — Jason Frischer (clinical) [Ep 116 · 1:43](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=103)
- "The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry" — Jason Frischer (guideline) [Ep 116 · 2:25](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=145)
- "Water-soluble contrast enema is typically used for evaluation" — Jason Frischer (clinical) [Ep 116 · 2:25](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=145)
- "The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel" — Jason Frischer (clinical) [Ep 116 · 2:42](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=162)
- "The transition zone is from contracted rectum that suddenly opens up into dilated rectum" — Aaron Garrison (clinical) [Ep 116 · 2:55](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=175)
- "A rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease" — Jason Frischer (clinical) [Ep 116 · 3:14](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=194)
- "In Hirschsprung's disease, the rectosigmoid ratio is less than 1, which is the inverse of normal where the rectum is usually more dilated than the proximal colon" — Aaron Garrison (clinical) [Ep 116 · 3:23](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=203)
- "Inability to evacuate the contrast is a finding suggestive of Hirschsprung's disease" — Aaron Garrison (clinical) [Ep 116 · 3:23](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=203)
- "In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema" — Aaron Garrison (clinical) [Ep 116 · 3:23](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=203)
- "Rectal biopsy is the most important part of diagnostic workup and is the true definitive diagnosis" — Jason Frischer (guideline) [Ep 116 · 3:49](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=229)
- "Typical features on biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of colon esterase staining, and an absence of calretinine staining" — Jason Frischer (clinical) [Ep 116 · 4:04](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=244)
- "To be considered an adequate biopsy, it must be taken from the rectum at least 1 cm above the dentate line and must include both mucosa and submucosal layers" — Jason Frischer (guideline) [Ep 116 · 4:04](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=244)
- "A rectal biopsy can be obtained through suction technique or open full thickness technique" — Jason Frischer (clinical) [Ep 116 · 4:29](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=269)
- "The suction technique is typically used for patients less than 6 months of age" — Jason Frischer (guideline) [Ep 116 · 4:29](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=269)
- "One should consider using a full thickness technique for patients older than 6 months or when a suction biopsy is inadequate" — Jason Frischer (guideline) [Ep 116 · 4:29](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=269)
- "Suction rectal biopsy is done at the bedside and is painless" — Aaron Garrison (clinical) [Ep 116 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=287)
- "If suction biopsy is non-diagnostic, the patient can go to the operating room for a full thickness rectal biopsy done transanally" — Aaron Garrison (guideline) [Ep 116 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=287)
- "In anorectal manometry for Hirschsprung disease, there is a lack of the recto anal inhibitory reflex (RAIR)" — Aaron Garrison (clinical) [Ep 116 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=287)
- "The RAIR may be absent in other conditions as well, and some children have a false positive test" — Aaron Garrison (clinical) [Ep 116 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=287)
- "Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis" — Jason Frischer (guideline) [Ep 116 · 5:42](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=342)
- "The expectation is that children with Hirschsprung disease will live a normal life with some close management and care" — Aaron Garrison (opinion) [Ep 116 · 6:07](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=367)
- "Children with Hirschsprung disease will need this condition managed for life" — Aaron Garrison (clinical) [Ep 116 · 6:07](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=367)
- "NPO babies diagnosed with Hirschsprung disease typically manage with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended" — Aaron Garrison (guideline) [Ep 116 · 6:37](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=397)
- "Many times neonates are not distended and can be kept decompressed by doing irrigations, allowing them to have breast milk until ready for surgery" — Aaron Garrison (clinical) [Ep 116 · 6:37](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=397)
- "Older children with Hirschsprung disease are more difficult because the colon has become dilated and they're not amenable to just doing a primary pull through in many cases" — Aaron Garrison (clinical) [Ep 116 · 7:03](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=423)
- "Older children will start on an enema program and some may need diversion more proximally to give the colon time to decompress" — Aaron Garrison (guideline) [Ep 116 · 7:03](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=423)
- "There are three goals to surgical management: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity" — Jason Frischer (guideline) [Ep 116 · 7:29](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=449)
- "The three procedures for Hirschsprung disease all involve a transanal approach of removing the aganglionic colon and pulling down healthy colon and sewing it to the anus" — Jason Frischer (clinical) [Ep 116 · 7:59](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=479)
- "The Swensen technique is a full thickness dissection and anastomosis" — Jason Frischer (clinical) [Ep 116 · 7:59](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=479)
- "The Suave procedure is a mucosectomy where you leave a cuff of aganglionic bowel and bring the ganglionated bowel through that cuff of rectum and perform the anastomosis" — Jason Frischer (clinical) [Ep 116 · 7:59](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=479)
- "The Duamel procedure involves performing a pouch with an anastomosis of aganglionic and ganglionated bowel" — Jason Frischer (clinical) [Ep 116 · 7:59](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=479)
- "Early postoperative complications include really bad diaper rash and excoriation that can often need to be treated like a burn" — Aaron Garrison (clinical) [Ep 116 · 8:48](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=528)
- "Anastomotic leak is a complication to watch for, though fortunately rare in these patients" — Aaron Garrison (clinical) [Ep 116 · 8:48](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=528)
- "Hirschsprung's associated enterocolitis is the main complication everyone needs to be aware of" — Aaron Garrison (clinical) [Ep 116 · 8:48](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=528)
- "Hirschsprung's associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth" — Jason Frischer (clinical) [Ep 116 · 9:15](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=555)
- "A child with enterocolitis presents with abdominal distention, vomiting, fever, and change in bowel habits" — Jason Frischer (clinical) [Ep 116 · 9:15](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=555)
- "Enterocolitis must be recognized as potential enterocolitis and treated urgently" — Jason Frischer (guideline) [Ep 116 · 9:15](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=555)
- "Treatment for enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations" — Jason Frischer (guideline) [Ep 116 · 9:15](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=555)
- "Depending on the severity of enterocolitis, broad-spectrum antibiotics are sometimes added and patients are usually started on metronidazole" — Jason Frischer (guideline) [Ep 116 · 9:15](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=555)
- "About 80% of kids with Hirschsprung's disease are constipated and will need some kind of management" — Aaron Garrison (epidemiological) [Ep 116 · 10:09](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=609)
- "Assuming the operation's been done well and there's not any transition zone or strictures, most patients are expected to do very well and be in kindergarten socially confident" — Aaron Garrison (opinion) [Ep 116 · 10:09](https://library.globalcastmd.com/watch/hirschsprung-disease-in-brief-5023?t=609)
- "Microaggressions are verbal, nonverbal, environmental slights, snubs, invalidations, or insults that send hostile, derogatory, or negative messages to individuals based solely on their marginalized group membership" — Craig Lillehei (clinical) [Ep 126 · 3:30](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=210)
- "Microaggressions have a cumulative impact causing isolation and self-doubt despite being termed 'micro'" — Craig Lillehei (clinical) [Ep 126 · 4:00](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=240)
- "In the TOTAL trial for severe CDH, FETO significantly improved survival" — Craig Lillehei (clinical) [Ep 126 · 10:00](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=600)
- "In the TOTAL trial for moderate CDH, FETO showed some improvement in survival but did not approach statistical significance" — Craig Lillehei (clinical) [Ep 126 · 10:20](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=620)
- "The TOTAL trial was conducted over an 11-year period at multiple centers with variable CDH management protocols" — Craig Lillehei (clinical) [Ep 126 · 10:50](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=650)
- "FETO is associated with prematurity and premature rupture of membranes as complications" — Craig Lillehei (clinical) [Ep 126 · 11:20](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=680)
- "NPO guidelines for children are based on very poor evidence and vary significantly between institutions" (clinical) [Ep 126 · 15:00](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=900)
- "Pulmonary aspiration during elective pediatric surgery is very rare and usually occurs in emergency surgeries in high-risk children" (epidemiological) [Ep 126 · 15:20](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=920)
- "Clear liquids containing carbohydrates empty the stomach very quickly regardless of patient age" (clinical) [Ep 126 · 15:50](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=950)
- "British and Irish consensus recommends one hour NPO for clear liquids, four hours for breast milk, six hours for solid foods in children under 17" (guideline) [Ep 126 · 16:10](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=970)
- "ASA currently recommends two hours for clear liquids, four hours for breast milk, six hours for non-human milk and light meals, eight hours for heavy meals" (guideline) [Ep 126 · 16:40](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1000)
- "European Society of Anesthesia recommends one hour for clear liquids, three hours for breast milk, four hours for formula, six hours for everything else" (guideline) [Ep 126 · 17:10](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1030)
- "Prolonged NPO periods cause ketone body generation, hypoglycemia, and patient irritability" (clinical) [Ep 126 · 17:40](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1060)
- "In standard C-arm configuration, the x-ray source is below the table and the image intensifier is above" (clinical) [Ep 126 · 23:20](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1400)
- "Placing lead shields on top of the patient during fluoroscopy does nothing to protect them because radiation comes from below the table" (clinical) [Ep 126 · 23:40](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1420)
- "If a shield is in the fluoroscopy field, automatic brightness control increases x-ray energy, increasing patient exposure" (clinical) [Ep 126 · 24:10](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1450)
- "Collimation focuses the x-ray beam to a specific area, increasing detail while decreasing total patient dose by reducing the irradiated surface area" (clinical) [Ep 126 · 25:00](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1500)
- "Magnification setting on fluoroscopy significantly increases radiation dose to both patient and room personnel" (clinical) [Ep 126 · 25:30](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1530)
- "Pulse mode fluoroscopy is feasible for most pediatric surgery applications and reduces radiation compared to continuous mode" (clinical) [Ep 126 · 25:50](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1550)
- "CT scan for suspected airway foreign body has 94% accuracy in identifying foreign bodies when present" (clinical) [Ep 126 · 33:20](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2000)
- "CT scan can identify non-radiopaque foreign bodies including plastic" (clinical) [Ep 126 · 33:40](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2020)
- "In the Midwest Pediatric Surgery Consortium study of 521 primary lung lesions, none of the prenatally diagnosed lesions were malignant" (clinical) [Ep 126 · 36:40](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2200)
- "Approximately 10% of postnatally diagnosed lung lesions were malignant in the consortium study" (epidemiological) [Ep 126 · 37:10](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2230)
- "About half of malignant lung lesions were associated with DICER1 mutation" (clinical) [Ep 126 · 37:30](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2250)
- "No malignant lung lesion had a systemic feeding vessel in the consortium study" (clinical) [Ep 126 · 37:50](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2270)
- "CT scan sensitivity and specificity for detecting malignancy in lung lesions was poor with low inter-rater reliability among radiologists" (clinical) [Ep 126 · 38:10](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2290)
- "The IMPACT study showed piperacillin-tazobactam had significantly lower postoperative abscess rate, ER visit rate, and CT scan rate compared to ceftriaxone-metronidazole for perforated appendicitis" (clinical) [Ep 126 · 43:20](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2600)
- "A NSQIP study of 654 patients showed opposite results, suggesting ceftriaxone-metronidazole was preferred over piperacillin-tazobactam" (clinical) [Ep 126 · 44:00](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2640)
- "Mechanical bowel preparation has no effect on surgical site infection rates" — Paul Yzotrak (clinical) [Ep 126 · 50:00](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3000)
- "Some data suggests mechanical bowel prep actually increases surgical site infections" — Paul Yzotrak (clinical) [Ep 126 · 50:20](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3020)
- "The NEC trial showed neurodevelopmental outcomes are improved with laparotomy compared to peritoneal drainage" — Paul Yzotrak (clinical) [Ep 126 · 53:20](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3200)
- "The NEC trial cutoff for laparotomy was approximately one kilogram" — Paul Yzotrak (clinical) [Ep 126 · 53:50](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3230)
- "Neuroblastoma with segmental chromosomal abnormalities but no MYCN amplification is now classified as high risk based on 2020-21 COG data" — Paul Yzotrak (guideline) [Ep 126 · 62:30](https://library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3750)
- "The Swenson operation was the original operation for Hirschsprung disease, involving full thickness rectal dissection performed transabdominally" — Mimi Denning (clinical) [Ep 136 · 3:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=192)
- "Wide rectal dissection in early Hirschsprung surgery injured the nervi erigentes, leading to fecal incontinence, bladder dysfunction, and sexual dysfunction" — Marc Levitt (clinical) [Ep 136 · 3:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=213)
- "Dr. Douamel in France developed a technique leaving the original rectum in place while pulling ganglionated bowel through" — Mimi Denning (clinical) [Ep 136 · 4:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=252)
- "The submucosal dissection technique stays within the rectal wall to avoid nerve injury, eventually breaking through full thickness for the pull-through" — Mimi Denning (clinical) [Ep 136 · 4:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=270)
- "Dr. Yancey published his submucosal dissection technique in the Journal of the National Medical Association in 1952" — Marc Levitt (clinical) [Ep 136 · 5:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=307)
- "Dr. Suave published his submucosal dissection technique in the journal Surgery in 1964, twelve years after Dr. Yancey" — Marc Levitt (clinical) [Ep 136 · 6:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=360)
- "Dr. Yancey and Dr. Suave's articles demonstrate essentially an identical technique of submucosal dissection" — Marc Levitt (clinical) [Ep 136 · 6:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=380)
- "In 1951-1952, Black academics could not publish their work in mainstream surgical journals due to structural inequities" — Marc Levitt (epidemiological) [Ep 136 · 6:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=400)
- "Dr. Yancey did not express anger about Dr. Suave's later publication, instead emphasizing the value and purpose of the National Medical Association" — Carolyn Yancey (opinion) [Ep 136 · 7:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=454)
- "Dr. Yancey completed his surgical training under Dr. Charles Drew at Friedman's Hospital" — Carolyn Yancey (epidemiological) [Ep 136 · 8:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=490)
- "After training, Dr. Yancey had two options: go into the military or work at a Veterans Affairs Hospital" — Carolyn Yancey (epidemiological) [Ep 136 · 8:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=520)
- "Dr. Yancey established the first postgraduate academic training program in the state of Alabama for Black surgeons at Tuskegee VA" — Carolyn Yancey (epidemiological) [Ep 136 · 9:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=540)
- "The preliminary preclinical work for the pull-through technique was done at the veterinarian hospital in Tuskegee" — Carolyn Yancey (clinical) [Ep 136 · 9:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=580)
- "Three of Dr. Yancey's four children went into medicine" — Carolyn Yancey (epidemiological) [Ep 136 · 11:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=680)
- "Dr. Henri Ford mentioned Dr. Yancey's work in his 2018 APSA presidential address, surprising most pediatric surgeons in attendance" — Marc Levitt (epidemiological) [Ep 136 · 5:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=307)
- "Dr. Newman brought Dr. Yancey's story to the Hirschsprung interest group at APSA, leading to efforts to change nomenclature and references" — Jason Frischer (epidemiological) [Ep 136 · 12:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=746)
- "The Hirschsprung interest group members are writing papers, reviewing manuscripts, writing board questions, and involved in billing codes, making them ideal advocates for the name change" — Erika Newman (opinion) [Ep 136 · 13:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=820)
- "The Yancey-Suave nomenclature is now being incorporated into teaching, operative notes, and journal review processes" — Marc Levitt (epidemiological) [Ep 136 · 14:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=870)
- "The National Medical Association was created in the basement of First Congregational Church in Atlanta to provide Black doctors a place to publish their work during segregation" — Carolyn Yancey (epidemiological) [Ep 136 · 15:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=954)
- "Dr. Yancey worked at Hughes Fawley Pavilion Hospital, which was the hospital for colored patients, and Grady Memorial Hospital in Atlanta" — Carolyn Yancey (epidemiological) [Ep 136 · 16:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=1000)
- "Dr. Yancey did not have privileges to see colored patients at Emory University Hospital on campus until about 1964" — Carolyn Yancey (epidemiological) [Ep 136 · 17:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=1050)
- "The study was retrospective and conducted in the Netherlands between 1998 and 2018" — Cecilia Gigena (epidemiological) [Ep 137 · 0:00](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=0)
- "The study included patients under three years old who underwent stoma reversal" — Cecilia Gigena (epidemiological) [Ep 137 · 0:00](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=0)
- "244 patients were included in the study" — Cecilia Gigena (epidemiological) [Ep 137 · 0:00](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=0)
- "10% of patients developed strictures" — Cecilia Gigena (epidemiological) [Ep 137 · 0:00](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=0)
- "95% of strictures occurred in patients with necrotizing enterocolitis" — Cecilia Gigena (clinical) [Ep 137 · 0:00](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=0)
- "68% of all patients had a contrast enema prior to stoma reversal" — Cecilia Gigena (epidemiological) [Ep 137 · 0:00](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=0)
- "Contrast enema was able to detect 92% of strictures" — Cecilia Gigena (clinical) [Ep 137 · 0:00](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=0)
- "Contrast enema prior to stoma reversal appears useful primarily in patients who had necrotizing enterocolitis" — Cecilia Gigena (opinion) [Ep 137 · 0:00](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=0)
- "Saline is used to flush or clean the colon of stool in pediatric patients" — Emily Rice (clinical) [Ep 140 · 0:30](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=30)
- "Saline flushes can be administered through a Malone or through an enema in the child's bottom" — Emily Rice (clinical) [Ep 140 · 0:40](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=40)
- "Saline is used for irrigations, another method of cleaning the colon" — Emily Rice (clinical) [Ep 140 · 0:50](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=50)
- "Commercial saline can be expensive and is occasionally not covered by insurance" — Emily Rice (opinion) [Ep 140 · 1:00](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=60)
- "Homemade saline does not cost much and is very easy to make" — Emily Rice (opinion) [Ep 140 · 1:05](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=65)
- "The recipe for homemade saline is one cup of warm tap water mixed with half a teaspoon of table salt" — Emily Rice (clinical) [Ep 140 · 1:35](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=95)
- "The recipe can be scaled by adding half a teaspoon of salt for each additional cup of water" — Emily Rice (clinical) [Ep 140 · 1:45](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=105)
- "For four cups of saline, a total of two teaspoons of salt should be added" — Emily Rice (clinical) [Ep 140 · 1:55](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=115)
- "The saline solution must be allowed to cool before use in flushes, enemas, or irrigations" — Emily Rice (clinical) [Ep 140 · 2:05](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=125)
- "In the United States, it is safe to use tap water from kitchen or bathroom sinks for making saline" — Emily Rice (guideline) [Ep 140 · 2:20](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=140)
- "In locations where tap water is unsafe to drink, water should be boiled for 15 minutes before adding salt" — Emily Rice (guideline) [Ep 140 · 2:28](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=148)
- "Boiled water must be allowed to cool after adding salt before use" — Emily Rice (clinical) [Ep 140 · 2:38](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=158)
- "Homemade saline can be stored in the refrigerator for up to one week" — Emily Rice (guideline) [Ep 140 · 2:42](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=162)
- "Caregivers should always consult with the colorectal team or pediatrician before using saline for bowel management" — Emily Rice (guideline) [Ep 140 · 0:20](https://library.globalcastmd.com/watch/how-to-make-saline-6743?t=20)
- "The Mini-ACE device is used to perform a daily colon flush in pediatric patients" — Justine Gagnon (clinical) [Ep 142 · 0:00](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=0)
- "Families should only change the Mini-ACE device if instructed to do so by the child's medical team" — Justine Gagnon (guideline) [Ep 142 · 0:00](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=0)
- "Sterile water is created by boiling tap water and cooling it to room temperature" — Justine Gagnon (clinical) [Ep 142 · 0:50](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=50)
- "The blue stylet makes the Mini-ACE tube stiffer during insertion to facilitate placement" — Justine Gagnon (clinical) [Ep 142 · 1:50](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=110)
- "A pea-sized amount of water-soluble lubrication gel is applied to the end of the Mini-ACE device" — Justine Gagnon (clinical) [Ep 142 · 1:50](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=110)
- "The Mini-ACE balloon contains 2ml of sterile water when inflated" — Justine Gagnon (clinical) [Ep 142 · 1:50](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=110)
- "When the balloon is empty, it becomes hard to pull back on the syringe plunger" — Justine Gagnon (clinical) [Ep 142 · 2:30](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=150)
- "The blue stylet must be removed from the irrigation port after device insertion" — Justine Gagnon (clinical) [Ep 142 · 3:00](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=180)
- "The syringe plunger should be kept pushed down when disconnecting from the balloon port" — Justine Gagnon (clinical) [Ep 142 · 3:00](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=180)
- "Gentle tugging on the device verifies that the balloon is secure in the tract" — Justine Gagnon (clinical) [Ep 142 · 3:00](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=180)
- "If unable to deflate the balloon, cleaning the balloon port with a cotton swab may remove blocking substances" — Justine Gagnon (clinical) [Ep 142 · 3:15](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=195)
- "Families should contact the colorectal nursing team if unable to deflate the balloon after cleaning the port" — Justine Gagnon (guideline) [Ep 142 · 3:15](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=195)
- "Families should contact the colorectal nursing team if unable to reinsert the Mini-ACE device" — Justine Gagnon (guideline) [Ep 142 · 3:15](https://library.globalcastmd.com/watch/how-to-change-your-child-s-miniace-balloon-device-6746?t=195)
- "Children with Hirschsprung disease or functional constipation have colons that may not move stool through the body as quickly as it should, called dysmotility." — Emily Rice (clinical) [Ep 141 · 0:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=0)
- "When stool sits in the colon for too long, it can cause bacteria to grow and can lead to enterocolitis, an inflammation of the colon." — Emily Rice (clinical) [Ep 141 · 0:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=0)
- "Rectal irrigations help prevent and treat enterocolitis by putting saline into the colon to clean stool out and prevent infection." — Emily Rice (clinical) [Ep 141 · 0:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=0)
- "If a child has a history of Hirschsprung disease and shows signs of enterocolitis or dehydration, an irrigation should be performed and the medical team contacted immediately." — Emily Rice (guideline) [Ep 141 · 0:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=0)
- "A 24-French silicone Foley catheter is used for rectal irrigations; for children under one year of age, a 20-French catheter is used." — Emily Rice (clinical) [Ep 141 · 1:30](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=90)
- "The child should be positioned on their back with knees bent and pulled up towards the chest to visualize the anus and allow stool and gas to exit." — Emily Rice (clinical) [Ep 141 · 2:30](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=150)
- "The Foley catheter should be gently inserted into the rectum about 4-6 inches." — Emily Rice (clinical) [Ep 141 · 2:30](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=150)
- "20 milliliters of saline should be instilled with each flush using the large catheter-tipped syringe." — Emily Rice (clinical) [Ep 141 · 2:30](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=150)
- "It is important to wait between each flush for fluid to drain and to ensure 20 milliliters is returned before repeating." — Emily Rice (clinical) [Ep 141 · 2:30](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=150)
- "Irrigation should continue until the fluid draining from the catheter is clear." — Emily Rice (clinical) [Ep 141 · 2:30](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=150)
- "The catheter should not be inserted all the way to the end and should not be forced; it will easily follow the pathway or curve of the colon when gently advanced." — Emily Rice (clinical) [Ep 141 · 2:30](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=150)
- "If saline is pushed in but no water or stool comes back out, pull the catheter out a little bit then gently push it back in." — Emily Rice (clinical) [Ep 141 · 4:30](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=270)
- "If no saline or stool returns with irrigation, check the catheter for blockage such as food or thick stool, as stool can block the tiny holes at the catheter tip." — Emily Rice (clinical) [Ep 141 · 4:30](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=270)
- "If there is still no return after troubleshooting, contact the medical team or pediatrician." — Emily Rice (guideline) [Ep 141 · 4:30](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=270)
- "Signs of enterocolitis include fever, a swollen or large belly, foul-smelling stool, or no stool out in 24 hours." — Emily Rice (clinical) [Ep 141 · 5:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=300)
- "Signs of dehydration include not urinating as much as normal, fewer wet diapers, dry or sticky mouth, few or no tears when crying, sunken eyes, cool skin, irritability, dizziness, or being more tired than usual." — Emily Rice (clinical) [Ep 141 · 5:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=300)
- "If a child develops signs of enterocolitis or dehydration, the medical team or pediatrician should be contacted immediately." — Emily Rice (guideline) [Ep 141 · 5:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=300)
- "Colonoscopy is still the best test for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect" — Conor Delaney (clinical) [Ep 208 · 1:15](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=75)
- "Serrated adenomas have good evidence of genetic predisposition and may tie into many family cancer syndromes" — Conor Delaney (clinical) [Ep 208 · 2:03](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=123)
- "Serrated polyps have a really high risk of cancer" — Conor Delaney (clinical) [Ep 208 · 2:03](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=123)
- "Some serrated polyps are flat and difficult to see, making retroflexion in the cecum useful as they're often on the inferior or superior side of the valve" — Conor Delaney (clinical) [Ep 208 · 3:26](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=206)
- "Historical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent" — Conor Delaney (epidemiological) [Ep 208 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=543)
- "Current local recurrence rates should be under 10 percent, with Cleveland Clinic's last 10 years at about 3 percent" — Conor Delaney (epidemiological) [Ep 208 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=543)
- "Distal margin requirements for rectal cancer: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they're not poorly differentiated" — Conor Delaney (guideline) [Ep 208 · 4:59](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=299)
- "MRI is probably 90 to mid-90s percent accurate at T staging and probably high 80s to 90% accurate for nodal staging" — Conor Delaney (clinical) [Ep 208 · 13:11](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=791)
- "Ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement" — Conor Delaney (clinical) [Ep 208 · 13:11](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=791)
- "The standard of care has shifted from ultrasound to MRI for rectal cancer staging" — Conor Delaney (guideline) [Ep 208 · 14:02](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=842)
- "Historical local recurrence rates for transanally excised rectal cancers was about 18%, remarkably consistent across outcome data from several big centers" — Conor Delaney (epidemiological) [Ep 208 · 14:19](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=859)
- "Transanal resection is generally kept for patients who aren't fit for a rectal resection, or patients whose tumor is so close to the dentate line you'd have to give them a permanent stoma" — Conor Delaney (guideline) [Ep 208 · 14:19](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=859)
- "If it's a rectal cancer, it needs to be a full thickness excision; you would never do an ESD type procedure" — Conor Delaney (guideline) [Ep 208 · 16:23](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=983)
- "Neoadjuvant therapy is generally indicated for T3 or node-positive disease" — Conor Delaney (guideline) [Ep 208 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=1045)
- "In Europe, radiation has gone towards five times five gray given over five days, with surgery about a week to two weeks later" — Conor Delaney (guideline) [Ep 208 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=1045)
- "In the US, radiation is six-week, 40 to 45 gray, given with chemotherapy, staged over six weeks, then a six-week to eight-week waiting period" — Conor Delaney (guideline) [Ep 208 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=1045)
- "25 gray over a short period is equivalent to 40 to 45 over a longer period from a radiotherapeutic perspective" — Conor Delaney (clinical) [Ep 208 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=1045)
- "For colon cancer surgery, you're looking for at least a five centimeter proximal and distal margin, usually determined by blood supply, and at least 12 lymph nodes, with many hoping for at least 16" — Conor Delaney (guideline) [Ep 208 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=1162)
- "You should be able to do a total mesocolic excision with five mils of blood loss, in the plane between Toltz fascia and the embryological peritoneum on the mesocolon" — Conor Delaney (clinical) [Ep 208 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=1162)
- "Scandinavian data showed local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate because they weren't doing adequate colon cancer surgery" — Conor Delaney (epidemiological) [Ep 208 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=1162)
- "For a cecal tumor, you should take 10 centimeters of small bowel; if it's mid-ascending colon, you should take 5" — Conor Delaney (guideline) [Ep 208 · 22:44](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=1364)
- "Extracorporeal stapled anastomosis for laparoscopic right colectomy has reported leak rates of 0.8% over 1,000 cases" — Conor Delaney (epidemiological) [Ep 208 · 23:59](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=1439)
- "The Weiss Center for Hereditary Colorectal Cancer has the biggest polyposis database in the world and probably now the biggest HNPCC database as well" — Conor Delaney (clinical) [Ep 208 · 24:32](https://library.globalcastmd.com/watch/colorectal-cancer-13749?t=1472)
- "Colonoscopy is still the best test for colon cancer detection, though not perfect, finding the vast majority of cancers and polyps" — Conor Delaney (clinical) [Ep 209 · 1:15](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=75)
- "Serrated adenomas (previously called hyperplastic polyps in right colon) have good evidence of genetic predisposition and tie into many family cancer syndromes" — Conor Delaney (clinical) [Ep 209 · 2:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=123)
- "Serrated polyps have a very high risk of cancer" — Conor Delaney (clinical) [Ep 209 · 2:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=123)
- "Serrated adenomas are often flat and difficult to see, requiring retroflexion in the cecum to visualize them on the inferior or superior side of the valve or folds" — Conor Delaney (clinical) [Ep 209 · 3:26](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=206)
- "Required distal margin for rectal cancer is 5 centimeters if achievable, 2 centimeters if achievable, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated" — Conor Delaney (clinical) [Ep 209 · 4:59](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=299)
- "Six centimeters from anal verge in an 80-year-old 90-pound female can be almost mid-rectum, while in a 6'6" 300-pound male can be top of anal canal or close to dentate line" — Conor Delaney (clinical) [Ep 209 · 4:59](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=299)
- "Upper third rectal cancers likely will not need preoperative therapy and likely will not need a stoma" — Conor Delaney (clinical) [Ep 209 · 6:51](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=411)
- "Middle and lower third rectal cancers have good chance of needing preoperative neoadjuvant therapy and very good chance of needing temporary or rarely permanent stoma" — Conor Delaney (clinical) [Ep 209 · 6:51](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=411)
- "Distant staging for rectal cancer is best with CT abdomen for liver and most guidelines have transitioned to CT chest rather than chest x-ray" — Conor Delaney (guideline) [Ep 209 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=543)
- "Majority of local staging has transitioned to MRI with high resolution, high Tesla magnet standardized protocol" — Conor Delaney (guideline) [Ep 209 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=543)
- "MRI is particularly good at distinguishing T3, T4 and particularly good at looking at circumferential resection margins" — Conor Delaney (clinical) [Ep 209 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=543)
- "Historical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent and some up to 50 percent" — Conor Delaney (epidemiological) [Ep 209 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=543)
- "Current local recurrence rates should be under 10 percent, and Cleveland Clinic's last 10 years was about 3 percent with optimized surgery, imaging, and patient selection" — Conor Delaney (epidemiological) [Ep 209 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=543)
- "MRI is the best way to assess circumferential resection margin" — Conor Delaney (clinical) [Ep 209 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=543)
- "Endoscopic ultrasound can be used selectively for distinguishing T1s and T2s for potential transanal resection but does not assess circumferential resection margin" — Conor Delaney (clinical) [Ep 209 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=543)
- "Total mesorectal excision can be performed with about 5 mils of blood loss because it is a bloodless plane" — Conor Delaney (clinical) [Ep 209 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=543)
- "If pathological margin is negative, chance of local recurrence is low" — Conor Delaney (clinical) [Ep 209 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=543)
- "MRI is probably 90 to mid-90s percent accurate at T staging and probably high 80s to 90 percent accurate for nodal staging" — Conor Delaney (clinical) [Ep 209 · 13:18](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=798)
- "Ultrasound is much more operator dependent and probably only 70 percent accurate for predicting nodal involvement" — Conor Delaney (clinical) [Ep 209 · 13:18](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=798)
- "Transanal resection is appropriate for tumors less than a third of circumference, ideally less than two centimeters, that are T1" — Conor Delaney (clinical) [Ep 209 · 14:07](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=847)
- "Historical local recurrence rates for transanally excised rectal cancers was about 18 percent, remarkably consistent across outcome data from several big centers" — Conor Delaney (epidemiological) [Ep 209 · 14:07](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=847)
- "For rectal cancer, full thickness excision is required; ESD type procedure would never be done for cancer" — Conor Delaney (clinical) [Ep 209 · 15:58](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=958)
- "Most accepted guidelines for neoadjuvant therapy are for tumors that are T3 (outside wall of rectum) or node positive" — Conor Delaney (guideline) [Ep 209 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1045)
- "If node negative and T1 or T2 (stage one tumor), particularly if upper third, neoadjuvant therapy can be omitted" — Conor Delaney (guideline) [Ep 209 · 13:11](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=791)
- "In Europe, short course radiation is five times five gray given over five days, then operate about one to two weeks later" — Conor Delaney (clinical) [Ep 209 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1045)
- "In US, long course is six-week 40 to 45 gray given with chemotherapy staged over six weeks, then six to eight week waiting period" — Conor Delaney (clinical) [Ep 209 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1045)
- "25 gray over short period is equivalent dose to 40 to 45 over longer period from radiotherapeutic perspective" — Conor Delaney (clinical) [Ep 209 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1045)
- "Longer course chemoradiation can make big difference for tumor response and physical downstaging, particularly for bulky tumors" — Conor Delaney (clinical) [Ep 209 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1045)
- "For colon cancer, need at least five centimeter proximal and distal margin, usually determined by blood supply, and at least 12 lymph nodes, ideally at least 16" — Conor Delaney (clinical) [Ep 209 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1162)
- "For sigmoid cancer, most surgeons do high ligation above takeoff of left colic artery" — Conor Delaney (clinical) [Ep 209 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1162)
- "Total mesocolic excision should be achievable with five mils of blood loss, dissecting between embryological peritoneum of retroperitoneum (Toltz fascia) and embryological peritoneum on mesocolon" — Conor Delaney (clinical) [Ep 209 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1162)
- "Scandinavian data showed local recurrence rates for colon cancer were even higher than rectal cancer rates (which were high 20s) because they were not doing adequate colon cancer surgery" — Conor Delaney (epidemiological) [Ep 209 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1162)
- "After focusing on technique, Scandinavian centers got rectal cancer local recurrence rate down to under 10 percent" — Conor Delaney (epidemiological) [Ep 209 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1162)
- "For cecal tumor or near ileocecal valve, should take 10 centimeters of small bowel; if mid-ascending colon, should take 5 centimeters" — Conor Delaney (clinical) [Ep 209 · 22:29](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1349)
- "Extracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8 percent over 1,000 cases" — Conor Delaney (epidemiological) [Ep 209 · 22:29](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1349)
- "Cleveland Clinic has biggest polyposis database in world and probably biggest HNPCC database as well through Weiss Center for Hereditary Colorectal Cancer" — Conor Delaney (epidemiological) [Ep 209 · 24:13](https://library.globalcastmd.com/watch/colorectal-cancer-13750?t=1453)
- "Colonoscopy is still the best test for colon cancer detection, though not perfect—it doesn't find every cancer or polyp but finds the vast majority" — Conor Delaney (clinical) [Ep 210 · 1:15](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=75)
- "Serrated adenomas (previously called hyperplastic polyps in right colon) have good evidence of genetic predisposition and tie into many family cancer syndromes" — Conor Delaney (clinical) [Ep 210 · 2:03](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=123)
- "Serrated polyps have a very high risk of cancer" — Conor Delaney (clinical) [Ep 210 · 2:03](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=123)
- "Serrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they're often on the inferior or superior side of the valve or folds" — Conor Delaney (clinical) [Ep 210 · 3:26](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=206)
- "Distal margin requirements for rectal cancer: 5cm if possible, 2cm if possible, 1cm for very lowest tumors as long as not poorly differentiated" — Conor Delaney (clinical) [Ep 210 · 6:28](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=388)
- "Six centimeters from anal verge can mean different anatomical locations: may be anorectal ring or close to dentate line in a large person, requiring different surgical approaches" — Conor Delaney (clinical) [Ep 210 · 4:59](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=299)
- "Historical local recurrence rates for rectal cancer from good institutions were 20-38% and some up to 50%; nowadays should be under 10%, and Cleveland Clinic's last 10 years was about 3%" — Conor Delaney (epidemiological) [Ep 210 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=543)
- "MRI is the best way to assess circumferential resection margin in rectal cancer" — Conor Delaney (clinical) [Ep 210 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=543)
- "MRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer" — Conor Delaney (clinical) [Ep 210 · 13:32](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=812)
- "Endoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement" — Conor Delaney (clinical) [Ep 210 · 13:32](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=812)
- "Standard of care has shifted from ultrasound to MRI for rectal cancer staging" — Jeffrey Ponsky (guideline) [Ep 210 · 14:06](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=846)
- "Historical local recurrence rates for transanally excised rectal cancers was about 18%, remarkably consistent across outcome data from several big centers" — Conor Delaney (epidemiological) [Ep 210 · 14:19](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=859)
- "For rectal cancer, if doing transanal resection even for T1, must do full thickness resection, never ESD; ESD or EMR is only for benign polyps" — Conor Delaney (clinical) [Ep 210 · 16:23](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=983)
- "Neoadjuvant therapy for rectal cancer is generally indicated for T3 or node-positive disease" — Conor Delaney (guideline) [Ep 210 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1045)
- "Threatened circumferential resection margin (wanting 1-2mm) is an indication for neoadjuvant therapy" — Conor Delaney (clinical) [Ep 210 · 17:25](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1045)
- "Short-course radiation is 5 times 5 gray over 5 days, then operate 1-2 weeks later (European approach)" — Conor Delaney (clinical) [Ep 210 · 17:18](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1038)
- "Long-course chemoradiation is 40-45 gray over 6 weeks with chemotherapy, then 6-8 week waiting period (US approach)" — Conor Delaney (clinical) [Ep 210 · 17:18](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1038)
- "25 gray over short period is equivalent dose to 40-45 gray over longer period, but longer course better for tumor response and physical downstaging of bulky tumors" — Conor Delaney (clinical) [Ep 210 · 17:18](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1038)
- "For colon cancer surgery, looking for at least 12 lymph nodes, many would hope for at least 16" — Conor Delaney (clinical) [Ep 210 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1162)
- "Total mesorectal excision can be done with about 5 mils of blood loss because it's a bloodless plane; if there's bleeding, you're in the wrong plane unless deliberately outside" — Conor Delaney (clinical) [Ep 210 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=543)
- "Total mesocolic excision should be done with 5 mils of blood loss, in the plane between embryological peritoneum of retroperitoneum (Toltz fascia) and embryological peritoneum on mesocolon" — Conor Delaney (clinical) [Ep 210 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1162)
- "Scandinavian data showed local recurrence rate for colon cancer was even higher than rectal cancer (high 20s%) because they weren't doing adequate colon cancer surgery" — Conor Delaney (epidemiological) [Ep 210 · 19:22](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1162)
- "For cecal or ileocecal valve tumors, should take 10 centimeters of small bowel; if mid-ascending colon, should take 5cm" — Conor Delaney (clinical) [Ep 210 · 22:44](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1364)
- "Extracorporeal stapled anastomosis for right hemicolectomy has reported leak rates of 0.8% over 1,000 cases" — Conor Delaney (epidemiological) [Ep 210 · 23:59](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1439)
- "If negative pathological margin achieved in rectal cancer surgery, chance of local recurrence is low" — Conor Delaney (clinical) [Ep 210 · 9:03](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=543)
- "Transanal resection criteria: generally tumors less than 1/3 circumference, ideally less than 2cm, that are T1" — Conor Delaney (clinical) [Ep 210 · 14:19](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=859)
- "For most young curable patients, people tend to favor radical resection over transanal resection; transanal kept for patients unfit for rectal resection or tumor so close to dentate line would require permanent stoma" — Conor Delaney (opinion) [Ep 210 · 14:19](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=859)
- "Node negative and T1 or T2 (stage one tumor), particularly if upper third rectum, can omit neoadjuvant radiation" — Conor Delaney (guideline) [Ep 210 · 13:11](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=791)
- "Indications for genetic workup: any risk of Bethesda criteria, first degree relatives, somebody young in family, cancer under 40, multiple cancers in family, non-GI cancers in family" — Conor Delaney (guideline) [Ep 210 · 24:32](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1472)
- "Genetic assessment may change the operation: if right colon cancer with multiple polyps or significant history, maybe better with subtotal colectomy; if familial polyposis, maybe proctocolectomy" — Conor Delaney (clinical) [Ep 210 · 24:32](https://library.globalcastmd.com/watch/colorectal-cancer-13754?t=1472)
- "Every patient with cloaca history requires evaluation of three systems: urologic, gynecologic, and colorectal" — Jason Frischer (clinical) [Ep 223 · 1:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=111)
- "Spina bifida bladders and cloaca bladders need to stay empty to prevent kidney damage" — Jason Frischer (clinical) [Ep 223 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=191)
- "A 13-year-old cloaca patient historically would often show up with kidney damage, and many unfortunately ended up with renal transplant" — Jason Frischer (epidemiological) [Ep 223 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=191)
- "Cystatin C is helpful to check GFR and renal function in cloaca patients" — Jason Frischer (clinical) [Ep 223 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=191)
- "Female anorectal malformation patients require cesarean section for childbirth" — Chris Geyer (clinical) [Ep 223 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=235)
- "Every patient with an anorectal malformation needs a gynecology colleague to ensure they are doing well" — Chris Geyer (opinion) [Ep 223 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=235)
- "Anorectal malformation patients can have excellent anatomical repair and still have soiling" — Jason Frischer (clinical) [Ep 223 · 5:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=309)
- "The most common cause for redoing anorectal malformation patients is anus placed in the wrong position" — Chris Geyer (epidemiological) [Ep 223 · 5:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=309)
- "Anorectal manometry is not part of standard initial workup for anorectal malformation patients" — Marc Levitt (guideline) [Ep 223 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=389)
- "There are many ways to tell if the anus is in proper position, such as electrical stimulation and rectal ultrasound or MRI" — Marc Levitt (clinical) [Ep 223 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=389)
- "All anorectal malformation patients get an exam under anesthesia (EUA)" — Jason Frischer (guideline) [Ep 223 · 7:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=434)
- "The rectosigmoid can be very inert in ARM patients even when the anus is not strictured" — Marc Levitt (clinical) [Ep 223 · 9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=545)
- "Mega-rectosigmoid in ARM patients can be both inherent and acquired from failure to aggressively treat constipation over many years" — Marc Levitt (clinical) [Ep 223 · 10:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=619)
- "The rectum is vitally important for bowel control in anorectal malformation patients" — Jason Frischer (clinical) [Ep 223 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=713)
- "ARM patients don't really have anal canal sensation or an internal sphincter unless the very distal aspect of the rectum was saved" — Jason Frischer (clinical) [Ep 223 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=713)
- "Distention of the rectum (proprioception) provides the cue to squeeze the external sphincter and hold in stool" — Jason Frischer (clinical) [Ep 223 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=713)
- "If you remove the rectum in ARM patients, you lose the capacity for proprioception" — Jason Frischer (clinical) [Ep 223 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=713)
- "Prior to 1980 and the PSARP, an abdominal perineal pull-through was done for ARM, throwing the rectum away and pulling sigmoid down, which was wrong" — Jason Frischer (clinical) [Ep 223 · 13:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=809)
- "Older ARM patients who had abdominal perineal pull-through can be recognized on contrast study by haustral markings at the anus and in the pelvis" — Jason Frischer (clinical) [Ep 223 · 13:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=809)
- "Removing the rectum in ARM almost guarantees incontinence" — Chris Geyer (clinical) [Ep 223 · 14:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=887)
- "Rectal tapering technique involves going in laparoscopically or open, tapering on the anti-mesenteric side with a stent or dilator in the rectum to ensure good lumen size" — Chris Geyer (clinical) [Ep 223 · 15:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=945)
- "After rectal tapering, bowel management becomes more manageable and anatomy studied one year after has not shown re-dilation" — Chris Geyer (clinical) [Ep 223 · 15:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=945)
- "Many ARM kids still have trouble with incontinence even with the best operative plans due to their anatomy and musculature" — Jason Frischer (clinical) [Ep 223 · 16:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1009)
- "A sacral ratio of 0.45 indicates the sacrum and perineal musculature are not great" — Jason Frischer (clinical) [Ep 223 · 16:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1009)
- "Colons can empty surprisingly well with antegrade enemas only, potentially avoiding resection" — Jason Frischer (clinical) [Ep 223 · 17:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1062)
- "Very often ARM patients with mega-rectosigmoid have an analplasty that is not good—either strictured, mislocated, or prolapsed" — Jason Frischer (clinical) [Ep 223 · 19:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1164)
- "If the anus is just strictured, making it bigger might allow the colon to decompress and improve" — Jason Frischer (clinical) [Ep 223 · 20:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1214)
- "NotebookLM is a free offering from Google that can upload any content and create realistic-sounding podcasts between two people" — Todd Ponsky (clinical) [Ep 222 · 2:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=150)
- "NotebookLM creates content only from uploaded documents, not from external sources, making it function as a custom expert based solely on provided materials" — Marc Levitt (clinical) [Ep 222 · 5:47](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=347)
- "A review article that took two weeks to produce five years ago can now be generated in minutes using NotebookLM with the same 30 source articles" — Todd Ponsky (clinical) [Ep 222 · 6:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=399)
- "NotebookLM can identify gaps in knowledge across multiple research articles and recognize when new articles fill those gaps" — Todd Ponsky (clinical) [Ep 222 · 7:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=430)
- "Colorectal and pelvic disorders in children often involve interconnected issues affecting digestive, urinary, and reproductive systems, and sometimes bones and muscles of spine and hips" (clinical) [Ep 222 · 11:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=711)
- "Key conditions requiring multidisciplinary approach include anorectal malformations, Hirschsprung disease, severe constipation from colonic motility issues, and neurogenic bladder/bowel dysfunction in spina bifida patients" (clinical) [Ep 222 · 12:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=750)
- "Initial driving forces behind successful programs are strong focus, genuine passion, deep interest from key people, and solid work ethic, with detailed knowledge developing over time" (opinion) [Ep 222 · 14:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=847)
- "A dedicated physician leader, most often a pediatric surgeon, is necessary with genuine interest, commitment to long-term care, and clear vision for improving colorectal care quality" (guideline) [Ep 222 · 14:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=869)
- "Essential initial specialties for multidisciplinary conferences include general surgery, urology, gynecology, GI motility specialist, and critically a dedicated nursing team" (guideline) [Ep 222 · 15:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=951)
- "A dedicated and passionate nurse specializing in bowel management is the backbone of the program; without this nurse, the program won't function effectively regardless of surgical expertise" (clinical) [Ep 222 · 16:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=972)
- "Finding a pediatric gynecologist can be challenging; in those situations a pediatric surgeon might manage gynecological aspects for female patients" (clinical) [Ep 222 · 17:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1023)
- "If involving an adult gynecologist, they must have specific expertise in Müllerian anomalies or disorders of sexual development" (guideline) [Ep 222 · 17:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1023)
- "GI colleagues need interest in motility and performing manometry studies, which involve inserting a thin flexible tube to measure muscle contractions in the digestive tract" (clinical) [Ep 222 · 17:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1073)
- "Clear guidelines are needed for managing constipation, knowing when to refer to multidisciplinary team, and defining when standard medical treatments have failed" (guideline) [Ep 222 · 18:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1096)
- "Radiologists need education on colorectal diseases including how to properly perform and interpret contrast enemas, colostograms, and cloacograms" (guideline) [Ep 222 · 19:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1140)
- "Active participation from surgeons in imaging studies is important, especially initially, to ensure everyone interprets findings consistently" (guideline) [Ep 222 · 19:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1140)
- "Regular multidisciplinary meetings, ideally once or twice weekly, are essential for reviewing individual patient needs and developing coordinated care plans" (guideline) [Ep 222 · 20:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1225)
- "A dedicated multidisciplinary outpatient clinic is ideal, but if not possible, coordinate appointments so patients see different specialists on the same day even in different locations" (guideline) [Ep 222 · 20:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1239)
- "Continuous learning strategies include visiting established centers, staying current with research, watching surgical videos, and visiting other multidisciplinary programs within your own hospital" (guideline) [Ep 222 · 21:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1292)
- "Surgical videos are helpful for building confidence and understanding techniques but are not a substitute for actual hands-on surgical experience" (opinion) [Ep 222 · 23:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1392)
- "The colorectal nurse needs strong foundation in different types of anorectal malformations, Hirschsprung disease, neurogenic bladder/bowel, and skills in preoperative/postoperative care including bowel irrigations, enemas, catheter management, and teaching families anal dilations" (guideline) [Ep 222 · 24:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1460)
- "Essential supplies include Hegar dilators for stretching narrowed passages, various catheters, gravity bags for enemas, and specialized surgical retractors like the Lone Star retractor" (clinical) [Ep 222 · 25:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1545)
- "Key data to track includes total referrals, total visits, new patients, patients from outside region, surgical cases (inpatient and outpatient), length of stay, revenues, expenses, and safety/quality metrics like complication rates" (guideline) [Ep 222 · 26:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1611)
- "Telephone encounters with patients and families should be carefully documented to justify adequate nursing staff, as these patients require significant ongoing support" (guideline) [Ep 222 · 27:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1666)
- "Children with colorectal and pelvic conditions often need long-term chronic care and don't follow typical recovery paths of standard surgical patients" (clinical) [Ep 222 · 27:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1666)
- "In private hospitals, business case emphasis is on attracting patients and downstream revenue; in public hospitals, focus is on demonstrating cost savings through reduced complications, shorter stays, fewer ER visits, and improved quality of life" (clinical) [Ep 222 · 29:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1759)
- "Building trust with referring physicians requires being polite and patient with colleagues hesitant to refer primary surgical cases, especially those who have managed these conditions themselves for years" (opinion) [Ep 222 · 29:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1798)
- "A significant portion of patients initially referred for management issues will likely need further surgical intervention down the line" (clinical) [Ep 222 · 30:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1837)
- "A dedicated care coordinator or scheduler is a top priority for resource allocation to prevent nurses from spending disproportionate time on scheduling tasks" (guideline) [Ep 222 · 31:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1893)
- "Building bench strength by initially sharing resources from existing departments (like allocating portion of general surgery nurse time) can be more cost-effective when starting" (guideline) [Ep 222 · 32:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=1929)
- "Most hospitals have staff in planning and data analysis departments with expertise in developing business cases; engaging these internal resources early is smart" (guideline) [Ep 222 · 33:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=2037)
- "All involved providers must be properly credentialed with government payers like Medicaid and private insurance companies, both within state and in neighboring states" (guideline) [Ep 222 · 35:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=2143)
- "Weekly new patient intake meetings involve nursing team gathering medical records, developing initial multidisciplinary care plan, verifying information with families, and addressing pre-certification/billing issues" (guideline) [Ep 222 · 36:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=2204)
- "For families traveling significant distances, programs try to consolidate as many appointments as possible into a single visit" (guideline) [Ep 222 · 37:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-13845?t=2263)
- "Every patient with cloaca history requires evaluation of three systems: urologic, gynecologic, and colorectal" — Marc Levitt (clinical) [Ep 224 · 1:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=111)
- "Cystatin C is helpful to check GFR and renal function in cloaca patients" — Marc Levitt (clinical) [Ep 224 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=191)
- "Spina bifida bladders and cloaca bladders need to stay empty to prevent kidney damage" — Marc Levitt (clinical) [Ep 224 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=191)
- "A 13-year-old cloaca patient historically would often show up with kidney damage, and many unfortunately ended up with renal transplant" — Marc Levitt (epidemiological) [Ep 224 · 3:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=191)
- "Perineal-only repair approach suggests the original cloaca was relatively low" — Chris Geyer (clinical) [Ep 224 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=235)
- "Female patients with anorectal malformation require cesarean section for childbirth" — Chris Geyer (clinical) [Ep 224 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=235)
- "Every patient with an anorectal malformation needs a gynecologist colleague to ensure they are doing well" — Chris Geyer (guideline) [Ep 224 · 3:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=235)
- "Patients can have excellent anatomical repair and still have soiling in anorectal malformation" — Marc Levitt (clinical) [Ep 224 · 5:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=309)
- "The most common cause for redoing anorectal malformation patients is incorrect anal placement" — Marc Levitt (epidemiological) [Ep 224 · 5:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=309)
- "Anorectal manometry is not part of standard initial workup for anorectal malformation patients" — Jason Frischer (guideline) [Ep 224 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=389)
- "Electrical stimulation and rectal ultrasound or MRI are preferred methods to determine if anus is in proper position" — Chris Geyer (clinical) [Ep 224 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=389)
- "The rectosigmoid can be inert in ARM patients even without stricture" — Marc Levitt (clinical) [Ep 224 · 9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=545)
- "Mega-rectosigmoid etiology is both inherent motility problems and acquired from failure to aggressively treat constipation over many years" — Marc Levitt (clinical) [Ep 224 · 10:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=619)
- "The rectum is vitally important for bowel control in anorectal malformation patients" — Marc Levitt (clinical) [Ep 224 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=713)
- "Anorectal malformation patients don't really have anal canal sensation or internal sphincter" — Marc Levitt (clinical) [Ep 224 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=713)
- "Distention of the rectum (proprioception) provides the cue to squeeze the external sphincter and hold in stool" — Marc Levitt (clinical) [Ep 224 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=713)
- "If you remove the rectum, you lose the capacity for proprioception and bowel control" — Marc Levitt (clinical) [Ep 224 · 11:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=713)
- "Prior to 1980 and the PSARP, abdominal perineal pull-through was performed, throwing the rectum away and pulling sigmoid down, which was wrong" — Chris Geyer (clinical) [Ep 224 · 13:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=809)
- "Older patients who had abdominal perineal pull-through can be recognized on contrast study by haustral markings at the anus in the pelvis" — Marc Levitt (clinical) [Ep 224 · 13:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=809)
- "Rectal tapering can be performed both laparoscopically and open at time of colostomy closure or after failed bowel management" — Chris Geyer (clinical) [Ep 224 · 14:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=862)
- "Tapering technique involves anti-mesenteric side tapering with stent or dilator in rectum, using stapling and sometimes over-sewing" — Chris Geyer (clinical) [Ep 224 · 15:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=945)
- "After rectal tapering, bowel management becomes more manageable and anatomy studied one year after has not shown re-dilation" — Chris Geyer (clinical) [Ep 224 · 15:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=945)
- "A sacral ratio of 0.45 indicates the sacrum and perineal musculature are not great, making the patient likely a bowel management candidate" — Jason Frischer (clinical) [Ep 224 · 16:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1009)
- "Patients with poor sacral ratios will likely never achieve successful bowel control given the quality of their pelvis and amount of sacral regression" — Jason Frischer (clinical) [Ep 224 · 16:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1009)
- "Colons can empty well with antegrade enemas only, potentially avoiding resection" — Marc Levitt (clinical) [Ep 224 · 17:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1072)
- "Very often patients with mega-rectosigmoid have analplasty that is not good - either strictured, mislocated, or prolapsed" — Marc Levitt (clinical) [Ep 224 · 19:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1164)
- "If the anus is just strictured, making it bigger might allow the colon to decompress and improve" — Marc Levitt (clinical) [Ep 224 · 20:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13847?t=1214)
- "Trisomy 21 is associated with approximately 50 times higher incidence of Hirschsprung disease than in non-trisomy 21 patients" — Lily Chang (epidemiological) [Ep 225 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=178)
- "About 5 to 10 percent of trisomy 21 patients have Hirschsprung disease" — Lily Chang (epidemiological) [Ep 225 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=178)
- "Not all children with trisomy 21 have their underlying Hirschsprung disease identified early in life; some present later with constipation" — Marc Levitt (clinical) [Ep 225 · 3:17](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=197)
- "Free air is an indication to go directly to the operating room rather than attempt irrigations" — Marc Levitt (clinical) [Ep 225 · 4:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=286)
- "In Hirschsprung disease with perforation, the cecum perforates due to Laplace's law when the transition zone is around the hepatic flexure" — Marc Levitt (clinical) [Ep 225 · 5:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=352)
- "In anorectal malformation patients with perforation, the sigmoid colon typically perforates with a linear longitudinal tear along the taenia" — Jason Frischer (clinical) [Ep 225 · 6:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=387)
- "Finding a perforation in the cecum should prompt rectal biopsy for Hirschsprung disease, and most patients would receive an ileostomy" — Jason Frischer (clinical) [Ep 225 · 6:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=413)
- "Irrigation breaks the cycle of physiologic obstruction at both the sphincter level and in the aganglionic segment" — Jason Frischer (clinical) [Ep 225 · 7:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=454)
- "Stasis leads to bacterial overgrowth, which leads to translocation and sepsis in Hirschsprung disease" — Jason Frischer (clinical) [Ep 225 · 7:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=454)
- "Proper irrigation involves instilling small aliquots of warm saline (20-40 mLs at a time) and evacuating it, not just infusing into the colon" — Marc Levitt (clinical) [Ep 225 · 8:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=491)
- "Cold saline can change the temperature of a small child during irrigations, so warm saline should be used" — Jason Frischer (clinical) [Ep 225 · 8:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=521)
- "Hirschsprung disease is almost never an emergency operation; irrigations usually win the day" — Marc Levitt (opinion) [Ep 225 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=592)
- "Rectosigmoid ratio less than one on contrast enema is indicative of Hirschsprung disease" — Lily Chang (clinical) [Ep 225 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=640)
- "Sawtoothing in the rectum on contrast enema represents hyperperistalsis and is classic for Hirschsprung disease" — Jason Frischer (clinical) [Ep 225 · 10:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=655)
- "Definitive diagnosis of Hirschsprung disease requires absence of ganglion cells in 100 levels and presence of hypertrophic nerves greater than 40 microns" — Marc Levitt (clinical) [Ep 225 · 11:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=688)
- "Frozen section can only definitively rule out Hirschsprung disease, not confirm it, because confirmation requires 100 levels with no ganglion cells" — Marc Levitt (clinical) [Ep 225 · 11:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=688)
- "Calretinin stain absence further confirms Hirschsprung disease; if calretinin is present, ganglion cells are nearby" — Christy Raylan (clinical) [Ep 225 · 11:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=714)
- "If a patient is being fed and irrigations are going well, they can go home; if not being fed, diversion is reasonable" — Marc Levitt (opinion) [Ep 225 · 15:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=920)
- "For leveling biopsies, start with sigmoid colon; if frozen section shows ganglion cells, no other biopsies are necessary" — Marc Levitt (clinical) [Ep 225 · 16:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=974)
- "Do not biopsy the appendix for Hirschsprung mapping; it is not helpful and many patients' appendixes are aganglionic" — Marc Levitt (clinical) [Ep 225 · 18:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1086)
- "If going to OR for elective pull-through and no ganglion cells found in sigmoid/left colon, should not do pull-through that day; should wait for permanent section" — Philippa Jalius (opinion) [Ep 225 · 19:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1170)
- "Frozen sections can be difficult to interpret in the setting of active enterocolitis due to inflammation" — Christy Raylan (clinical) [Ep 225 · 20:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1234)
- "In areas without frozen section availability, strategy is to bring up the dilated portion which is more likely to be functional" — Marc Levitt (clinical) [Ep 225 · 21:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1261)
- "Ileostomy is not an option in many parts of the world due to risk of dehydration and limited access to medical care" — Marc Levitt (clinical) [Ep 225 · 21:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1261)
- "80% of Hirschsprung cases are rectosigmoid disease" — Marc Levitt (epidemiological) [Ep 225 · 21:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1316)
- "Ileostomy is preferred in resource-rich settings where patients can be kept hydrated and have easy access to healthcare" — Jason Frischer (opinion) [Ep 225 · 22:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1372)
- "Colonic mesentery may be shortened after diverting colostomy due to division and inflammation, making pull-through more difficult" — Marc Levitt (clinical) [Ep 225 · 23:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1391)
- "Frozen section should be performed on the ileostomy to ensure it will function" — Jason Frischer (clinical) [Ep 225 · 23:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1421)
- "If sphincters are overstretched during pull-through, patients will not get enterocolitis but will have fecal incontinence" — Marc Levitt (clinical) [Ep 225 · 24:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1455)
- "Elegant surgical technique that preserves the anal canal and sphincters will still result in some enterocolitis because patients cannot relax their internal sphincter" — Philippa Jalius (clinical) [Ep 225 · 25:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1508)
- "Botox injection at one month post-pull-through did not prevent enterocolitis in a published study" — Marc Levitt (clinical) [Ep 225 · 26:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1570)
- "Botox injection at the anal sphincter at time of restoring intestinal continuity is being studied prospectively but is not 100% effective" — Jason Frischer (clinical) [Ep 225 · 26:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1614)
- "Families should be taught irrigation technique and practice before pull-through so they know how to do it if enterocolitis occurs" — Jason Frischer (clinical) [Ep 225 · 28:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13848?t=1684)
- "Trisomy 21 is associated with approximately 50 times higher incidence of Hirschsprung disease than in non-trisomy 21 patients" — Lily Chang (epidemiological) [Ep 226 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=178)
- "About 5 to 10 percent of trisomy 21 patients have Hirschsprung disease" — Lily Chang (epidemiological) [Ep 226 · 2:58](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=178)
- "Hirschsprung disease is almost never an emergency operation" — Marc Levitt (clinical) [Ep 226 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=592)
- "Irrigations usually win the day in managing Hirschsprung-associated enterocolitis" — Marc Levitt (clinical) [Ep 226 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=592)
- "In Hirschsprung patients with free air, perforation typically occurs in the cecum" — Jason Frischer (clinical) [Ep 226 · 5:49](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=349)
- "When cecal perforation occurs in Hirschsprung, the transition zone is probably somewhere around the hepatic flexure" — Marc Levitt (clinical) [Ep 226 · 5:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=352)
- "In anorectal malformation patients with perforation, the perforation typically occurs in the sigmoid colon as a longitudinal tear along the tinea" — Jason Frischer (clinical) [Ep 226 · 6:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=387)
- "The septic source in Hirschsprung is not the dilated bowel itself but the Hirschsprung enterocolitis" — Philippa Jalius (clinical) [Ep 226 · 9:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=542)
- "Proper irrigation technique involves instilling small aliquots of warm saline (20-40 mLs at a time) and evacuating it rather than just infusing into the colon lumen" — Marc Levitt (clinical) [Ep 226 · 8:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=491)
- "Cold saline can change the temperature of a small child during irrigations, so warm saline should be used" — Jason Frischer (clinical) [Ep 226 · 8:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=521)
- "Rectosigmoid ratio less than one on contrast enema is indicative of Hirschsprung disease" — Lily Chang (clinical) [Ep 226 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=640)
- "Sawtoothing in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease" — Jason Frischer (clinical) [Ep 226 · 10:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=655)
- "Definitive pathologic diagnosis of Hirschsprung requires absence of ganglion cells in 100 levels and presence of hypertrophic nerves greater than 40 microns" — Marc Levitt (clinical) [Ep 226 · 11:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=688)
- "Frozen section can only definitively rule out Hirschsprung disease, not confirm it, because confirmation requires 100 levels with no ganglion cells" — Marc Levitt (clinical) [Ep 226 · 11:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=688)
- "Absent calretinin stain further confirms Hirschsprung disease, while present calretinin indicates ganglion cells are nearby" — Christy Raylan (clinical) [Ep 226 · 11:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=714)
- "Minimum wait time of four weeks from treating enterocolitis before doing definitive surgery is recommended" — Jason Frischer (guideline) [Ep 226 · 14:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=865)
- "Literature from PCPLC shows similar outcomes for Hirschsprung surgery delayed to about three months" — Jason Frischer (clinical) [Ep 226 · 14:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=869)
- "For leveling biopsies, the sigmoid is the 'money' location to start because 80% of Hirschsprung cases are rectosigmoid" — Marc Levitt (clinical) [Ep 226 · 16:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=974)
- "If ganglion cells are found on frozen section of sigmoid, no further biopsies are necessary" — Marc Levitt (clinical) [Ep 226 · 16:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=993)
- "Without frozen section available, mapping should include left colon, transverse colon, and hepatic flexure/right colon" — Jason Frischer (clinical) [Ep 226 · 17:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1043)
- "Do not biopsy the appendix for Hirschsprung diagnosis as it is not helpful and many patients' appendixes are aganglionic" — Marc Levitt (guideline) [Ep 226 · 18:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1086)
- "Frozen sections can be difficult to interpret in the setting of active enterocolitis due to inflammation" — Christy Raylan (clinical) [Ep 226 · 20:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1234)
- "In resource-limited settings without easy access to healthcare, colonic ostomy is preferable to ileostomy due to dehydration risk" — Marc Levitt (clinical) [Ep 226 · 21:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1261)
- "Ileostomy is preferred when possible because mesentery from a diverted colostomy can be shortened and inflamed, making it harder to reach during pull-through" — Marc Levitt (opinion) [Ep 226 · 23:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1391)
- "Frozen section should be performed on the ileostomy to ensure it will function" — Jason Frischer (guideline) [Ep 226 · 23:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1421)
- "Overstretching sphincters during pull-through prevents enterocolitis but causes fecal incontinence" — Marc Levitt (clinical) [Ep 226 · 24:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1455)
- "Elegant pull-through technique that preserves the anal canal and sphincters will still result in some enterocolitis because patients cannot relax their internal sphincter" — Philippa Jalius (clinical) [Ep 226 · 25:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1508)
- "Botox at one month post-pull-through did not prevent enterocolitis in a published negative study" — Marc Levitt (clinical) [Ep 226 · 26:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1570)
- "Families should be taught irrigation technique and practice it before the pull-through surgery" — Jason Frischer (guideline) [Ep 226 · 28:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1684)
- "The most common complication of Malone procedure is stricture occurring in 17 to 20% of patients" — Philippa Jalus (clinical) [Ep 227 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=389)
- "About 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work" — Jason Frischer (clinical) [Ep 227 · 5:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=337)
- "If appendix is seven centimeters or greater it can be split, requiring two centimeters minimum for Malone and five centimeters minimum for Mitrofanoff" — Jason Frischer (clinical) [Ep 227 · 9:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=543)
- "A neo-Malone does just as well as a Malone, so if you can only use the appendix for one channel it should be the Mitrofanoff because an appendix-based Mitrofanoff does much better than a small bowel Monty" — Philippa Jalus (clinical) [Ep 227 · 9:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=586)
- "In a study of 10 Malones in a row without plicating, five leaked, leading to decision to plicate all appendicostomies" — Jason Frischer (clinical) [Ep 227 · 8:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=515)
- "Poiseuille's law governs flow of fluid through a tube based on radius to the fourth power and length; longer appendix less likely to leak" — Jason Frischer (clinical) [Ep 227 · 7:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=457)
- "Deflux is a non-surgical procedure where sterile biodegradable gel is injected into structural wall to act as valve preventing backflow" — Philippa Jalus (clinical) [Ep 227 · 2:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=153)
- "If short and stumpy appendix, best for Malone and Mitrofanoff should be made from small bowel" — Jason Frischer (clinical) [Ep 227 · 9:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=543)
- "If appendix is five to seven centimeters, not enough to share and should go for Mitrofanoff, requiring neo-Malone" — Jason Frischer (clinical) [Ep 227 · 9:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=543)
- "Small bowel volvulus around appendix has occurred in two or three cases" — Marc Levitt (clinical) [Ep 227 · 13:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=801)
- "Stenosis rate can be minimized by using 10 French tube not 8, leaving it in for a month, and catheterizing twice a day" — Jason Frischer (clinical) [Ep 227 · 16:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=973)
- "Leaving indwelling tubes increases prolapse rate due to pressure on appendiceal base pushing up mucosa" — Jason Frischer (clinical) [Ep 227 · 16:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=1014)
- "Urologists almost never get stenosis of Mitrofanoff because they catheterize every four hours; catheterizing Malone twice daily has reduced stenosis rate" — Jason Frischer (clinical) [Ep 227 · 17:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=1065)
- "Appendicitis in a Malone is impossible unless the hole closes, because there is no obstruction" — Marc Levitt (clinical) [Ep 227 · 20:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=1255)
- "In South Africa they never take out the appendix as part of laparoscopic appendectomy for other conditions; it is a United States practice" — Marc Levitt (clinical) [Ep 227 · 21:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=1286)
- "One carcinoid tumor (neuroendocrine tumor) was found in appendiceal tip sent to pathology after Malone creation" — Marc Levitt (clinical) [Ep 227 · 22:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=1325)
- "Mitrofanoff is a surgical procedure creating channel from bladder to skin surface allowing patients to urinate via catheter through small opening in lower abdomen" — Philippa Jalus (clinical) [Ep 227 · 1:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=95)
- "Malone appendicostomy is a surgical procedure creating channel between abdomen and colon to treat fecal incontinence and constipation" — Philippa Jalus (clinical) [Ep 227 · 1:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=95)
- "For leaking Malone, first check if patient is cleaning themselves out with enemas; if backed up, enemas may not be effective" — Jeffrey Avansino (clinical) [Ep 227 · 6:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=406)
- "Water-soluble fiber can be tried to thicken stool so content entering right colon is thicker, then flush with enema" — Jeffrey Avansino (clinical) [Ep 227 · 6:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=406)
- "If patient not doing well with flushes or getting significant nausea, must do contrast study through Malone to check for reflux into terminal ileum" — Jeffrey Avansino (clinical) [Ep 227 · 14:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=884)
- "Appendix should not be removed in first Crohn's or anorectal malformation patient or child with spine issues, absent sacrum, or spina bifida" — Marc Levitt (guideline) [Ep 227 · 21:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=1286)
- "When doing neo-Malone, try to orient catheter entry into right colon to avoid retrograde catheterization into ileum" — Marc Levitt (clinical) [Ep 227 · 14:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=856)
- "Visualizing floppy cecum with laparoscope means patient could have volvulus; should check alignment of Treitz before completing case" — Philippa Jalus (clinical) [Ep 227 · 13:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13850?t=831)
- "Stricture is the most common Malone complication, occurring in 17 to 20% of patients" — Philippa Jalus (epidemiological) [Ep 228 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=389)
- "Leakage occurs less commonly than stricture in Malone procedures" — Philippa Jalus (epidemiological) [Ep 228 · 6:29](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=389)
- "Deflux injection was common management for reflux through ureter and was extrapolated to Mitrofanovs in the late 2000s" — Philippa Jalus (clinical) [Ep 228 · 7:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=443)
- "Flow of fluid through a tube is based on Poiseuille's law: radius to the fourth power and length" — Jason Frischer (clinical) [Ep 228 · 7:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=457)
- "A longer appendix is less likely to leak and may not need plication" — Jason Frischer (clinical) [Ep 228 · 8:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=515)
- "In a study of 10 Malones without plication, five leaked, leading to universal plication policy" — Jason Frischer (clinical) [Ep 228 · 8:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=515)
- "Universal plication has resulted in no leakage for several years" — Jason Frischer (clinical) [Ep 228 · 8:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=515)
- "Short and stumpy appendix is best for Malone; Mitrofanoff should be made from small bowel in this case" — Jason Frischer (clinical) [Ep 228 · 9:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=543)
- "Five to seven centimeter appendix is not enough to share and should go to Mitrofanoff because long-term Mitrofanovs do much better; requires neo-Malone creation" — Jason Frischer (clinical) [Ep 228 · 9:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=543)
- "Appendix seven centimeters or greater can be split, requiring minimum two centimeters for Malone and five centimeters for Mitrofanoff" — Jason Frischer (clinical) [Ep 228 · 9:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=543)
- "A neo-Malone does just as well as an appendix-based Malone" — Philippa Jalus (clinical) [Ep 228 · 9:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=586)
- "An appendix-based Mitrofanoff does much better than a small bowel Monty" — Philippa Jalus (clinical) [Ep 228 · 9:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=586)
- "About 60% of the time there is success with using a split appendix for both channels" — Jason Frischer (epidemiological) [Ep 228 · 5:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=337)
- "About 40% of the time a split appendix cannot be made to work for both channels" — Jason Frischer (epidemiological) [Ep 228 · 5:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=337)
- "Small bowel volvulus around the appendix stalk has been observed in two or three cases" — Marc Levitt (clinical) [Ep 228 · 13:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=801)
- "Stenosis rate can be minimized by using 10-French tube (not 8), leaving it in for a month, and catheterizing twice daily" — Jason Frischer (clinical) [Ep 228 · 16:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=971)
- "Using a G-tube device in 10-French and stenting the channel for many months reduces stenosis incidence" — Jason Frischer (clinical) [Ep 228 · 16:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=971)
- "Leaving indwelling tubes increases prolapse rate by creating pressure on appendiceal base pushing up mucosa" — Jason Frischer (clinical) [Ep 228 · 16:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=1014)
- "Urologists almost never get stenosis of Mitrofanoff because they catheterize every four hours" — Jason Frischer (clinical) [Ep 228 · 17:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=1065)
- "Catheterizing Malone tract twice daily has reduced stenosis rate" — Jason Frischer (clinical) [Ep 228 · 17:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=1065)
- "Only 10 to 20% of patients have problems with their Malone post-procedure" — Philippa Jalus (epidemiological) [Ep 228 · 16:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=961)
- "Appendicitis is impossible in a patent Malone because there is no obstruction" — Marc Levitt (clinical) [Ep 228 · 20:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=1255)
- "Appendicitis can only occur in a Malone if the hole closes" — Marc Levitt (clinical) [Ep 228 · 20:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=1255)
- "Appendix should not be removed during other procedures in patients with Crohn's disease, anorectal malformation, spine issues, absent sacrum, or spina bifida" — Marc Levitt (clinical) [Ep 228 · 21:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=1286)
- "In South Africa, appendix is never removed as part of laparoscopic appendectomy; it is a United States practice" — Marc Levitt (clinical) [Ep 228 · 21:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=1286)
- "Appendix tip should be sent to pathology; one case revealed a carcinoid (neuroendocrine tumor)" — Marc Levitt (clinical) [Ep 228 · 22:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-43-13851?t=1321)
- "Anorectal malformation is defined as a birth defect that occurs when a baby's anus and rectum don't develop normally during pregnancy, occurring more commonly in females with a prevalence of about one in 5,000 births." — Thomas Hsu (epidemiological) [Ep 229 · 1:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=84)
- "About 60% of anorectal malformation patients in some regions are discharged home without being identified." — Chris Westgarth-Taylor (epidemiological) [Ep 229 · 1:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=65)
- "When laparoscopy reveals a blind-ending colon with no distal segment visible, an end colostomy is preferable to a divided colostomy to preserve blood supply to the distal rectum." — Marc Levitt (clinical) [Ep 229 · 2:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=141)
- "A cloaca is defined by the presence of a single perineal orifice." — Marc Levitt (clinical) [Ep 229 · 4:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=248)
- "The anatomy in this case is similar to Meyer-Rokitansky-Küster-Hauser syndrome, with ovaries, remnant fallopian tubes, and no other Müllerian structures." — Marc Levitt (clinical) [Ep 229 · 5:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=332)
- "Meyer-Rokitansky-like anatomy with anorectal malformation is extremely rare." — Marc Levitt (epidemiological) [Ep 229 · 5:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=335)
- "The more common scenario is recto-vestibular fistula with distal vaginal atresia, where the rectum ends as a fistula in the vestibule with a normal urethra but no vagina." — Marc Levitt (clinical) [Ep 229 · 6:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=397)
- "The sacral anatomy in this case appears foreshortened, suggesting caudal regression syndrome." — Marc Levitt (clinical) [Ep 229 · 7:18](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=438)
- "Laparoscopic colostomy creation allows identification of incidental findings like malrotation that might be missed with standard left lower quadrant colostomy." — Thomas Hsu (clinical) [Ep 229 · 4:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=293)
- "In cases with limited dissection and a colocolonic anastomosis plus simple anoplasty, not diverting can be safe without risk of anastomotic breakdown." — Marc Levitt (opinion) [Ep 229 · 10:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=612)
- "If diversion were needed in this case, an ileostomy would be the preferred choice." — Thomas Hsu (clinical) [Ep 229 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=628)
- "Colonic neovaginas are not great for patients 20 years down the road and should be avoided when possible." — Marc Levitt (opinion) [Ep 229 · 11:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=674)
- "In most cloacas, the native vagina should be able to reach and vaginal replacement should be avoided." — Marc Levitt (clinical) [Ep 229 · 11:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=674)
- "Options for vaginal reconstruction include dilation of the existing introitus, buccal graft placement, or future tissue engineering solutions." — Jason Frischer (clinical) [Ep 229 · 11:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=695)
- "A neovagina could potentially serve as a temporary bridge to allow menstruation, with removal 20 years later when tissue engineering options become available." — Marc Levitt (opinion) [Ep 229 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=766)
- "If a neovagina functions well without problems, there may be no need to remove it even if it was intended as temporary." — Jason Frischer (opinion) [Ep 229 · 13:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=789)
- "Using the colon in this case for vaginal replacement would be risky due to compromised blood supply from the prior divided stoma." — Marc Levitt (clinical) [Ep 229 · 13:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=801)
- "Vascular anomalies associated with anorectal malformations are under-recognized and poorly documented in the literature." — Marc Levitt (clinical) [Ep 229 · 15:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=911)
- "Surgeons should be willing to stop an operation when encountering uncertain anatomy, gather more information, and return to complete the procedure rather than proceeding blindly." — Jason Frischer (opinion) [Ep 229 · 15:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=957)
- "Visualization of the bladder neck does not predict its competency and ability to hold back urine; urodynamics are needed for assessment." — Thomas Hsu (clinical) [Ep 229 · 17:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=1059)
- "The odds of fecal continence for this child are concerning given the sacral anatomy, though sphincter stimulation response was very good." — Marc Levitt (clinical) [Ep 229 · 17:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=1033)
- "The patient not leaking urine continuously is a positive finding for future urinary continence." — Chris Westgarth-Taylor (clinical) [Ep 229 · 17:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13852?t=1059)
- "Anorectal malformation is defined as a birth defect that occurs when a baby's anus and rectum don't develop normally during pregnancy, causing abnormalities in the anal opening, rectum, and occasionally surrounding structures" — Thomas Hsu (clinical) [Ep 230 · 1:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=84)
- "Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births" — Thomas Hsu (epidemiological) [Ep 230 · 1:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=99)
- "About 60% of anorectal malformation patients in some regions are discharged home without being identified" — Chris Westgarth-Taylor (epidemiological) [Ep 230 · 1:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=65)
- "When you see a blind ending piece of colon during initial laparoscopy, the best approach is to use that as your end stoma rather than doing a divided colostomy to avoid interfering with blood supply to the distal segment" — Marc Levitt (clinical) [Ep 230 · 2:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=141)
- "The more common scenario in anorectal malformation with absent vagina is a recto-vestibular fistula with completely normal urethra but no vagina in between, which would be called recto-vestibular fistula with distal vaginal atresia" — Marc Levitt (clinical) [Ep 230 · 6:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=383)
- "In most cloacas, you should be able to get the native vagina to reach, avoiding the need for vaginal replacement" — Marc Levitt (clinical) [Ep 230 · 11:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=674)
- "Colonic neovaginas are not great for patients 20 years down the road and should be avoided if possible" — Marc Levitt (opinion) [Ep 230 · 11:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=674)
- "A dilatable introitus can potentially be dilated in the future to create a functional vagina" — Jason Frischer (clinical) [Ep 230 · 11:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=695)
- "Buccal graft can be laid into the opened introital area as an option for vaginal reconstruction" — Marc Levitt (clinical) [Ep 230 · 11:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=716)
- "Tissue engineering options for vaginal reconstruction are expected to be available within 20 years or potentially shorter" — Marc Levitt (opinion) [Ep 230 · 11:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=716)
- "A neovagina could be provided as a temporary bridge to allow menstruation, then potentially removed 20 years later when better options become available" — Marc Levitt (clinical) [Ep 230 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=766)
- "If there is no problem with a neovagina bridge, there is no need to go in and remove tissue later" — Jason Frischer (opinion) [Ep 230 · 13:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=789)
- "Using the colon in this case for vaginal replacement would be problematic due to blood supply concerns from the original divided stoma procedure" — Thomas Hsu (clinical) [Ep 230 · 13:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=801)
- "Vascular anomalies associated with anorectal malformation are a topic that has never been much written about" — Marc Levitt (clinical) [Ep 230 · 15:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=911)
- "Aberrant external iliac artery can loop up within the abdominal wall and look like the obliterated umbilical artery while actually supplying blood to an extremity" — Marc Levitt (clinical) [Ep 230 · 15:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=911)
- "Surgeons are judged by what they are willing to stop for; it is wise to stop an operation when uncertain about anatomy, gather more information, and return another day" — Jason Frischer (opinion) [Ep 230 · 15:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=957)
- "The visualization of the bladder neck will not predict its competency and ability to hold back urine" — Thomas Hsu (clinical) [Ep 230 · 17:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=1059)
- "This patient will need urodynamics in the future to assess bladder function" — Thomas Hsu (clinical) [Ep 230 · 17:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=1059)
- "The advantage of doing colostomy laparoscopically is that malrotation may be discovered, which might remain undiagnosed with a standard left lower quadrant colostomy" — Thomas Hsu (clinical) [Ep 230 · 4:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=293)
- "In this case with limited dissection and a colocolonic anastomosis at the colostomy closure site plus an analplasty with a couple of posterior sutures, not diverting is a safe decision" — Marc Levitt (clinical) [Ep 230 · 10:12](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=612)
- "If diversion were needed in this case, an ileostomy would be the preferred choice" — Thomas Hsu (clinical) [Ep 230 · 10:28](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=628)
- "The limited posterior sagittal incision was deliberately kept out of the perineal body to avoid scarring that would interfere with future gynecological reconstruction" — Chris Westgarth-Taylor (clinical) [Ep 230 · 10:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=653)
- "Tetralogy of Fallot was diagnosed prenatally in this patient" — Megan Durham (clinical) [Ep 231 · 2:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=127)
- "Prenatal echocardiogram revealed tetralogy of Fallot with large VSD, bidirectional shunt, moderate pulmonary valve stenosis, right ventricular outflow tract obstruction, mild right ventricular hypertrophy, and very small PDA" — Megan Durham (clinical) [Ep 231 · 3:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=180)
- "The patient had a perineal fistula with meconium visible along the scrotal raphae" — Marc Levitt (clinical) [Ep 231 · 3:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=233)
- "Presence of an anal dimple, raised area, and good color change suggests a good sphincter" — Marc Levitt (clinical) [Ep 231 · 4:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=246)
- "A perineal fistula with external opening is one of the less complicated anorectal malformation lesions" — Megan Durham (clinical) [Ep 231 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=323)
- "Primary repair in the neonatal period is optimal for perineal fistula in a baby without cardiac defect" — Megan Durham (opinion) [Ep 231 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=323)
- "Dilation without operating room intervention is possible for perineal fistula, especially in females with vestibular fistula" — Marc Levitt (clinical) [Ep 231 · 6:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=392)
- "In males, perineal fistula dilation is more dangerous because the opening is near the urethra" — Marc Levitt (clinical) [Ep 231 · 6:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=392)
- "In cardiac patients with external ARM opening, dilation is typically performed as long as evacuation is adequate" — Jason Frischer (clinical) [Ep 231 · 7:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=444)
- "Concern exists about healing of ARM repair in blue babies with significant cardiac lesions requiring early surgery" — Jason Frischer (opinion) [Ep 231 · 7:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=468)
- "Patient had cross-fused ectopia of left kidney with normally positioned right kidney" — Megan Durham (clinical) [Ep 231 · 8:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=513)
- "Patient had conus at L2, which is normal" — Megan Durham (clinical) [Ep 231 · 8:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=513)
- "Patient had sacral dysplasia with foreshortened sacrum" — Megan Durham (clinical) [Ep 231 · 8:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=513)
- "VCUG showed small diverticulum along right bladder base, otherwise normal" — Rod Gerardo (clinical) [Ep 231 · 8:54](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=534)
- "VCUG is obtained if there are renal anomalies" — Megan Durham (clinical) [Ep 231 · 9:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=544)
- "Patient had significant tetralogy spells with desaturation to 60s when crying during dilation attempts" — Megan Durham (clinical) [Ep 231 · 9:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=554)
- "Laparoscopic colostomy was performed on day of life two" — Megan Durham (clinical) [Ep 231 · 9:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=554)
- "A turnable loop ostomy (95-5 percentage loop) behaves like an end colostomy but allows distal contrast studies" — Marc Levitt (clinical) [Ep 231 · 9:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=583)
- "For cardiac babies, laparoscopic insufflation pressures are started at 8 mmHg" — Megan Durham (clinical) [Ep 231 · 10:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=623)
- "Irrigating the distal rectum preoperatively helps keep insufflation pressures low during laparoscopy" — Megan Durham (clinical) [Ep 231 · 10:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=623)
- "If umbilical line is present, Palmer's Point access with Hasson technique is an alternative to umbilical access" — Marc Levitt (clinical) [Ep 231 · 10:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=650)
- "Patient's PDA completely closed postnatally" — Rod Gerardo (clinical) [Ep 231 · 11:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=699)
- "Patient required emergent tetralogy of Fallot repair on day of life five due to persistent hypercyanotic spells" — Megan Durham (clinical) [Ep 231 · 11:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=716)
- "PSARP was performed approximately three months after cardiac repair" — Rod Gerardo (clinical) [Ep 231 · 12:19](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=739)
- "Low anorectal malformations (perineal fistula) should have good continence prognosis" — Marc Levitt (clinical) [Ep 231 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=753)
- "Continence depends on sensation in anal canal, absence of dentate line, spine anatomy, type of ARM, and sacral anatomy" — Marc Levitt (clinical) [Ep 231 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=753)
- "Sacral ratio measurement should wait until three months of age" — Marc Levitt (clinical) [Ep 231 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=753)
- "Half of this patient's perineal fistula opening was anterior to the muscular complex, requiring formal repositioning into the center of the anal muscular complex" — Megan Durham (clinical) [Ep 231 · 13:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=816)
- "The fistula tract along the median raphae was left alone because the perineal fistula did not extend up into the raphae itself" — Marc Levitt (clinical) [Ep 231 · 13:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=836)
- "The fistula tract is only one millimeter deep and should not be aggressively pursued surgically" — Marc Levitt (clinical) [Ep 231 · 14:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=850)
- "When fistula opening is 50-50 (half within, half anterior to sphincter complex), leave the anterior wall and mobilize posteriorly to achieve 80-20 reconstruction" — Jason Frischer (clinical) [Ep 231 · 14:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=863)
- "If fistula is completely outside the sphincteric ellipse, full mobilization is required" — Marc Levitt (clinical) [Ep 231 · 14:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13856?t=897)
- "In Georgia, when a baby gets diagnosed with prenatal cardiac disease, the cardiac group gets called early and gets involved, including reviewing echocardiograms and meeting with high-risk OB" — Rod Gerardo (clinical) [Ep 232 · 2:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=164)
- "Missed anorectal malformations are a topic for a separate podcast" — Megan Durham (opinion) [Ep 232 · 3:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=233)
- "An anal dimple with raised area and good color change indicates there is probably a good sphincter" — Marc Levitt (clinical) [Ep 232 · 4:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=246)
- "Tiny white beads in the scrotal raphae indicate the ARM lesion is one of the less complicated lesions with an opening somewhere along the perineal body" — Megan Durham (clinical) [Ep 232 · 5:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=324)
- "For a perineal fistula ARM without cardiac defect, primary repair would be the optimal choice" — Megan Durham (clinical) [Ep 232 · 6:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=363)
- "Dilation without going to the OR might be a good choice in a baby you don't want to take to the operating room" — Marc Levitt (clinical) [Ep 232 · 6:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=363)
- "For patients with ARM and really significant cardiac anomaly, an ostomy is probably the standard choice" — Rod Gerardo (clinical) [Ep 232 · 6:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=373)
- "In a female patient with vestibular or perineal fistula, there is no rush to operate" — Marc Levitt (clinical) [Ep 232 · 6:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=392)
- "In a male, the perineal hole is not always easy to see and dilation is more dangerous because it is near the urethra" — Marc Levitt (clinical) [Ep 232 · 6:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=392)
- "With care and Hagar dilators, you can get egressive stool and never go to the OR" — Marc Levitt (clinical) [Ep 232 · 6:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=392)
- "In a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they are evacuating okay" — Jason Frischer (clinical) [Ep 232 · 7:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=444)
- "The concern with significant cardiac lesions requiring early surgery in a blue baby is worry about healing of the repair" — Jason Frischer (clinical) [Ep 232 · 7:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=468)
- "There is no need to do a colostomy in a baby with perineal fistula and cardiac disease; you can dilate and do the repair primarily later" — Marc Levitt (clinical) [Ep 232 · 8:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=493)
- "A conus at L2 is normal" — Megan Durham (clinical) [Ep 232 · 8:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=513)
- "A baby is too young in the neonatal period to calculate a sacral ratio" — Megan Durham (clinical) [Ep 232 · 8:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=513)
- "VCUG is obtained if there are renal anomalies" — Megan Durham (clinical) [Ep 232 · 8:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=537)
- "Every time they tried to dilate this baby, the baby would cry and desat down to the 60s due to TET spells" — Megan Durham (clinical) [Ep 232 · 9:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=554)
- "A turnable loop ostomy behaves like an end ostomy with a 95-5 percentage split, and no one knows except the surgeon that there is another side where you can do a contrast study" — Marc Levitt (clinical) [Ep 232 · 9:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=583)
- "For cardiac babies undergoing laparoscopy, initial insufflation pressure is set around 8 mmHg if tolerated" — Megan Durham (clinical) [Ep 232 · 10:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=623)
- "Starting flow rate for insufflation in babies is set at 1 L/min" — Megan Durham (clinical) [Ep 232 · 10:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=623)
- "If the anus can be irrigated, evacuating stool helps keep insufflation pressures low during laparoscopy" — Megan Durham (clinical) [Ep 232 · 10:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=623)
- "If the baby has an umbilical line, consider Palmer's Point access rather than umbilical access, using a Hasson technique" — Rod Gerardo (clinical) [Ep 232 · 11:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=660)
- "When accessing the umbilicus, dissect in with a mosquito, make sure you are in without touching any vessel before insufflation, and clear the line of air" — Marc Levitt (clinical) [Ep 232 · 11:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=668)
- "It is important to irrigate the distal bowel as much as possible during colostomy creation" — Jason Frischer (clinical) [Ep 232 · 11:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=681)
- "A technique for distal irrigation involves having someone look laparoscopically while passing a tube into the distal segment and performing irrigation under direct visualization" — Marc Levitt (clinical) [Ep 232 · 11:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=681)
- "This baby's PDA completely closed postnatally" — Rod Gerardo (clinical) [Ep 232 · 11:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=699)
- "Despite maneuvers, this baby continued to have hypercyanotic spells and required heart surgery sooner than the initially planned 6 months" — Rod Gerardo (clinical) [Ep 232 · 11:39](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=699)
- "Emergent tetralogy of Fallot repair was performed on day of life 5" — Rod Gerardo (clinical) [Ep 232 · 12:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=730)
- "PSARP was planned for about 3 months after colostomy" — Megan Durham (clinical) [Ep 232 · 12:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=734)
- "A baby with a low ARM lesion where the perineal fistula is closely approximated to the anal muscular complex should do really well for continence" — Megan Durham (clinical) [Ep 232 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=753)
- "Important factors for continence include sensation in the anal canal, absence of the dentate line, quality of the spine, quality of the anorectal malformation, and quality of the sacrum" — Megan Durham (clinical) [Ep 232 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=753)
- "Sacral ratio measurement should wait until 3 months of age" — Megan Durham (clinical) [Ep 232 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=753)
- "When half of the perineal fistula opening is anterior to the muscular complex, the entire opening should be formally moved back into the center around the anal muscular complex" — Megan Durham (clinical) [Ep 232 · 13:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=816)
- "The pearls along the median raphae should be scraped off at about one millimeter depth; do not dive in to find the fistula tract as it will disappear with good anoplasty and anterior rectal wall mobilization" — Marc Levitt (clinical) [Ep 232 · 14:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=842)
- "Pearls along the raphae can persist into teenage years and young adulthood if not addressed" — Marc Levitt (clinical) [Ep 232 · 14:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=842)
- "When 50% of the fistula is within the muscle complex and 50% is anterior, leave the anterior wall (the danger zone) and mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction" — Marc Levitt (clinical) [Ep 232 · 14:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=863)
- "If the fistula is completely outside the sphincteric ellipse, a full mobilization must be performed" — Marc Levitt (clinical) [Ep 232 · 14:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-32-anorectal-malformations-and-cardiac-anomalies-13857?t=863)
- "Alberto Pena historically kept patients mandatory NPO for seven days with central line and hyperalimentation, feeding on day seven if healed" — Marc Levitt (clinical) [Ep 233 · 1:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=73)
- "A study comparing NPO for seven days versus clear liquids for seven days showed the same amount of stool output in both groups" — Marc Levitt (clinical) [Ep 233 · 2:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=151)
- "Hard stool passage, not stool passage itself, is the primary risk factor for perineal body dehiscence" — Marc Levitt (clinical) [Ep 233 · 3:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=210)
- "Current protocol uses regular IV (no PICC line) and clear liquids or breast milk for five days, with better healing observed by day five than day one or two" — Marc Levitt (clinical) [Ep 233 · 4:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=240)
- "Phoenix group performs early repairs before infants are on anything except breast milk or formula, with early discharge (POD 2-3) and very low dehiscence rate" — Christine (clinical) [Ep 233 · 4:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=272)
- "Perineal body dehiscence usually leads to no perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it" — Marc Levitt (clinical) [Ep 233 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=323)
- "Patients who required redo surgery for perineal body dehiscence were invariably fed right away and discharged home" — Marc Levitt (clinical) [Ep 233 · 6:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=387)
- "A randomized controlled trial of dilation versus non-dilation for primary PSARP (cloacas excluded) showed stricture rates of 10-20% in both groups" — Marc Levitt (clinical) [Ep 233 · 9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=545)
- "The backup plan for stricture in the non-dilation group was aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty, often performed at the time of colostomy closure" — Marc Levitt (clinical) [Ep 233 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=640)
- "Many patients' anoplasties look absolutely fine eight weeks later at colostomy closure if never touched with a dilator, when the anoplasty is healthy with no tension and good blood supply" — Marc Levitt (clinical) [Ep 233 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=640)
- "Family survey identified dilations as by far the number one concern relative to care of patients with anorectal malformation" — Marc Levitt (epidemiological) [Ep 233 · 11:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=712)
- "Dilations can drive couples apart, with one family member typically responsible for performing them, and that person often not wanting to attend clinic visits over time" — Kathy (clinical) [Ep 233 · 13:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=784)
- "Jack Langer's protocol involves seeing patients weekly in clinic and passing a dilator without having families do it at home" — Marc Levitt (clinical) [Ep 233 · 13:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=828)
- "In the dilation study, approximately 20% required a redo operation (either local or total), with four patients requiring total redo anoplasties for stricture (two in dilation arm who chose not to dilate, two in non-dilation arm)" — Jason Frischer (clinical) [Ep 233 · 14:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=844)
- "Data exists showing patients can be restored to full continence with a redo operation for stricture indication" — Marc Levitt (clinical) [Ep 233 · 16:16](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=976)
- "In the dilation study, no family has yet chosen dilation when presented with the option" — Marc Levitt (epidemiological) [Ep 233 · 17:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1056)
- "For redo operations, anoplasties are made slightly larger knowing there will be some contraction, and these patients are not dilated postoperatively but undergo EUA at one month to check for early stricture" — Marc Levitt (clinical) [Ep 233 · 19:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1177)
- "For primary repairs, the analplasty lumen is made to match what the maximal rectal lumen can be, filling the sphincter, typically resulting in size 13 or 14 Hegar" — Marc Levitt (clinical) [Ep 233 · 21:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13858?t=1260)
- "Harold Hirschsprung figured out that a baby could be sick due to this problem, but he did not understand the pathology" — Marc Levitt (clinical) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "The disease is named Hirschsprung disease, not apostrophe S" — Marc Levitt (guideline) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "Orvar Swenson figured out the pathology and defined the fact that there were no ganglion cells" — Marc Levitt (clinical) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "Prior to Swenson's work, removal of the dilated colon was the treatment, which was a mistake because it was the distal colon, the narrow colon that was the problem" — Marc Levitt (clinical) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "Swenson developed the first operation for Hirschsprung disease, which is a full thickness rectal dissection" — Marc Levitt (clinical) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "Dr. Yancey was the first surgeon who described a submucosal dissection for Hirschsprung disease, but published in a journal that not many people read" — Marc Levitt (clinical) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "Dr. Suave published his article on submucosal dissection years later in a journal that more people read, so the technique bears his name rather than Yancey's" — Marc Levitt (clinical) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "The Suave technique was developed because people said the Swenson caused fecal and urinary incontinence or voiding dysfunction, though Swenson argued they were doing the dissection too wide" — Marc Levitt (clinical) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "Doing a proper Swenson right on the bowel wall, similar to a PSARP, avoids nerve injury; if you see fat, you can get closer, as the nerves are in the fatty layer" — Marc Levitt (clinical) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "Duhamel's technique leaves the original rectum behind and does a pull through next to it, then mates the two lumens" — Marc Levitt (clinical) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "The Duhamel technique is now only appropriate for an ilio Duhamel, though the speaker would still do an ilioanal" — Marc Levitt (opinion) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "Rabine did a low anterior resection for Hirschsprung disease, leaving about six centimeters behind, and some patients did fine with ganglionated bowel pooping through the aganglionated segment" — Marc Levitt (clinical) [Ep 236 · 0:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=26)
- "Dr. Boley was the first to do the primary coloanal anastomosis of a Suave, eliminating the need to leave bowel hanging out and return at day seven" — Marc Levitt (clinical) [Ep 236 · 5:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=357)
- "The proper description is the Suave technique with the Boley modification, or Suave-Boley" — Marc Levitt (guideline) [Ep 236 · 5:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=357)
- "Henry So was the first surgeon to do a primary pull-through, a trans-abdominal procedure with no preceding stoma" — Marc Levitt (clinical) [Ep 236 · 5:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=357)
- "So performed primary pull-throughs because patients with stomas in the Philippines faced such social stigma that babies were basically left to die by their families" — Marc Levitt (epidemiological) [Ep 236 · 5:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=357)
- "Dr. Martin was the first surgeon in chief and pediatric surgeon at Cincinnati Children's Hospital" — Jason Frischer (clinical) [Ep 236 · 9:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=580)
- "Dr. Martin developed the Martin procedure, an expansion of the Duhamel leaving a longer aganglionated segment of rectum and pulling through ganglionated bowel for long segment Hirschsprung disease" — Jason Frischer (clinical) [Ep 236 · 9:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=580)
- "Martin published in 1977, before the J pouch, taking the endorectal pull through used for Hirschsprung disease and transferring that technique to ulcerative colitis treatment" — Marc Levitt (clinical) [Ep 236 · 10:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=634)
- "Martin did total proctocolectomy using endorectal techniques from Hirschsprung disease and performed ilioanal anastomosis for ulcerative colitis, before the J pouch modified that technique" — Marc Levitt (clinical) [Ep 236 · 10:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=634)
- "The transanal dissection and Suave plane dissection is the same concept as the mucosectomy in ulcerative colitis" — Marc Levitt (clinical) [Ep 236 · 10:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=634)
- "Helen Noblet figured out the suction rectal biopsy and is from Melbourne, Australia" — Marc Levitt (clinical) [Ep 236 · 11:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=701)
- "Keith Jorgensen did the laparoscopic version of the Suave, with Tom Inge on the original paper" — Marc Levitt (clinical) [Ep 236 · 11:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=701)
- "In Jorgensen's original description, they talked about leaving a five centimeter cuff, which nowadays would be way too much" — Marc Levitt (opinion) [Ep 236 · 11:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=701)
- "Jack Langer and Luis de la Torre approached Hirschsprung surgery transanally, doing transanal resection of the rectosigmoid with or without laparoscopy or laparotomy" — Marc Levitt (clinical) [Ep 236 · 11:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=701)
- "Some places around the world are doing transanal only approaches, and the speaker does that in certain circumstances" — Marc Levitt (opinion) [Ep 236 · 11:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=701)
- "Dan Teitelbaum did an incredible amount of work in Hirschsprung disease, particularly significant research in enterocolitis, before passing away from a brain tumor" — Marc Levitt (clinical) [Ep 236 · 11:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=701)
- "In Phoenix, most perineal fistula repairs are performed before infants are on anything except breast milk or formula, with early discharge on post-op day 2-3" — Christine (clinical) [Ep 234 · 4:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=272)
- "Alberto Pena's original protocol required mandatory NPO for 7 days with central line and hyperalimentation, feeding only on day 7 if healed" — Marc Levitt (clinical) [Ep 234 · 1:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=73)
- "A study comparing NPO for 7 days versus clear liquids for 7 days found the same amount of stool output in both groups" — Marc Levitt (clinical) [Ep 234 · 2:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=151)
- "The problem is not pooping itself but passage of hard stool that can disrupt the perineal body anastomosis" — Marc Levitt (clinical) [Ep 234 · 3:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=210)
- "Breast milk does not cause constipation, while regular diet or formula causes more constipation" — Marc Levitt (clinical) [Ep 234 · 1:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=73)
- "Perineal body dehiscence usually leads to no perineal body over several months and requires redo surgery because the anterior anoplasty has no sphincter around it" — Marc Levitt (clinical) [Ep 234 · 5:23](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=323)
- "Patients who required redo surgery for dehiscence were invariably fed right away and discharged home" — Marc Levitt (clinical) [Ep 234 · 6:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=370)
- "NPO patients still stool very thin and liquidy stool that does not disrupt the anastomosis" — Marc Levitt (clinical) [Ep 234 · 8:22](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=502)
- "A randomized controlled trial of dilation versus non-dilation for primary PSARP (excluding cloacas) showed stricture rates of 10-20% in both groups" — Marc Levitt (clinical) [Ep 234 · 9:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=545)
- "The backup plan for strictures in the non-dilation group was aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty" — Marc Levitt (clinical) [Ep 234 · 9:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=580)
- "Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if never touched with a dilator" — Marc Levitt (clinical) [Ep 234 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=640)
- "When families were asked their biggest concern about anorectal malformation care, dilations were number one by far" — Marc Levitt (epidemiological) [Ep 234 · 11:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=680)
- "Four patients in the dilation study required redo operations for stricture: two in the dilation arm (both chose not to dilate) and two in the non-dilation arm" — Marc Levitt (clinical) [Ep 234 · 14:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=844)
- "Approximately 20% of patients in the dilation study required either local or total redo operations, mostly local procedures" — Jason Frischer (clinical) [Ep 234 · 15:02](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=902)
- "Full continence can be restored with a redo operation for stricture, based on available data" — Jason Frischer (clinical) [Ep 234 · 16:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=990)
- "Dilations can drive couples apart, with one family member typically responsible for performing them, leading to guilt and trauma" — Kathy (clinical) [Ep 234 · 12:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=726)
- "Jack Langer's protocol involves seeing patients weekly in clinic and passing a dilator without having families do it at home" — Marc Levitt (clinical) [Ep 234 · 13:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=828)
- "In the Phoenix protocol, families are seen twice weekly in clinic for physician-performed dilations if they are not comfortable doing home dilations" — Christine (clinical) [Ep 234 · 13:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=794)
- "Making anoplasties slightly larger in resource-limited settings where patients will not return for follow-up accounts for expected contraction" — Marc Levitt (clinical) [Ep 234 · 19:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=1177)
- "For redo operations, anoplasties are intentionally made larger knowing there will be contraction, and these are not dilated but examined under anesthesia at one month" — Marc Levitt (clinical) [Ep 234 · 20:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=1230)
- "For primary repairs, the anoplasty lumen is made to match what the maximal rectal lumen can be, filling the sphincter, typically resulting in size 13-14 Hegar" — Marc Levitt (clinical) [Ep 234 · 20:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-29-female-arm-13859?t=1230)
- "Definitive diagnostic workup for cloacal malformation is typically performed at 5-6 months of age" — Jason Frischer (clinical) [Ep 237 · 1:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=105)
- "The diagnostic workup includes multidisciplinary team evaluation with urology, gynecology, and colorectal surgery, followed by cystovaginoscopy and examination under anesthesia" — Richard Wood (clinical) [Ep 237 · 1:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=116)
- "Preoperative urodynamics catheter placement is performed as part of the examination" — Richard Wood (clinical) [Ep 237 · 2:31](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=151)
- "During cystoscopy of the common channel, the vagina or vaginas are the easiest structures to enter, while accessing the urethra and bladder is challenging because it requires pointing far upward" — Richard Wood (clinical) [Ep 237 · 3:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=188)
- "The rectal fistula entrance is not always apparent during endoscopy and may require fluid injection through the mucous fistula to define it" — Richard Wood (clinical) [Ep 237 · 3:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=210)
- "When a septum is present, the rectal fistula is very often visible in the bottom of the septum on the rectal side" — Richard Wood (clinical) [Ep 237 · 3:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=230)
- "3D cloacogram is acquired by injecting contrast into all three structures (urethra, vagina, rectum) and using vascular C-arm imaging with specialized software" — Richard Wood (clinical) [Ep 237 · 4:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=245)
- "During cystoscopy it is important to identify cervices to understand Müllerian development and to look for ureteral orifices which may have anomalous attachments to the bladder or bladder neck" — Jason Frischer (clinical) [Ep 237 · 4:34](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=274)
- "The common channel takes a very significant turn as it passes behind the pubis, particularly in longer common channel cases" — Amanda Jensen (clinical) [Ep 237 · 6:26](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=386)
- "Cystoscopy significantly undermeasures anatomical structures compared to 3D reconstruction because the straight scope cannot accurately measure the turn behind the pubis" — Amanda Jensen (clinical) [Ep 237 · 6:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=405)
- "Routine endoscopy allows general pediatric surgeons to differentiate straightforward from complex cloacas and identify cases that should be referred to specialized centers" — Jason Frischer (opinion) [Ep 237 · 7:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=461)
- "As recently as 10-15 years ago, many cloacal repairs required revision because surgeons attempted repairs that were more complicated than anticipated" — Jason Frischer (epidemiological) [Ep 237 · 8:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=510)
- "Lower confluence cloacas can be elegantly repaired by appropriately trained surgeons, while higher confluence cases with vaginal replacements and ectopic ureters should be done at specialized centers" — Jason Frischer (opinion) [Ep 237 · 9:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=540)
- "Type 1 cloaca is defined as common channel length less than 1 centimeter and represents a hypospadiac urethra with rectovaginal fistula" — Richard Wood (clinical) [Ep 237 · 10:07](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=607)
- "For type 1 cloaca, the hypospadiac urethral orifice is not touched, and the repair consists of vaginoplasty, introitoplasty, and PSARP" — Richard Wood (clinical) [Ep 237 · 10:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=640)
- "Even in type 1 cloaca with short common channel, the true rectum can still be positioned high, making imaging important to determine rectal height" — Richard Wood (clinical) [Ep 237 · 11:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=665)
- "For common channel length between 1-3 cm with urethral length greater than 1.5 cm, the patient is amenable to total urogenital mobilization (TUM) and PSARP" — Richard Wood (clinical) [Ep 237 · 11:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=690)
- "If urethral length is less than 1.5 cm, urogenital separation is advocated because performing TUM would result in the bladder neck being sewn near the perineum, potentially rendering the patient incontinent" — Amanda Jensen (clinical) [Ep 237 · 11:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=717)
- "For common channel greater than 3 cm, patients often have urethral length less than 1.5 cm and require urogenital separation with repair of the common channel as the urethra" — Richard Wood (clinical) [Ep 237 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=766)
- "When vagina or vaginas cannot reach the perineum, vaginal replacement may be needed to bridge the gap" — Amanda Jensen (clinical) [Ep 237 · 13:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=788)
- "If the rectum is positioned high, an abdominal approach may be needed to mobilize length, changing the PSARP approach to LARP (laparoscopic-assisted PSARP)" — Richard Wood (clinical) [Ep 237 · 13:32](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=812)
- "Hardy Hendren was the father of cloacal management in the late 1960s and 70s with specific focus on urology and urethral reconstruction" — Marc Levitt (clinical) [Ep 237 · 14:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=844)
- "Alberto Pena developed total urogenital mobilization (TUM) in 1996 as a major advance, keeping urethra and vagina together as a unit to mobilize forward" — Marc Levitt (clinical) [Ep 237 · 14:35](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=875)
- "Prior to 1996, all cloacal patients underwent urogenital separation" — Marc Levitt (clinical) [Ep 237 · 14:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=890)
- "The algorithm using common channel length of 3 cm and urethral length of 1.5 cm as decision points was presented in 2017 and represents the next major change after TUM" — Marc Levitt (clinical) [Ep 237 · 15:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=914)
- "Hardy Hendren at age 91 endorsed the 2017 algorithm at APSA, stating he agreed with everything presented" — Marc Levitt (opinion) [Ep 237 · 16:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=970)
- "The algorithm has been validated in 116 consecutive patients without needing to change the surgical plan in any case" — Richard Wood (clinical) [Ep 237 · 17:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1056)
- "The major change in the 2017 algorithm was ensuring measurement of urethral length, whereas previously only common channel length (<3 cm or >3 cm) was considered" — Marc Levitt (clinical) [Ep 237 · 18:13](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1093)
- "Urethral length is defined as the distance from where the common channel splits (where urethra leaves the common channel) to where it enters the bladder, not from the single perineal orifice to bladder neck" — Richard Wood (clinical) [Ep 237 · 19:09](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1149)
- "Accurate urethral length measurement is fundamentally important to ensure the bladder neck lands above the urogenital diaphragm where the external sphincter complex lies" — Richard Wood (clinical) [Ep 237 · 19:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1190)
- "3D imaging provides the most accurate urethral measurement because cystoscopy straightens structures and can falsely measure them due to the anatomical curve" — Richard Wood (clinical) [Ep 237 · 20:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-18-cloaca-part-2-13862?t=1200)
- "A single perineal orifice in a newborn should clue you into a cloaca, where the vagina, urethra, and rectum are fused together inside creating a single common channel" — Richard Wood (clinical) [Ep 238 · 2:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=125)
- "Hydrocolpos is the distension of the vagina caused by the accumulation of fluid" — Richard Wood (clinical) [Ep 238 · 2:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=145)
- "A cloaca or anorectal malformation is associated with VACTERL and needs to be worked up as such" — Richard Wood (guideline) [Ep 238 · 2:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=160)
- "VACTERL association consists of vertebral anomalies, imperforate anus, cardiovascular anomalies, tracheoesophageal fistulas, esophageal atresia, renal or radial anomalies, and limb defects; three or more anomalies are needed for the association" — Amanda Jensen (clinical) [Ep 238 · 3:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=190)
- "A hydrocolpos on prenatal ultrasound should alert to the possibility of a cloaca" — Richard Wood (clinical) [Ep 238 · 3:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=224)
- "Abnormal kidneys, a single kidney, or a two-vessel cord on prenatal ultrasound can be associated with cloaca" — Richard Wood (clinical) [Ep 238 · 4:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=250)
- "The diagnostic yield for cloacal malformations on prenatal ultrasound is still much lower than desired" — Richard Wood (epidemiological) [Ep 238 · 3:44](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=224)
- "In a large majority of patients with cloaca, the diagnosis is made at birth" — Hira Ahmad (epidemiological) [Ep 238 · 5:41](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=341)
- "Children with cloacas are female and do not need workup for karyotyping or disorders of sexual differentiation, despite potentially prominent clitoral hood and labial tissue" — Richard Wood (guideline) [Ep 238 · 7:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=440)
- "Initial workup for cloaca should consist of NG tube and chest x-ray, cardiac echo, and pelvic and renal ultrasound to assess for TEF, cardiac anomalies, hydrocolpos, and hydronephrosis" — Richard Wood (guideline) [Ep 238 · 7:56](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=476)
- "If bilateral hydronephrosis and hydrocolpos are present, the hydrocolpos needs to be managed as part of initial treatment" — Richard Wood (clinical) [Ep 238 · 9:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=540)
- "Modern practice has moved away from routine vaginostomy toward clean intermittent catheterization through the common channel for hydrocolpos drainage" — Richard Wood (clinical) [Ep 238 · 9:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=551)
- "To perform CIC for hydrocolpos, pass a tube through the common channel, drain fluid, confirm tube placement in the hydrocolpos with ultrasound, then perform recurrent catheterization" — Richard Wood (clinical) [Ep 238 · 9:24](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=564)
- "When catheterizing the common channel, you are more likely to get into the vagina than the bladder due to the anatomy of the urethral takeoff" — Marc Levitt (clinical) [Ep 238 · 11:08](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=668)
- "Initial catheterization should be performed with bedside ultrasound confirmation that the tube is in the hydrocolpos and is decompressing it" — Richard Wood (guideline) [Ep 238 · 12:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=753)
- "When the hydrocolpos is drained, the bladder fills, demonstrating that the hydrocolpos was obstructing the ureters" — Marc Levitt (clinical) [Ep 238 · 13:11](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=791)
- "A vesicostomy is the wrong move in almost every cloaca; the hydrocolpos needs to be drained instead" — Marc Levitt (opinion) [Ep 238 · 13:59](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=839)
- "Initial catheterization frequency is three times daily, which can be reduced to twice daily when families begin performing it at home" — Richard Wood (guideline) [Ep 238 · 15:01](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=901)
- "Serial ultrasounds should be performed every 2-3 days initially, then stretched to weekly, to confirm adequate kidney decompression" — Richard Wood (guideline) [Ep 238 · 15:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=930)
- "After discharge, monthly ultrasounds should be performed to ensure continued kidney decompression, which can be stretched to every six weeks if doing well" — Richard Wood (guideline) [Ep 238 · 16:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=960)
- "Even with a vaginostomy tube, you must continue checking that the kidneys are decompressed, as the tube may not be doing its job" — Richard Wood (clinical) [Ep 238 · 16:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1000)
- "Colostomy should be performed as proximally as possible, at the descending-sigmoid junction, to ensure enough length for distal work" — Richard Wood (clinical) [Ep 238 · 17:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1073)
- "Laparoscopy for newborn colostomy formation provides good anatomical views of the pelvis, allows precise colostomy site selection, and avoids a wound between the two stomas" — Richard Wood (clinical) [Ep 238 · 18:42](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1122)
- "If a vaginostomy is needed in a patient with a vaginal septum, open the anterior wall of the hydrocolpos and remove a small portion of the septum to drain both sides through one hole" — Richard Wood (clinical) [Ep 238 · 20:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1215)
- "Vaginostomy tubes can become encrusted and colonized, so there is some advantage to tubeless vaginostomy" — Richard Wood (clinical) [Ep 238 · 21:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1260)
- "For massive hydrocolpos requiring open vaginostomy, use a lower midline incision to get above the hydrocolpos, which is very adherent to the anterior abdominal wall and inflamed" — Marc Levitt (clinical) [Ep 238 · 21:37](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1297)
- "A single perineal orifice with no anal opening is a cloaca and does not need an endocrine workup, whereas a perineal opening with a normal anus is a urogenital sinus and does need an endocrine workup" — Marc Levitt (guideline) [Ep 238 · 22:51](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1371)
- "Urogenital sinus patients can also have hydrocolpos and hydronephrosis, requiring similar management but without colostomy" — Marc Levitt (clinical) [Ep 238 · 23:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1420)
- "After initial management, follow patients closely to ensure kidneys are well decompressed, the baby is growing and thriving, and parents are managing the stoma" — Richard Wood (guideline) [Ep 238 · 24:36](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1476)
- "With urine and stool effectively drained, patients should be thriving unless other underlying issues are present" — Richard Wood (clinical) [Ep 238 · 25:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-17-cloaca-part-1-13863?t=1520)
- "Suction rectal biopsy confirms the diagnosis of Hirschsprung's disease" (clinical) [Ep 239 · 1:37](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=97)
- "Two different operative approaches exist for Hirschsprung disease depending on whether transition zone is proximal and complicated versus distal" (clinical) [Ep 239 · 1:37](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=97)
- "For non-rectosigmoid transition zones, combined laparoscopy and transanal approach is preferred" — Andrea Frischer (clinical) [Ep 239 · 5:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=303)
- "Deep laparoscopic dissection into pelvis minimizes transanal work needed" — Andrea Badillo (clinical) [Ep 239 · 5:56](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=356)
- "Overstretching of sphincters during extensive transanal dissection is a morbidity that needs to be avoided" — Andrea Badillo (clinical) [Ep 239 · 5:56](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=356)
- "Transanal dissection should take under one hour in a primary pull-through" — Marc Levitt (clinical) [Ep 239 · 6:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=393)
- "Full thickness biopsy must include seromuscular side same size as mucosal side, cut as a square cube" — Aaron Garrison (clinical) [Ep 239 · 7:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=429)
- "Port placement includes umbilical port, right lower and upper quadrant ports, with camera switched to right upper quadrant" — Marc Levitt (clinical) [Ep 239 · 8:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=496)
- "Should wait for frozen section before taking mesentery" — Andrea Badillo (clinical) [Ep 239 · 9:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=570)
- "Pathology must confirm ganglion cells and nerves less than 40 microns" — Andrea Badillo (clinical) [Ep 239 · 10:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=600)
- "Biopsy must include submucosa to avoid finding ganglion cells in seromuscular layer but hypertrophic nerves in submucosal layer" — Andrea Frischer (clinical) [Ep 239 · 10:19](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=619)
- "Mesenteric dissection should stay close to bowel wall, not deep in mesentery, to reduce bleeding" — Andrea Frischer (clinical) [Ep 239 · 11:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=660)
- "Must stay right on the bowel during dissection because too wide dissection of distal rectum causes incontinence and urinary retention from nerve injury" — Marc Levitt (clinical) [Ep 239 · 11:42](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=702)
- "Must preserve arcade along left colon and sigmoid to get enough distance to reach pelvis" — Andrea Frischer (clinical) [Ep 239 · 12:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=746)
- "For distal disease, can take just distal branches of IMA; for left colon involvement may need to take IMA to get reach" — Marc Levitt (clinical) [Ep 239 · 12:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=755)
- "Transanal dissection should identify dentate line and mark about one centimeter above into anal canal for division line" — Andrea Badillo (clinical) [Ep 239 · 13:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=782)
- "Preference is Swenson full thickness dissection in areolar plane which is bloodless, not submucosal dissection with cuff" — Marc Levitt (opinion) [Ep 239 · 14:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=852)
- "If doing a cuff, make it very short (about one centimeter) and must split the cuff" — Marc Levitt (clinical) [Ep 239 · 14:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=852)
- "Patient can be kept supine with legs wrapped and fastened to ether screen for standard cases" — Andrea Frischer (clinical) [Ep 239 · 15:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=904)
- "Should go about five centimeters above biopsy site for safe margin" — Andrea Frischer (clinical) [Ep 239 · 16:06](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=966)
- "Tacking sutures on serosa to sidewall at three and six o'clock positions anchor bowel in place" — Aaron Garrison (clinical) [Ep 239 · 16:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=990)
- "Reinforcement layer is critical to line up mucosa edge to mucosa edge" — Rod Gerardo (clinical) [Ep 239 · 17:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=1020)
- "Anorectoplasty is an incredibly particular procedure where if you don't get it perfect, you might not have the best outcomes" — Rod Gerardo (opinion) [Ep 240 · 0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=0)
- "Oftentimes your first shot might be your only shot to give this patient a good outcome" — Rod Gerardo (opinion) [Ep 240 · 0:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=20)
- "The original malformation in case 1 was a prostatic fistula" — Marc Levitt (clinical) [Ep 240 · 4:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=270)
- "Case 1 patient has a tethered cord and a middle-of-the-road sacral ratio of 0.66" — Marc Levitt (clinical) [Ep 240 · 4:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=280)
- "The family doesn't really care how technically elegant is your anorectoplasty, they care about whether the child is going to be clean and in normal underwear" — Marc Levitt (opinion) [Ep 240 · 5:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=350)
- "The higher the malformation, the worse the prognosis" — Marc Levitt (clinical) [Ep 240 · 6:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=375)
- "Sacral ratio 0.7 or greater usually means normal or close to normal sphincters" — Marc Levitt (clinical) [Ep 240 · 6:25](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=385)
- "A good sacrum represents good muscle tone and spine innervation of that area" — Marc Levitt (clinical) [Ep 240 · 6:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=400)
- "The most common associated spinal anomaly is tethered cord, but the worst is myelomeningocele" — Marc Levitt (clinical) [Ep 240 · 6:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=415)
- "It's amazingly common to have a mislocated anus" — Marc Levitt (clinical) [Ep 240 · 7:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=470)
- "A key pitfall is opening the PSARP incision first rather than marking the sphincters first" — Marc Levitt (clinical) [Ep 240 · 8:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=480)
- "Case 2 patient was born with a vestibular fistula with normal spine and excellent sacrum" — Marc Levitt (clinical) [Ep 240 · 8:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=520)
- "Case 2 is a much better prognosis bowel control patient but with similar anatomic problem" — Marc Levitt (clinical) [Ep 240 · 8:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=535)
- "The electrical stimulator is the same one that anesthesia uses for their train of four" — Marc Levitt (clinical) [Ep 240 · 9:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=590)
- "You have to tell your anesthesiologist not to give skeletal muscle relaxant because the stimulator is weaker than the traditional expensive stimulator" — Marc Levitt (clinical) [Ep 240 · 10:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=600)
- "In higher malformations like bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated" — Jason Frischer (clinical) [Ep 240 · 10:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=630)
- "The vast majority of redo operations were for mislocation, then stricture, then less common reasons including remnant fistula and rectal prolapse" — Marc Levitt (clinical) [Ep 240 · 12:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=720)
- "Quality of life improved with a redo operation" — Marc Levitt (clinical) [Ep 240 · 12:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=750)
- "Patients had improved ability to achieve continence after redo" — Marc Levitt (clinical) [Ep 240 · 12:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=760)
- "20% of patients with a poor sacrum or poor spine developed bowel control after their redo" — Marc Levitt (clinical) [Ep 240 · 12:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=775)
- "Patients with good potential (good sacrum and spine) did extremely well after redo" — Marc Levitt (clinical) [Ep 240 · 13:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=790)
- "Patients who did not develop voluntary bowel movements were still able to be clean with bowel management program using enemas or antegrade Malone" — Marc Levitt (clinical) [Ep 240 · 13:15](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=795)
- "The average age of patients in the study is about three and a half years" — Marc Levitt (epidemiological) [Ep 240 · 13:21](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=801)
- "There's an advantage to getting the anatomy right the younger the child is" — Marc Levitt (opinion) [Ep 240 · 13:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=820)
- "For a two-year-old with mislocated anus or bad prolapse, redo should be offered to let them live with better anatomy in diapers for a year or two before potty training" — Marc Levitt (opinion) [Ep 240 · 13:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=830)
- "Many patients present after potty training age because they're incontinent, and evaluation reveals the anus isn't in the right place" — Marc Levitt (clinical) [Ep 240 · 14:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=850)
- "For older presenting patients, a Malone is usually added at the time of redo so they can learn control with new anatomy before stopping flushes" — Marc Levitt (clinical) [Ep 240 · 14:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=870)
- "The process of learning control with new anatomy may take six to 12 months" — Marc Levitt (clinical) [Ep 240 · 14:48](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13865?t=888)
- "Laparoscopic approach allows deep pelvic dissection minimizing transanal work and avoiding sphincter overstretching" — Aaron Garrison (clinical) [Ep 241 · 6:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=360)
- "Transanal dissection in primary pull-through should take under one hour when adequate laparoscopic dissection is performed" — Jason Frischer (clinical) [Ep 241 · 6:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=393)
- "Full-thickness biopsy should be a cube with seromuscular side matching mucosal side dimensions" — Aaron Garrison (clinical) [Ep 241 · 7:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=429)
- "Frozen section must confirm ganglion cells and nerves less than 40 microns" — Andrea Badillo (clinical) [Ep 241 · 10:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=600)
- "Frozen section biopsy must include submucosa to avoid missing hypertrophic nerves in submucosal layer" — Marc Levitt (clinical) [Ep 241 · 10:19](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=619)
- "Mesenteric dissection should stay close to bowel wall to minimize bleeding and avoid injury to nerves" — Aaron Garrison (clinical) [Ep 241 · 11:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=660)
- "Historical Swenson operations done through abdomen with wide distal rectal dissection caused incontinence and urinary retention from nerve injury" — Marc Levitt (clinical) [Ep 241 · 11:42](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=702)
- "Marginal arcade along left colon and sigmoid must be preserved to achieve adequate length for pelvic reach" — Andrea Badillo (clinical) [Ep 241 · 12:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=746)
- "For distal disease only distal IMA branches need division; for left colon disease IMA itself may require division" — Jason Frischer (clinical) [Ep 241 · 12:43](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=763)
- "Transanal mucosal incision should be made one centimeter above dentate line" — Andrea Badillo (clinical) [Ep 241 · 13:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=782)
- "Lone Star retractor pins advance in three stages: at skin to identify dentate, covering dentate, then underneath pins at mucosal opening" — Andrea Badillo (clinical) [Ep 241 · 13:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=782)
- "Swenson full-thickness dissection follows areolar plane which is essentially bloodless" — Marc Levitt (clinical) [Ep 241 · 14:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=852)
- "If Soave muscular cuff is used it should be very short, approximately one centimeter, and must be split" — Marc Levitt (clinical) [Ep 241 · 14:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=852)
- "Five-centimeter margin above biopsy site is safe for resection" — Aaron Garrison (clinical) [Ep 241 · 16:06](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=966)
- "Lateral tacking sutures to pelvic sidewall at three and six o'clock positions anchor the pull-through" — Aaron Garrison (clinical) [Ep 241 · 16:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=990)
- "Reinforcement layer is critical to align bowel edges for mucosa-to-mucosa anastomosis" — Rod Gerardo (clinical) [Ep 241 · 17:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=1020)
- "Anorectoplasty is an incredibly particular procedure where if you don't get it perfect, you might not have the best outcomes" — Rod Gerardo (opinion) [Ep 242 · 0:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=0)
- "Oftentimes your first shot might be your only shot to give this patient a good outcome" — Rod Gerardo (opinion) [Ep 242 · 0:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=20)
- "The first case patient has a rectal prostatic fistula as the original malformation" — Marc Levitt (clinical) [Ep 242 · 4:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=270)
- "The first case patient has a tethered cord" — Marc Levitt (clinical) [Ep 242 · 4:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=280)
- "The first case patient has a sacral ratio of 0.66" — Marc Levitt (clinical) [Ep 242 · 4:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=285)
- "A sacral ratio of 0.7 or greater usually means normal or close to normal sphincters" — Marc Levitt (clinical) [Ep 242 · 6:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=360)
- "The higher the malformation, the worse the prognosis" — Marc Levitt (clinical) [Ep 242 · 5:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=350)
- "Patients with myelomeningocele have much more trouble with continence than those with tethered cord" — Marc Levitt (clinical) [Ep 242 · 6:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=410)
- "It's amazingly common to have a mislocated anus" — Marc Levitt (clinical) [Ep 242 · 7:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=470)
- "A key pitfall is opening the PSARP incision first rather than marking the sphincters first" — Marc Levitt (clinical) [Ep 242 · 8:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=480)
- "The second case patient was born with a vestibular fistula, has normal spine and excellent sacrum" — Marc Levitt (clinical) [Ep 242 · 8:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=520)
- "The electrical stimulator used is the same one anesthesia uses for train of four" — Marc Levitt (clinical) [Ep 242 · 9:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=580)
- "Anesthesiologists should not give skeletal muscle relaxant when using the stimulator because it's weaker than traditional stimulators" — Marc Levitt (clinical) [Ep 242 · 10:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=600)
- "In higher malformations like bladder neck fistula, the sphincter complex is sometimes more anterior than anticipated" — Jason Frischer (clinical) [Ep 242 · 10:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=630)
- "The vast majority of redo operations were for mislocation" — Marc Levitt (clinical) [Ep 242 · 11:50](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=710)
- "Stricture was the second most common reason for redo operations" — Marc Levitt (clinical) [Ep 242 · 12:00](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=720)
- "Less common reasons for redo included remnant of original fistula (roof), rectal prolapse, and others" — Marc Levitt (clinical) [Ep 242 · 12:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=730)
- "Quality of life improved with a redo operation" — Marc Levitt (clinical) [Ep 242 · 12:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=750)
- "Patients had improved ability to achieve continence after redo" — Marc Levitt (clinical) [Ep 242 · 12:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=760)
- "20% of patients with a poor sacrum or poor spine developed bowel control after their redo" — Marc Levitt (clinical) [Ep 242 · 12:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=775)
- "Patients with good potential (good sacrum and spine) did extremely well after redo" — Marc Levitt (clinical) [Ep 242 · 13:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=790)
- "Patients who did not develop voluntary bowel movements were still able to be clean with bowel management program using enemas or antegrade Malone" — Marc Levitt (clinical) [Ep 242 · 13:20](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=800)
- "The average age of patients in the study was about three and a half years" — Marc Levitt (epidemiological) [Ep 242 · 13:10](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=790)
- "There is an advantage to getting the anatomy right the younger the child is" — Marc Levitt (opinion) [Ep 242 · 13:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=820)
- "The process of learning to achieve control with new anatomy after redo may take six to 12 months" — Marc Levitt (clinical) [Ep 242 · 14:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-2-13867?t=870)
- "VACTERL mnemonic stands for: V (vertebral abnormalities), A (anorectal malformations), C (cardiac abnormalities), E (esophageal atresia), R (renal abnormalities), and L (limb abnormalities)" — Marc Levitt (clinical) [Ep 243 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=181)
- "Plain x-ray of the abdomen can identify vertebral abnormalities including hemivertebra in anorectal malformation workup" — Marc Levitt (clinical) [Ep 243 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=181)
- "Cardiac evaluation should include both physical exam and echocardiogram in anorectal malformation patients" — Marc Levitt (clinical) [Ep 243 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=181)
- "NG tube should be passed to rule out esophageal atresia in anorectal malformation workup" — Marc Levitt (clinical) [Ep 243 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=181)
- "Kidney ultrasound is needed to evaluate for renal abnormalities in anorectal malformation patients" — Marc Levitt (clinical) [Ep 243 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=181)
- "True sacral ratio measurements should wait until the child is three months of age" — Marc Levitt (clinical) [Ep 243 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=181)
- "Pre-sacral mass is found almost half the time in anal stenosis or rectal atresia defects" — Jason Frischer (epidemiological) [Ep 243 · 4:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=255)
- "Patients with pre-sacral mass in the setting of anorectal malformation will end up getting an MRI" — Jason Frischer (clinical) [Ep 243 · 4:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=255)
- "Cross-table lateral radiograph is typically obtained at about the 24-hour mark to visualize the gas column location" — Jason Frischer (clinical) [Ep 243 · 5:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=305)
- "For cross-table lateral, the baby is positioned prone with a bump under the buttocks to make the buttock the highest point where air will rise" — Rod Gerardo (clinical) [Ep 243 · 6:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=361)
- "Sacral ratio greater than 0.7 connotes a very good prognosis for bowel control" — Marc Levitt (clinical) [Ep 243 · 7:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=428)
- "Well-formed buttock, good muscle, and true area where sphincter mechanism can be located, combined with well-developed sacrum, indicate likely good prognosis" — Jason Frischer (clinical) [Ep 243 · 7:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=456)
- "The danger of posterior sagittal approach without knowing rectal location is finding something midline and white like the urethra, bladder neck, or bladder itself" — Marc Levitt (clinical) [Ep 243 · 9:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=551)
- "Colostomy and distal colostogram are done to know exactly where the rectum is and whether to approach it perineally or laparoscopically" — Marc Levitt (clinical) [Ep 243 · 9:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=551)
- "Colostomy carries its own complications, as does colostomy closure" — Marc Levitt (clinical) [Ep 243 · 10:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=616)
- "If a primary anoplasty is performed without identifying a fistula, the child can start peeing out their anus postoperatively" — Marc Levitt (clinical) [Ep 243 · 10:54](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=654)
- "During primary posterior sagittal approach, the posterior wall of the rectum should be opened and the anterior wall inspected to rule out fistula" — Marc Levitt (clinical) [Ep 243 · 12:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=720)
- "In patients with low rectum, dissecting a little bit of the anterior wall and carefully lifting it off the urinary tract will usually rule out fistula" — Rod Gerardo (clinical) [Ep 243 · 12:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=736)
- "Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra" — Jason Frischer (clinical) [Ep 243 · 12:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=754)
- "95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula" — Marc Levitt (epidemiological) [Ep 243 · 13:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=795)
- "Distal colostogram should still be performed in Down syndrome patients with anorectal malformation despite lower fistula prevalence" — Marc Levitt (clinical) [Ep 243 · 13:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13868?t=795)
- "VACTERL mnemonic stands for: V (vertebral abnormalities), A (anorectal malformations), C (cardiac abnormalities), E (esophageal atresia), R (renal abnormalities), L (limb abnormalities)" — Marc Levitt (clinical) [Ep 244 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=181)
- "Plain x-ray of the abdomen can identify vertebral abnormalities including hemivertebra" — Marc Levitt (clinical) [Ep 244 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=181)
- "Cardiac workup should include both physical exam and echocardiogram" — Marc Levitt (clinical) [Ep 244 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=181)
- "NG tube should be passed to rule out esophageal atresia" — Marc Levitt (clinical) [Ep 244 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=181)
- "Kidney ultrasound is needed to evaluate for renal abnormalities" — Marc Levitt (clinical) [Ep 244 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=181)
- "True sacral ratio measurements should wait until the child is three months of age" — Marc Levitt (clinical) [Ep 244 · 3:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=181)
- "Pre-sacral masses are rare in typical imperforate anus cases" — Jason Frischer (epidemiological) [Ep 244 · 4:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=255)
- "In anal stenosis or rectal atresia defects, pre-sacral mass is found almost half the time" — Jason Frischer (epidemiological) [Ep 244 · 4:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=255)
- "Patients with pre-sacral mass will need MRI" — Jason Frischer (clinical) [Ep 244 · 4:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=255)
- "Cross-table lateral radiograph should be obtained at about 24 hours of life, give or take a few hours" — Jason Frischer (clinical) [Ep 244 · 5:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=305)
- "For cross-table lateral, baby is positioned prone with buttock at highest point where air will rise to" — Rod Gerardo (clinical) [Ep 244 · 6:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=361)
- "Cross-table lateral can be obtained at bedside in neonatal unit by placing baby on bump under buttocks" — Rod Gerardo (clinical) [Ep 244 · 6:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=361)
- "Sacral ratio greater than 0.7 connotes very good prognosis for bowel control" — Marc Levitt (clinical) [Ep 244 · 7:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=428)
- "Well-formed buttock, good muscle, and true area where sphincter mechanism can be located indicate likely good prognosis" — Jason Frischer (clinical) [Ep 244 · 7:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=456)
- "The danger of posterior sagittal approach without knowing rectal location is finding midline white structures like urethra, bladder neck, or bladder itself" — Marc Levitt (clinical) [Ep 244 · 9:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=551)
- "Colostomy and distal colostogram allow knowing exactly where rectum is and whether to approach perineally or laparoscopically" — Marc Levitt (clinical) [Ep 244 · 9:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=551)
- "Colostomy carries its own complications, as does colostomy closure" — Marc Levitt (clinical) [Ep 244 · 10:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=616)
- "If fistula is ignored during primary anaplasty, child can start peeing out their anus postoperatively" — Marc Levitt (clinical) [Ep 244 · 10:54](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=654)
- "During primary repair, opening posterior wall of rectum and inspecting anterior wall can rule out fistula in low rectum cases" — Marc Levitt (clinical) [Ep 244 · 12:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=720)
- "Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra" — Jason Frischer (clinical) [Ep 244 · 12:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=754)
- "95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula" — Marc Levitt (epidemiological) [Ep 244 · 13:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=795)
- "Distal colostogram should still be performed in Down syndrome patients to rule out the 5% who have fistula" — Marc Levitt (clinical) [Ep 244 · 13:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-1-13869?t=795)
- "Many non-Hirschsprung causes can present identically to Hirschsprung's disease in newborns, including maternal magnesium sulfate administration, hypothyroidism, opiate exposure, and milk protein allergy" — Marc Levitt (clinical) [Ep 245 · 0:55](https://library.globalcastmd.com/watch/hirschsprung-13870?t=55)
- "10% of patients with meconium plug have Hirschsprung's disease" — Marc Levitt (epidemiological) [Ep 245 · 2:00](https://library.globalcastmd.com/watch/hirschsprung-13870?t=120)
- "After passing a meconium plug, suction rectal biopsy should still be performed for confirmation, and if positive for Hirschsprung's, the contrast study should be repeated to better visualize the transition zone" — Marc Levitt (guideline) [Ep 245 · 3:00](https://library.globalcastmd.com/watch/hirschsprung-13870?t=180)
- "In total colonic Hirschsprung's disease, there is often no obvious transition zone on contrast study" — Marc Levitt (clinical) [Ep 245 · 3:30](https://library.globalcastmd.com/watch/hirschsprung-13870?t=210)
- "Suction rectal biopsy is the gold standard for diagnosing Hirschsprung's disease" — Marc Levitt (guideline) [Ep 245 · 4:00](https://library.globalcastmd.com/watch/hirschsprung-13870?t=240)
- "Bacterial overgrowth from stasis leads to bacterial translocation because mucosal integrity in Hirschsprung's disease is abnormal" — Marc Levitt (clinical) [Ep 245 · 4:42](https://library.globalcastmd.com/watch/hirschsprung-13870?t=282)
- "Constipated babies without Hirschsprung's disease do not develop enterocolitis because their mucosal integrity and IgA levels are normal" — Marc Levitt (clinical) [Ep 245 · 5:20](https://library.globalcastmd.com/watch/hirschsprung-13870?t=320)
- "Down syndrome patients have worse enterocolitis in Hirschsprung's disease because they have a weaker immune barrier" — Marc Levitt (clinical) [Ep 245 · 5:38](https://library.globalcastmd.com/watch/hirschsprung-13870?t=338)
- "Proper irrigation technique uses a 20 French silicone Foley catheter with warm saline in 10-20cc aliquots, washing the inside of the colon by injecting and allowing drainage, moving the catheter a few centimeters each time, which may take 30 minutes" — Marc Levitt (guideline) [Ep 245 · 5:44](https://library.globalcastmd.com/watch/hirschsprung-13870?t=344)
- "Irrigations often need to be performed two or three times per day" — Marc Levitt (guideline) [Ep 245 · 7:00](https://library.globalcastmd.com/watch/hirschsprung-13870?t=420)
- "If irrigations do not reach the transition zone, distension will not improve" — Marc Levitt (clinical) [Ep 245 · 7:10](https://library.globalcastmd.com/watch/hirschsprung-13870?t=430)
- "An ileostomy does not require pathology confirmation at 3 AM and the baby will reliably start stooling and feel well" — Marc Levitt (clinical) [Ep 245 · 8:20](https://library.globalcastmd.com/watch/hirschsprung-13870?t=500)
- "A loop ileostomy where both sides are equal is inappropriate because stool will jump across and fill the aganglionic segment, causing continued distension and potential enterocolitis" — Marc Levitt (clinical) [Ep 245 · 9:26](https://library.globalcastmd.com/watch/hirschsprung-13870?t=566)
- "Post-pull-through patients present with two distinct problems: obstruction or soiling, and these two groups rarely overlap" — Marc Levitt (clinical) [Ep 245 · 11:51](https://library.globalcastmd.com/watch/hirschsprung-13870?t=711)
- "Obstructed patients typically do well for about six months after pull-through, then develop chronic distension and may have several enterocolitis episodes" — Marc Levitt (clinical) [Ep 245 · 12:10](https://library.globalcastmd.com/watch/hirschsprung-13870?t=730)
- "A Soave procedure without an adequately cut cuff, or with a cuff that has rolled up or refused, will cause physiologic obstruction" — Marc Levitt (clinical) [Ep 245 · 12:40](https://library.globalcastmd.com/watch/hirschsprung-13870?t=760)
- "A retained cuff presents as a rubbery circumferential ring outside the pull-through on digital exam" — Marc Levitt (clinical) [Ep 245 · 13:10](https://library.globalcastmd.com/watch/hirschsprung-13870?t=790)
- "A twisted pull-through (180 or 360 degrees) causes obstruction and can be felt on digital exam when you cannot get into the pelvis and feel like you are hitting a wall" — Marc Levitt (clinical) [Ep 245 · 13:30](https://library.globalcastmd.com/watch/hirschsprung-13870?t=810)
- "A cuff may show extra space in the presacral area on lateral contrast study because the pull-through is pushed forward instead of hugging the sacrum" — Marc Levitt (clinical) [Ep 245 · 14:00](https://library.globalcastmd.com/watch/hirschsprung-13870?t=840)
- "In Duhamel procedures, a large pouch reaching into the pelvis can cause obstruction as stool flows through ganglionic bowel, enters the pouch, and sits there" — Marc Levitt (clinical) [Ep 245 · 14:30](https://library.globalcastmd.com/watch/hirschsprung-13870?t=870)
- "For Duhamel patients, biopsy must be done on the posterior wall because the anterior wall is the original aganglionic rectum" — Marc Levitt (guideline) [Ep 245 · 15:40](https://library.globalcastmd.com/watch/hirschsprung-13870?t=940)
- "Every child born with Hirschsprung's disease has 100% possibility of having bowel control because the continence mechanism is normal and sphincters are not weak" — Marc Levitt (clinical) [Ep 245 · 16:13](https://library.globalcastmd.com/watch/hirschsprung-13870?t=973)
- "Overstretching of sphincters or starting transanal dissection too low and removing the dentate line will lead to fecal incontinence" — Marc Levitt (clinical) [Ep 245 · 17:30](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1050)
- "If the anus appears closed when the patient is awake, that usually means good sphincters" — Marc Levitt (clinical) [Ep 245 · 18:40](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1120)
- "The vast majority of Hirschsprung's patients are constipated and need stimulant laxatives, not stool softeners" — Marc Levitt (clinical) [Ep 245 · 19:20](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1160)
- "Adding water-soluble fiber to laxatives provides bulk to prevent watery stool, which is difficult to control, while maintaining the propulsion effect of the laxative" — Marc Levitt (clinical) [Ep 245 · 19:40](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1180)
- "A non-dilated colon on X-ray or contrast study in a patient stooling five times per day indicates a fast-moving colon requiring constipating management rather than laxatives" — Marc Levitt (clinical) [Ep 245 · 20:20](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1220)
- "Nighttime soiling occurs because patients are totally dependent on voluntary external sphincter control, which they lose awareness of during sleep" — Marc Levitt (clinical) [Ep 245 · 20:48](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1248)
- "Most children should be in normal underwear by age three or four" — Marc Levitt (opinion) [Ep 245 · 22:10](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1330)
- "Malone procedures are typically performed between age three and a half and eight or nine years" — Marc Levitt (clinical) [Ep 245 · 21:50](https://library.globalcastmd.com/watch/hirschsprung-13870?t=1310)
- "Many non-Hirschsprung causes can mimic the disease including premature rupture of membranes, maternal magnesium sulfate, hypothyroidism, opiate exposure, and milk protein allergy" — Marc Levitt (clinical) [Ep 246 · 0:55](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=55)
- "Anorectal malformation, small left colon syndrome, and colonic atresia are surgical conditions that can present similarly to Hirschsprung's disease" — Marc Levitt (clinical) [Ep 246 · 2:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=120)
- "10% of patients with meconium plug have Hirschsprung's disease" — Marc Levitt (epidemiological) [Ep 246 · 2:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=155)
- "Suction rectal biopsy should be performed even after successful passage of meconium plug to rule out Hirschsprung's disease" — Marc Levitt (guideline) [Ep 246 · 3:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=180)
- "Contrast study should be repeated after meconium plug passage because the rectosigmoid will be dilated with the plug present, obscuring the transition zone" — Marc Levitt (clinical) [Ep 246 · 3:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=195)
- "In total colonic Hirschsprung's disease there is often no obvious transition zone on contrast study" — Marc Levitt (clinical) [Ep 246 · 3:40](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=220)
- "Contrast study serves as a surgical GPS map even though suction rectal biopsy is the gold standard for diagnosis" — Marc Levitt (opinion) [Ep 246 · 4:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=240)
- "Bacterial overgrowth from stasis leads to bacterial translocation because mucosal integrity in Hirschsprung's disease is abnormal" — Marc Levitt (clinical) [Ep 246 · 4:41](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=281)
- "Constipated babies without Hirschsprung's disease do not develop enterocolitis because their mucosal integrity and IgA levels are normal" — Marc Levitt (clinical) [Ep 246 · 5:20](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=320)
- "Down syndrome patients have worse enterocolitis because they have a weaker immune barrier" — Marc Levitt (clinical) [Ep 246 · 5:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=335)
- "Proper irrigation protocol uses a 20 French silicone Foley catheter with warm saline in 10-20cc aliquots, washing the colon for up to 30 minutes, two to three times per day" — Marc Levitt (guideline) [Ep 246 · 5:44](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=344)
- "If irrigations do not reach the transition zone, distension will not improve and stoma creation should be considered" — Marc Levitt (clinical) [Ep 246 · 7:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=420)
- "Leveling colostomy requires bringing dilated bowel to the surface with or without frozen section confirmation" — Marc Levitt (clinical) [Ep 246 · 7:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=445)
- "Ileostomy with colonic biopsies is preferred because it is extremely reliable, does not require pathology at 3 AM, and the baby will thrive while awaiting definitive pathology results" — Marc Levitt (opinion) [Ep 246 · 7:50](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=470)
- "Ileostomy is difficult to manage in many parts of the world where babies can become dehydrated quickly" — Marc Levitt (clinical) [Ep 246 · 8:30](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=510)
- "The ileostomy approach requires three operations versus two, but reduces risk by making each operation more straightforward" — Marc Levitt (opinion) [Ep 246 · 9:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=540)
- "A loop ileostomy where both sides are equal is inappropriate because stool will jump across and fill the aganglionic segment, causing continued distension and potential enterocolitis" — Marc Levitt (clinical) [Ep 246 · 9:26](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=566)
- "Turnbull ileostomy technique involves cutting the bowel completely on one side of the loop and folding it over to create an end-appearing stoma with flat distal limb" — Marc Levitt (clinical) [Ep 246 · 10:10](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=610)
- "Post-pull-through patients present with two distinct problems: obstruction or soiling, and these rarely overlap" — Marc Levitt (clinical) [Ep 246 · 11:26](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=686)
- "Obstructed patients typically do well for six months post-pull-through, then develop chronic distension, recurrent enterocolitis, and sometimes failure to thrive" — Marc Levitt (clinical) [Ep 246 · 11:50](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=710)
- "Anatomic causes of obstruction include inadequately cut Soave cuff, rolled-up or fused cuff, twisted pull-through, duhamel spur, large duhamel pouch, transition zone pull-through, and stricture" — Marc Levitt (clinical) [Ep 246 · 12:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=745)
- "A retained cuff appears as a rubbery circumferential ring outside the pull-through on digital exam and shows increased presacral space on lateral contrast study" — Marc Levitt (clinical) [Ep 246 · 13:00](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=780)
- "A twisted pull-through prevents the examining finger from entering the pelvis and creates a sensation of hitting a wall when palpating abdominally" — Marc Levitt (clinical) [Ep 246 · 13:40](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=820)
- "In duhamel patients, biopsy must be taken from the posterior wall because the anterior wall is the original aganglionic rectum" — Marc Levitt (guideline) [Ep 246 · 15:20](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=920)
- "Empiric Botox injection is appropriate when physical exam, contrast study, and biopsy reveal no anatomic or pathologic cause of obstruction, suggesting non-relaxing sphincters" — Marc Levitt (guideline) [Ep 246 · 15:45](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=945)
- "Every child born with Hirschsprung's disease has 100% potential for bowel control because the continence mechanism is normal" — Marc Levitt (clinical) [Ep 246 · 16:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=975)
- "Hirschsprung's sphincters are too good rather than weak, unlike anorectal malformation where associated spinal problems, poor sacrum, or poor muscles limit continence potential" — Marc Levitt (clinical) [Ep 246 · 16:50](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1010)
- "Overstretching of sphincters or starting transanal dissection too low and removing the dentate line will cause iatrogenic fecal incontinence" — Marc Levitt (clinical) [Ep 246 · 17:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1045)
- "Patients with iatrogenically damaged sphincters or dentate line require mechanical bowel management with enemas (peristeen or Malone) rather than medical management" — Marc Levitt (guideline) [Ep 246 · 17:55](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1075)
- "A closed anus appearance when awake usually indicates good sphincters" — Marc Levitt (clinical) [Ep 246 · 18:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1105)
- "The vast majority of Hirschsprung's patients are constipated and need stimulant laxatives (senna or bisacodyl), not stool softeners" — Marc Levitt (clinical) [Ep 246 · 18:40](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1120)
- "Adding water-soluble fiber to stimulant laxatives provides bulk to prevent watery stool while maintaining propulsion, creating one to two well-formed stools per day" — Marc Levitt (guideline) [Ep 246 · 19:05](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1145)
- "Botox is often required to help patients overcome withholding or non-relaxing internal sphincter during potty training" — Marc Levitt (clinical) [Ep 246 · 19:35](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1175)
- "Some Hirschsprung's patients have hypermotility and stool too frequently; stopping stimulant laxatives in these patients can achieve continence within two days" — Marc Levitt (clinical) [Ep 246 · 19:55](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1195)
- "X-ray showing no stool accumulation in a child stooling five times daily indicates fast-moving colon; contrast study showing non-dilated colon confirms hypermotility" — Marc Levitt (clinical) [Ep 246 · 20:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1225)
- "Hypermotile patients require constipating diet, water-soluble fiber, and occasionally loperamide to achieve one to two formed stools per day" — Marc Levitt (guideline) [Ep 246 · 20:25](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1225)
- "Nighttime soiling occurs because patients are totally dependent on voluntary external sphincter control, which is lost during sleep" — Marc Levitt (clinical) [Ep 246 · 21:01](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1261)
- "Behavioral modifications for nighttime soiling include attempting to stool before bed and giving a small enema before bed to keep the rectum empty for eight hours" — Marc Levitt (guideline) [Ep 246 · 21:28](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1288)
- "Malone antegrade continence enema is appropriate when rectal enemas are not tolerated, peristeen is ineffective, or families prefer not to use the rectal route" — Marc Levitt (guideline) [Ep 246 · 21:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1296)
- "Most Malone procedures are performed between ages 3.5 and 8-9 years, around the time of potty training when it becomes clear antegrade flushes are required" — Marc Levitt (clinical) [Ep 246 · 22:10](https://library.globalcastmd.com/watch/hirschsprung-s-disease-with-dr-marc-levitt-13871?t=1330)
- "Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period" — Marc Levitt (epidemiological) [Ep 247 · 2:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=175)
- "Male with perineal fistula may pass meconium through tiny anterior opening, presenting in first year with severe constipation after rectum and sigmoid dilate" — Marc Levitt (clinical) [Ep 247 · 3:02](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=182)
- "Standard newborn care no longer includes rectal thermometry, making ARM diagnosis harder if perineum not visually examined" — Marc Levitt (clinical) [Ep 247 · 4:01](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=241)
- "Relocating perineal fistula into sphincters improves anatomy but does not completely fix inherent constipation" — Marc Levitt (clinical) [Ep 247 · 4:53](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=293)
- "Patients with uncorrected perineal fistula have semblance of continence with formed stool but soil with loose stool or athletic activity because sphincters cannot completely close the anteriorly located hole" — Marc Levitt (clinical) [Ep 247 · 5:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=320)
- "Newborn anus should accept Hagar dilator size 12; one-year-old should accept size 15" — Marc Levitt (clinical) [Ep 247 · 6:05](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=365)
- "Bucket-handle skin tag at perineum indicates underlying perineal fistula even if fistula not directly visible" — Marc Levitt (clinical) [Ep 247 · 6:41](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=401)
- "Perineal fistula in female is most confounding diagnosis in pediatric colorectal surgery with high rates of both missed and overdiagnosis" — Marc Levitt (opinion) [Ep 247 · 7:28](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=448)
- "Female perineal fistula diagnostic criteria: inadequate perineal body, undersized hole, and hole not centered in sphincter" — Marc Levitt (clinical) [Ep 247 · 7:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=470)
- "If female anus is adequate size and centered in sphincter, no surgery needed even if perineal body appears short; perineal body will lengthen with growth" — Marc Levitt (clinical) [Ep 247 · 8:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=510)
- "Examination under anesthesia with stimulation can confirm whether opening is properly centered in sphincter when diagnosis uncertain" — Marc Levitt (clinical) [Ep 247 · 9:37](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=577)
- "Anesthesia nerve stimulator ($150) with modified needles works as well as commercial Pena stimulator ($15,000)" — Marc Levitt (clinical) [Ep 247 · 10:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=650)
- "Vast majority of male ARM patients have rectourethral fistula at bladder neck, prostatic, or bulbar level" — Marc Levitt (epidemiological) [Ep 247 · 12:38](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=758)
- "Rectourethral fistulas should not be approached primarily because rectal location is uncertain; colostomy with distal colostogram is safe standard" — Marc Levitt (guideline) [Ep 247 · 13:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=780)
- "Opening posterior sagittal incision without knowing rectal location will find whitish shiny midline structure that may be bladder neck, not rectum" — Marc Levitt (clinical) [Ep 247 · 13:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=810)
- "Cloaca can be missed in newborn period; patient may present at six months with constipation before diagnosis made" — Marc Levitt (clinical) [Ep 247 · 14:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=840)
- "Ambiguous genitalia (clitoromegaly from endocrine stimulation) with urogenital sinus has normal anus and is distinct from cloaca (no anus, normal ovaries)" — Marc Levitt (clinical) [Ep 247 · 15:49](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=949)
- "Most common colostomy error is opening too distal in sigmoid, restricting ultimate pull-through" — Marc Levitt (clinical) [Ep 247 · 17:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1020)
- "Incompletely diverted loop colostomy allows stool to spill across and contaminate distal segment, causing urinary tract infections" — Marc Levitt (clinical) [Ep 247 · 17:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1040)
- "Transverse colostomy with large rectourethral fistula causes left colon to absorb urine, leading to acidosis" — Marc Levitt (clinical) [Ep 247 · 18:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1090)
- "Recommended colostomy technique: very proximal sigmoid with separated stomas (tiny flat mucous fistula), now done laparoscopically" — Marc Levitt (guideline) [Ep 247 · 18:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1120)
- "Colostomy prolapse is related to mobility of colon segment; mid-transverse can prolapse both sides, proximal sigmoid only distal side can prolapse" — Marc Levitt (clinical) [Ep 247 · 19:58](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1198)
- "Mark anoplasty location on intact perineal skin before making incision by drawing circle around pinkish sphincter ellipse and stimulation zone" — Marc Levitt (guideline) [Ep 247 · 21:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1270)
- "Surgeons get lost among jumping muscles after opening posterior sagittal incision and place anus in wrong location; pre-marking prevents this" — Marc Levitt (clinical) [Ep 247 · 21:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1310)
- "Distal colostogram is absolutely vital study; many mistakes from poorly done study and misinterpretation" — Marc Levitt (opinion) [Ep 247 · 23:29](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1409)
- "Distal colostogram must answer: where is rectum, how low is it, is it reachable posterior sagittally or better laparoscopically, and what is relationship to urinary tract" — Marc Levitt (clinical) [Ep 247 · 23:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1430)
- "Common colostogram error: insufficient contrast and pressure gives false impression rectum is high or no fistula present" — Marc Levitt (clinical) [Ep 247 · 24:25](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1465)
- "Flat rectal bottom at pubococcygeal line on colostogram means insufficient pressure; need to overcome PC line (sphincter compression) to see bulging rectum and fistula" — Marc Levitt (clinical) [Ep 247 · 24:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1490)
- "Rectourethral fistula level determined by urethra as reverse-C or elbow: fistula at/below elbow is bulbar, above elbow is prostatic, at bladder neck is bladder neck" — Marc Levitt (clinical) [Ep 247 · 25:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1540)
- "Bulbous rectum may be reachable posterior sagittally and hard laparoscopically; tapered rectum better laparoscopically" — Marc Levitt (clinical) [Ep 247 · 25:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1540)
- "Opening posterior sagittal without knowing rectal location will find whitish shiny midline structure that may be bladder neck; can be mobilized and brought down as anoplasty, draining liquid (urine) postoperatively" — Marc Levitt (clinical) [Ep 247 · 26:52](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1612)
- "Prostatic fistulas are right under coccyx; bulbar fistulas are distal to coccyx near perineal skin; bladder neck fistulas not reachable posterior sagittally" — Marc Levitt (clinical) [Ep 247 · 28:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1680)
- "Bulbar and low prostatic with bulbous rectum best approached posterior sagittally; high prostatic with tapered rectum and bladder neck best approached laparoscopically" — Marc Levitt (guideline) [Ep 247 · 30:03](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1803)
- "Laparoscopy for bulging rectum below peritoneal reflection risks leaving remnant of original fistula (ROOF) if surgeon is timid" — Marc Levitt (clinical) [Ep 247 · 30:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1850)
- "Laparoscopy replaces laparotomy, not PSARP; should do mini-PSARP with laparoscopy for safe peritoneal entry and posterior rectal tacking to prevent prolapse" — Marc Levitt (opinion) [Ep 247 · 31:38](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=1898)
- "Rectal prolapse occurs in about 3% of cases when surgical principles respected, particularly in patients without great muscles" — Marc Levitt (epidemiological) [Ep 247 · 33:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2010)
- "Rectal prolapse >3mm should be treated because it causes bleeding, mucus, and impairs continence in patients with good muscles by preventing sphincter closure" — Marc Levitt (clinical) [Ep 247 · 33:54](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2034)
- "Circumferential prolapse can be treated in two staged hemi-circumferential ambulatory procedures, avoiding hospitalization and eliminating need for dilation" — Marc Levitt (clinical) [Ep 247 · 34:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2080)
- "Perineal body dehiscence is most common cause of reoperation in female ARM repairs" — Marc Levitt (epidemiological) [Ep 247 · 36:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2160)
- "Preventing perineal body dehiscence requires complete anterior rectal wall mobilization to areolar plane with posterior vagina to avoid tension" — Marc Levitt (clinical) [Ep 247 · 36:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2180)
- "Traditional seven-day NPO on 10% dextrose after female ARM repair being replaced by clear liquids only for one week; major problem is hard stool, not stool volume" — Marc Levitt (clinical) [Ep 247 · 36:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2210)
- "Early perineal body dehiscence (days 5-8) can be salvaged by immediate re-suturing in OR; late recognition requires reoperation" — Marc Levitt (clinical) [Ep 247 · 37:47](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2267)
- "Laparoscopic dissection of bladder neck fistula is challenging; rectum completely dependent on IMA because prior colostomy disrupted left colic collaterals" — Marc Levitt (clinical) [Ep 247 · 39:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2360)
- "Taking IMA or branches too close to aorta during laparoscopic mobilization will cause rectal ischemia due to lack of collateralization" — Marc Levitt (clinical) [Ep 247 · 39:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2380)
- "ARM continence potential predicted by three factors: malformation type, sacral ratio, and spine quality (ARM continence index)" — Marc Levitt (clinical) [Ep 247 · 42:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2560)
- "Bulbar fistula with sacral ratio 1.0 and normal spine should have bowel control; bladder neck with ratio 0.4 and tethered cord has no chance" — Marc Levitt (clinical) [Ep 247 · 43:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2600)
- "Initial management of four-year-old with ARM soiling: bowel management with enemas to achieve cleanliness, then trial laxatives in older patients with continence potential" — Marc Levitt (guideline) [Ep 247 · 44:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2640)
- "Redo pull-through indicated for any continence potential with imperfect anatomy: misplaced anus, stricture, prolapse, or remnant of original fistula" — Marc Levitt (guideline) [Ep 247 · 44:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2690)
- "ARM differs from other surgery because errors manifest years later when continence expected, not immediately; surgeon cannot learn from delayed feedback" — Marc Levitt (opinion) [Ep 247 · 46:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2800)
- "The vast majority of patients with Hirschsprung disease do extremely well after pull-through, with normal emptying and bowel control." — Marc Levitt (clinical) [Ep 250 · 3:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=208)
- "Problem patients divide into two types: obstruction patients who do not empty, and soiling patients." — Marc Levitt (clinical) [Ep 250 · 3:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=230)
- "Enterocolitis after a well-done pull-through is not uncommon, particularly in babies who have very tight sphincters and can keep them tight for many hours." — Marc Levitt (clinical) [Ep 250 · 4:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=260)
- "After about age one, patients should learn to empty and relax their sphincters and have a more normal bowel movement pattern." — Marc Levitt (clinical) [Ep 250 · 4:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=290)
- "Evaluation of a child with persistent obstruction and enterocolitis involves a contrast study of the colon and an examination under anesthesia." — Marc Levitt (clinical) [Ep 250 · 5:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=310)
- "Anatomic causes of post-pull-through obstruction include distal stricture, obstructing cuff, Duhamel pouch dysfunction, twisted pull-through, and dilated segment." — Marc Levitt (clinical) [Ep 250 · 5:38](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=338)
- "The Suave cuff (retained outer rectal wall) can cause obstruction if not properly split or if it has fused or scarred down." — Marc Levitt (clinical) [Ep 250 · 6:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=360)
- "A pull-through done to transition zone bowel (with hypertrophic nerves larger than 40 microns) rather than healthy ganglionated bowel can lead to obstruction." — Marc Levitt (clinical) [Ep 250 · 7:32](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=452)
- "Healthy pull-through segment should have ganglion cells and nerves 40 microns or less in size; anything larger is transition zone bowel that might not function." — Marc Levitt (clinical) [Ep 250 · 7:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=471)
- "Treatment of enterocolitis includes hydration, intravenous metronidazole (most effective antibiotic), and aggressive rectal irrigations two to three times daily." — Marc Levitt (clinical) [Ep 250 · 8:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=499)
- "Rectal irrigations use 10 to 20 cc per insertion through a large Foley catheter (size 20-22), allowing drainage between insertions to wash the colon." — Marc Levitt (clinical) [Ep 250 · 9:37](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=577)
- "Metronidazole has the same efficacy whether given IV or PO because in both cases it is excreted in the bile." — Marc Levitt (clinical) [Ep 250 · 11:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=681)
- "Approximately 15-20% of patients can have an episode of enterocolitis within the first year after pull-through, but after one year they should not be having enterocolitis anymore." — Marc Levitt (epidemiological) [Ep 250 · 12:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=741)
- "On contrast study, the pull-through should hug the sacrum; if diverted forward by a space-occupying mass, this may indicate an obstructing cuff." — Marc Levitt (clinical) [Ep 250 · 12:58](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=778)
- "The Suave cuff is outside the pull-through and cannot be detected intraluminally with endoscopy; it must be felt on digital rectal exam." — Marc Levitt (clinical) [Ep 250 · 16:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1000)
- "On examination under anesthesia, palpate along the hollow of the sacrum with the fifth digit to feel the cuff as a rubbery, thick rubber-band structure around the pull-through." — Marc Levitt (clinical) [Ep 250 · 17:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1040)
- "Biopsy should be taken above the dentate line by about one centimeter and sent for permanent section (not frozen) to assess ganglion cells and nerve size." — Marc Levitt (clinical) [Ep 250 · 17:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1070)
- "A patient with transition-zone pull-through who is not doing well needs a redo pull-through to healthy ganglionated bowel." — Marc Levitt (clinical) [Ep 250 · 18:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1101)
- "Redo pull-through for transition zone often requires removing the sigmoid curve to reach healthy bowel." — Marc Levitt (clinical) [Ep 250 · 19:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1140)
- "For obstructing cuff, dissect between bowel and cuff, then make a second plane outside the cuff in the Swenson plane and remove the posterior and lateral portions of the cuff to break the ring." — Marc Levitt (clinical) [Ep 250 · 20:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1230)
- "Myectomies that have been traditionally successful may have been cutting the Suave cuff rather than the internal sphincter, though surgeons thought they were cutting sphincter." — Marc Levitt (opinion) [Ep 250 · 21:49](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1309)
- "Myectomies are problematic because they can hurt skeletal muscle and leave the patient incontinent; different surgeons perform them differently with inconsistent technique." — Marc Levitt (opinion) [Ep 250 · 22:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1350)
- "Post-pull-through sphincter problems are relatively rare compared to anatomic causes of obstruction." — Marc Levitt (opinion) [Ep 250 · 23:58](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1438)
- "If all anatomic possibilities have been ruled out and pathology is okay but the child still behaves as obstructed, the problem must be the sphincter, which can be confirmed with anorectal manometry." — Marc Levitt (clinical) [Ep 250 · 24:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1470)
- "Botox acts as a temporary myectomy and is preferred over permanent myectomy because it wears off as children learn to coordinate stooling with sphincter relaxation." — Marc Levitt (clinical) [Ep 250 · 25:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1510)
- "Botox can be coordinated with laxatives at 4-8 weeks post-injection when tone is partially returning, helping children learn appropriate bowel movement patterns." — Marc Levitt (clinical) [Ep 250 · 26:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1560)
- "Botox will temporarily improve a cuff problem if the injection migrates up to the cuff level, but the patient will not get better long-term and will keep recurring." — Marc Levitt (clinical) [Ep 250 · 26:45](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1605)
- "Anorectal manometry can measure the length of high tone: one centimeter suggests sphincter dysfunction, while three to four centimeters indicates sphincter plus cuff." — Marc Levitt (clinical) [Ep 250 · 27:17](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1637)
- "Redo of a Duhamel pouch is probably the hardest operation in Hirschsprung disease due to extensive pelvic fibrosis from the stapled connection." — Marc Levitt (opinion) [Ep 250 · 29:49](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1789)
- "All patients with Hirschsprung disease should be able to empty spontaneously and should be clean." — Marc Levitt (opinion) [Ep 250 · 32:58](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=1978)
- "Patients with Hirschsprung disease are born with a normal anal canal and normal sphincters; if anything, their sphincters are too good." — Marc Levitt (clinical) [Ep 250 · 33:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2000)
- "Many soiling Hirschsprung patients have lost anal canal or weak sphincters, and the only possible conclusion is that these are iatrogenic from starting transanal dissection too low or overstretching." — Marc Levitt (opinion) [Ep 250 · 33:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2030)
- "Evaluation of soiling patients includes determining the original surgery type, assessing sphincter patulousness by visual and digital exam and manometry, and assessing dentate line integrity." — Marc Levitt (clinical) [Ep 250 · 34:47](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2087)
- "A contrast study can serve as a poor man's colonic manometry: narrow non-dilated pull-through suggests hypermotility, while dilated pull-through suggests hypomotility." — Marc Levitt (clinical) [Ep 250 · 37:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2220)
- "Soiling patients with good anal canal and sphincter but non-dilated colon are hypermotile and need slowing down with constipating diet, loperamide, and water-soluble fiber." — Marc Levitt (clinical) [Ep 250 · 37:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2260)
- "Soiling patients with good anal canal and sphincter but dilated colon are hypomotile and need laxatives to speed them up." — Marc Levitt (clinical) [Ep 250 · 38:15](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2295)
- "Soiling patients with lost anal canal or sphincter and non-dilated colon need a small-volume enema program plus treatment for hypermotility." — Marc Levitt (clinical) [Ep 250 · 38:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2320)
- "Soiling patients with lost anal canal or sphincter and dilated colon need a larger-volume enema and do not need hypermotility treatment." — Marc Levitt (clinical) [Ep 250 · 39:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2350)
- "The first question in any soiling patient is whether they have the capacity for bowel control, determined by whether sphincters and anal canal are intact." — Marc Levitt (clinical) [Ep 250 · 41:02](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2462)
- "Patients with capacity for bowel control can usually be treated with medicines, while those without capacity will need some sort of enema program." — Marc Levitt (clinical) [Ep 250 · 41:31](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13875?t=2491)
- "Hirschsprung disease affects approximately 1 in 5,000 children" — Mike (epidemiological) [Ep 252 · 7:40](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=460)
- "In Hirschsprung disease, nerve ganglia in the colon wall are absent in the distal portion, preventing the affected segment from relaxing" — Mike (clinical) [Ep 252 · 5:58](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=358)
- "The natural state of the large bowel is the squeezed state, and it normally cycles between squeezed and unsqueezed as stool moves through" — Mike (clinical) [Ep 252 · 6:48](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=408)
- "Down syndrome has a higher incidence of Hirschsprung disease than the general population" — Mike (epidemiological) [Ep 252 · 8:09](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=489)
- "Hirschsprung disease shows genetic clustering with documented cases spanning three generations (grandparent, child, grandchild)" — Mike (epidemiological) [Ep 252 · 8:45](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=525)
- "Nerve ganglia normally migrate from top to bottom during intestinal development, so Hirschsprung disease always affects bowel from the distal end upward with no skip areas" — Mike (clinical) [Ep 252 · 10:32](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=632)
- "Most babies pass meconium in the first 24 hours; failure to do so raises suspicion for Hirschsprung disease" — Mike (clinical) [Ep 252 · 11:05](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=665)
- "Rare Hirschsprung cases with very limited distal involvement can present beyond the newborn period with chronic constipation rather than acute obstruction" — Mike (clinical) [Ep 252 · 12:12](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=732)
- "Older children with undiagnosed Hirschsprung disease typically show failure to thrive, persistent abdominal distention, and episodes of diarrhea (actually enterocolitis) in addition to constipation" (clinical) [Ep 252 · 13:01](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=781)
- "Maternal magnesium sulfate given to slow contractions during difficult delivery can make newborn bowels very slow for several days" — Mike (clinical) [Ep 252 · 14:21](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=861)
- "Hypothyroidism and maternal narcotic exposure can cause slow bowel function in newborns mimicking Hirschsprung disease" — Mike (clinical) [Ep 252 · 14:21](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=861)
- "Contrast enema in Hirschsprung disease shows a narrow distal colon segment with dilated proximal colon" — Mike (clinical) [Ep 252 · 16:11](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=971)
- "Definitive diagnosis of Hirschsprung disease requires rectal biopsy showing both absent ganglion cells and thickened nerves around where ganglion cells should be" — Mike (clinical) [Ep 252 · 16:11](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=971)
- "Initial management of Hirschsprung disease involves rectal irrigation with a catheter to decompress the bowel and wash out stagnant stool and bacteria" — Mike (clinical) [Ep 252 · 18:14](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1094)
- "Rectal irrigation is distinct from enema: irrigation involves continuous washing with fluid going in and coming back out, while enema is injection followed by waiting" — Mike (clinical) [Ep 252 · 18:14](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1094)
- "Historical management of Hirschsprung disease 15-20 years ago required three operations over six months: colostomy, pull-through procedure, and colostomy closure" — Mike (clinical) [Ep 252 · 20:15](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1215)
- "Modern Hirschsprung surgery can be performed entirely through the anus with no abdominal incisions, sometimes with laparoscopic assistance, in the first week of life" — Mike (clinical) [Ep 252 · 20:15](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1215)
- "In Hirschsprung enterocolitis, diarrhea occurs inside the colon but cannot exit due to distal obstruction, causing severe dehydration without visible diarrhea output" — Mike (clinical) [Ep 252 · 21:57](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1317)
- "Several babies die annually in the United States from Hirschsprung enterocolitis, and it is a common cause of newborn death in the developing world" — Mike (epidemiological) [Ep 252 · 21:57](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1317)
- "In enterocolitis, bacteria translocate across the inflamed colonic lining into the bloodstream, and the most distended bowel segment can perforate if the process continues" — Mike (clinical) [Ep 252 · 23:10](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1390)
- "Children with Hirschsprung disease who are not doing well after surgery should be evaluated for anatomic problems, which are almost always definable and fixable" — Mike (opinion) [Ep 252 · 24:02](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1442)
- "Hirschsprung disease is not a condition that improves over time on its own; persistent problems require investigation and intervention" — Mike (opinion) [Ep 252 · 24:02](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1442)
- "Evaluation of suboptimal Hirschsprung outcomes includes contrast study to assess current colonic anatomy, biopsy to confirm adequate bowel was pulled through, and surgical examination of the pull-through segment" — Mike (clinical) [Ep 252 · 24:02](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1442)
- "Even after anatomically perfect Hirschsprung surgery, many children have mild constipation requiring laxatives and minor dietary modifications" — Mike (clinical) [Ep 252 · 27:05](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1625)
- "Normal babies with constipation or impaction do not develop the severe bacterial overgrowth and systemic illness seen in Hirschsprung enterocolitis, suggesting unique susceptibility of Hirschsprung colonic lining" — Mike (clinical) [Ep 252 · 27:51](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1671)
- "The two major research priorities in Hirschsprung disease are identifying the specific causative gene and understanding the mechanism of enterocolitis susceptibility" — Mike (opinion) [Ep 252 · 27:51](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1671)
- "Dr. Levitt has treated patients from all 50 US states and 88 countries" — Mike (epidemiological) [Ep 252 · 32:50](https://library.globalcastmd.com/watch/hirschsprung-disease-pediacast-287-13877?t=1970)
- "Adrenal hemorrhage is the most common prenatal suprarenal mass, more common with history of fetal stress" — Daniel von Allmen (clinical) [Ep 74 · 2:00](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=120)
- "Familial neuroblastoma occurs in about 1% of patients" — Tony Sandler (epidemiological) [Ep 74 · 3:27](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=207)
- "The GetNucturne study showed that many prenatally diagnosed neuroblastomas can be safely observed without surgery" — Daniel von Allmen (clinical) [Ep 74 · 7:24](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=444)
- "Of 84 prenatally diagnosed cases observed in the GetNucturne study, 16 (about 20%) underwent resection, with 98% event-free survival and 100% overall survival" — Tony Sandler (clinical) [Ep 74 · 9:09](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=549)
- "Surveillance for prenatally diagnosed neuroblastoma is intensive in the first year with ultrasound and urine catecholamines at birth, 3 weeks, 6 weeks, 12 weeks, then spacing out" — Erika Newman (guideline) [Ep 74 · 9:58](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=598)
- "A case occurred where a prenatally diagnosed adrenal mass resolved but the child presented at age 3 with widely metastatic high-risk neuroblastoma" — Daniel von Allmen (clinical) [Ep 74 · 10:23](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=623)
- "Five centimeters is used as a size threshold for considering surgical resection of observed neuroblastoma" — Tony Sandler (opinion) [Ep 74 · 12:31](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=751)
- "A 50% increase in tumor volume or 50% increase in urine VMA or HVA prompts consideration of surgery" — Erika Newman (guideline) [Ep 74 · 13:20](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=800)
- "Lymph node status in neuroblastoma is not as important for changing therapy as it is in Wilms tumor" — Daniel von Allmen (clinical) [Ep 74 · 14:21](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=861)
- "Stage MS (formerly 4S) neuroblastoma with liver metastases can cause respiratory compromise from mass effect" — Erika Newman (clinical) [Ep 74 · 15:14](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=914)
- "Stage MS neuroblastoma can be treated with aggressive observation, chemotherapy, radiation, or emergent decompressive laparotomy if respiratory compromise occurs" — Erika Newman (clinical) [Ep 74 · 15:42](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=942)
- "Classic findings of stage MS include high urine catecholamines, blue blebs on skin, liver metastases, and adrenal mass" — Tony Sandler (clinical) [Ep 74 · 16:32](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=992)
- "NMYC amplification in stage MS changes classification from MS to M (stage 4) and makes it high-risk" — Erika Newman (clinical) [Ep 74 · 17:32](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1052)
- "Ten percent of neuroblastomas are not MIBG-avid and might be detected by PET scan" — Daniel von Allmen (clinical) [Ep 74 · 22:12](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1332)
- "Open biopsy allows adequate tissue for NMYC amplification, ALK mutation, and ploidy studies" — Tony Sandler (clinical) [Ep 74 · 23:50](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1430)
- "Approximately half of children's hospitals use percutaneous biopsy for suspected neuroblastoma" — Erika Newman (epidemiological) [Ep 74 · 26:56](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1616)
- "Percutaneous biopsy is equivalent to open biopsy for diagnosis, high versus low risk determination, and NMYC amplification, but falls short for determining 11q loss of heterozygosity" — Erika Newman (clinical) [Ep 74 · 28:10](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1690)
- "Optimizing percutaneous biopsy requires 10-12 cores, higher gauge needle, and pathologist performing frozen section to confirm viable tumor" — Erika Newman (clinical) [Ep 74 · 29:10](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1750)
- "Open biopsy patients had higher risk of blood transfusion, higher narcotic use, and more hospital admissions compared to percutaneous biopsy" — Erika Newman (clinical) [Ep 74 · 30:17](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1817)
- "NMYC amplification automatically makes neuroblastoma high-risk regardless of other factors" — Tony Sandler (clinical) [Ep 74 · 31:38](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1898)
- "Loss of heterozygosity at 11q is the most common segmental chromosomal alteration and can bump NMYC non-amplified patients to high or intermediate risk" — Erika Newman (clinical) [Ep 74 · 33:49](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2029)
- "Age cutoff for risk stratification is now 18 months rather than 12 months" — Tony Sandler (guideline) [Ep 74 · 35:25](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2125)
- "High-risk neuroblastoma patients require double lumen external central line for bone marrow transplant" — Erika Newman (clinical) [Ep 74 · 37:20](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2240)
- "Stem cell harvesting for high-risk neuroblastoma is usually after the second cycle of chemotherapy" — Tony Sandler (clinical) [Ep 74 · 45:31](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2731)
- "Optimal timing for surgical resection is after cycle 3-4 of induction chemotherapy" — Erika Newman (opinion) [Ep 74 · 41:49](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2509)
- "Tumor volume does not significantly decrease after cycle 2-3 of chemotherapy" — Daniel von Allmen (clinical) [Ep 74 · 43:17](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2597)
- "After 5-6 cycles of chemotherapy, tumors become more fibrotic and harder to resect" — Erika Newman (clinical) [Ep 74 · 43:17](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2597)
- "Goal of surgery is greater than 90% tumor resection based on COG study showing improved event-free survival" — Daniel von Allmen (clinical) [Ep 74 · 44:04](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2644)
- "European neuroblastoma group study of nearly 1000 cases showed >90% resection improved both event-free and overall survival" — Daniel von Allmen (clinical) [Ep 74 · 45:28](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2728)
- "About 70% of patients can achieve greater than 90% resection" — Daniel von Allmen (epidemiological) [Ep 74 · 45:28](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2728)
- "High-risk neuroblastoma responds well to chemotherapy due to high proliferative rate" — Tony Sandler (clinical) [Ep 74 · 45:31](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2731)
- "Recent German/European publication stated that amount of local disease resection does not make a difference in outcome" — Tony Sandler (clinical) [Ep 74 · 46:00](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2760)
- "Patients with high-risk neuroblastoma die of systemic metastatic disease, not local disease" — Tony Sandler (clinical) [Ep 74 · 46:40](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2800)
- "Good local control is achieved with combination of radiation and aggressive surgery" — Daniel von Allmen (clinical) [Ep 74 · 47:40](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2860)
- "There is zero correlation between surgeon's operative note description of resection extent and post-operative imaging findings" — Daniel von Allmen (clinical) [Ep 74 · 52:19](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3139)
- "Surgeons frequently overestimate the amount of tumor resection achieved" — Daniel von Allmen (opinion) [Ep 74 · 52:19](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3139)
- "Nephrectomy should be avoided in neuroblastoma surgery because it requires reduction of chemotherapy doses" — Tony Sandler (clinical) [Ep 74 · 53:13](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3193)
- "Monoclonal antibody against ganglioside GD2 improved two-year survival in high-risk neuroblastoma from 46% to 60%" — Tony Sandler (clinical) [Ep 74 · 53:44](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3224)
- "Checkpoint inhibitors have not been successful in neuroblastoma because it is not an immunogenic tumor" — Tony Sandler (clinical) [Ep 74 · 54:40](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3280)
- "Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period" — Marc Levitt (epidemiological) [Ep 248 · 2:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=175)
- "Males with missed perineal fistulas typically present in the first year of life with severe constipation" — Marc Levitt (clinical) [Ep 248 · 3:05](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=185)
- "The standard now is to not check rectal temperature but to check temperature on the forehead or in the ear, which means you don't have to look at the anus" — Marc Levitt (clinical) [Ep 248 · 4:15](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=255)
- "Relocating a perineal fistula into the sphincters does not completely fix constipation, though it improves the anatomy" — Marc Levitt (clinical) [Ep 248 · 4:53](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=293)
- "A newborn anus should be Hagar dilator size 12, and a one-year-old should be size 15" — Marc Levitt (clinical) [Ep 248 · 6:05](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=365)
- "A bucket handle skin tag is consistent with a perineal fistula, and you can pass a probe underneath it" — Marc Levitt (clinical) [Ep 248 · 6:41](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=401)
- "Beads of meconium (black) or mucus (white) along the scrotal raphae are consistent with a perineal fistula" — Marc Levitt (clinical) [Ep 248 · 7:05](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=425)
- "If the hole is of adequate size and centered in the sphincter, even if appearing slightly anterior with a short perineal body, the patient does not need surgery" — Marc Levitt (clinical) [Ep 248 · 8:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=520)
- "You can do examination under anesthesia and stimulate to confirm whether the hole is properly centered within the sphincter" — Marc Levitt (clinical) [Ep 248 · 9:51](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=591)
- "An anesthesia nerve stimulator costs $150 compared to $15,000 for a dedicated Pena stimulator and works just as well with different needles" — Marc Levitt (clinical) [Ep 248 · 10:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=650)
- "The vast majority of male ARM patients will have a rectourethral fistula" — Marc Levitt (epidemiological) [Ep 248 · 12:38](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=758)
- "All rectourethral fistulas go slightly below the peritoneal reflection, making it difficult to distinguish bladder neck, prostatic, or bulbar level by laparoscopy alone" — Marc Levitt (clinical) [Ep 248 · 12:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=775)
- "Patients with rectourethral fistulas should be managed with colostomy and distal colostogram rather than primary repair" — Marc Levitt (clinical) [Ep 248 · 13:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=810)
- "A cloaca patient can present at six months with constipation, having been successfully stooling out the cloaca" — Marc Levitt (clinical) [Ep 248 · 14:04](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=844)
- "Ambiguous genitalia with clitoromegaly and a urogenital sinus has a completely normal anus, distinguishing it from cloaca which has no anus" — Marc Levitt (clinical) [Ep 248 · 15:49](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=949)
- "The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through" — Marc Levitt (clinical) [Ep 248 · 17:04](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1024)
- "Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections" — Marc Levitt (clinical) [Ep 248 · 17:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1050)
- "Transverse colostomies with large rectourethral fistulas cause the left colon to absorb all the urine, potentially causing acidosis" — Marc Levitt (clinical) [Ep 248 · 18:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1120)
- "Prolapse is related to where in the colon you choose to do the colostomy; mid-transverse can prolapse on both sides, hepatic flexure only distally, proximal sigmoid only distally" — Marc Levitt (clinical) [Ep 248 · 20:03](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1203)
- "The anoplasty location should be marked on the skin surface before making any incision to avoid getting lost when looking at jumping muscles from the stimulator" — Marc Levitt (clinical) [Ep 248 · 21:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1270)
- "If you see a straight line on the bottom of the rectum on distal colostogram corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure" — Marc Levitt (clinical) [Ep 248 · 24:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1470)
- "If the fistula is at the urethral elbow or below, it's bulbar; above the elbow is prostatic; at the bladder neck is bladder neck fistula" — Marc Levitt (clinical) [Ep 248 · 25:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1510)
- "When opening posterior sagittally without knowing rectal location, you will find a whitish shiny structure that may be bladder neck, not rectum" — Marc Levitt (clinical) [Ep 248 · 26:52](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1612)
- "Prostatic fistulas are usually right under the coccyx; bulbar fistulas are distal to the coccyx, nearly at the perineal skin" — Marc Levitt (clinical) [Ep 248 · 28:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1680)
- "Bulbar or low prostatic rectums with a bulge are more easily approached posterior sagittally; high prostatic tapered rectums are best served by laparoscopy" — Marc Levitt (clinical) [Ep 248 · 30:03](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1803)
- "Laparoscopy for a bulging rectum below the peritoneal reflection risks leaving behind a remnant of the original fistula (roof)" — Marc Levitt (clinical) [Ep 248 · 30:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1850)
- "Laparoscopy replaces laparotomy but should not give away the advantages of PSARP; a mini-PSARP allows safe entry and rectal fixation to prevent prolapse" — Marc Levitt (opinion) [Ep 248 · 31:38](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=1898)
- "Prolapse occurs in about 3% of cases, particularly in those without great muscles" — Marc Levitt (epidemiological) [Ep 248 · 33:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2010)
- "Rectal prolapse more than about 3 millimeters should be trimmed, ideally when the patient still has their colostomy" — Marc Levitt (clinical) [Ep 248 · 34:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2070)
- "Circumferential prolapse can be done in two stages (half the circumference each) in ambulatory settings, avoiding hospitalization and the need for dilation" — Marc Levitt (clinical) [Ep 248 · 34:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2095)
- "The most common cause of reoperation is female repair in which the perineal body dehisces" — Marc Levitt (epidemiological) [Ep 248 · 35:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2155)
- "Proper anterior rectal wall mobilization requires getting to the areolar plane between rectum and vagina to avoid tension on the anoplasty" — Marc Levitt (clinical) [Ep 248 · 36:15](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2175)
- "Perineal body closure should use 3-0 suture in a baby and 4-0 Vicryl on the perineal skin" — Marc Levitt (clinical) [Ep 248 · 36:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2210)
- "Traditional management is NPO for seven days on 10% dextrose; recently trialing clear liquids only for a week to prevent hard stool without complete NPO" — Marc Levitt (clinical) [Ep 248 · 37:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2230)
- "If perineal body dehiscence is caught on day five to eight, taking the patient back to OR to re-suture can salvage the situation" — Marc Levitt (clinical) [Ep 248 · 37:47](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2267)
- "The rectum after colostomy is completely dependent on the IMA because collaterals down the left colic may have been disrupted" — Marc Levitt (clinical) [Ep 248 · 39:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2370)
- "Continence potential can be predicted by three factors: original malformation type, sacral ratio, and spine quality (the ARM continence index)" — Marc Levitt (clinical) [Ep 248 · 42:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2540)
- "A bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control" — Marc Levitt (clinical) [Ep 248 · 43:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2600)
- "A bladder neck fistula with sacral ratio of 0.4 and tethered cord or myelomeningocele has no chance of good bowel control" — Marc Levitt (clinical) [Ep 248 · 43:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2620)
- "Initial management of soiling four-year-old is mechanical bowel management with enemas to achieve cleanliness, then trial laxatives for those with continence potential" — Marc Levitt (clinical) [Ep 248 · 44:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13873?t=2650)
- "Perineal fistulas in males are commonly missed in newborn period because baby passes meconium and no one notices abnormal anal anatomy" — Marc Levitt (clinical) [Ep 249 · 2:55](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=175)
- "Missed perineal fistulas typically present in first year of life with severe constipation" — Marc Levitt (clinical) [Ep 249 · 3:15](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=195)
- "Rectum and sigmoid dilate when stool passes through tiny fistulous orifice that is not normal anal or rectal mucosa" — Marc Levitt (clinical) [Ep 249 · 3:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=210)
- "Standard practice now is to check temperature on forehead or ear rather than rectally, making it easier to miss anorectal malformations" — Marc Levitt (clinical) [Ep 249 · 4:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=250)
- "Relocating perineal fistula into sphincters does not completely fix constipation but improves anatomy" — Marc Levitt (clinical) [Ep 249 · 4:53](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=293)
- "Patients with uncorrected perineal fistula have some continence with formed stool but soil with loose stool or athletic activity because sphincters cannot completely close the hole" — Marc Levitt (clinical) [Ep 249 · 5:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=320)
- "Newborn anus should accept size 12 Hagar dilator and one-year-old should accept size 15" — Marc Levitt (clinical) [Ep 249 · 6:05](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=365)
- "Normal anus shows pinkish ellipse representing sphincter mechanism; in perineal fistula the hole is anterior to this ellipse" — Marc Levitt (clinical) [Ep 249 · 6:25](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=385)
- "Bucket handle skin tag is consistent with perineal fistula; fistula may not be visible but probe can pass underneath" — Marc Levitt (clinical) [Ep 249 · 6:41](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=401)
- "Beads of meconium (black) or mucus (white) along scrotal raphae consistent with perineal fistula" — Marc Levitt (clinical) [Ep 249 · 7:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=420)
- "Female perineal fistula diagnosed by three criteria: hole too close to vagina (inadequate perineal body), inadequate hole size, and hole not centered in sphincter" — Marc Levitt (clinical) [Ep 249 · 7:51](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=471)
- "Many females diagnosed with ARM are actually normal; if hole is adequate size and centered in sphincter, no surgery needed even if perineal body appears short" — Marc Levitt (clinical) [Ep 249 · 8:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=510)
- "Examination under anesthesia with stimulation can confirm whether hole is properly centered in sphincter when uncertain" — Marc Levitt (clinical) [Ep 249 · 9:51](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=591)
- "Anesthesia nerve stimulator costs $150 versus $15,000 for commercial Pena stimulator and works equally well with appropriate needle probes" — Marc Levitt (clinical) [Ep 249 · 10:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=650)
- "Vast majority of male ARM patients have rectourethral fistula at bladder neck, prostatic, or bulbar level" — Marc Levitt (epidemiological) [Ep 249 · 12:38](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=758)
- "Rectourethral fistulas should not be approached primarily because rectum location is unknown; colostomy with distal colostogram is safer" — Marc Levitt (opinion) [Ep 249 · 13:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=780)
- "Cross-table lateral film at 20 hours showing very low rectum is rare exception where primary posterior sagittal approach acceptable" — Marc Levitt (opinion) [Ep 249 · 13:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=810)
- "Cloaca can be missed in newborn period; patient presented at 6 months with constipation before diagnosis" — Marc Levitt (clinical) [Ep 249 · 14:04](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=844)
- "Ambiguous genitalia with clitoromegaly and normal anus indicates urogenital sinus with virilization, not cloaca" — Marc Levitt (clinical) [Ep 249 · 15:49](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=949)
- "Cloaca patients have no anus and urogenital sinus but no endocrine problem and normal ovaries" — Marc Levitt (clinical) [Ep 249 · 16:29](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=989)
- "Most common colostomy error is opening too distal in sigmoid, restricting ultimate pull-through" — Marc Levitt (clinical) [Ep 249 · 17:04](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1024)
- "Incompletely diverting loop colostomy allows stool to spill across and contaminate distal segment, leading to UTIs" — Marc Levitt (clinical) [Ep 249 · 17:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1050)
- "Transverse colostomy with large rectourethral fistula causes left colon to absorb urine, leading to acidosis" — Marc Levitt (clinical) [Ep 249 · 18:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1100)
- "Preferred colostomy technique is proximal sigmoid with separated stomas, tiny flat mucous fistula, performed laparoscopically" — Marc Levitt (opinion) [Ep 249 · 18:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1130)
- "Prolapse risk depends on colon mobility; mid-transverse can prolapse both sides, hepatic flexure only distal, proximal sigmoid only distal if mucous fistula not made tiny and flat" — Marc Levitt (clinical) [Ep 249 · 20:03](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1203)
- "Anoplasty location should be marked on skin surface before making incision to avoid getting lost when muscles are jumping from stimulator" — Marc Levitt (opinion) [Ep 249 · 21:10](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1270)
- "Surgeons put anuses in wrong locations because they don't mark the center before opening and get confused by stimulated muscles" — Marc Levitt (opinion) [Ep 249 · 22:36](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1356)
- "Distal colostogram must use adequate contrast and pressure to overcome pubococcygeal line compression; inadequate study gives false impression of high rectum or absent fistula" — Marc Levitt (clinical) [Ep 249 · 23:29](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1409)
- "Flattening of rectum corresponding to pubococcygeal line indicates radiologist did not give enough contrast or pressure" — Marc Levitt (clinical) [Ep 249 · 24:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1470)
- "Fistula at urethral elbow or below is bulbar; above elbow is prostatic; at bladder neck is bladder neck fistula" — Marc Levitt (clinical) [Ep 249 · 25:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1520)
- "Bulbous rectum may be reachable posterior sagittally and hard to do laparoscopically; tapered rectum better approached laparoscopically" — Marc Levitt (opinion) [Ep 249 · 25:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1550)
- "Opening posterior sagittal without knowing rectum location risks finding whitish shiny structure that is bladder neck, not rectum" — Marc Levitt (clinical) [Ep 249 · 26:52](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1612)
- "Prostatic fistula rectum is right under coccyx; bulbar is distal to coccyx; bladder neck not reachable posterior sagittally" — Marc Levitt (clinical) [Ep 249 · 27:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1650)
- "Bulbar and low prostatic with bulge best approached posterior sagittally; high prostatic tapered and bladder neck best via laparoscopy" — Marc Levitt (opinion) [Ep 249 · 30:03](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1803)
- "Laparoscopy for rectum below peritoneal reflection risks leaving remnant of original fistula (ROOF) if surgeon is timid" — Marc Levitt (clinical) [Ep 249 · 30:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1850)
- "Laparoscopy replaces laparotomy but should include mini-PSARP for safe pelvic entry and rectal tacking to prevent prolapse" — Marc Levitt (opinion) [Ep 249 · 31:38](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=1898)
- "Prolapse occurs in about 3% of cases, particularly in those without great muscles" — Marc Levitt (epidemiological) [Ep 249 · 33:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2010)
- "Rectal prolapse causes bleeding, mucus, and inhibits bowel control in patients with good muscle potential" — Marc Levitt (clinical) [Ep 249 · 33:54](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2034)
- "Prolapse more than 3mm should be trimmed; circumferential prolapse done in two stages in ambulatory setting to avoid hospitalization and stricture" — Marc Levitt (opinion) [Ep 249 · 34:30](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2070)
- "Perineal body dehiscence most common cause of reoperation in females; prevented by complete anterior rectal wall mobilization from vagina" — Marc Levitt (clinical) [Ep 249 · 35:35](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2135)
- "Perineal body closure should use 3-0 suture in baby and 4-0 Vicryl on perineal skin" — Marc Levitt (opinion) [Ep 249 · 36:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2200)
- "Clear liquids only for one week post-op prevents hard stool that can split perineal body repair" — Marc Levitt (opinion) [Ep 249 · 37:00](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2220)
- "Perineal body dehiscence can be salvaged by taking patient back to OR on day 5-8 to re-suture; by 3-4 weeks too late" — Marc Levitt (clinical) [Ep 249 · 37:47](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2267)
- "Laparoscopy risks leaving remnant of original fistula if too timid, or urinary tract injury if dissecting rectum too low" — Marc Levitt (clinical) [Ep 249 · 38:38](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2318)
- "IMA must be preserved in laparoscopy because prior colostomy disrupted left colic collaterals; rectum completely dependent on IMA" — Marc Levitt (clinical) [Ep 249 · 39:20](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2360)
- "PSARP for rectum that is too high risks finding and potentially mobilizing bladder neck instead of rectum" — Marc Levitt (clinical) [Ep 249 · 40:17](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2417)
- "ARM continence potential predicted by three factors: malformation type, sacral ratio, and spine quality" — Marc Levitt (clinical) [Ep 249 · 42:09](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2529)
- "Bulbar fistula with sacral ratio of 1 and normal spine should have bowel control; bladder neck with sacral ratio 0.4 and tethered cord has no chance" — Marc Levitt (clinical) [Ep 249 · 42:50](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2570)
- "Four-year-old with soiling first managed with bowel management enemas to achieve cleanliness, then trial of laxatives if continence potential exists" — Marc Levitt (opinion) [Ep 249 · 43:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2620)
- "Redo pull-through indicated if patient has continence potential and imperfect anatomy: misplaced anus, stricture, prolapse, or remnant of original fistula" — Marc Levitt (opinion) [Ep 249 · 44:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2680)
- "ARM complications may not become apparent for years, making it difficult for surgeons to learn from technical errors" — Marc Levitt (opinion) [Ep 249 · 46:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2800)
- "The vast majority of patients with Hirschsprung disease do extremely well after pull-through, with no emptying problems and normal bowel control" — Marc Levitt (clinical) [Ep 251 · 3:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=208)
- "Problem patients after pull-through divide into two types: obstruction patients who cannot empty, and soiling patients" — Marc Levitt (clinical) [Ep 251 · 3:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=230)
- "Enterocolitis after a well-done pull-through is not uncommon, particularly in babies, because babies have very tight sphincters capable of staying tight for many hours" — Marc Levitt (clinical) [Ep 251 · 4:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=260)
- "After about age one, patients should learn to empty and relax their sphincters with a more normal bowel movement pattern" — Marc Levitt (clinical) [Ep 251 · 4:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=290)
- "Evaluation of post-pull-through obstruction involves a contrast study of the colon and an examination under anesthesia" — Marc Levitt (clinical) [Ep 251 · 5:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=310)
- "Anatomic causes of post-pull-through obstruction include distal stricture, obstructing cuff, atonic Duhamel pouch, twisted pull-through (up to 360 degrees), and dilated distal segment" — Marc Levitt (clinical) [Ep 251 · 5:36](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=336)
- "Pathologic cause of obstruction: pull-through not done to ganglionated bowel with normal-sized nerves (transition zone)" — Marc Levitt (clinical) [Ep 251 · 7:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=420)
- "Healthy pull-through segment requires ganglion cells present and nerve roots no bigger than 40 microns; larger nerves indicate transition zone bowel that might not function" — Marc Levitt (clinical) [Ep 251 · 7:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=471)
- "Treatment for post-pull-through enterocolitis: hydration, intravenous metronidazole (most effective antibiotic), and aggressive irrigations two to three times daily" — Marc Levitt (clinical) [Ep 251 · 8:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=499)
- "Irrigation technique: 10-20 cc per kilo into large Foley (size 20-22), allow to drip out, repeat while moving tube to wash colon interior" — Marc Levitt (clinical) [Ep 251 · 9:39](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=579)
- "Metronidazole has same efficacy IV or PO because in both cases it is excreted in the bile" — Marc Levitt (clinical) [Ep 251 · 11:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=681)
- "In diverted colon (with ileostomy), metronidazole will not work for colitis because drug exits via ileostomy; vancomycin enemas needed instead" — Marc Levitt (clinical) [Ep 251 · 11:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=690)
- "Approximately 15-20% of patients can have an enterocolitis episode within the first year after pull-through, but after one year they should not be having enterocolitis" — Marc Levitt (epidemiological) [Ep 251 · 12:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=741)
- "On contrast study, pull-through should hug the sacrum; if diverted forward by space-occupying mass, suspect obstructing cuff" — Marc Levitt (clinical) [Ep 251 · 12:58](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=778)
- "Obstructing cuff may be palpable on digital rectal exam as rubbery thick rubber-band structure around pull-through along sacral hollow, but is outside the lumen and not visible on endoscopy" — Marc Levitt (clinical) [Ep 251 · 15:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=918)
- "For transition zone pull-through causing obstruction, management is redo pull-through to healthy ganglionated bowel, often requiring removal of retained sigmoid curve" — Marc Levitt (clinical) [Ep 251 · 18:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1101)
- "For obstructing cuff, dissect between bowel and cuff, then make second plane outside cuff in Swenson plane; remove posterior-lateral ring (not entire circumference) to break the ring and solve obstruction" — Marc Levitt (clinical) [Ep 251 · 20:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1230)
- "Myectomies that have been traditionally successful may have been cutting the Soave cuff rather than internal sphincter, but technique varies widely between surgeons" — Marc Levitt (opinion) [Ep 251 · 21:49](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1309)
- "Myectomies can hurt skeletal muscle and leave patient incontinent; strongly argue against them" — Marc Levitt (opinion) [Ep 251 · 22:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1360)
- "Post-pull-through sphincter problems are relatively rare compared to anatomic problems; not usually the sphincter causing obstruction" — Marc Levitt (clinical) [Ep 251 · 24:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1445)
- "Many Hirschsprung patients have tight sphincters on anorectal manometry, with powerful internal sphincter that fails to relax" — Marc Levitt (clinical) [Ep 251 · 24:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1445)
- "For obstructed child with no anatomic problem and confirmed sphincter dysfunction on manometry, Botox is indicated" — Marc Levitt (clinical) [Ep 251 · 24:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1480)
- "Botox acts as temporary myectomy; preferred over permanent myectomy because it wears off as child learns sphincter coordination, avoiding permanent incontinence risk" — Marc Levitt (clinical) [Ep 251 · 25:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1520)
- "Botox timing strategy: inject, then at 4-8 weeks start aggressive laxatives as Botox wears off, helping child learn appropriate bowel movement pattern" — Marc Levitt (clinical) [Ep 251 · 26:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1570)
- "Botox can temporarily improve cuff obstruction if injection migrates to cuff level, but patient will recur because cuff must be removed for long-term fix" — Marc Levitt (clinical) [Ep 251 · 26:45](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1605)
- "Anorectal manometry can distinguish sphincter dysfunction (1 cm high-tone zone) from sphincter plus cuff (3-4 cm high-tone zone)" — Marc Levitt (clinical) [Ep 251 · 27:17](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1637)
- "Redo of Duhamel pouch is probably the hardest operation in Hirschsprung disease due to pelvic fibrosis from stapled connection" — Marc Levitt (opinion) [Ep 251 · 30:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1820)
- "All patients with Hirschsprung disease should be able to empty spontaneously and should be clean" — Marc Levitt (opinion) [Ep 251 · 31:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1900)
- "Patients with Hirschsprung disease are born with normal anal canal and normal sphincters; if anything, sphincters are too good" — Marc Levitt (clinical) [Ep 251 · 32:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1950)
- "No Hirschsprung patient is born with missing anal canal or weak sphincter; when present, these are iatrogenic from surgeon starting transanal dissection too low and invading dentate line" — Marc Levitt (clinical) [Ep 251 · 33:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=1980)
- "Sphincter destruction can result from overstretching during aggressive transabdominal or transanal dissection" — Marc Levitt (clinical) [Ep 251 · 34:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2040)
- "Capacity for bowel control in soiling patients determined by sphincter integrity (assessed by visual exam, digital exam, anorectal manometry) and dentate line preservation" — Marc Levitt (clinical) [Ep 251 · 35:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2120)
- "Contrast study serves as 'poor man's colonic manometry': narrow non-dilated pull-through suggests hypermotility; dilated pull-through suggests hypomotility" — Marc Levitt (clinical) [Ep 251 · 37:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2220)
- "Soiling patient with intact anal canal/sphincter and non-dilated colon: hypermotile, needs slowing with constipating diet, loperamide, water-soluble fiber" — Marc Levitt (clinical) [Ep 251 · 37:40](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2260)
- "Soiling patient with intact anal canal/sphincter and dilated colon: hypomotile, needs laxatives to speed up, has capacity for bowel control" — Marc Levitt (clinical) [Ep 251 · 38:15](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2295)
- "Soiling patient with destroyed anal canal/sphincter and non-dilated colon: hypermotile without continence capacity, needs small-volume enema plus constipating regimen" — Marc Levitt (clinical) [Ep 251 · 38:15](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2295)
- "Soiling patient with destroyed anal canal/sphincter and dilated colon: needs larger volume enema, no hypermotility treatment" — Marc Levitt (clinical) [Ep 251 · 38:51](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2331)
- "Hirschsprung soiling differs from anorectal malformation incontinence because Hirschsprung patients ought to have good anal canal and sphincter; if absent, it relates to surgery" — Marc Levitt (clinical) [Ep 251 · 39:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2360)
- "Patients with capacity for bowel control (intact sphincter/anal canal) may receive bridge enema program for social continence while transitioning to appropriate medical regimen" — Marc Levitt (clinical) [Ep 251 · 40:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2420)
- "Surgical management for soiling patients without capacity for bowel control: Malone appendicostomy or cecostomy" — Marc Levitt (clinical) [Ep 251 · 42:35](https://library.globalcastmd.com/watch/hirschsprung-disease-part-2-13876?t=2555)

## Changelog
- Aug 31: 182 doctors auto-found from episode dossiers
- Aug 30: 150 doctors auto-found from episode dossiers
- Aug 30: 137 doctors auto-found from episode dossiers
- Aug 30: Members-only episodes removed from this collection
- Aug 29: 183 doctors auto-found from episode dossiers
- Aug 29: 187 doctors auto-found from episode dossiers
- Aug 29: Collection generated from campaign corpus: 384 items, 229 dossiers, summaries for 2 audience(s)
- Aug 29: Collection reviewed and published
- Aug 29: Collection generated from campaign corpus: 231 items, 227 dossiers, summaries for 0 audience(s)
- Aug 29: Collection generated from campaign corpus: 231 items, 227 dossiers, summaries for 2 audience(s)
- Aug 29: Collection generated from campaign corpus: 231 items, 227 dossiers, summaries for 1 audience(s)

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