# Hirschsprung disease — GCMD Library living collection

Everything in the library about Hirschsprung disease — built automatically from dossiers that name it.

Also covered as: enterocolitis · anorectal malformation · constipation · fecal incontinence · Hirschsprung's disease · total colonic aganglionosis · malrotation · trisomy 21

Updated: n/a · 98 episodes · 2598 cited statements

## Episodes
### Fundamentals
- [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)
- [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)
- [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)
- [Malrotation with Dr. Meera Kotagal](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621) — podcast · 13:25 · [machine version](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621.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)
- [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)
- [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)
- [Function Tests & Pain Management: Pancreatic Disease](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968) — video · 26:27 · [machine version](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968.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)
- [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)
- [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 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)
- [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)
- [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)

### Acute Management
- [Acute Pancreatitis](https://library.globalcastmd.com/watch/acute-pancreatitis-871) — podcast · 45:24 · [machine version](https://library.globalcastmd.com/watch/acute-pancreatitis-871.md)

### Medical Management
- [Intestinal Failure with Dr. Brad Warner](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927) — podcast · 52:46 · [machine version](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927.md)
- [Practical Approach: Intestinal Failure Innovations](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035) — video · 116:52 · [machine version](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035.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)

### Surgical Management
- [Malrotation](https://library.globalcastmd.com/watch/malrotation-629) — video · 42:31 · [machine version](https://library.globalcastmd.com/watch/malrotation-629.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 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: 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)
- [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)
- [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)
- [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)
- [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)
- [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)
- [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)
- [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)
- [Turnbull Stoma](https://library.globalcastmd.com/watch/turnbull-stoma-11526) — video · 4:56 · [machine version](https://library.globalcastmd.com/watch/turnbull-stoma-11526.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 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)
- [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)

### Complications
- [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)
- [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)
- [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)
- [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)
- [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)
- [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)

### Evidence & Research
- [Journal of Pediatric Surgery Article Review: January 2022 APSA Issue](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103) — podcast · 13:09 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103.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)
- [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)
- [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)
- [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)
- [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)
- [Heat 3 Winner: Shruthi Srinivas, MD - Best of the Best in Pediatric Surgery 2024](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018) — video · 1:47 · [machine version](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018.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 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)
- [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)

### Case-Based Learning
- [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)
- [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)
- [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 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)
- [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)
- [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 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)

### In-Depth Reviews
- [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)
- [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)
- [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)
- [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)
- [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)
- [Update Course Rewind: 2021 Top Ten Key Takeaways](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578) — video · 16:02 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578.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)
- [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)

### Emerging & Future Directions
- [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)
- [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 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)
- [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)
- [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)
- [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)

### Long-Term Care
- [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)
- [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)
- [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)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=0) Introduction and Anatomical Considerations (Ep 81)
- [1:26](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=86) Mesenteric Preservation Rationale (Ep 81)
- [1:58](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=118) Surgical Technique Demonstration (Ep 81)
- [0:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=0) Introduction and Episode Overview (Ep 60)
- [1:33](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=93) Hirschsprung-Associated Inflammatory Bowel Disease (Ep 60)
- [3:51](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=231) COVID-19 Pandemic Impact on Pediatric Appendicitis (Ep 60)
- [7:31](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=451) Critical Airway Response Team for Button Battery Removal (Ep 60)
- [10:01](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2023-caps-issue-7077?t=601) Summary and Closing (Ep 60)
- [0:00](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=0) Introduction and Dilation Practice Survey (Ep 61)
- [3:00](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=180) Evidence Against Routine Dilations (Ep 61)
- [7:30](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=450) Dilation Practice Variations and International Perspectives (Ep 61)
- [13:55](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=835) Botox for Hirschsprung-Associated Enterocolitis (Ep 61)
- [18:20](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1100) Enterocolitis Pathophysiology and Botox Evidence (Ep 61)
- [25:10](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1510) Perineal Body-Sparing PSARP Techniques (Ep 61)
- [0:00](https://library.globalcastmd.com/watch/transitional-care-in-anorectal-malformation-and-hirschsprung-s-disease-8940?t=0) Transitional Care Challenges and Solutions in Pediatric Colorectal Conditions (Ep 68)
- [0:00](https://library.globalcastmd.com/watch/cuidado-de-transici-n-en-malformaci-n-anorrectal-y-enfermedad-de-hirschsprung-8946?t=0) Transition Care Barriers in Anorectal Malformations and Hirschsprung Disease (Ep 69)
- [0:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=0) Introduction and Hirschsprung Disease Study (Ep 73)
- [6:47](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=407) Gastroschisis Management Systematic Review (Ep 73)
- [13:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=836) Clavien-Madadi Classification Validation (Ep 73)
- [18:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=1092) Summary and Conclusion (Ep 73)
- [0:00](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=0) Postoperative Dilation Protocols in Hirschsprung Disease (Ep 74)
- [0:00](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=0) Introduction and Plain Radiograph Findings in Hirschsprung Disease (Ep 2)
- [5:41](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=341) Enterocolitis Recognition on Plain Films and Enema Accuracy (Ep 2)
- [11:20](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=680) Contrast Enema Technique - Dr. Ocelami's Approach (Ep 2)
- [21:31](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1291) Contrast Enema Technique - Dr. Kraus's Approach and Long-Segment Disease Challenges (Ep 2)
- [31:40](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1900) Post-Operative Enema Findings and Clinical Debate on Ultra-Short Segment Disease (Ep 2)
- [40:00](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2400) Closing Remarks on Internal Sphincter Achalasia Concept (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114?t=0) Transition of Care for Colorectal Conditions: Systematic Review Findings (Ep 70)
- [0:00](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=0) Introduction (Ep 72)
- [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) Study Design (Ep 72)
- [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) Key Findings (Ep 72)
- [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) Conclusion and Call to Action (Ep 72)
- [0:00](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=0) Patient positioning and port placement (Ep 11)
- [1:15](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=75) Laparoscopic mesenteric dissection to pelvic floor (Ep 11)
- [4:35](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=275) Timing of surgery and completion of laparoscopic phase (Ep 11)
- [5:10](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=310) Transanal dissection and mucosal plane development (Ep 11)
- [7:46](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=466) Muscular cuff division and colon mobilization (Ep 11)
- [8:57](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=537) Coloanal anastomosis and postoperative course (Ep 11)
- [0:00](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=0) Introduction and Appendicitis Review (Ep 14)
- [5:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=310) Initial Evaluation and Diagnosis of Hirschsprung Disease (Ep 14)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "The speaker now performs laparoscopy to identify the bowel segment for stoma creation rather than the traditional left lower quadrant incision approach" (clinical) [Ep 81 · 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 81 · 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 81 · 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 81 · 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 81 · 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 81 · 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 81 · 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 81 · 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 81 · 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 81 · 2:33](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=153)
- "The bowel is opened on the anti-mesenteric side" (clinical) [Ep 81 · 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 81 · 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 81 · 3:43](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=223)
- "The main complication related to a loop stoma is prolapse" (clinical) [Ep 81 · 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 81 · 4:22](https://library.globalcastmd.com/watch/turnbull-stoma-11526?t=262)
- "The Hirschsprung-associated IBD study was retrospective, looked at data from 2000 to 2021 at 17 institutions" — Cecilia Gigena (clinical) [Ep 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 60 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 27:12](https://library.globalcastmd.com/watch/update-course-2023-updates-in-colorectal-pathology-7268?t=1632)
- "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 68 · 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 68 · 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 68 · 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 68 · 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 68 · 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 68 · 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 68 · 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 68 · 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 69 · 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 69 · 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 69 · 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 69 · 0:47](https://library.globalcastmd.com/watch/cuidado-de-transici-n-en-malformaci-n-anorrectal-y-enfermedad-de-hirschsprung-8946?t=47)
- "85% of Hirschsprung disease patients in the study were diagnosed at less than 1 year of age" — Em Gootee (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 73 · 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 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 73 · 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 73 · 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 73 · 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 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 73 · 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 73 · 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 73 · 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 73 · 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 (host_summary) [Ep 73 · 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 (host_summary) [Ep 73 · 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 74 · 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 74 · 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 74 · 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 74 · 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 74 · 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 74 · 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 74 · 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 74 · 0:46](https://library.globalcastmd.com/watch/the-use-of-postoperative-calibrations-in-hirschsprung-disease-9460?t=46)
- "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." — Steven Kraus (opinion) [Ep 2 · 1:02](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=62)
- "Signs of Hirschsprung disease on plain abdominal radiographs of a newborn include transition zone, distal bowel obstruction, dilated colon, and bowel mucosal irregularities." — Steven Kraus (clinical) [Ep 2 · 1:41](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=101)
- "In a newborn, you cannot tell the difference between colon and small bowel on plain radiograph; you can only identify multiple dilated loops suggesting distal bowel obstruction." — Steven Kraus (clinical) [Ep 2 · 3:23](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=203)
- "The differential diagnosis for neonatal distal bowel obstruction appearance includes Hirschsprung disease, small left colon syndrome (meconium plug syndrome, immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five entities make up about 99% of cases." — Steven Kraus (clinical) [Ep 2 · 3:57](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=237)
- "Seeing air in the rectum on plain radiograph does not rule out Hirschsprung disease." — Steven Kraus (clinical) [Ep 2 · 5:32](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=332)
- "The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph." — Steven Kraus (clinical) [Ep 2 · 5:43](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=343)
- "Air-fluid levels visible on cross-table or decubitus views in the colon are a sign of inflammatory process or enterocolitis." — Steven Kraus (clinical) [Ep 2 · 6:58](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=418)
- "Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise." — Steven Kraus (clinical) [Ep 2 · 8:14](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=494)
- "The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease." — Steven Kraus (clinical) [Ep 2 · 9:46](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=586)
- "The false negative rate of contrast enema for detecting transition zone is between 20% and 25% according to multiple studies." — Steven Kraus (epidemiological) [Ep 2 · 10:33](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=633)
- "Total colonic Hirschsprung disease and short segment disease are particularly difficult diagnoses to make on enema, contributing to the false negative rate." — Steven Kraus (clinical) [Ep 2 · 11:04](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=664)
- "The false positive transition zone rate on enema is up to 43%." — Steven Kraus (epidemiological) [Ep 2 · 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 (epidemiological) [Ep 2 · 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 (epidemiological) [Ep 2 · 11:47](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=707)
- "For short segment disease (rectosigmoid or low transition), the concordance between radiologic and pathologic transition zone is about 75%." — Steven Kraus (epidemiological) [Ep 2 · 13:27](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=807)
- "For long segment disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zone is only about 25%." — Steven Kraus (epidemiological) [Ep 2 · 13:54](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=834)
- "If an enema shows a high transition zone, the actual pathologic transition could be anywhere, and repeat enemas will not reliably improve localization." — Steven Kraus (clinical) [Ep 2 · 14:05](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=845)
- "In patients with long segment disease, it is better to plan the operation assuming the transition may be high rather than relying on enema localization." — Steven Kraus (opinion) [Ep 2 · 14:29](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=869)
- "The technique for contrast enema involves inserting only a small part of the rectal tube (2-3 cm) into the rectum." — Rodrigo Ocelami (clinical) [Ep 2 · 16:34](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=994)
- "Never use a Foley catheter inside the rectum for contrast enema in suspected Hirschsprung disease." — Rodrigo Ocelami (clinical) [Ep 2 · 16:42](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1002)
- "In the neonatal period, use water-soluble contrast diluted 50% with saline." — Rodrigo Ocelami (clinical) [Ep 2 · 17:04](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1024)
- "Inject contrast very slowly and gently with a syringe under continuous fluoroscopy to avoid distending the aganglionic segment." — Rodrigo Ocelami (clinical) [Ep 2 · 17:16](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1036)
- "After the neonatal period, fill only up to the transverse colon; if the studied segment appears normal in distension, caliber, and mucosa, and the splenic flexure shows no suggestion of total colonic disease, stop at the transverse colon." — Rodrigo Ocelami (clinical) [Ep 2 · 17:41](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1061)
- "Obtain images in left lateral, right lateral, and AP positions, and remove the tube to visualize the rectum without obstruction." — Rodrigo Ocelami (clinical) [Ep 2 · 18:10](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1090)
- "The primary finding to look for is the transition zone; once found, the diagnosis is made and contrast administration can stop." — Rodrigo Ocelami (clinical) [Ep 2 · 18:47](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1127)
- "Inversion of the rectosigmoid index is a helpful sign in diagnosing Hirschsprung disease." — Rodrigo Ocelami (clinical) [Ep 2 · 19:03](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1143)
- "The aganglionic segment will appear spastic, which is why contrast should not be given in large amounts or too fast, or the spasticity will be missed." — Rodrigo Ocelami (clinical) [Ep 2 · 19:18](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1158)
- "Always counsel families about good hydration after the study and show them the contrast material so they know what to expect when the child evacuates it." — Rodrigo Ocelami (clinical) [Ep 2 · 20:08](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1208)
- "The main technical points are: never use a Foley in the rectum, inject contrast very slowly and gently under continuous fluoroscopy, and look for the diagnostic signs." — Rodrigo Ocelami (clinical) [Ep 2 · 20:47](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1247)
- "Dr. Kraus uses an iodinated water-soluble contrast with osmolality of about 400, which is hyperosmotic and helps clean the colon but can cause dehydration in neonates if it remains." — Steven Kraus (clinical) [Ep 2 · 21:42](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1302)
- "Dr. Kraus uses gravity infusion from a bag with large-bore tubing at a moderate pace rather than slow drip, to show distal and proximal segments quickly and visualize the transition zone rapidly." — Steven Kraus (clinical) [Ep 2 · 22:31](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1351)
- "Early maximal distention is the best time to see the transition zone, because waiting too long can allow distention of the distal aganglionic segment since it is soft tissue, not a rigid pipe." — Steven Kraus (clinical) [Ep 2 · 23:01](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1381)
- "If the colon in a neonate looks small, fill the entire colon and attempt reflux into the terminal ileum to evaluate for other diagnoses such as meconium ileus." — Steven Kraus (clinical) [Ep 2 · 23:30](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1410)
- "Dr. Kraus uses a 12-14 French Foley catheter in full-term neonates and smaller sizes in premature infants." — Steven Kraus (clinical) [Ep 2 · 23:47](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1427)
- "A true lateral image with femurs superimposed is essential to visualize the presacral space properly." — Steven Kraus (clinical) [Ep 2 · 24:03](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1443)
- "In a normal enema, the proximal colon toward the splenic flexure is always a little smaller than the rectum." — Steven Kraus (clinical) [Ep 2 · 24:18](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1458)
- "If a Foley catheter balloon is inflated in the distal rectum to prevent leakage, it will obscure very short segment Hirschsprung disease and cause a missed diagnosis." — Steven Kraus (clinical) [Ep 2 · 24:40](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1480)
- "Rectosigmoid transition zone cases (typical short segment Hirschsprung) are usually concordant between radiology and pathology." — Steven Kraus (clinical) [Ep 2 · 25:04](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1504)
- "In total colonic Hirschsprung disease, the rectum does not appear bigger than the rest of the colon as it should normally; the entire colon appears uniformly small." — Steven Kraus (clinical) [Ep 2 · 25:30](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1530)
- "In premature infants, the enema does not follow the usual rules; the colon can look uniformly small due to immaturity, making it difficult to distinguish from total colonic Hirschsprung." — Steven Kraus (clinical) [Ep 2 · 25:42](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1542)
- "Contrast enemas can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy." — Steven Kraus (clinical) [Ep 2 · 26:03](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1563)
- "In infants younger than 35-36 weeks, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of enema for Hirschsprung is reduced." — Steven Kraus (clinical) [Ep 2 · 26:15](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1575)
- "Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt." — Steven Kraus (clinical) [Ep 2 · 28:06](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1686)
- "The rectosigmoid index (rectum larger than sigmoid) is a useful principle, but one should not stop there—examine all the way to the splenic flexure." — Steven Kraus (clinical) [Ep 2 · 29:30](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1770)
- "A case initially interpreted as small left colon based on abrupt splenic flexure transition and meconium plugs proved to be total colonic aganglionosis with transition in the terminal ileum." — Steven Kraus (clinical) [Ep 2 · 29:51](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1791)
- "When there is a proximal transition zone on enema, you cannot accurately predict where the pathologic transition will be; it may be much more proximal than the radiologic appearance suggests." — Steven Kraus (clinical) [Ep 2 · 30:51](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1851)
- "If a collection has unusual characteristics such as a proximal transition, consider a more invasive surgical approach (open or laparoscopic with intraoperative biopsies) rather than transanal pull-through, since the true transition location is uncertain." — Steven Kraus (opinion) [Ep 2 · 31:07](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1867)
- "Dr. Ponsky performs suction rectal biopsy in almost any patient who required a contrast enema to rule out distal obstruction, regardless of whether the enema suggests meconium plug, small left colon, or other diagnosis." — Todd Ponsky (opinion) [Ep 2 · 31:46](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1906)
- "Dr. Pena would perform rectal biopsy in a case of apparent small left colon because he cannot distinguish it from Hirschsprung disease." — Alberto Peña (opinion) [Ep 2 · 32:44](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=1964)
- "In the Soave procedure, partial-thickness dissection leaves a cuff of aganglionic tissue, which if prominent causes a widened presacral space visible on lateral enema view." — Steven Kraus (clinical) [Ep 2 · 34:18](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2058)
- "A true lateral view of the rectum is very important in post-surgical patients to assess the presacral space." — Steven Kraus (clinical) [Ep 2 · 34:55](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2095)
- "The Duhamel procedure creates a chimera of aganglionic distal segment with ganglionic proximal segment in a patchwork fashion, not side-to-side or end-to-end." — Steven Kraus (clinical) [Ep 2 · 35:51](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2151)
- "In symptomatic Duhamel patients, an anterior pouch is visible on enema, often containing stool; enlargement of this pouch compresses the ganglionic bowel and causes obstruction." — Steven Kraus (clinical) [Ep 2 · 36:13](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2173)
- "Dr. Pena questions whether patients who develop the characteristic dilated Duhamel pouch actually had true Hirschsprung disease, since by definition aganglionic bowel should not distend even after 10-15 years." — Alberto Peña (opinion) [Ep 2 · 36:54](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2214)
- "Dr. Pena recommends that when resecting a Duhamel pouch, the specimen should be oriented and the pathologist alerted to determine whether ganglion cells are present in the rectal portion, to test the hypothesis that these were misdiagnosed cases." — Alberto Peña (opinion) [Ep 2 · 37:41](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2261)
- "Dr. Collins reports that the Duhamel pouches she has examined pathologically have contained both ganglionic and aganglionic parts." — Todd Ponsky (clinical) [Ep 2 · 38:05](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2285)
- "Dr. Pena states that if he sees a patient with megacolon and constipation on enema, he will not perform a rectal biopsy because it is a waste of time from his point of view." — Alberto Peña (opinion) [Ep 2 · 40:28](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2428)
- "Dr. Pena argues that taking a biopsy in a patient with idiopathic constipation risks getting an aganglionic result that does not mean anything, because the patient does not have Hirschsprung disease." — Alberto Peña (opinion) [Ep 2 · 40:39](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2439)
- "There is a normal physiologic aganglionic segment in the distal rectum, but its length at different ages (preterm, term, 6 months) has never been accurately determined in humans." — Alberto Peña (clinical) [Ep 2 · 41:32](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2492)
- "Someone could take a biopsy in the normal physiologic aganglionic area and get a result of no ganglion cells, which does not indicate Hirschsprung disease." — Alberto Peña (clinical) [Ep 2 · 42:05](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2525)
- "The internal sphincter has been defined as a thickening of the circular layer of normal smooth muscle bowel, but Dr. Pena states he has never personally observed this thickening when opening normal rectums at different ages." — Alberto Peña (opinion) [Ep 2 · 42:14](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2534)
- "If the internal sphincter thickening exists, nobody has determined its exact boundaries at different ages." — Alberto Peña (clinical) [Ep 2 · 42:45](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2565)
- "Internal sphincter achalasia is a manometric concept, not an anatomic concept, similar to the lower esophageal sphincter." — Alberto Peña (opinion) [Ep 2 · 43:16](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2596)
- "Dr. Pena does not perform or recommend myectomies, myotomies, or botulinum toxin injections for internal sphincter achalasia because the target muscle area is undefined and these procedures paralyze muscle to facilitate stool passage rather than curing a condition of unknown origin." — Alberto Peña (opinion) [Ep 2 · 43:16](https://library.globalcastmd.com/watch/evaluation-management-of-hirschsprung-s-disease-626?t=2596)
- "Patients with anorectal malformations and Hirschsprung's disease need transfer from pediatric to adult providers to manage their colorectal conditions" — Alex Halpern (clinical) [Ep 70 · 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 70 · 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 70 · 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 70 · 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 70 · 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 70 · 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 70 · 0:43](https://library.globalcastmd.com/watch/transition-from-pediatric-to-adult-healthcare-for-colorectal-conditions-a-systematic-review-9114?t=43)
- "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 72 · 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 72 · 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 72 · 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 72 · 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 72 · 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 72 · 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 72 · 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)
- "The JRS 3 millimeter sealer is used as the primary mode of dissection for laparoscopic-assisted pull-through in Hirschsprung's disease." (host_summary) [Ep 11 · 0:00](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=0)
- "The patient was a newborn weighing 3.2 kg." (host_summary) [Ep 11 · 0:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=32)
- "A super umbilical ring incision is used for small newborns to place the Veress needle and 4 mm trocar, with care taken to avoid the umbilical vein by placing the trocar just to the left of midline." (host_summary) [Ep 11 · 0:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=36)
- "A full thickness biopsy is obtained from the muscular wall approximately 5 centimeters above the transition zone between the distal sigmoid and rectum." (host_summary) [Ep 11 · 0:53](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=53)
- "The key to mesenteric dissection is staying exactly adjacent to the colon wall to prevent injury to surrounding structures." (clinical) [Ep 11 · 1:21](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=81)
- "Because all heat and energy remains between the jaws of the sealer, there is no danger in injuring surrounding structures by brushing aside them with the sealer." (clinical) [Ep 11 · 1:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=92)
- "Small perforating vessels are grasped, sealed, and then pulled down off the rectal wall during circumferential dissection." (clinical) [Ep 11 · 1:48](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=108)
- "Dissection at the peritoneal reflection uses the same technique of grasping the peritoneal reflection and small perforating vessels and pulling them down off the colon." (clinical) [Ep 11 · 2:10](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=130)
- "The 3 millimeter sealer allows dissection of vessels and mobilization of tissue around the colon without risk of pass-pointing, unlike the 3 millimeter hook which was previously the preferred mode of dissection." (clinical) [Ep 11 · 2:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=152)
- "Using the 3 mm sealer eliminates the need for instrument changes with the right hand throughout the case." (clinical) [Ep 11 · 2:55](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=175)
- "Carrying the laparoscopic 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 11 · 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 3 mm sealer, it is safe for the instrument to be adjacent to the bladder, vagina, prostate, and other surrounding structures." (clinical) [Ep 11 · 3:42](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=222)
- "Energy being only between the jaws of the instrument diminishes the risk of injury to the ureters, vas deferens, and other vital structures." (clinical) [Ep 11 · 4:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=245)
- "The preferred timing is to perform this operation in the newborn period prior to discharge to home, though it is acceptable if the child tolerates rectal irrigations to let them grow." (opinion) [Ep 11 · 4:35](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=275)
- "With current technology, the operation is considered extremely safe in the newborn period." (opinion) [Ep 11 · 4:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=285)
- "For the transanal dissection, traction stitches are placed inside the anus just proximal to the dentate line and then out to the skin, slightly inverting the anus so the dentate line can be clearly visualized." (clinical) [Ep 11 · 5:13](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=313)
- "Between 4 to 8 sutures are used to evert the anus." (clinical) [Ep 11 · 5:38](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=338)
- "A mucosal incision is made with hand cautery 2 to 3 millimeters proximal to the dentate line and crypt." (clinical) [Ep 11 · 5:53](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=353)
- "The key to the transanal portion is that it should all take place externally to the anus." (clinical) [Ep 11 · 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 transanal 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 11 · 6:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=396)
- "Sharp dissection is preferred to mobilize the submucosal space, although blunt dissection can also be used." (opinion) [Ep 11 · 7:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=425)
- "Performing the dissection external to the anus protects the external sphincter muscles and improves the chance of good continence." (clinical) [Ep 11 · 7:31](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?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 11 · 8:57](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=537)
- "The coloanal anastomosis is performed with 12 to 16 sutures total, placing 3 to 4 additional sutures in each quadrant after the initial 4 quadrant stay sutures." (clinical) [Ep 11 · 9:19](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=559)
- "Vicryl suture is used for the anastomosis in newborns." (clinical) [Ep 11 · 9:44](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=584)
- "This operation took 70 minutes." (clinical) [Ep 11 · 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 11 · 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 less than 24 hours after the procedure." (clinical) [Ep 11 · 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 11 · 10:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=636)
- "Gauze packing is placed in the anus at the end of the procedure." (clinical) [Ep 11 · 10:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-760?t=645)
- "The best treatment for Hirschsprung disease is irrigations using a large bore tube (20 French Foley) with warm saline, instilling 10-20 cc aliquots at a time and allowing fluid mixed with stool to drain back." — Marc Levitt (clinical) [Ep 14 · 8:43](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=523)
- "It is very rare that Hirschsprung disease is a surgical emergency, but if you don't irrigate and overcome the distal obstruction, it will become an emergency." — Marc Levitt (clinical) [Ep 14 · 8:55](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=535)
- "For rectal biopsy in suspected Hirschsprung disease, you must be at least 1 centimeter in from the dentate line. If you biopsy too close to the dentate line, everyone has an aganglionic segment there and you could get the wrong answer." — Marc Levitt (clinical) [Ep 14 · 12:38](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=758)
- "The pathologist must report both the absence of ganglion cells AND the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung disease - that could be a biopsy taken too low." — Marc Levitt (clinical) [Ep 14 · 13:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=803)
- "Hirschsprung disease has an immune component and the lining of the bowel (mucosa) is much more susceptible to bacterial translocation. Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia." — Marc Levitt (clinical) [Ep 14 · 14:59](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=899)
- "If irrigations are not working and the baby is ill, you need to divert. The recommendation is to divert in the ileum rather than doing a leveling colostomy, because frozen section can be inaccurate, particularly as you move higher in the colon." — Marc Levitt (clinical) [Ep 14 · 15:42](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=942)
- "The Swenson operation involved full-thickness transabdominal dissection down below the peritoneal reflection. The operation was often done incorrectly with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence." — Marc Levitt (clinical) [Ep 14 · 18:14](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1094)
- "The Suave operation used a mucosal dissection to keep the outer rectal wall intact and avoid injury. The original Suave would leave the colon coming through the anus for a week before doing the coloanal anastomosis; Dr. Scott Boley modified it to do everything in one stage." — Marc Levitt (clinical) [Ep 14 · 19:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1168)
- "The Duhamel operation leaves the original rectum in place, removes the aganglionic portion from the peritoneal reflection, and pulls ganglionic bowel in a retrorectal position, connecting the two lumens with a stapler." — Marc Levitt (clinical) [Ep 14 · 20:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1218)
- "Of the four classic procedures (Swenson, Suave, Duhamel, Rabine), only the Swenson actually leaves behind virtually no Hirschsprung tissue. The others leave behind outer rectal wall or original rectum. Many patients did well despite this because ganglionic bowel, if it's good, can overcome a lot." — Marc Levitt (clinical) [Ep 14 · 21:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1278)
- "Dr. Henrys in the Philippines pioneered primary pull-through operations (without initial colostomy) out of necessity because patients would never return to clinic due to social stigma against colostomies." — Marc Levitt (clinical) [Ep 14 · 22:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1339)
- "Keith Jorgeson applied laparoscopic skills to Hirschsprung disease, doing the colonic work laparoscopically with a Suave dissection from above. Luis de la Torre and Jack Langer developed the transanal approach, starting the dissection from below." — Marc Levitt (clinical) [Ep 14 · 23:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1401)
- "The current preferred approach is a transanal Swenson (full-thickness dissection). It is the purest operation, leaving behind no Hirschsprung except the very bottom just above the dentate line. If you find the right plane, it's elegant and bloodless." — Marc Levitt (opinion) [Ep 14 · 25:34](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1534)
- "Dr. Orvar Swenson, who recently died at age 105, maintained that the Swenson operation was good all along and people just weren't doing it right, which gave it a bad reputation." — Marc Levitt (clinical) [Ep 14 · 26:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1583)
- "Even Suave enthusiasts are making shorter and shorter cuffs over time. Jorgeson's original laparoscopic Suave recommended a 5 cm cuff; nowadays Langer and de la Torre do 1-1.5 cm cuffs, essentially approaching a Swenson." — Marc Levitt (clinical) [Ep 14 · 27:06](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1626)
- "Laparoscopy is appropriate for all cases to find the transition zone level. A transanal-only approach is only appropriate when you have a very reachable, obvious transition zone at mid-sigmoid that you can comfortably reach transanally." — Marc Levitt (opinion) [Ep 14 · 28:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1730)
- "There is significant morbidity from an overly aggressive transanal-only approach trying to reach the transition zone without going into the abdomen. If you're too aggressive transanally trying to visualize the dissection, you would have been better off with laparoscopic dissection." — Marc Levitt (clinical) [Ep 14 · 29:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1758)
- "Total colonic Hirschsprung patients present differently: the diagnosis isn't made right away, the contrast study is not typical, and irrigations don't go well. These patients need laparoscopy first to find the biopsy location." — Marc Levitt (clinical) [Ep 14 · 31:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1878)
- "The biggest technical problems are: (1) surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or (2) they give very aggressive exposure and overstretch the sphincters." — Marc Levitt (clinical) [Ep 14 · 34:09](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2049)
- "Proper technique requires marking 1 cm proximal to the dentate line with a purple mark and placing 5-0 silk stitches circumferentially at that level. This preserves the anal canal, dentate line, plus an additional 1 cm of columnar epithelium before starting dissection." — Marc Levitt (clinical) [Ep 14 · 35:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2130)
- "By definition, you're leaving behind 1 cm of columnar epithelium that is Hirschsprung disease, plus the internal sphincter which has a problem with relaxation. However, good ganglionic bowel is able to overcome that, and the baby eventually learns to relax the sphincter." — Marc Levitt (clinical) [Ep 14 · 36:39](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2199)
- "The rectum doesn't really have a mesentery; the rectum's blood supply is intramural. As you get higher and reach the peritoneal reflection, that's when you start to see sigmoidal vessels where rectum transitions to sigmoid." — Marc Levitt (clinical) [Ep 14 · 38:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2299)
- "The anterior rectum frees up much quicker than the posterior rectum. Break into the peritoneal reflection anteriorly first. In transanal-only cases, you can pull the sigmoid out anteriorly, do a full-thickness biopsy, and send it while continuing the posterior dissection." — Marc Levitt (clinical) [Ep 14 · 38:45](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2325)
- "For laparoscopic biopsies through the umbilicus, a seromuscular biopsy (without violating mucosa) may show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa. If using this technique, send a full-thickness biopsy later to confirm the level is appropriate." — Marc Levitt (clinical) [Ep 14 · 40:56](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2456)
- "Pathologists must report not only ganglion cells but also the quality of nerves with actual micron measurements. Nerves should be 40 microns or less. Anything bigger than 40 microns is transition zone bowel." — Marc Levitt (clinical) [Ep 14 · 44:03](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2643)
- "The concept of 'go 5 cm above the transition zone' is inaccurate. Transition zone is a spectrum - some are 10 cm, some are 3 cm. You need confirmatory biopsy with ganglion cell information and nerve quality measured in microns." — Marc Levitt (clinical) [Ep 14 · 44:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2660)
- "It's preferable to take the IMA, preserve the arcade, and have the left colon and sigmoid nice and straight down into the perineum. This makes for an easy-to-irrigate baby. Many patients have not had enough of a pull-through with the entire sigmoid loop still there, requiring redo to remove more." — Marc Levitt (clinical) [Ep 14 · 45:57](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2757)
- "For anything proximal to the splenic flexure, do colonic biopsies and an ileostomy and wait, because frozen section has been notoriously fraught with errors in those cases. There is no urgency. Another option is to take biopsies, quit without diverting, and return 3-4 days later for pull-through with permanent section results." — Marc Levitt (clinical) [Ep 14 · 47:02](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2822)
- "Postoperatively, wait until the belly is absolutely soft and flat with bowel function before feeding. Get an X-ray because abdominal distention is sometimes subclinical. This usually takes 3-4 days. Feeding too early risks the baby going home distended and returning with enterocolitis." — Marc Levitt (clinical) [Ep 14 · 53:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3203)
- "Routine postoperative management: at one month, check the anus with Hagar dilators (not finger). Most babies need calibration rather than true dilation. The stimulation of passing the Hagar has value to help the baby more successfully empty." — Marc Levitt (clinical) [Ep 14 · 54:39](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3279)
- "Flagyl is only used to treat enterocolitis, not routinely postoperatively. Give a pre-op dose of second-generation cephalosporin and maybe 2 post-op doses." — Marc Levitt (clinical) [Ep 14 · 55:52](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3352)
- "Routine irrigations are only done postoperatively if the baby develops significant distention, which is rare. However, for total colonic patients after ileoanal pull-through, send all patients home on irrigations for 3 months." — Marc Levitt (clinical) [Ep 14 · 56:31](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3391)
- "For hepatic flexure transition zone (rare), open the patient rather than laparoscopy. Take down the entire right colon, recognize the ileocolic vessel and how it feeds the vessel paralleling the right colon. Often need to take the right colic artery. De-rotate the colon so cecum is at the hepatic liver bed, then do pull-through down the right side of abdomen." — Marc Levitt (clinical) [Ep 14 · 57:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3425)
- "If bringing de-rotated colon down the left side of abdomen, must mobilize the ligament of Treitz so the mesenteric vessel is not draped across the third portion of duodenum, which can cause duodenal obstruction." — Marc Levitt (clinical) [Ep 14 · 58:02](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3482)
- "The negative appendectomy rate among hospitals is a median of 2.6% with a range from 0 to 17%, according to Kurt Newman's 2003 paper in Journal of Pediatric Surgery reviewing the PHIS database." — Nick Bruns (host_summary) [Ep 14 · 1:59](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=119)
- "For incidental Meckel's diverticulum during laparoscopy, Zani's 2008 Annals of Surgery review recommended leaving it, stating the risk of complications is not worth the extremely low mortality rate of 0.001%." — Nick Bruns (host_summary) [Ep 14 · 2:44](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=164)
- "The 50-year Mayo Clinic experience (Park et al., 2005, Annals of Surgery) recommended selective resection of Meckel's diverticulum based on four features: age less than 50, male sex, length greater than 2 cm, or presence of histologically abnormal tissue." — Nick Bruns (host_summary) [Ep 14 · 3:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=190)
- "A Miami Children's Hospital paper (Al-Khoury et al., JAMA Surgery 2012) studied 200 consecutive non-perforated appendicitis patients. 80% were same-day discharges with similar complication and readmission rates compared to overnight stays." — Nick Bruns (host_summary) [Ep 14 · 4:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=268)
- "The Finnish Pediatric Surgery Hub was established in 2021 by pediatric surgeons from Finland's five neonatal surgery centers." — Lizzie Lee (clinical) [Ep 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 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 75 · 3:52](https://library.globalcastmd.com/watch/quick-literature-updates-episode-17-9803?t=232)
- "APSA published best practices for locum tenens surgeons, hospitals and agencies" — Lizzie Lee (guideline) [Ep 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 2:10](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=130)
- "59 surgeons completed the questionnaire" — Alex Halpern (epidemiological) [Ep 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 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 80 · 3:46](https://library.globalcastmd.com/watch/quick-literature-updates-ep-23-11174?t=226)
- "Cloacal exstrophy is a spectrum of congenital malformations affecting the gastrointestinal/colorectal area, urogenital tract, spine and cord, and sometimes lower extremity motion." — Alberto Peña (clinical) [Ep 33 · 1:31](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=91)
- "Babies with cloacal exstrophy are born with an omphalocele, bladder exstrophy (two separated hemibladders), open cecum between the hemibladders, and separated pubic bones." — Alberto Peña (clinical) [Ep 33 · 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 33 · 3:08](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=188)
- "Male patients have two separated hemiphalluses with normal gonads; female patients have two hemivaginas below the exstrophic bladder leading to two hemiuteri." — Alberto Peña (clinical) [Ep 33 · 3:32](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=212)
- "Cloacal exstrophy represents a spectrum of colonic anatomy from normal colon to almost absent or completely absent colon, sometimes with two ceca or two appendices and bizarre blood supply." — Alberto Peña (clinical) [Ep 33 · 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's management and outcomes." — Alberto Peña (clinical) [Ep 33 · 4:57](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=297)
- "A variant exists where babies are born with intact abdominal skin (no omphalocele, no bladder exstrophy externally) but have a completely open bladder inside with no bladder neck and a single large perineal orifice." — Alberto Peña (clinical) [Ep 33 · 5:44](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=344)
- "While surgical techniques, intensive care, parenteral nutrition, and metabolic management have improved, functional outcomes (bowel control, urinary control, sexual function, spinal abnormalities) remain severely limited and cannot be made normal." — Alberto Peña (clinical) [Ep 33 · 7:02](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=422)
- "Historical practice was to perform bilateral gonadectomy, remove hemiphalluses, create a vagina with bowel, and assign female gender to XY patients with cloacal exstrophy." — Alberto Peña (clinical) [Ep 33 · 8:31](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=511)
- "Patients raised as female despite XY chromosomes exhibited male attitudes and behavior, and many became upset upon learning their chromosomal sex and that gonads were removed without their consent." — Alberto Peña (clinical) [Ep 33 · 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 aspect of being male, that they wanted their gonads back for fertility (modern techniques allow fertilization and children), and that being male is much more than having a phallus." — Alberto Peña (opinion) [Ep 33 · 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 pediatric urologists and plastic surgeons working on phallus reconstruction techniques." — Alberto Peña (guideline) [Ep 33 · 10:34](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=634)
- "When a prominent pediatric urologist dominates management, patients receive good urologic attention but inadequate gastrointestinal care; the reverse occurs when pediatric surgeons dominate." — Alberto Peña (clinical) [Ep 33 · 12:13](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=733)
- "The pediatric surgeon's role in the initial operation is to close the omphalocele (if possible), separate urothelium from intestinal mucosa by placing stitches at the edges and making an incision, allowing the urologist to bring hemibladders together." — Alberto Peña (clinical) [Ep 33 · 13:03](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=783)
- "It is very common but very harmful for pediatric surgeons to simply create an ileostomy, leaving all colon distally attached to the urinary tract." — Alberto Peña (clinical) [Ep 33 · 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 congenital bladder augmentation that causes hyperchloremic acidosis from urine absorption, interfering with growth and development." — Alberto Peña (clinical) [Ep 33 · 15:31](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=931)
- "Defunctionalized colonic tissue left distally will not grow; colon requires passage of fecal matter through its lumen to grow." — Alberto Peña (clinical) [Ep 33 · 16:03](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=963)
- "The pediatric surgeon must incorporate all gastrointestinal tissue into the fecal stream and create a true end colostomy to ensure fecal matter passes through all colonic tissue." — Alberto Peña (clinical) [Ep 33 · 16:23](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=983)
- "Patients who received ileostomy with defunctionalized colon present at 2-3 years with poor growth, hyperchloremic acidosis managed by nephrologists, and large ileostomy losses." — Alberto Peña (clinical) [Ep 33 · 16:41](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1001)
- "The rescue operation involves taking down the ileostomy, finding and incorporating colonic tissue into the GI tract, and creating an end colostomy; acidosis disappears the next day." — Alberto Peña (clinical) [Ep 33 · 17:03](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1023)
- "Surgeons must accept that cloacal exstrophy is a spectrum and be prepared to deal with complex, variable colonic anatomy rather than taking the easy way out with an ileostomy." — Alberto Peña (opinion) [Ep 33 · 19:13](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1153)
- "Some institutions routinely perform pelvic osteotomy at the initial operation to facilitate bladder and omphalocele reconstruction, while others wait 2-3 months to do it separately." — Alberto Peña (clinical) [Ep 33 · 21:00](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1260)
- "Even after osteotomy, it is very difficult to see a cloacal exstrophy patient with pubic bones completely together; they usually remain separated." — Alberto Peña (clinical) [Ep 33 · 21:09](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1269)
- "Even a technically correct end colostomy often has poor motility, and babies may not pass stool easily, sometimes developing bacterial overgrowth similar to Hirschsprung disease." — Alberto Peña (clinical) [Ep 33 · 22:06](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1326)
- "Families must be taught to irrigate the colostomy with small volumes of saline through a tube to evacuate fecal material when peristalsis is inadequate." — Alberto Peña (clinical) [Ep 33 · 23:00](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1380)
- "Decision-making for bowel control begins around age 3 when parents want to send the child to school clean and dry (no stool or urine in diaper)." — Alberto Peña (clinical) [Ep 33 · 23:30](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1410)
- "Most cloacal exstrophy patients have an inadequate, tiny bladder requiring bladder augmentation with gastrointestinal tract, necessitating coordination between pediatric surgery and urology." — Alberto Peña (clinical) [Ep 33 · 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 permanent colostomy and should never have terminal ileum pulled through, even if sphincter evidence exists, because they will never have bowel control." — Alberto Peña (clinical) [Ep 33 · 24:42](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1482)
- "Pull-through is only considered for patients with capacity to form solid stool (adequate colon), as bowel management only works with solid stool." — Alberto Peña (clinical) [Ep 33 · 25:04](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1504)
- "It is extremely unusual for cloacal exstrophy patients to have spontaneous bowel control; the overwhelming majority need a bowel management program (enema administration to keep patient clean)." — Alberto Peña (clinical) [Ep 33 · 25:20](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1520)
- "Pediatric surgeons should not underestimate the growth capacity of tiny colonic pieces during the newborn period; even small segments will grow over three years if fecal stream passes through them." — Alberto Peña (clinical) [Ep 33 · 25:47](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1547)
- "Annual contrast studies through the colostomy (retrograde injection) are performed to assess colonic growth." — Alberto Peña (clinical) [Ep 33 · 26:07](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1567)
- "Before committing to pull-through, a trial bowel management program is performed through the colostomy: enemas are given to empty the colonic pouch, and if the patient stays 24 hours without stool in the colostomy bag, pull-through is likely to succeed." — Alberto Peña (clinical) [Ep 33 · 26:41](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1601)
- "Bowel management trial through colostomy is typically started after age 3 when families consider avoiding the stoma for school." — Alberto Peña (clinical) [Ep 33 · 27:35](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1655)
- "If a patient has very little colon and cannot form solid stool, the urologist is free to use bowel for bladder augmentation; if the patient has borderline colon, the urologist must use stomach for augmentation to preserve bowel for fecal function." — Alberto Peña (clinical) [Ep 33 · 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 the bladder and augmentation anterior to it; therefore, bladder augmentation must not be done before deciding on pull-through, or accessing the colon will be extremely difficult." — Alberto Peña (clinical) [Ep 33 · 28:54](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1734)
- "Contrast enema through the colostomy can distinguish true liquid stool from paradoxical diarrhea (liquid stool around solid fecal impaction)." — Alberto Peña (clinical) [Ep 33 · 29:56](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1796)
- "Pull-through and bladder augmentation are ideally performed together in a single operation lasting approximately 12 hours, with pediatric surgery going first (posterior dissection) followed by urology (anterior augmentation)." — Alberto Peña (clinical) [Ep 33 · 31:04](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1864)
- "During pull-through, if the patient has one or two appendices, a Malone appendicostomy can be created for antegrade enema administration, as the appendix remains in the abdomen when colon is pulled down." — Alberto Peña (clinical) [Ep 33 · 31:28](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1888)
- "Urologists almost never use colon for bladder augmentation in cloacal exstrophy because colon is needed to form solid stool; they typically use small bowel or stomach." — Alberto Peña (clinical) [Ep 33 · 31:57](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1917)
- "Occasionally, when a patient has a giant colonic pouch with very poor motility, the poor motility makes it good for bowel management (irrigate once daily, stays clean between irrigations), and a piece can be shared with urology for augmentation." — Alberto Peña (clinical) [Ep 33 · 32:18](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1938)
- "Midline abdominal incision from xiphoid to pubis is used for pull-through to preserve the flanks and quadrants for potential future stomas." — Alberto Peña (clinical) [Ep 33 · 33:13](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=1993)
- "The colostomy is circumferentially dissected and separated from the abdominal wall, then the blood supply is carefully studied because cloacal exstrophy patients have very bizarre, aberrant vascular anatomy." — Alberto Peña (clinical) [Ep 33 · 33:56](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2036)
- "Careful observation of the vascular anatomy allows the surgeon to decide which vessels can be ligated to mobilize the colon to the perineum without compromising blood supply; sometimes no vessels need to be ligated." — Alberto Peña (clinical) [Ep 33 · 34:39](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2079)
- "The space behind the bladder is easily created, and the bowel is placed posteriorly; patients do not need prone positioning because the exstrophy makes everything anterior, so a supine frog-leg position provides full perineal access." — Alberto Peña (clinical) [Ep 33 · 35:53](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2153)
- "Cloacal exstrophy patients are lifelong patients due to orthopedic problems (separated pubic bones causing abnormal gait) and spinal problems (tethered cord requiring neurosurgical follow-up and potential cord release)." — Alberto Peña (clinical) [Ep 33 · 37:33](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2253)
- "Some teenagers are unhappy about separated pubic bones causing abnormal gait (feet pointing laterally); some dedicated orthopedic surgeons have been able to bring pubic bones closer together." — Alberto Peña (clinical) [Ep 33 · 37:38](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2258)
- "During pull-through, vaginal reconstruction is attempted by approximating the hemivaginas as much as possible; the degree of separation varies on the spectrum." — Alberto Peña (clinical) [Ep 33 · 38:50](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2330)
- "When hemivaginas are close with only a septum separating them superiorly, the septum is removed as high as possible; when vaginas run in completely different directions, one hemivagina may be removed, leaving the one with the better-looking cervix." — Alberto Peña (clinical) [Ep 33 · 39:07](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2347)
- "Patients with functional hemiuterus may become pregnant, but it is high-risk pregnancy requiring specialized pediatric gynecology follow-up; in general, pregnancy is not advised." — Alberto Peña (clinical) [Ep 33 · 39:53](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2393)
- "Hemiuterus has a great tendency to produce miscarriages and premature labor; delivery must be by cesarean section due to limited abdominal space." — Alberto Peña (clinical) [Ep 33 · 40:10](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2410)
- "Bladder augmentation requires a Mitrofanoff conduit (appendix or part of a long appendix, sometimes shared half for urology and half for Malone) for intermittent catheterization to empty the bladder." — Alberto Peña (clinical) [Ep 33 · 40:37](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2437)
- "Augmented bladders produce large amounts of mucus; if mucus is not removed, it forms stones, so families must be taught to irrigate the bladder (not just empty it) to remove mucus and prevent infections." — Alberto Peña (clinical) [Ep 33 · 41:07](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2467)
- "Bladder irrigation is sometimes performed with gentamicin to ensure all mucus is removed." — Alberto Peña (clinical) [Ep 33 · 41:33](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2493)
- "Lifelong urologic follow-up is needed to monitor for reflux and kidney damage; the Mitrofanoff may stop working or leak urine, requiring revision or valve tightening." — Alberto Peña (clinical) [Ep 33 · 41:45](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2505)
- "Patients transitioning to adult hospitals often feel uncomfortable because adult urologists and orthopedic surgeons lack experience with these congenital malformations; patients prefer to remain in pediatric environments even as adults." — Alberto Peña (clinical) [Ep 33 · 42:29](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2549)
- "Dr. Peña observes that cloacal exstrophy patients are particularly charming, intelligent, beautiful, and charismatic when they grow up, and some have energy to help others manage their own problems." — Alberto Peña (opinion) [Ep 33 · 43:03](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2583)
- "The Pull-Through Network is a national organization (similar to cystic fibrosis or breast cancer organizations) for parents and patients with anorectal malformations, Hirschsprung disease, or bowel/urinary control problems; it has over 1000 members, holds annual meetings, and invites doctors to give talks." — Alberto Peña (clinical) [Ep 33 · 43:42](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2622)
- "Colorectal and urogenital problems have been left behind in terms of scientific approach and research funding because they are not 'elegant' problems—they involve stool, urine, and sex—and institutions are not eager to receive these patients." — Alberto Peña (opinion) [Ep 33 · 44:48](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2688)
- "The initial operation includes omphalocele closure (sometimes requiring staged closure), bowel-bladder separation, end colostomy creation, bladder closure attempt (sometimes requiring multiple stages), and in some institutions, pelvic osteotomy (either at initial operation or 2-3 months later)." — Alberto Peña (clinical) [Ep 33 · 46:00](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2760)
- "Between the initial operation and pull-through, colostomy irrigation is often needed to manage poor colonic motility." — Alberto Peña (clinical) [Ep 33 · 46:54](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2814)
- "Prenatal diagnosis of anorectal and urogenital malformations is easier for complex defects (like cloacal exstrophy) than simple defects because complex cases have associated findings (spinal problems, absent bladder) visible on imaging." — Alberto Peña (clinical) [Ep 33 · 47:58](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2878)
- "Absent bladder on prenatal ultrasound (due to exstrophy) is a bad sign and can be detected as early as week 20 of pregnancy." — Alberto Peña (clinical) [Ep 33 · 48:48](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2928)
- "Prenatal diagnosis allows families to decide about pregnancy continuation and, if continuing, to deliver at a center with a multidisciplinary team experienced in these malformations." — Alberto Peña (clinical) [Ep 33 · 49:38](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=2978)
- "Certain malformations require centers of excellence where surgeons focus and sacrifice other areas of practice; attempting to train all surgeons superficially in complex conditions results in damaged children and no one becoming truly trained." — Alberto Peña (opinion) [Ep 33 · 50:04](https://library.globalcastmd.com/watch/cloacal-exstrophy-with-dr-alberto-pe-a-309?t=3004)
- "The best treatment for Hirschsprung disease is irrigations using a large bore tube (20 French Foley) with warm saline, instilling 10-20 cc aliquots at a time and allowing fluid mixed with stool to drain back." — Marc Levitt (clinical) [Ep 31 · 8:43](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=523)
- "It is very rare that Hirschsprung disease is a surgical emergency, but if you don't irrigate and overcome the distal obstruction, it will become an emergency." — Marc Levitt (clinical) [Ep 31 · 8:55](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=535)
- "For rectal biopsy in suspected Hirschsprung disease, you must be at least 1 centimeter in from the dentate line. If you biopsy too close to the dentate line, everyone has an aganglionic segment there and you could get the wrong answer." — Marc Levitt (clinical) [Ep 31 · 12:38](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=758)
- "The pathologist must report both the absence of ganglion cells AND the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung disease - that could be a biopsy taken too low." — Marc Levitt (clinical) [Ep 31 · 13:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=803)
- "Hirschsprung disease has an immune component and the lining of the bowel (mucosa) is much more susceptible to bacterial translocation. Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia." — Marc Levitt (clinical) [Ep 31 · 14:59](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=899)
- "If irrigations are not working and the baby is ill, you need to divert. The recommendation is to divert in the ileum rather than doing a leveling colostomy, because frozen section can be inaccurate, particularly as you move higher in the colon." — Marc Levitt (clinical) [Ep 31 · 15:42](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=942)
- "The Swenson operation involved full-thickness transabdominal dissection down below the peritoneal reflection. The operation was often done incorrectly with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence." — Marc Levitt (clinical) [Ep 31 · 18:14](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1094)
- "The Suave operation used a mucosal dissection to keep the outer rectal wall intact and avoid injury. The original Suave would leave the colon coming through the anus for a week before doing the coloanal anastomosis; Dr. Scott Boley modified it to do everything in one stage." — Marc Levitt (clinical) [Ep 31 · 19:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1168)
- "The Duhamel operation leaves the original rectum in place, removes the aganglionic portion from the peritoneal reflection, and pulls ganglionic bowel in a retrorectal position, connecting the two lumens with a stapler." — Marc Levitt (clinical) [Ep 31 · 20:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1218)
- "Of the four classic procedures (Swenson, Suave, Duhamel, Rabine), only the Swenson actually leaves behind virtually no Hirschsprung tissue. The others leave behind outer rectal wall or original rectum. Many patients did well despite this because ganglionic bowel, if it's good, can overcome a lot." — Marc Levitt (clinical) [Ep 31 · 21:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1278)
- "Dr. Henrys in the Philippines pioneered primary pull-through operations (without initial colostomy) out of necessity because patients would never return to clinic due to social stigma against colostomies." — Marc Levitt (clinical) [Ep 31 · 22:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1339)
- "Keith Jorgeson applied laparoscopic skills to Hirschsprung disease, doing the colonic work laparoscopically with a Suave dissection from above. Luis de la Torre and Jack Langer developed the transanal approach, starting the dissection from below." — Marc Levitt (clinical) [Ep 31 · 23:21](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1401)
- "The current preferred approach is a transanal Swenson (full-thickness dissection). It is the purest operation, leaving behind no Hirschsprung except the very bottom just above the dentate line. If you find the right plane, it's elegant and bloodless." — Marc Levitt (opinion) [Ep 31 · 25:34](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1534)
- "Dr. Orvar Swenson, who recently died at age 105, maintained that the Swenson operation was good all along and people just weren't doing it right, which gave it a bad reputation." — Marc Levitt (clinical) [Ep 31 · 26:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1583)
- "Even Suave enthusiasts are making shorter and shorter cuffs over time. Jorgeson's original laparoscopic Suave recommended a 5 cm cuff; nowadays Langer and de la Torre do 1-1.5 cm cuffs, essentially approaching a Swenson." — Marc Levitt (clinical) [Ep 31 · 27:06](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1626)
- "Laparoscopy is appropriate for all cases to find the transition zone level. A transanal-only approach is only appropriate when you have a very reachable, obvious transition zone at mid-sigmoid that you can comfortably reach transanally." — Marc Levitt (opinion) [Ep 31 · 28:50](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1730)
- "There is significant morbidity from an overly aggressive transanal-only approach trying to reach the transition zone without going into the abdomen. If you're too aggressive transanally trying to visualize the dissection, you would have been better off with laparoscopic dissection." — Marc Levitt (clinical) [Ep 31 · 29:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1758)
- "Total colonic Hirschsprung patients present differently: the diagnosis isn't made right away, the contrast study is not typical, and irrigations don't go well. These patients need laparoscopy first to find the biopsy location." — Marc Levitt (clinical) [Ep 31 · 31:18](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1878)
- "The biggest technical problems are: (1) surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or (2) they give very aggressive exposure and overstretch the sphincters." — Marc Levitt (clinical) [Ep 31 · 34:09](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2049)
- "Proper technique requires marking 1 cm proximal to the dentate line with a purple mark and placing 5-0 silk stitches circumferentially at that level. This preserves the anal canal, dentate line, plus an additional 1 cm of columnar epithelium before starting dissection." — Marc Levitt (clinical) [Ep 31 · 35:30](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2130)
- "By definition, you're leaving behind 1 cm of columnar epithelium that is Hirschsprung disease, plus the internal sphincter which has a problem with relaxation. However, good ganglionic bowel is able to overcome that, and the baby eventually learns to relax the sphincter." — Marc Levitt (clinical) [Ep 31 · 36:39](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2199)
- "The rectum doesn't really have a mesentery; the rectum's blood supply is intramural. As you get higher and reach the peritoneal reflection, that's when you start to see sigmoidal vessels where rectum transitions to sigmoid." — Marc Levitt (clinical) [Ep 31 · 38:19](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2299)
- "The anterior rectum frees up much quicker than the posterior rectum. Break into the peritoneal reflection anteriorly first. In transanal-only cases, you can pull the sigmoid out anteriorly, do a full-thickness biopsy, and send it while continuing the posterior dissection." — Marc Levitt (clinical) [Ep 31 · 38:45](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2325)
- "For laparoscopic biopsies through the umbilicus, a seromuscular biopsy (without violating mucosa) may show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa. If using this technique, send a full-thickness biopsy later to confirm the level is appropriate." — Marc Levitt (clinical) [Ep 31 · 40:56](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2456)
- "Pathologists must report not only ganglion cells but also the quality of nerves with actual micron measurements. Nerves should be 40 microns or less. Anything bigger than 40 microns is transition zone bowel." — Marc Levitt (clinical) [Ep 31 · 44:03](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2643)
- "The concept of 'go 5 cm above the transition zone' is inaccurate. Transition zone is a spectrum - some are 10 cm, some are 3 cm. You need confirmatory biopsy with ganglion cell information and nerve quality measured in microns." — Marc Levitt (clinical) [Ep 31 · 44:20](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2660)
- "It's preferable to take the IMA, preserve the arcade, and have the left colon and sigmoid nice and straight down into the perineum. This makes for an easy-to-irrigate baby. Many patients have not had enough of a pull-through with the entire sigmoid loop still there, requiring redo to remove more." — Marc Levitt (clinical) [Ep 31 · 45:57](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2757)
- "For anything proximal to the splenic flexure, do colonic biopsies and an ileostomy and wait, because frozen section has been notoriously fraught with errors in those cases. There is no urgency. Another option is to take biopsies, quit without diverting, and return 3-4 days later for pull-through with permanent section results." — Marc Levitt (clinical) [Ep 31 · 47:02](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2822)
- "Postoperatively, wait until the belly is absolutely soft and flat with bowel function before feeding. Get an X-ray because abdominal distention is sometimes subclinical. This usually takes 3-4 days. Feeding too early risks the baby going home distended and returning with enterocolitis." — Marc Levitt (clinical) [Ep 31 · 53:23](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3203)
- "Routine postoperative management: at one month, check the anus with Hagar dilators (not finger). Most babies need calibration rather than true dilation. The stimulation of passing the Hagar has value to help the baby more successfully empty." — Marc Levitt (clinical) [Ep 31 · 54:39](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3279)
- "Flagyl is only used to treat enterocolitis, not routinely postoperatively. Give a pre-op dose of second-generation cephalosporin and maybe 2 post-op doses." — Marc Levitt (clinical) [Ep 31 · 55:52](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3352)
- "Routine irrigations are only done postoperatively if the baby develops significant distention, which is rare. However, for total colonic patients after ileoanal pull-through, send all patients home on irrigations for 3 months." — Marc Levitt (clinical) [Ep 31 · 56:31](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3391)
- "For hepatic flexure transition zone (rare), open the patient rather than laparoscopy. Take down the entire right colon, recognize the ileocolic vessel and how it feeds the vessel paralleling the right colon. Often need to take the right colic artery. De-rotate the colon so cecum is at the hepatic liver bed, then do pull-through down the right side of abdomen." — Marc Levitt (clinical) [Ep 31 · 57:05](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3425)
- "If bringing de-rotated colon down the left side of abdomen, must mobilize the ligament of Treitz so the mesenteric vessel is not draped across the third portion of duodenum, which can cause duodenal obstruction." — Marc Levitt (clinical) [Ep 31 · 58:02](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3482)
- "The negative appendectomy rate among hospitals is a median of 2.6% with a range from 0 to 17%, according to Kurt Newman's 2003 paper in Journal of Pediatric Surgery reviewing the PHIS database." — Nick Bruns (host_summary) [Ep 31 · 1:59](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=119)
- "For incidental Meckel's diverticulum during laparoscopy, Zani's 2008 Annals of Surgery review recommended leaving it, stating the risk of complications is not worth the extremely low mortality rate of 0.001%." — Nick Bruns (host_summary) [Ep 31 · 2:44](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=164)
- "The 50-year Mayo Clinic experience (Park et al., 2005, Annals of Surgery) recommended selective resection of Meckel's diverticulum based on four features: age less than 50, male sex, length greater than 2 cm, or presence of histologically abnormal tissue." — Nick Bruns (host_summary) [Ep 31 · 3:10](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=190)
- "A Miami Children's Hospital paper (Al-Khoury et al., JAMA Surgery 2012) studied 200 consecutive non-perforated appendicitis patients. 80% were same-day discharges with similar complication and readmission rates compared to overnight stays." — Nick Bruns (host_summary) [Ep 31 · 4:28](https://library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=268)
- "Associated malformations in colorectal patients affect airway and cardiac systems, relevant to anesthesia choices" — Mark (clinical) [Ep 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 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 62 · 23:57](https://library.globalcastmd.com/watch/colorectal-surgery-what-does-the-anesthesia-provider-need-to-know-7276?t=1437)
- "Hirschsprung's disease is also known as agangliosis of the colon" (clinical) [Ep 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 65 · 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 agangliosis of the colon" (clinical) [Ep 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 64 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 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 63 · 3:10](https://library.globalcastmd.com/watch/hirschsprung-associated-enterocolitis-in-children-an-ernica-animation-for-parents-and-families-7808?t=190)
- "For Hirschsprung disease with high transition zone, laparoscopic biopsy and mobilization followed by transanal technique is the preferred approach to avoid being surprised by total colonic aganglionosis during a primary transanal procedure." (opinion) [Ep 5 · 2:05](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=125)
- "An average pediatric surgeon doing primary transanal Hirschsprung pull-through will encounter a higher-than-expected transition zone or total colonic aganglionosis approximately 1 in 10 to 1 in 15 times during their career." (epidemiological) [Ep 5 · 2:19](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=139)
- "A pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions." — Jason Frischer (opinion) [Ep 5 · 4:22](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=262)
- "For standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study." — Jason Frischer (clinical) [Ep 5 · 5:46](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=346)
- "Post-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation)." — Jason Frischer (clinical) [Ep 5 · 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; if no anatomic cause is found, perform biopsy." — Jason Frischer (clinical) [Ep 5 · 7:25](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=445)
- "For Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns)." — Jason Frischer (clinical) [Ep 5 · 9:04](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=544)
- "Going only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation." — Jason Frischer (clinical) [Ep 5 · 9:04](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=544)
- "Injury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line." — Jason Frischer (opinion) [Ep 5 · 9:43](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=583)
- "The top of the anal columns serves as a consistent anatomic landmark for Hirschsprung dissection level; measuring from anoderm to top of columns in newborns yields a reproducible distance." (clinical) [Ep 5 · 10:36](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=636)
- "In ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region." — Jason Frischer (clinical) [Ep 5 · 10:39](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=639)
- "The dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line." — Jason Frischer (clinical) [Ep 5 · 11:39](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=699)
- "Deliberately leaving a zone of aganglionosis above the dentate line is preferable to risking fecal incontinence; the resulting ultra-short segment can be overcome with laxatives, but incontinence cannot be overcome." — Belinda (opinion) [Ep 5 · 12:23](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=743)
- "For newborn females with vestibular fistula and normal sacrum/renal ultrasound, initial management with dilations is appropriate; many surgeons start with this approach." — Mark (clinical) [Ep 5 · 14:03](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=843)
- "Anorectal malformations that appear widely displaced from normal anal position in the newborn period may show less displacement after a few weeks to months of growth, making initial observation reasonable." — Mark (clinical) [Ep 5 · 14:31](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=871)
- "Primary anoplasty repair in the newborn period is technically challenging; the dissection between vagina and rectum is thinner and it is harder to identify the center of the sphincter in a 2 kg baby compared to an 8-9 kg baby." — Belinda (clinical) [Ep 5 · 15:39](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=939)
- "Prolonged dilations for vestibular fistula cause scarring and inflammation; dilations should be limited to maximum Hegar size 7-8 with stool softeners, as dilating to 11-12 makes subsequent repair difficult." — Belinda (clinical) [Ep 5 · 16:27](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=987)
- "The traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates." — Jason Frischer (clinical) [Ep 5 · 17:17](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1037)
- "Conservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding." — Jason Frischer (clinical) [Ep 5 · 17:27](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1047)
- "When vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through." — Jason Frischer (clinical) [Ep 5 · 18:54](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1134)
- "Rectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance." — Jason Frischer (clinical) [Ep 5 · 20:09](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1209)
- "Testing for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed." — Jason Frischer (clinical) [Ep 5 · 20:49](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1249)
- "Initial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management." — Jason Frischer (clinical) [Ep 5 · 21:19](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1279)
- "Transabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure)." — Jason Frischer (host_summary) [Ep 5 · 23:02](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1382)
- "Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone." — Jason Frischer (host_summary) [Ep 5 · 23:36](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1416)
- "Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice." — Jason Frischer (host_summary) [Ep 5 · 23:56](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1436)
- "Ventral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory." — Jason Frischer (clinical) [Ep 5 · 24:10](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1450)
- "Ventral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age." — Jason Frischer (clinical) [Ep 5 · 24:55](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1495)
- "Mesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs." — Jason Frischer (clinical) [Ep 5 · 24:10](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1450)
- "Sclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection." — Jason Frischer (clinical) [Ep 5 · 22:45](https://library.globalcastmd.com/watch/hirschsprung-disease-imperforate-anus-rectal-prolapse-update-course-2015-675?t=1365)
- "The Hirschsprung-associated IBD study was retrospective, gathering patients from 2000 to 2021 at 17 institutions" — Cecilia Gigena (epidemiological) [Ep 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 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 66 · 3:44](https://library.globalcastmd.com/watch/quick-literature-updates-episode-15-7927?t=224)
- "Dr. Mina Yeina discussed lipid nanoparticle delivery of microRNA 148A and attenuation of intestinal inflammation during NEC" (clinical) [Ep 67 · 0:04](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=4)
- "Dr. Joseph Davidson presented on sexual function and fertility outcomes in Hirschsprung's disease patients" (clinical) [Ep 67 · 0:20](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=20)
- "Dr. Shruthi Srinivas presented outcomes from colonic pull-through for cloacal atrophy" (clinical) [Ep 67 · 0:25](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=25)
- "Dr. Kala presented on single-cell guided prenatal derivation of fetal organoids" (clinical) [Ep 67 · 0:31](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=31)
- "Dr. Zheng presented on clinical characteristics and MMP-7 levels for biliary atresia" (clinical) [Ep 67 · 0:40](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=40)
- "Dr. Shruthi Srinivas won Heat 3 with her presentation on outcomes from colonic pull-through for cloacal atrophy, differentiated by colon length, in a multi-institutional study" (clinical) [Ep 67 · 1:15](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=75)
- "The competition between the second and third presentations was very tight" (opinion) [Ep 67 · 0:50](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=50)
- "The rate of Hirschsprung disease and anorectal malformation occurring together is less than 2%" — Jill Knepprath (epidemiological) [Ep 84 · 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 84 · 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 84 · 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 84 · 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 84 · 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 84 · 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 84 · 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 84 · 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 84 · 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 84 · 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 84 · 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 84 · 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 85 · 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 85 · 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 85 · 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 85 · 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 85 · 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 85 · 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 85 · 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 85 · 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 85 · 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 85 · 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 85 · 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 85 · 1:31](https://library.globalcastmd.com/watch/update-course-rewind-2025-hirschsprung-arm-rare-but-real-12084?t=91)
- "The study was published in 2026 in the Journal of Pediatric Surgery" — Megan Reed Evaurri (clinical) [Ep 86 · 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 86 · 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 86 · 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 86 · 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 86 · 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 86 · 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 86 · 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 86 · 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 86 · 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 86 · 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 86 · 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 86 · 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 86 · 1:27](https://library.globalcastmd.com/watch/safety-and-utility-of-long-acting-steroid-injection-for-management-of-post-operative-stricture-12169?t=87)
- "In the 1970s fluoroscopy was done by everybody very well; nowadays with MRI, CT, and ultrasound there has been a shift and fluoroscopy is almost a lost art." — Steven Kraus (opinion) [Ep 6 · 1:02](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=62)
- "Multiple abnormalities can be seen on plain radiographs in Hirschsprung disease: distal bowel obstruction, dilated colon, and bowel mucosal irregularities." — Steven Kraus (clinical) [Ep 6 · 2:26](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=146)
- "In a newborn you cannot tell the difference between colon and small bowel on plain radiograph; you can only say there are multiple dilated loops suggesting distal bowel obstruction." — Steven Kraus (clinical) [Ep 6 · 3:23](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=203)
- "Bubbles of meconium in newborn bowel are not necessarily pneumatosis; this is a fairly common appearance for meconium distributed throughout bowel." — Steven Kraus (clinical) [Ep 6 · 3:35](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=215)
- "The most common causes of distal bowel obstruction in neonates are Hirschsprung disease, small left colon syndrome (meconium plug syndrome/immature colon), anorectal malformation, meconium ileus, and ileal atresia—these five make up about 99% of cases." — Steven Kraus (epidemiological) [Ep 6 · 4:00](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=240)
- "Bowel wall thickening and striations on plain radiograph may indicate spasm and suggest Hirschsprung disease; with bowel thickening you must also think of enterocolitis." — Steven Kraus (clinical) [Ep 6 · 5:04](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=304)
- "Seeing air in the rectum does not rule out Hirschsprung disease." — Steven Kraus (clinical) [Ep 6 · 5:32](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=332)
- "The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph." — Steven Kraus (clinical) [Ep 6 · 6:18](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=378)
- "Air-fluid levels in the colon on cross-table or decubitus view are a sign of inflammatory process or enterocolitis in the colon." — Steven Kraus (clinical) [Ep 6 · 6:58](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=418)
- "Enterocolitis in a newborn is Hirschsprung disease until proven otherwise." — Steven Kraus (clinical) [Ep 6 · 8:14](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=494)
- "Total intestinal Hirschsprung disease is very, very rare; Dr. Kraus had seen only one case." — Steven Kraus (clinical) [Ep 6 · 8:32](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=512)
- "The contrast enema in a newborn does not always allow making the diagnosis or ruling out Hirschsprung disease." — Steven Kraus (clinical) [Ep 6 · 10:22](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=622)
- "The false negative rate of transition zone by enema is between 20% and 25% according to multiple studies." — Steven Kraus (host_summary) [Ep 6 · 10:33](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=633)
- "The false negative rate may be lower in the hands of experienced fluoroscopists, but taking all comers the rate is 20-25%." — Steven Kraus (opinion) [Ep 6 · 10:43](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=643)
- "Total colonic Hirschsprung disease is a very difficult diagnosis to make on enema." — Steven Kraus (clinical) [Ep 6 · 11:04](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=664)
- "Short segment disease is also difficult to diagnose, partly due to technique and how the enema is performed." — Steven Kraus (clinical) [Ep 6 · 11:10](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=670)
- "The false positive transition zone rate is up to 43%." — Steven Kraus (host_summary) [Ep 6 · 11:20](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=680)
- "A study in the early 2000s found radiologist agreement for transition zone location was fairly high at 90%." — Steven Kraus (host_summary) [Ep 6 · 11:35](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=695)
- "The concordance rate between radiology and pathology for transition zone location was only about 62%, just over a coin toss." — Steven Kraus (host_summary) [Ep 6 · 11:47](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=707)
- "For short segment disease (rectosigmoid or low transition), concordance between radiologic and pathologic transition zone was about 75%." — Steven Kraus (host_summary) [Ep 6 · 13:27](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=807)
- "For long segment disease (descending colon, splenic flexure, or more proximal), concordance between radiologic and pathologic transition zone was only about 25%." — Steven Kraus (host_summary) [Ep 6 · 13:43](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=823)
- "If you find a high transition zone on enema, the actual pathologic transition could be anywhere; repeat enemas in long segment disease are futile and will not give better indication of transition location." — Steven Kraus (clinical) [Ep 6 · 14:05](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=845)
- "In a patient with longer segment disease, plan the operation thinking the transition may be high rather than relying on the first enema to determine the correct operation." — Steven Kraus (clinical) [Ep 6 · 14:39](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=879)
- "Dr. Ocelami's technique: insert rectal tube only 2-3 centimeters into the rectum, never use a Foley catheter inside the rectum, hold the buttocks tight or ask older child to hold contrast." — Rodrigo Ocelami (clinical) [Ep 6 · 16:34](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=994)
- "In the neonatal period use water soluble contrast diluted 50% contrast and 50% saline, infuse very gently and very slowly with a syringe (not gravity) under fluoroscopy to avoid distending the aganglionic segment." — Rodrigo Ocelami (clinical) [Ep 6 · 17:04](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1024)
- "After the neonatal period, fill only up to the transverse colon; if the studied segment is normal in distension, caliber, and mucosa, and the splenic flexure shows no suggestion of total colonic disease, stop at the transverse colon." — Rodrigo Ocelami (clinical) [Ep 6 · 17:41](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1061)
- "Obtain two images in left lateral decubitus, two in right lateral decubitus, and two in AP position; remove the tube to get a good look at the rectum without the tube." — Rodrigo Ocelami (clinical) [Ep 6 · 18:10](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1090)
- "The main goal is to find the transition zone; as soon as you find it, stop the contrast because the diagnosis is made." — Rodrigo Ocelami (clinical) [Ep 6 · 18:50](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1130)
- "The inversion of the rectal sigmoid index is very helpful and valued as a sign." — Rodrigo Ocelami (clinical) [Ep 6 · 19:05](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1145)
- "The affected or aganglionic segment will be spastic; if you give contrast with too much volume or too fast you will miss the spasticity of the affected segment." — Rodrigo Ocelami (clinical) [Ep 6 · 19:18](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1158)
- "Irregularity of the bowel and enterocolitis are good signs to look for on enema." — Rodrigo Ocelami (clinical) [Ep 6 · 19:37](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1177)
- "Always talk to the family after the study; ask for good hydration after using barium or water soluble contrast to help the child evacuate and avoid dehydration." — Rodrigo Ocelami (clinical) [Ep 6 · 20:02](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1202)
- "Always show the family the contrast used so when white stuff comes out they know what is going on." — Rodrigo Ocelami (clinical) [Ep 6 · 20:16](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1216)
- "The main points of technique: never use Foley inside the rectum, inject contrast very slowly and gently using fluoroscopy all the time, look for the signs, and talk to the family before and after the study." — Rodrigo Ocelami (clinical) [Ep 6 · 20:47](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1247)
- "Dr. Kraus uses iodinated water soluble contrast with osmolality about 400, which is hyperosmotic and similar to agents used to clean the colon; it helps make the diagnosis and attempts to clean the colon." — Steven Kraus (clinical) [Ep 6 · 21:42](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1302)
- "If contrast stays in little neonates they can get dehydrated and run into trouble; the neonatal ICU must be aware of this." — Steven Kraus (clinical) [Ep 6 · 22:05](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1325)
- "Dr. Kraus uses gravity infusion from a bag with very large tubing at a moderate pace (not slow) to show distal and proximal parts quickly and see the transition zone rapidly." — Steven Kraus (clinical) [Ep 6 · 22:31](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1351)
- "Early maximal distention is best to see the transition zone; if you wait a long time you can distend the distal aganglionic part because it is soft tissue, not a lead pipe." — Steven Kraus (clinical) [Ep 6 · 23:10](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1390)
- "If the colon in the neonate looks small, fill the entire colon and attempt to reflux into the terminal ileum to make other diagnoses if present." — Steven Kraus (clinical) [Ep 6 · 23:30](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1410)
- "Dr. Kraus uses a Foley catheter in full-term infants (12-14 French) and smaller size in premature infants." — Steven Kraus (clinical) [Ep 6 · 23:47](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1427)
- "On a true lateral image the femurs are on top of each other and the presacral space is well seen; you really want to attempt to get that view." — Steven Kraus (clinical) [Ep 6 · 24:03](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1443)
- "On frontal view make sure you see the tube but also see distal to it; do not cut off the rectum or you will miss a very distal transition zone." — Steven Kraus (clinical) [Ep 6 · 24:11](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1451)
- "In a normal neonate the proximal colon toward the splenic flexure is always a little bit smaller than the rectum." — Steven Kraus (clinical) [Ep 6 · 24:22](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1462)
- "If you have a Foley catheter blown up in the distal rectum to prevent leakage, you will miss short segment Hirschsprung disease every single time." — Steven Kraus (clinical) [Ep 6 · 24:40](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1480)
- "Use a tube without a balloon, or if you use a balloon push it in further so it does not block the end of the colon." — Steven Kraus (clinical) [Ep 6 · 24:51](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1491)
- "Rectosigmoid transition cases are usually concordant pathologically and radiologically." — Steven Kraus (clinical) [Ep 6 · 25:04](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1504)
- "In total colonic Hirschsprung the rectum does not look bigger than the rest of the colon like it should be; when you see a colon that is one smallish size all the way through, think about total colonic disease." — Steven Kraus (clinical) [Ep 6 · 25:30](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1530)
- "The enema in a premature infant does not follow the rules; it could be immature and look small, so you cannot tell the difference between immaturity and Hirschsprung." — Steven Kraus (clinical) [Ep 6 · 25:47](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1547)
- "Contrast enemas can be done in premature infants; anything greater than 35 to 36 weeks gestational age is reasonable for diagnostic accuracy." — Steven Kraus (clinical) [Ep 6 · 26:03](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1563)
- "If you go back further in gestational age when necrotizing enterocolitis becomes much more prevalent, you will not have the same diagnostic accuracy." — Steven Kraus (clinical) [Ep 6 · 26:15](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1575)
- "If the rectum and sigmoid transition is at about S2 or distal to S1-S2, it is distal rectal disease; if more proximal than that, it is typical rectosigmoid transition." — Steven Kraus (clinical) [Ep 6 · 27:30](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1650)
- "Small left colon syndrome (meconium plug syndrome) usually has a transition at the splenic flexure that is very abrupt." — Steven Kraus (clinical) [Ep 6 · 28:06](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1686)
- "A case with small rectum on scout, small colon to splenic flexure, and meconium plugs appeared to be small left colon but was actually Hirschsprung disease with total colonic aganglionosis and terminal ileum transition." — Steven Kraus (clinical) [Ep 6 · 29:51](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1791)
- "If you have a proximal transition zone you cannot accurately say where that transition is; this should make you think about doing something more invasive rather than just transanal approach." — Steven Kraus (clinical) [Ep 6 · 30:59](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1859)
- "Dr. Ponsky always performs suction rectal biopsy in almost any patient who needed a contrast enema to rule out distal obstruction, whether meconium plug, small colon, or other cause." — Todd Ponsky (clinical) [Ep 6 · 31:46](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1906)
- "Dr. Ponsky performs rectal biopsy even in meconium ileus cases." — Todd Ponsky (clinical) [Ep 6 · 32:15](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1935)
- "If it is clearly meconium ileus with reflux into terminal ileum and clinical improvement, some surgeons will not do rectal biopsy." — Todd Ponsky (host_summary) [Ep 6 · 32:23](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1943)
- "Dr. Peña would not do biopsy if sure it is meconium ileus, but would do biopsy for a picture of small left colon because he does not know how to distinguish it from Hirschsprung." — Alberto Peña (clinical) [Ep 6 · 32:37](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=1957)
- "In Soave procedure there is partial thickness dissection leaving a cuff of tissue; if the cuff is prominent it causes a very wide presacral space best seen on lateral view." — Steven Kraus (clinical) [Ep 6 · 34:18](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2058)
- "It is very important in post-surgical patients to get a really good true lateral view of the rectum to assess presacral space." — Steven Kraus (clinical) [Ep 6 · 34:59](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2099)
- "The Duhamel procedure is a chimera of part of the aganglionic segment distally with more proximally the ganglionic segment, not put side to side or end to end but a patchwork." — Steven Kraus (clinical) [Ep 6 · 35:56](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2156)
- "In symptomatic Duhamel patients you see an extra pouch anteriorly containing stool; enlargement of this pouch and its impression on the ganglionic bowel causes the obstruction." — Steven Kraus (clinical) [Ep 6 · 36:13](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2173)
- "Dr. Peña wonders why Duhamel patients get dilated rectum; by definition Hirschsprung disease is a condition where the aganglionic segment does not get distended even after 10-15 years, yet in these patients the rectum is very stretched and fecally impacted." — Alberto Peña (opinion) [Ep 6 · 36:54](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2214)
- "Dr. Peña suspects that all patients who developed the traditional Duhamel pouch may never have had Hirschsprung disease; he invites surgeons to orient the resected pouch and have pathologists study whether there are ganglion cells in that rectum." — Alberto Peña (opinion) [Ep 6 · 37:30](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2250)
- "Dr. Collins has seen resected Duhamel pouches that had both ganglionic and aganglionic parts, but does not know what their contrast enemas looked like." — Todd Ponsky (clinical) [Ep 6 · 38:05](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2285)
- "Dr. Peña states that if he sees a patient with a contrast enema showing redundant stool-filled colon with normal rectum, he will not take a rectal biopsy because it is a waste of time and the patient has no Hirschsprung disease." — Alberto Peña (opinion) [Ep 6 · 40:26](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2426)
- "Dr. Peña states there is no way to differentiate so-called ultra-short segment Hirschsprung from idiopathic constipation." — Alberto Peña (opinion) [Ep 6 · 41:00](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2460)
- "The rectum has ganglion cells in normal ganglionic bowel, then there is one area with no ganglion cells, but the length of that normal aganglionic segment has never been accurately determined at different ages in humans." — Alberto Peña (clinical) [Ep 6 · 41:32](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2492)
- "There is no accurate study of the normal aganglionic segment length in a preemie, full-term baby, or 6-month-old baby; this is a challenge for young pediatric surgeons to contribute." — Alberto Peña (opinion) [Ep 6 · 41:42](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2502)
- "Somebody could take a biopsy in the normal aganglionic area and get a result of no ganglion cells, but it does not mean anything clinically." — Alberto Peña (opinion) [Ep 6 · 42:05](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2525)
- "The internal sphincter has been defined as a thickening of the circular layer of normal smooth muscle bowel, but Dr. Peña has never personally seen that thickening despite opening normal rectums at different ages." — Alberto Peña (opinion) [Ep 6 · 42:14](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2534)
- "If the internal sphincter thickening exists, nobody has determined the exact limit of that thickening at different ages, so it becomes a kind of magic or witchery type of diagnosis." — Alberto Peña (opinion) [Ep 6 · 42:45](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2565)
- "Internal anal sphincter achalasia is a manometric concept, not an anatomic concept, similar to the lower esophageal sphincter and other sphincters that have been defined but never anatomically seen." — Alberto Peña (opinion) [Ep 6 · 43:16](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2596)
- "Dr. Peña does not perform myectomies or myotomies and does not recommend those procedures because we do not know where to inject or what area of muscle to target." — Alberto Peña (opinion) [Ep 6 · 43:36](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2616)
- "Botox and similar injections paralyze whatever muscle is there and facilitate passing of stool, but they are not curing a condition of unknown origin." — Alberto Peña (opinion) [Ep 6 · 43:48](https://library.globalcastmd.com/watch/radiology-and-image-diagnosis-of-hirschsprung-disease-733?t=2628)
- "The 3-millimeter sealer is used as the primary mode of dissection for laparoscopic-assisted pull-through in Hirschsprung's disease." (host_summary) [Ep 10 · 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." (host_summary) [Ep 10 · 0:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=32)
- "A supraumbilical ring incision is used for the Veress needle and 4-millimeter trocar camera port in small newborns, with the trocar placed just to the left of midline to avoid the umbilical vein." (host_summary) [Ep 10 · 0:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=36)
- "A full-thickness biopsy is obtained from the muscular wall approximately 5 centimeters above the transition zone between the distal sigmoid and rectum." (host_summary) [Ep 10 · 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 10 · 1:21](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=81)
- "Because all heat and energy remains between the jaws of the sealer, there is no danger in injuring surrounding structures by brushing aside them with the sealer." (clinical) [Ep 10 · 1:32](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=92)
- "Small perforating vessels are grasped, sealed, and pulled down off the rectal wall circumferentially to dissect along the aganglionic portion of the colon." (clinical) [Ep 10 · 1:48](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=108)
- "The advantage of the 3-millimeter sealer is that it can both dissect off vessels and dissect around the colon to mobilize tissue, with no risk of pass-pointing as with a 3-millimeter hook." (clinical) [Ep 10 · 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; a bowel grasper is in the left hand and the sealer is the only instrument used in the right hand." (clinical) [Ep 10 · 2:55](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=175)
- "Carrying the 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 10 · 3:24](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?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 10 · 3:51](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?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 10 · 4:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=245)
- "When diagnosed, the preference is to perform this operation in the newborn period prior to discharge to home, as the operation is extremely safe with current technology." (opinion) [Ep 10 · 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 10 · 4:40](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=280)
- "A series of traction stitches are placed inside the anus just proximal to the dentate line and then out to the skin, slightly inverting the anus so the dentate line can be clearly visualized; 4 to 8 sutures are used." (clinical) [Ep 10 · 5:13](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=313)
- "A mucosal incision is made with handheld cautery 2 to 3 millimeters proximal to the dentate line." (clinical) [Ep 10 · 5:53](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=353)
- "Traction or stay sutures are placed in the mucosa to help retract it and allow for submucosal dissection." (clinical) [Ep 10 · 6:12](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=372)
- "The key to the transanal portion is that it should all take place externally to the anus, with no retractors ever placed within the external sphincter, which may cause these muscles to be damaged." (clinical) [Ep 10 · 6:28](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=388)
- "The beauty of the laparoscopic dissection down to the pelvic floor is that it allows release of the area so dissection can be carried out outside of the anus, protecting the external sphincter muscles and improving the chance of good continence." (clinical) [Ep 10 · 6:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=396)
- "Sharp dissection is preferred to mobilize the submucosal space, although blunt dissection can also be used." (opinion) [Ep 10 · 7:05](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=425)
- "The dissection is carried around circumferentially until the muscular cuff everts, at which point the peritoneal cavity is entered." (clinical) [Ep 10 · 7:20](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=440)
- "A stitch is placed as a retractor so the muscular cuff can be divided at the 6 o'clock position, and the dissection is carried circumferentially, allowing the colon to be pulled down through the anus." (clinical) [Ep 10 · 8:00](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=480)
- "The biopsy site is 5 to 6 centimeters above the obvious transition zone." (clinical) [Ep 10 · 8:19](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=499)
- "Remaining mesenteric attachments are taken externally using the 3-millimeter sealer to allow mobilization 5 to 6 centimeters above the biopsy site." (clinical) [Ep 10 · 8:27](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=507)
- "Laparoscopy is used to ensure proper orientation of the pull-through and that no structures are caught under the mesentery." (clinical) [Ep 10 · 8:48](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=528)
- "The colon is divided 5 to 6 centimeters above the biopsy site, which is 5 centimeters above the obvious transition zone." (clinical) [Ep 10 · 8:57](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=537)
- "Four quadrant stay sutures are placed, and 3 to 4 additional sutures are placed in each quadrant for a total of 12 to 16 sutures forming the new coloanal anastomosis, using 4-0 Vicryl suture in newborns." (clinical) [Ep 10 · 9:19](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=559)
- "This operation took 70 minutes." (clinical) [Ep 10 · 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 10 · 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 10 · 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 10 · 10:36](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=636)
- "A gauze packing is placed in the anus at the end of the procedure." (clinical) [Ep 10 · 10:45](https://library.globalcastmd.com/watch/technique-laparoscopic-assisted-pull-through-for-hirschsprung-s-disease-756?t=645)
- "Lipase half-life is about 7 days and is more specific for pancreatic pathology than amylase, which can be elevated in appendicitis, gynecologic conditions, or salivary disease." — Maissam Abu Al Haija (clinical) [Ep 12 · 3:00](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=180)
- "Amylase rises and normalizes much quicker than lipase, so in a patient presenting 2 days after symptom onset, amylase may not be the best indicator of pancreatitis." — Maissam Abu Al Haija (clinical) [Ep 12 · 2:40](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=160)
- "Ultrasound is the initial imaging modality for suspected uncomplicated acute pancreatitis in children because it is radiation-free and gives a reasonably good look at the pancreas." — Andrew Trout (clinical) [Ep 12 · 2:09](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=129)
- "Ultrasound is limited in the setting of suspected complications of pancreatitis; CT is the image of choice for complicated cases to better visualize necrosis, fluid collections, hemorrhage, or masses." — Maissam Abu Al Haija (clinical) [Ep 12 · 2:23](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=143)
- "The most helpful use of ultrasound in acute pancreatitis is looking for a biliary component—CBD dilation suggesting need for early ERCP, or gallstones that change management—not documenting pancreatitis or looking for complications." — Maissam Abu Al Haija (clinical) [Ep 12 · 4:03](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=243)
- "There is no data identifying a superior pain medication for acute pancreatitis; even adult studies have not identified optimal management." — Maissam Abu Al Haija (clinical) [Ep 12 · 6:21](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=381)
- "Opioids should not be avoided in acute pancreatitis; when used appropriately, they can help advance feeds, improve outcomes, and facilitate earlier discharge." — Maissam Abu Al Haija (clinical) [Ep 12 · 6:35](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=395)
- "Early nutrition (within 24 to 72 hours) in acute pancreatitis is associated with more favorable outcomes: it maintains gut barrier function, inhibits bacterial translocation, and lowers the incidence of systemic inflammatory response." — Maissam Abu Al Haija (clinical) [Ep 12 · 9:03](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=543)
- "A 2012 meta-analysis comparing TPN versus enteral nutrition in predicted severe acute pancreatitis showed enteral nutrition was associated with decreased organ failure, reduced surgical intervention rate, lower mortality, and fewer infections." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 9:32](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=572)
- "The Ekerwal 2007 study randomized 60 adult patients to eat on admission versus NPO and found that early feeding did not increase abdominal pain and decreased length of stay by 2 days." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 13:19](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=799)
- "In a Cincinnati Children's study of 38 admissions for mild pancreatitis, early nutrition was safe and feasible, and patients who received feeds had similar pain scores to those kept NPO." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 14:29](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=869)
- "Pilot analysis showed patients with the lowest pain scores were those who ate the most fat; fat intake did not increase length of stay." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 15:28](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=928)
- "Studies comparing NG feeds versus NJ feeds in acute pancreatitis show no difference in outcomes; duration of hospital stay and mortality were very similar, even in severe acute pancreatitis." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 12:41](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=761)
- "Aggressive IV fluid resuscitation (more than one-third of 72-hour fluid volume given in the first day) is associated with reduced mortality and reduced incidence of SIRS and organ failure at 72 hours." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 19:02](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1142)
- "In studies of aggressive resuscitation, the late resuscitation group received more total fluid than the early resuscitation group, suggesting a critical 24-hour window for intervention." — Maissam Abu Al Haija (clinical) [Ep 12 · 19:45](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1185)
- "A 2011 study of 40 patients using goal-directed management (resuscitating to urine output of 3 mL/kg/hour) showed early resuscitation with lactated Ringer's reduced inflammation markers (CRP) compared to normal saline." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 20:18](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1218)
- "In a Cincinnati Children's study of 201 patients, those kept NPO with low IV fluids had 35% rate of developing severe pancreatitis, versus 4.2% in those who ate early and received aggressive resuscitation." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 23:48](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1428)
- "For CT imaging of acute pancreatitis, a single portal venous phase is sufficient; multi-phase imaging is not needed in pediatric patients as the goal is to identify complications (venous thrombosis, necrosis, fluid collections), not masses." — Andrew Trout (clinical) [Ep 12 · 28:19](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1699)
- "Oral contrast is helpful in CT of pancreatitis to separate fluid-filled bowel loops from pancreatic fluid collections, but a sick patient who cannot tolerate oral contrast can still have an informative CT without it." — Andrew Trout (clinical) [Ep 12 · 28:41](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1721)
- "On contrast-enhanced CT, absent enhancement in pancreatic tissue is highly concerning for necrosis." — Andrew Trout (clinical) [Ep 12 · 29:51](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1791)
- "Ranson's criteria have not proven sensitive and specific for predicting severity in pediatric pancreatitis when validated in further studies, despite initial promise in a 2002 Midwest study." — Maissam Abu Al Haija (clinical) [Ep 12 · 30:31](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1831)
- "A Cincinnati Children's prognostic tool using white blood cell count, albumin value, and lipase on admission can predict severity in almost 70% of pediatric pancreatitis patients." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 31:20](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1880)
- "Antibiotics should not be used routinely in mild acute pancreatitis or in severe pancreatitis unless there is infected necrosis." — Maissam Abu Al Haija (clinical) [Ep 12 · 32:32](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1952)
- "When antibiotics are indicated for infected pancreatic necrosis, imipenem or 3rd generation cephalosporins are good initial choices." — Maissam Abu Al Haija (clinical) [Ep 12 · 33:08](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1988)
- "MRCP is not the most helpful imaging modality during an acute pancreatitis attack because edema obscures ductal anatomy; it is better reserved for workup of biliary and pancreatic ductal issues after resolution." — Maissam Abu Al Haija (clinical) [Ep 12 · 5:15](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=315)
- "The INSPPIRE consortium defines acute recurrent pancreatitis in children as at least two distinct episodes with complete resolution of pain and a one-month pain-free interval, or normalization of enzymes with complete pain resolution in less than one month." — Maissam Abu Al Haija (guideline) [Ep 12 · 34:34](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=2074)
- "Workup for acute recurrent pancreatitis includes inflammatory causes (IBD, celiac), systemic illnesses, mitochondrial diseases, cystic fibrosis, metabolic conditions (triglycerides, calcium, kidney disease), anatomic evaluation (MRCP, possibly ERCP), and genetic testing for PRSS1, SPINK1, CFTR, and CTRC." — Maissam Abu Al Haija (clinical) [Ep 12 · 35:31](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=2131)
- "In adult literature, there is growing evidence for endoscopic necrosectomy via EUS (transmural approach through stomach into necrotic cavity) showing good outcomes, but pediatric experience is extremely limited." — Tom Lynn (clinical) [Ep 12 · 41:01](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=2461)
- "Sticking needles or drains into the pancreas risks introducing infection into sterile necrosis; intervention should be avoided unless there is true significant clinical deterioration." — Jamie Nathan (opinion) [Ep 12 · 39:16](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=2356)
- "The pancreas can be difficult to visualize on ultrasound in larger patients, in patients who are not NPO (stomach full of gas), or when there is ileus from inflammation; bowel gas affects ultrasound wave penetration." — Andrew Trout (clinical) [Ep 12 · 25:33](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=1533)
- "In MRI of the pancreas after acute attacks have resolved, a prominent pancreatic duct (visible as a white stripe) and some atrophy/irregularity of contour may be seen, but these findings alone are not diagnostic of chronic pancreatitis." — Andrew Trout (clinical) [Ep 12 · 34:03](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=2043)
- "Evidence for secretin-enhanced MRCP in pediatric pancreatitis is limited; even adult literature shows iffy data on added value, though it may improve visualization of ductal anomalies in some cases." — Andrew Trout (clinical) [Ep 12 · 42:34](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=2554)
- "In a prospective acute pancreatitis registry at Cincinnati Children's (nearly 3 years old), increased weight percentile-for-age (not BMI) during the first attack predicts recurrence." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 43:35](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=2615)
- "Higher BMI may predict severe pancreatitis course in adults and children based on studies outside the US, though this has not yet been proven in the Cincinnati US population (sample size 85 patients)." — Maissam Abu Al Haija (epidemiological) [Ep 12 · 43:58](https://library.globalcastmd.com/watch/acute-pancreatitis-871?t=2638)
- "Notebook LM is a free offering of Google that can create realistic-sounding podcasts between two people from uploaded content" — Todd Ponsky (clinical) [Ep 77 · 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 77 · 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 77 · 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 (host_summary) [Ep 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 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 77 · 37:57](https://library.globalcastmd.com/watch/colorectal-quiz-episode-49-collaborating-for-kids-colorectal-pelvic-solutions-10649?t=2277)
- "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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 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 78 · 27:54](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1674)
- "Suction rectal biopsy is diagnostic for Hirschsprung's disease" (clinical) [Ep 82 · 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 82 · 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 82 · 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 82 · 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 82 · 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 82 · 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 82 · 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 82 · 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 82 · 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 82 · 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 82 · 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 82 · 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 82 · 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 83 · 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 83 · 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 83 · 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 83 · 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 83 · 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 83 · 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 83 · 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 83 · 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 83 · 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 83 · 1:41](https://library.globalcastmd.com/watch/update-course-rewind-2025-botox-for-hirschsprung-s-where-when-and-why-12049?t=101)
- "Ganglion cells are present in the rectal submucosa at 28 weeks gestation normally, though they may appear immature." — Margaret Collins (clinical) [Ep 9 · 2:43](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=163)
- "An experienced pediatric pathologist can recognize immature ganglion cells at 28 weeks gestation." — Margaret Collins (clinical) [Ep 9 · 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 9 · 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 9 · 5:27](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=327)
- "After infancy, there is increased separation of ganglia as a result of growth, making suction biopsy more difficult." — Margaret Collins (clinical) [Ep 9 · 5:33](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=333)
- "Beyond infancy, there is increased toughness of the stroma, making it more difficult to obtain a good suction rectal biopsy." — Margaret Collins (clinical) [Ep 9 · 5:47](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=347)
- "The anal canal becomes longer and thicker with age, contributing to increased suction biopsy failure rates." — Margaret Collins (clinical) [Ep 9 · 5:54](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=354)
- "If suction biopsy fails in children over one year, a deeper or full-thickness rectal biopsy should be considered as the first option." — Margaret Collins (clinical) [Ep 9 · 6:00](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=360)
- "Dr. Frykman was trained to stop attempting suction rectal biopsies at about 6 months of age and take patients to the operating room instead." — Todd Ponsky (opinion) [Ep 9 · 6:38](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=398)
- "After 6 months of age, the clinical picture of Hirschsprung disease is often so obvious that suction biopsy becomes less relevant." — Alberto Peña (opinion) [Ep 9 · 7:22](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=442)
- "The suction rectal biopsy is not the main element for diagnosis but one extra piece of information, particularly useful in newborn babies." — Alberto Peña (opinion) [Ep 9 · 7:54](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=474)
- "Having hypertrophic nerves is helpful in the setting of no ganglion cells in an otherwise adequate suction rectal biopsy." — Margaret Collins (clinical) [Ep 9 · 9:09](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=549)
- "Communication between surgeon and pathologist is essential when deciding whether to proceed with surgery based on biopsy findings." — Margaret Collins (opinion) [Ep 9 · 9:47](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=587)
- "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 9 · 15:45](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=945)
- "A better approach is to obtain a full-thickness rectal biopsy without frozen section, allow permanent sections and adjunctive studies, then plan surgical resection at a future date." — Margaret Collins (opinion) [Ep 9 · 16:28](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=988)
- "When diagnosing Hirschsprung disease on suction rectal biopsy, the pathologist is committing that child to losing at least some rectum." — Raj Kapoor (clinical) [Ep 9 · 17:26](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1046)
- "If a pathologist diagnoses Hirschsprung disease on suction biopsy and the surgeon finds ganglion cells at the peritoneal reflection, the patient still has short segment disease." — Raj Kapoor (clinical) [Ep 9 · 18:00](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1080)
- "A pathologist must be very confident when diagnosing Hirschsprung disease on biopsy, recognizing the medicolegal implications if the diagnosis is wrong." — Raj Kapoor (opinion) [Ep 9 · 18:35](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1115)
- "If there is any equivocation about the biopsy, clear communication with the surgeon is critical to discuss whether material is suboptimal or methods are inadequate." — Raj Kapoor (opinion) [Ep 9 · 19:05](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1145)
- "An experienced pathologist can recognize immature ganglion cells, probably even at 28 weeks, though this is rarely requested in suction biopsies." — Raj Kapoor (clinical) [Ep 9 · 20:35](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1235)
- "An experienced pathologist knows how to apply and interpret ancillary studies and, most importantly, knows when material is suboptimal." — Raj Kapoor (clinical) [Ep 9 · 20:52](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1252)
- "Large nerves are not present in the submucosa of all cases of Hirschsprung disease; total colonic aganglionosis is a classic example." — Margaret Collins (clinical) [Ep 9 · 23:58](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1438)
- "It is possible to have a suction rectal biopsy showing absent ganglion cells without demonstrating large nerves in the submucosa." — Margaret Collins (clinical) [Ep 9 · 24:03](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1443)
- "Nerve hypertrophy may be less apparent in very young infants as well as in older children." — Margaret Collins (clinical) [Ep 9 · 24:28](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1468)
- "When absent ganglion cells are found without hypertrophic nerves, the strength of clinical findings, biopsy adequacy, patient age, gender, contrast enema results, family history, and ancillary stains must all be considered." — Margaret Collins (clinical) [Ep 9 · 24:17](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1457)
- "Ancillary studies are extremely helpful when there are conflicting or ambiguous results or suboptimal specimen adequacy." — Raj Kapoor (clinical) [Ep 9 · 25:55](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1555)
- "If a patient has no ganglion cells and adequate submucosa but no hypertrophic nerves, a convincing abnormality in calretinin immunoreactivity or acetylcholinesterase staining can be enough to make the diagnosis of Hirschsprung disease." — Raj Kapoor (clinical) [Ep 9 · 26:33](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1593)
- "The 40-micron rule (nerves should not exceed 40 microns in diameter in distal rectum of infants under 6 months) is generally true but has rare exceptions, and does not hold in older children." — Raj Kapoor (clinical) [Ep 9 · 27:19](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1639)
- "Experienced pathologists develop a gestalt for recognizing too many, too big nerves rather than relying solely on measurements." — Raj Kapoor (clinical) [Ep 9 · 27:10](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1630)
- "The pattern of nerve hypertrophy involves a shift in caliber of all nerves, with more intermediate, moderately enlarged, and markedly enlarged nerves in greater concentration than normal." — Raj Kapoor (clinical) [Ep 9 · 27:54](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1674)
- "Pathologists should be brought more into the decision-making equation, considering not only histology but also clinical picture and radiological studies." — Miguel Reyes-Mujica (opinion) [Ep 9 · 28:45](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1725)
- "Complete communication between surgeons and pathologists will significantly reduce difficulties and possible errors." — Miguel Reyes-Mujica (opinion) [Ep 9 · 29:10](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1750)
- "Hirschsprung operations are too big to be made on a flimsy basis or with intraoperative improvisation like ordering frozen sections without a protocol." — Miguel Reyes-Mujica (opinion) [Ep 9 · 29:15](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1755)
- "In most hospitals, rectal biopsies are seen by more than one pathologist before a diagnosis is rendered." — Margaret Collins (clinical) [Ep 9 · 30:58](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1858)
- "At Cincinnati Children's, pathologists use a multi-headed microscope with a calibrated arrow to quickly measure nerve diameter during frozen sections without taking out calipers." — Margaret Collins (clinical) [Ep 9 · 31:26](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1886)
- "Transition zone characteristics include partial circumferential aganglionosis, which requires examining the whole circumference of bowel." — Margaret Collins (clinical) [Ep 9 · 32:12](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1932)
- "Transition zone contains ganglion cells that are not in their normal distribution completely around the circumference of the bowel." — Margaret Collins (clinical) [Ep 9 · 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 9 · 32:37](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1957)
- "Transition zone has hypertrophic nerves that can be evaluated with calretinin stain, more in the submucosa than in the myenteric plexus, with or without associated ganglion cells." — Margaret Collins (clinical) [Ep 9 · 32:37](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1957)
- "Submucosal hyperganglionosis (many ganglion cells in one ganglion, at least 10) is a more controversial feature of transition zone, where submucosa can look like IND type B." — Margaret Collins (clinical) [Ep 9 · 32:59](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=1979)
- "Ectopic ganglion cells can occur in normal biopsies and normally innervated bowel, making them a controversial transition zone feature." — Margaret Collins (clinical) [Ep 9 · 33:22](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2002)
- "A positive calretinin stain (showing nerve twigs in lamina propria) proximal to an aganglionic segment indicates ganglion cells are present even if not visible in that particular section." — Margaret Collins (clinical) [Ep 9 · 33:36](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2016)
- "The methodology used for IND diagnosis in Europe (15-micron thick sections, specific histochemical stains) has not been adopted in the United States." — Margaret Collins (clinical) [Ep 9 · 34:24](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2064)
- "IND has had inconsistent diagnostic criteria, with definitions changing several times over decades." — Margaret Collins (clinical) [Ep 9 · 34:55](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2095)
- "IND lacks adequate control data—studies have not compared constipated children to age-matched non-constipated controls to determine if features are causative." — Margaret Collins (clinical) [Ep 9 · 35:07](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2107)
- "IND should not be diagnosed in infants, is outgrown by age 4, does not require surgical therapy, and is self-correcting, making its clinical significance unclear." — Margaret Collins (clinical) [Ep 9 · 35:43](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2143)
- "Multiple authors have challenged whether IND diagnostic criteria represent one end of a normal spectrum." — Margaret Collins (clinical) [Ep 9 · 36:02](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2162)
- "The histopathological phenotype of IND may be a consequence or adaptation to downstream dysmotility rather than the cause." — Margaret Collins (clinical) [Ep 9 · 36:15](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2175)
- "In the United States, many features attributed to IND are considered transition zone in Hirschsprung disease." — Margaret Collins (clinical) [Ep 9 · 36:32](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2192)
- "There is not a single topographic study of intestinal neuronal dysplasia describing the anatomical extent of the histological abnormality." — Alberto Peña (clinical) [Ep 9 · 37:45](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2265)
- "Without topographic studies, there is no basis for resecting histologically abnormal portions of colon in IND, unlike in Hirschsprung disease where pathology determines resection extent." — Alberto Peña (opinion) [Ep 9 · 37:56](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2276)
- "The concept of IND is currently not clinically relevant, though there may be secrets in histological characterization of motility disorders to be studied in the future." — Alberto Peña (opinion) [Ep 9 · 38:27](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2307)
- "IND arose from the need to explain the subset of Hirschsprung patients with persistent symptoms after surgery." — Miguel Reyes-Mujica (clinical) [Ep 9 · 39:02](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2342)
- "IND was championed by a surgeon doing pathology rather than a pathologist, which is inappropriate." — Miguel Reyes-Mujica (opinion) [Ep 9 · 39:24](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2364)
- "IND should be considered a probably transitional developmental period in a subset of patients, not a condition requiring surgery." — Miguel Reyes-Mujica (opinion) [Ep 9 · 39:40](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2380)
- "Dr. Kapoor remains open-minded about whether there is an age-related change in the density of giant ganglia in the submucosa that is shifted in Hirschsprung patients." — Raj Kapoor (opinion) [Ep 9 · 40:49](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2449)
- "Studying IND properly requires many patients, patience in counting ganglion cells, and huge effort to correlate findings with outcome while controlling for other variables." — Raj Kapoor (opinion) [Ep 9 · 41:33](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2493)
- "The best way to diagnose hypoganglionosis is to consider only myenteric ganglion cell density, which requires resected bowel, not just suction biopsy." — Margaret Collins (clinical) [Ep 9 · 42:31](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2551)
- "Pathologists currently only confidently diagnose severe hypoganglionosis, based on long stretches of myenteric plexus containing small ganglia (one or two ganglion cells per ganglion) with minimal neuropil." — Margaret Collins (clinical) [Ep 9 · 42:45](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2565)
- "Less severe forms of hypoganglionosis can only be resolved for research purposes with dedicated ganglion cell counts using specific antibody markers." — Margaret Collins (clinical) [Ep 9 · 43:04](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2584)
- "Normal variation in ganglion cell density is huge, and large areas must be counted for accurate assessment, limiting the clinical value of diagnosing less severe hypoganglionosis." — Margaret Collins (clinical) [Ep 9 · 43:19](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2599)
- "Hypoganglionosis usually enters the differential diagnosis for patients who have had multiple surgical procedures and poor outcomes." — Margaret Collins (clinical) [Ep 9 · 43:34](https://library.globalcastmd.com/watch/cincihirsch-pathology-of-hirschprung-disease-737?t=2614)
- "Between 75 and 80% of Hirschsprung cases can be completed transanally, reaching normal ganglionic bowel from below." — Alberto Peña (clinical) [Ep 7 · 3:42](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=222)
- "The concordance between pathology and radiology is 75% in rectosigmoid Hirschsprung patients, meaning 25% are discordant." — Todd Ponsky (host_summary) [Ep 7 · 5:30](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=330)
- "Concordance between pathology and radiology is only 25% for long-segment Hirschsprung disease." — Todd Ponsky (host_summary) [Ep 7 · 5:39](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=339)
- "If you start transanally and cannot reach ganglionic bowel, you simply open the abdomen and continue the resection—this is not a complication." — Alberto Peña (opinion) [Ep 7 · 6:28](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=388)
- "When starting laparoscopically, you can look at the bowel and often tell what looks normal vs. abnormal, then take a biopsy at that level." — Todd Ponsky (clinical) [Ep 7 · 7:07](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=427)
- "If you start transanally and break through the peritoneum, it can be difficult to maintain pneumoperitoneum when you then go laparoscopically." — Todd Ponsky (clinical) [Ep 7 · 7:57](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=477)
- "Laparoscopic dissection is easy and gives you a head start when doing the transanal portion." — Todd Ponsky (opinion) [Ep 7 · 8:18](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=498)
- "Transanal approach results in absolutely no scar, and patients have minimal postoperative pain." — Andrea Bischoff (clinical) [Ep 7 · 8:59](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=539)
- "The main problems in Hirschsprung surgery are related to surgeon inexperience and technical incapacity, not the approach (laparoscopic vs. transanal vs. open)." — Alberto Peña (opinion) [Ep 7 · 11:10](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=670)
- "A bad surgeon will damage the patient both ways—laparoscopically or transanally." — Alberto Peña (opinion) [Ep 7 · 11:37](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=697)
- "The basic goal of Hirschsprung surgery is not to damage the sphincter mechanism, which has been damaged by both laparoscopic and non-laparoscopic techniques." — Alberto Peña (clinical) [Ep 7 · 11:45](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=705)
- "Patients complain about fecal incontinence, not the size of the scar." — Alberto Peña (opinion) [Ep 7 · 12:17](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=737)
- "When doing transanal dissection, the Lone Star retractor hooks should be placed at the pectinate line to protect the entire anal canal." — Alberto Peña (clinical) [Ep 7 · 14:13](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=853)
- "Surgeons must be careful not to stretch the anus too much during transanal dissection, as excessive stretch damages the sphincter mechanism and causes fecal incontinence." — Alberto Peña (clinical) [Ep 7 · 14:55](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=895)
- "The dissection should start 2 centimeters deep inside the rectum from the pectinate line, using multiple silk stitches to distribute tension and avoid tissue damage." — Alberto Peña (clinical) [Ep 7 · 15:21](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=921)
- "Dr. de la Torre originally started the transanal operation submucosally and rectally; Dr. Peña prefers full-thickness dissection like Dr. Swenson used to do." — Alberto Peña (clinical) [Ep 7 · 15:48](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=948)
- "Biopsies should be taken every 5 centimeters during transanal dissection until normal ganglionic bowel is found, then go 5 centimeters higher." — Alberto Peña (clinical) [Ep 7 · 16:08](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=968)
- "A two-layer anastomosis is performed: the first layer takes seromuscular of the bowel and tissue above the divided rectum; the second layer is mucosa-to-mucosa." — Alberto Peña (clinical) [Ep 7 · 16:31](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=991)
- "Keys to successful transanal surgery: respect the pectinate line and anal canal, don't stretch the anus too much, mobilize rectum to ensure ganglionic bowel with good blood supply, and perform anastomosis with no tension." — Alberto Peña (clinical) [Ep 7 · 17:12](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1032)
- "Prone position is preferred over lithotomy for transanal surgery because the surgeon is not the only one who can see, the field is not vertical, and instruments are not lost." — Alberto Peña (opinion) [Ep 7 · 17:22](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1042)
- "Leaving 1-2 centimeters of aganglionic bowel does not explain why patients don't behave well postoperatively." — Alberto Peña (opinion) [Ep 7 · 18:30](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1110)
- "Some patients operated with exactly the same technique do beautifully like normal individuals, while others have symptoms of enterocolitis, and we don't know why." — Alberto Peña (clinical) [Ep 7 · 18:42](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1122)
- "The majority of patients who come with symptoms of retention (enterocolitis or constipation) after pull-through do NOT have a portion of aganglionic bowel left—they simply behave that way." — Alberto Peña (clinical) [Ep 7 · 21:33](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1293)
- "A few patients do have an obvious piece of aganglionic bowel left, but usually it's much more than 2 centimeters." — Alberto Peña (clinical) [Ep 7 · 21:57](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1317)
- "When you finish the operation, the 2 centimeters of bowel you left above the pectinate line are already damaged, so you are very near the pectinate line." — Alberto Peña (clinical) [Ep 7 · 22:06](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1326)
- "The real concern about transanal surgery is fecal incontinence, which happens when the anal canal is damaged." — Alberto Peña (opinion) [Ep 7 · 22:21](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1341)
- "When we remove the rectum of a human being, we are already seriously affecting the mechanisms of bowel control because we are removing the natural reservoir." — Alberto Peña (clinical) [Ep 7 · 22:39](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1359)
- "Even adult ulcerative colitis patients with perfect operations and intact anal canals have problems with bowel control—they have accidents at night." — Alberto Peña (clinical) [Ep 7 · 22:50](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1370)
- "After removing the rectum, we connect a piece of colon that is constantly moving with peristalsis, whereas the rectum normally rests and only moves when it wants to empty." — Alberto Peña (clinical) [Ep 7 · 23:08](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1388)
- "Removing the rectum in a child results in passing stool constantly, requiring an intact anal canal, sensation, intact sphincter, and cooperation for bowel control." — Alberto Peña (clinical) [Ep 7 · 23:22](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1402)
- "Even in patients with a very well-preserved anal canal, some children have different degrees of fecal incontinence after Hirschsprung surgery." — Alberto Peña (clinical) [Ep 7 · 23:35](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1415)
- "Fecal incontinence after Hirschsprung surgery is much more common than we believe, and we have not been discussing it enough in pediatric surgical meetings." — Alberto Peña (opinion) [Ep 7 · 23:44](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1424)
- "Most patients with symptoms of enterocolitis and constipation after pull-through do not have residual aganglionic bowel." — Alberto Peña (clinical) [Ep 7 · 23:53](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1433)
- "Patients are born with bowel control; we provoke fecal incontinence through surgical technique." — Alberto Peña (opinion) [Ep 7 · 25:09](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1509)
- "Until the time of the video, Dr. Peña's group had performed 125 transanal operations: 56 primary Hirschsprung, 42 redo Hirschsprung, 21 for idiopathic constipation." — Alberto Peña (clinical) [Ep 7 · 25:34](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1534)
- "Transanal pull-through for idiopathic constipation is not a good operation." — Alberto Peña (opinion) [Ep 7 · 25:51](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1551)
- "When dissecting the anterior rectal wall transanally, the dissection must be conducted very meticulously because the rectum has a common wall with the vagina and prostatic urethra." — Alberto Peña (clinical) [Ep 7 · 26:24](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1584)
- "Cases with fistulas to the vagina or urinary tract after Hirschsprung surgery are unacceptable complications." — Alberto Peña (opinion) [Ep 7 · 26:45](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1605)
- "During full-thickness transanal dissection, if you see fat around the rectum, you can get closer to the rectum because that means you are not in the real rectal wall." — Alberto Peña (clinical) [Ep 7 · 27:04](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1624)
- "If you stay right on the bowel wall during dissection, you will not provoke denervation of the urinary tract, as Dr. Swenson emphasized." — Alberto Peña (host_summary) [Ep 7 · 27:23](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1643)
- "The outer layer of sutures fixes the rectum in the right position and releases tension from the inner layer." — Alberto Peña (clinical) [Ep 7 · 27:50](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1670)
- "Avoid using big retractors pulling in different directions during transanal surgery because that stretches the sphincter too much." — Alberto Peña (clinical) [Ep 7 · 29:10](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1750)
- "The Swenson technique was originally done in 3 stages: colostomy, then multiple biopsies to determine the exact length of aganglionic area, then pull-through." — Luis de la Torre (host_summary) [Ep 7 · 31:32](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1892)
- "The Duhamel technique was proposed to avoid anterior dissection of the rectum after many surgeons caused damage to pelvic structures (vagina, urethra) with the Swenson technique." — Luis de la Torre (host_summary) [Ep 7 · 32:13](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1933)
- "The Soave technique involved mucosectomy to leave a muscular cuff and pass the colon through the rectum, avoiding any dissection in the pelvis." — Luis de la Torre (host_summary) [Ep 7 · 32:49](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=1969)
- "In 1980, Philippine surgeons working in the United States published that they achieved primary endorectal pull-through for Hirschsprung patients." — Luis de la Torre (host_summary) [Ep 7 · 33:35](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2015)
- "Henry Soave said you need to do very good irrigation before starting any surgical procedure for Hirschsprung disease." — Luis de la Torre (host_summary) [Ep 7 · 34:05](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2045)
- "Laparoscopy for Hirschsprung is the same as laparotomy—it's the same Soave, Duhamel, or Swenson technique, just using different instruments." — Luis de la Torre (opinion) [Ep 7 · 34:35](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2075)
- "In many countries where laparoscopy is not common, surgeons continue using laparotomy and patients do well—it doesn't matter if they have laparotomy or laparoscopy." — Luis de la Torre (opinion) [Ep 7 · 35:01](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2101)
- "If you can do the Swenson procedure in 3 stages and the patient outcome is good, that's perfect—you don't need to do a transanal endorectal pull-through." — Luis de la Torre (opinion) [Ep 7 · 35:43](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2143)
- "To achieve the most accurate, functional, and anatomical surgery for Hirschsprung, you need good bowel (good irrigation, good pathology, no tension), caution in the blind zone (pelvis), and a perfect anastomosis (not too low, not too high, technically well-performed, preserving anal canal)." — Luis de la Torre (clinical) [Ep 7 · 62:47](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3767)
- "The anal canal is composed of three zones: anoderm (squamous epithelium), the area where the pectinate line lives, and the columnar zone." — Luis de la Torre (clinical) [Ep 7 · 64:05](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3845)
- "The columnar zone should be preserved for fecal control." — Luis de la Torre (clinical) [Ep 7 · 64:32](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3872)
- "Patients who have had different Hirschsprung techniques (transanal, laparoscopic, Soave, Swenson) and have none of these anal canal elements are fecally incontinent." — Luis de la Torre (clinical) [Ep 7 · 64:53](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3893)
- "Patients with destroyed anal canals from Hirschsprung surgery do not have enterocolitis but are fecally incontinent." — Luis de la Torre (clinical) [Ep 7 · 65:10](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3910)
- "It is prohibited to do the anastomosis below the columnar zone—if you do, the patient will be fecally incontinent." — Luis de la Torre (clinical) [Ep 7 · 66:09](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3969)
- "If you use all of the anal canal shadow area for anastomosis, the patient will have full fecal incontinence; if you use 50%, partial incontinence." — Luis de la Torre (clinical) [Ep 7 · 66:30](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3990)
- "Patients with total colonic aganglionosis have suboptimal long-term results and a high incidence of complications." — Andrea Bischoff (clinical) [Ep 7 · 70:05](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4205)
- "The most common complication in total colonic aganglionosis is ileostomy prolapse, which can be avoided by tacking the bowel proximal to the stoma to the abdominal wall." — Andrea Bischoff (clinical) [Ep 7 · 70:18](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4218)
- "Pouch pull-through is not recommended for patients with Hirschsprung disease due to obstructive symptoms." — Andrea Bischoff (opinion) [Ep 7 · 70:44](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4244)
- "Severe diaper rash in total colonic aganglionosis can happen if the anal canal is destroyed (fecal incontinence) or if the pull-through is performed too early." — Andrea Bischoff (clinical) [Ep 7 · 71:12](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4272)
- "For total colonic aganglionosis diagnosed in a healthy newborn, perform colectomy with straight ileoanal anastomosis and ileostomy at presentation." — Andrea Bischoff (clinical) [Ep 7 · 71:43](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4303)
- "Close the ileostomy in total colonic aganglionosis only when the child is toilet-trained for urine and willing to accept rectal irrigation." — Andrea Bischoff (clinical) [Ep 7 · 72:01](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4321)
- "Patients with total colonic aganglionosis have a higher risk for enterocolitis, and the best treatment for enterocolitis is rectal irrigation." — Andrea Bischoff (clinical) [Ep 7 · 72:13](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4333)
- "In total colonic aganglionosis, if ganglion cells are only present 45 cm proximal to the ileocecal valve, performing an ileoanal anastomosis and more proximal ileostomy would put the child in danger of decompensating a compensated situation." — Andrea Bischoff (clinical) [Ep 7 · 76:29](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4589)
- "Leaving unused colon in total colonic aganglionosis can lead to enterocolitis from mucus accumulation and infection, and it's difficult to irrigate." — Andrea Bischoff (clinical) [Ep 7 · 76:55](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4615)
- "Pediatric surgeons compete with each other trying to close stomas as early as possible, but this may not be best for the patient." — Alberto Peña (opinion) [Ep 7 · 78:20](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4700)
- "In Hirschsprung disease with or without total colonic aganglionosis, we resect the natural reservoir and connect high-motility bowel to the anal canal." — Alberto Peña (clinical) [Ep 7 · 78:43](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4723)
- "Adults who receive ileoanal anastomosis for ulcerative colitis live the rest of their lives trying to avoid accidents, with terrible diarrhea." — Alberto Peña (clinical) [Ep 7 · 79:09](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4749)
- "Creating intentional stasis in the bowel leads to bacterial proliferation, colitis, inflammatory changes, secretory diarrhea, and worsening symptoms." — Alberto Peña (clinical) [Ep 7 · 79:46](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4786)
- "If you wait until the patient is toilet-trained for urine (usually around 3 years), then close the ileostomy, the baby becomes totally trained for stool soon afterward, provided you did a correct operation and preserved the anal canal." — Alberto Peña (clinical) [Ep 7 · 79:52](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4792)
- "Patients with total colonic aganglionosis have a high incidence of enterocolitis and will most likely need rectal irrigation." — Alberto Peña (clinical) [Ep 7 · 80:23](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4823)
- "It's not easy to do rectal irrigations in a 3-year-old with severe diaper rash who doesn't want anything near the anus." — Alberto Peña (clinical) [Ep 7 · 80:46](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4846)
- "Laparoscopy in Hirschsprung can be used for diagnosis (leveling biopsies, ostomy creation), definitive surgery (mobilization, watching pull-through), and postoperatively (Malone creation)." — Todd Ponsky (clinical) [Ep 7 · 81:33](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=4893)
- "Benefits of laparoscopy over pure transanal: decreases stretch of anal sphincters on high dissections, allows dissection to pelvic floor (very short transanal component), prevents twisting of pulled-through bowel." — Todd Ponsky (clinical) [Ep 7 · 94:53](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=5693)
- "Pitfalls of laparoscopy: difficult with very distended colon (poor visualization), need to de-rotate right colon if pulling transverse/right colon (may require small laparotomy)." — Todd Ponsky (clinical) [Ep 7 · 94:15](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=5655)
- "Compared to laparotomy, laparoscopy decreases incision size, reduces discomfort, potentially allows earlier bowel function (1-2 days difference), and shorter hospitalization." — Todd Ponsky (clinical) [Ep 7 · 96:36](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=5796)
- "For transanal alone, laparoscopy doesn't offer much decrease in return of bowel function or postoperative hospitalization compared to pure transanal." — Todd Ponsky (opinion) [Ep 7 · 96:55](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=5815)
- "When doing rectal irrigation for Hirschsprung, if the patient improves immediately, they are a candidate for transanal approach." — Luis de la Torre (clinical) [Ep 7 · 55:35](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3335)
- "Patients with long-segment or total colonic aganglionosis do not improve with rectal irrigation." — Luis de la Torre (clinical) [Ep 7 · 60:03](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3603)
- "Patients with late presentation and chronic dilation of the colon (massive megacolon) are not suitable for primary transanal pull-through." — Luis de la Torre (clinical) [Ep 7 · 61:34](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3694)
- "Chronic dilation of the colon has poor motility, so these segments need to be resected." — Luis de la Torre (clinical) [Ep 7 · 62:18](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3738)
- "One of the most common problems in endorectal pull-through is leaving a large muscular cuff, which causes obstruction." — Luis de la Torre (clinical) [Ep 7 · 52:57](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3177)
- "To do a good endorectal pull-through, you need to identify a very good plane of dissection and observe the circular fibers of the rectum that will become the rectal cuff." — Luis de la Torre (clinical) [Ep 7 · 42:15](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2535)
- "If you are in the right plane of dissection during endorectal pull-through, the operation is almost bloodless." — Luis de la Torre (clinical) [Ep 7 · 42:36](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2556)
- "When you leave a muscular cuff with a huge, floppy, dilated colon, the patient will most probably have chronic obstruction, which produces chronic colitis." — Luis de la Torre (clinical) [Ep 7 · 42:55](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2575)
- "To create the muscular cuff, place two sutures: one taking mucosa and muscular cuff, the other taking just muscular cuff, then cut in between." — Luis de la Torre (clinical) [Ep 7 · 43:24](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2604)
- "After opening the muscular cuff, you can see the mesentery from the posterior wall; ligate and cut the vascular vessels to gain more length of colon." — Luis de la Torre (clinical) [Ep 7 · 43:51](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2631)
- "While waiting for frozen-section biopsy results, resect as much muscular cuff as possible and perform a myectomy on the posterior wall, resecting 1-2 cm in length and creating a short muscular cuff from below." — Luis de la Torre (clinical) [Ep 7 · 44:30](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=2670)
- "For frozen-section biopsies during Hirschsprung surgery, always send full-thickness biopsies, never small seromuscular biopsies, because pathologists suffer with very small biopsies on frozen section." — Luis de la Torre (clinical) [Ep 7 · 51:39](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3099)
- "The anastomosis should be performed with the most perfect technique possible, using fine sutures (5-0 or 6-0 Vicryl)." — Luis de la Torre (clinical) [Ep 7 · 53:50](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3230)
- "To perform the anastomosis, remove the Lone Star retractor hooks so you can see the anal canal again and ensure proper placement." — Luis de la Torre (clinical) [Ep 7 · 54:14](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=3254)
- "The PHOX2B gene provides instructions for making a protein that acts early in development to promote nerve cell formation and regulate neuron maturation." — Andrea Bischoff (host_summary) [Ep 7 · 121:44](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7304)
- "The PHOX2B protein is active in the neural crest, and neural crest cells migrate to form parts of the autonomic nervous system, which controls breathing, blood pressure, heart rate, and digestion." — Andrea Bischoff (host_summary) [Ep 7 · 121:58](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7318)
- "PHOX2B mutation is associated with congenital central hypoventilation syndrome, neuroblastoma, and Hirschsprung disease." — Andrea Bischoff (clinical) [Ep 7 · 122:15](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7335)
- "Congenital central hypoventilation syndrome is associated with Ondine's curse, where patients stop breathing when they fall asleep." — Alberto Peña (host_summary) [Ep 7 · 123:21](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7401)
- "Patients with congenital central hypoventilation syndrome need tracheostomy and assisted ventilation during sleep." — Andrea Bischoff (clinical) [Ep 7 · 124:17](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7457)
- "The association of Hirschsprung disease and anorectal malformation is very bad because every patient will be fecally incontinent." — Andrea Bischoff (clinical) [Ep 7 · 126:22](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7582)
- "Patients with anorectal malformation have no anal canal by definition." — Andrea Bischoff (clinical) [Ep 7 · 126:31](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7591)
- "Due to Hirschsprung disease, we will resect the natural reservoir (rectosigmoid), so patients with both conditions will be fecally incontinent." — Andrea Bischoff (clinical) [Ep 7 · 126:38](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7598)
- "It is very important to discuss guaranteed fecal incontinence with parents prior to surgery for combined Hirschsprung and anorectal malformation." — Andrea Bischoff (clinical) [Ep 7 · 126:47](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7607)
- "There are two types of Hirschsprung disease: a benign type where patients never have enterocolitis and can go for years with huge megacolon, and a bad group with manifestations during the newborn period who have great tendency to suffer enterocolitis even with good operation." — Alberto Peña (opinion) [Ep 7 · 120:08](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7208)
- "For contrast enema in Hirschsprung, do not overfill the colon—some technicians open the contrast and fill the entire colon, even the small bowel, and patients vomit." — Alberto Peña (clinical) [Ep 7 · 98:31](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=5911)
- "A good contrast study for Hirschsprung requires multiple films, including lateral views, to see if dilation goes all the way down to the pubococcygeal line." — Alberto Peña (clinical) [Ep 7 · 98:53](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=5933)
- "If dilation on contrast enema goes all the way down to the pubococcygeal line, that is not Hirschsprung, even if the biopsy says something different." — Alberto Peña (clinical) [Ep 7 · 98:58](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=5938)
- "For newborn babies with obvious Hirschsprung on contrast enema, keep NPO, place nasogastric tube, place central line, give parenteral nutrition, and do irrigations until abdomen is completely flat and you obtain bile through irrigations—then the baby is ready for surgery." — Alberto Peña (clinical) [Ep 7 · 110:52](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=6652)
- "For post-evacuation films in Hirschsprung contrast studies, delayed evacuation is seen in patients with Hirschsprung, but in equivocal cases, the aganglionic segment can be spastic and expel contrast, so post-evacuation films are not reliable for diagnosis." — Richard Krauss (clinical) [Ep 7 · 127:57](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7677)
- "In chronic constipation patients, about half of the contrast coming out on post-evacuation films is considered normal, but this is a gestalt assessment, not a precise measurement." — Richard Krauss (clinical) [Ep 7 · 128:30](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=7710)
- "When the proximal colon caliber doesn't look bigger than expected, suspect that the transition zone is more proximal than it appears—the remaining colon should be dilated if the transition is truly distal." — Richard Krauss (clinical) [Ep 7 · 87:46](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=5266)
- "In chronic constipation, the rectosigmoid is usually more dilated than the remainder of the colon, which is characteristic and different from Hirschsprung." — Richard Krauss (clinical) [Ep 7 · 97:47](https://library.globalcastmd.com/watch/surgical-procedures-for-hirschsprung-disease-736?t=5867)
- "The Colorectal Center patient population includes anorectal malformations (imperforate anus), Hirschsprung's disease, spina bifida, sacrococcygeal teratomas, trauma patients, and refractory constipation." — Jason Frischer (clinical) [Ep 1 · 0:15](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=15)
- "Appendicostomy (Malone/MAC/ACE procedure) involves bringing the appendix to the belly button with a valve mechanism to prevent reflux, allowing patients to independently administer flushes through the colon over 10–15 minutes, then sit on toilet for approximately 45 minutes to empty." — Jason Frischer (clinical) [Ep 1 · 2:32](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=152)
- "Sacral nerve stimulator is not FDA approved for children under 18, but is performed off-label; it acts like a heart pacemaker, stimulating the third sacral nerve to improve bowel and urinary continence outcomes." — Jason Frischer (clinical) [Ep 1 · 3:42](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=222)
- "Sacral nerve stimulator is a two-stage procedure (test phase and permanent phase) and has been performed at Cincinnati Children's for almost 3 years." — Jason Frischer (clinical) [Ep 1 · 4:41](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=281)
- "Solesta is an injection of hyaluronic acid polymer that fills space in the anal canal, used in patients with patulous (more open) anuses to help gain control." — Jason Frischer (clinical) [Ep 1 · 4:53](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=293)
- "Patients with deformed sacrums have lower likelihood of success with bowel management using medication alone (not on enema program)." — Jason Frischer (clinical) [Ep 1 · 7:27](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=447)
- "Malone procedure requires prior success with enemas because it only changes the route of administration; surgical procedure should not be performed on patients unsuccessful with enema program." — Jason Frischer (clinical) [Ep 1 · 7:50](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=470)
- "Malone procedure is typically performed starting at age 5 years and older, most commonly between ages 5 and 10–12 years." — Jason Frischer (clinical) [Ep 1 · 8:17](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=497)
- "Vomiting after enema can be caused by high-volume enema with irritant causing colon distention and discomfort." — Jason Frischer (clinical) [Ep 1 · 8:53](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=533)
- "To reduce enema-related nausea, give enema prior to meals or about an hour after a meal to allow digestion, avoiding administration right after a full meal when stomach distention plus bowel filling causes nausea." — Monica Holder (clinical) [Ep 1 · 9:11](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=551)
- "In cecostomy patients, if enema solution flows too fast or goes into small bowel instead of colon, it can cause vomiting; a study can track solution flow to diagnose this." — Monica Holder (clinical) [Ep 1 · 9:32](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=572)
- "Warming enema solution and ensuring irritant is not too strong for the child helps reduce vomiting; additive and volume must be adjusted to treat symptoms." — Monica Holder (clinical) [Ep 1 · 9:56](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=596)
- "Enema solution should be given over at least 5 minutes, sometimes 10–15 minutes, to avoid rapid distention and vomiting." — Monica Holder (clinical) [Ep 1 · 10:18](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=618)
- "Sacral nerve stimulator indication per manufacturer requires 50% improvement on symptoms; patient must have tried non-surgical bowel management first." — Jason Frischer (guideline) [Ep 1 · 10:59](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=659)
- "Sacral nerve stimulator requires normal sacrum; it is the least invasive option compared to Malone or Solesta when bowel management is working or needs improvement." — Jason Frischer (clinical) [Ep 1 · 11:17](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=677)
- "Using hybrid OR with 3D imaging, sacral nerve stimulator can be placed in patients with very abnormal sacrums by identifying anatomy in real-time." — Jason Frischer (clinical) [Ep 1 · 11:49](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=709)
- "Maximum enema volume is tailored to colon size based on contrast enema study; typically upper limit is around 500 mL for rectal and cecostomy/Malone enemas, occasionally slightly higher but rarely." — Monica Holder (clinical) [Ep 1 · 12:41](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=761)
- "For failed redo Hirschsprung's pull-through, redo surgery can almost always create a channel for stool evacuation via rectum/anus, even after 1–3 prior redos; very few patients end up with ileostomy if goal is rectal evacuation." — Jason Frischer (clinical) [Ep 1 · 13:45](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=825)
- "Patients with almost all large bowel removed may achieve cleanliness on enemas but require very regimented diet (avoiding laxative foods, high-sugar drinks) and multiple daily Imodium doses; some choose stoma over this quality-of-life burden." — Monica Holder (clinical) [Ep 1 · 15:27](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=927)
- "The large intestine (colon) primarily absorbs water; in adults it can absorb up to 1 liter of water per day. When colon is removed, stool becomes softer/looser because less water is absorbed." — Jason Frischer (clinical) [Ep 1 · 17:18](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1038)
- "Bowel management sometimes requires using Imodium to constipate/harden stool, then using enema to empty it—thickening stool first, then mechanically emptying." — Jason Frischer (clinical) [Ep 1 · 17:46](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1066)
- "There is no perfect surgery for constipation; if there were, all surgeons would recommend and perform it." — Jason Frischer (opinion) [Ep 1 · 19:12](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1152)
- "Transanal colon/rectum resection is minimally invasive but carries risk of post-surgical incontinence in some patients." — Jason Frischer (clinical) [Ep 1 · 19:20](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1160)
- "Colon resection for constipation may lessen treatment burden (e.g., reduce laxative dose from 10 to 5 squares of Ex-Lax) but this outcome is not guaranteed." — Jason Frischer (clinical) [Ep 1 · 19:56](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1196)
- "Before colon resection, offer sacral nerve stimulator and perform manometry (colonic and anorectal) to identify non-functioning colon segments or outlet problems (sphincter dysfunction)." — Jason Frischer (clinical) [Ep 1 · 20:22](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1222)
- "Anorectal manometry can reveal paradoxical sphincter function where child squeezes when trying to relax and vice versa; Botox works in younger children, physical therapy and biofeedback in older children for this." — Jason Frischer (clinical) [Ep 1 · 20:55](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1255)
- "Colon resection is a big surgery requiring bowel anastomosis with associated risks; once colon is resected, it cannot be replaced. All other treatments (sacral nerve, enemas, laxatives) are reversible." — Jason Frischer (clinical) [Ep 1 · 22:31](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1351)
- "Many patients referred for bowel resection have tried enemas/laxatives at doses based on age, weight, or manufacturer recommendations, but severe constipation often requires much higher doses than outlined; additional treatment may still achieve success." — Monica Holder (clinical) [Ep 1 · 23:02](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1382)
- "There is no research showing scary outcomes from long-term Senna (Ex-Lax) use; patients may need dose increases or decreases over time based on diet, exercise, and hormonal changes." — Monica Holder (clinical) [Ep 1 · 24:02](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1442)
- "Long-term Senna use causes melanosis coli (freckling appearance on colonoscopy) but no other long-term side effects beyond this visual finding." — Monica Holder (clinical) [Ep 1 · 24:45](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1485)
- "Senna laxative is like insulin for a diabetic—a necessary medication to help move bowels in severe constipation; dose may change over time but patients are not 'addicted' to it." — Jason Frischer (opinion) [Ep 1 · 25:25](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1525)
- "Excessive laxative dose causes diarrhea; laxative use must be adjusted and monitored by healthcare provider." — Monica Holder (clinical) [Ep 1 · 26:16](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1576)
- "Stimulant laxatives (Senna, Dulcolax) make the colon squeeze/push stool forward and reduce water absorption time, resulting in softer stool—two mechanisms that benefit the patient population." — Jason Frischer (clinical) [Ep 1 · 26:48](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1608)
- "Only two stimulant laxatives are available in the United States: Senna (Ex-Lax chocolate squares, tablet, liquid forms) and Dulcolax." — Jason Frischer (clinical) [Ep 1 · 27:17](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1637)
- "MiraLax is not a stimulant laxative; it prevents colon from absorbing water, keeping water in colon and making stool softer." — Jason Frischer (clinical) [Ep 1 · 27:35](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1655)
- "MiraLax is avoided in patients without full continence mechanisms because very loose stool is hard to control when nerves and muscle are partially impaired." — Jason Frischer (clinical) [Ep 1 · 27:51](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1671)
- "In spinal cord patients (tethered cord, spina bifida), stool is often so formed that MiraLax-type agent is needed to soften stool along with motility agents." — Jason Frischer (clinical) [Ep 1 · 28:15](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1695)
- "Patients with colostomy can still suffer from constipation and may require stool softener or laxative for daily colostomy output." — Monica Holder (clinical) [Ep 1 · 28:52](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1732)
- "When colonic manometry proves lower bowel has poor contraction, colostomy on upper colon allows lower colon to rest; after 6 months to 1 year (sometimes 2 years), repeat manometry checks if bowel has recovered motility, then colostomy can be closed." — Monica Holder (clinical) [Ep 1 · 29:19](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1759)
- "Bowel rest with colostomy is typically used in patients with anorectal malformation or Hirschsprung's pull-through complications (narrowing, stenosis, tightness) causing dilated colon/rectum upstream." — Jason Frischer (clinical) [Ep 1 · 30:09](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1809)
- "If colostomy is not working due to constipation, consider ileostomy to totally exclude colon and divert stool before it reaches colon." — Jason Frischer (clinical) [Ep 1 · 30:47](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1847)
- "Cone enemas are not routinely used in the Cincinnati program, but if patients are already using them successfully, the team will adjust enema ingredients within that delivery system." — Monica Holder (clinical) [Ep 1 · 31:16](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1876)
- "Enema-related pain requires evaluation for injury from enema device (fissures, cuts, ulcers in anal region) and also consideration of other abdominal organ causes (appendix, gallbladder) to avoid missing non-constipation diagnoses." — Monica Holder (clinical) [Ep 1 · 32:11](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=1931)
- "Peristeen device was originally designed for spina bifida patients, with features for those with limited finger dexterity or arm use; requires physician order and education for independent use." — Monica Holder (clinical) [Ep 1 · 33:27](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2007)
- "Peristeen has better success in patients age 8 or older; younger patients (under 8) had difficulty keeping the balloon device in the rectum." — Monica Holder (clinical) [Ep 1 · 34:08](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2048)
- "Peristeen insurance coverage is challenging; insurance companies typically deny initially because product is not widely used in US, requiring appeal letters and significant paperwork from healthcare provider." — Monica Holder (clinical) [Ep 1 · 34:33](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2073)
- "Michael Helmrath at Cincinnati Children's is growing colons in the lab from single cells, able to lengthen colon in mice and expanding to larger primates." — Jason Frischer (clinical) [Ep 1 · 35:30](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2130)
- "Anal sphincter tissue regeneration has been attempted by many researchers (using muscles from other areas, other sphincters from esophagus/stomach) but none have been proven to work; no successful procedure is currently offered." — Jason Frischer (clinical) [Ep 1 · 35:48](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2148)
- "Cincinnati Children's has nearly 3 years of experience with sacral nerve stimulators in children; it works in refractory constipation and combined urinary/stool issues, but pediatric patient heterogeneity makes outcome prediction difficult." — Jason Frischer (clinical) [Ep 1 · 37:00](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2220)
- "Sacral nerve stimulator was initially designed for urinary incontinence in postpartum women; during testing it was found to also help fecal constipation and incontinence, leading to later FDA approval for fecal symptoms." — Jason Frischer (clinical) [Ep 1 · 37:05](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2225)
- "Sacral nerve stimulator in adults is used in patients with normal anatomy/development, but in pediatrics it is used in patients with prior pelvic operations, malformations, or disease processes, making study difficult because every patient is different." — Jason Frischer (clinical) [Ep 1 · 37:30](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2250)
- "Sacral nerve stimulator has a temporary trial stage (1–2 weeks); if it doesn't work, the device is removed without implanting permanent battery." — Jason Frischer (clinical) [Ep 1 · 38:58](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2338)
- "Urinary symptom improvement with sacral nerve stimulator often exceeds the manufacturer's 50% improvement threshold." — Monica Holder (clinical) [Ep 1 · 39:22](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2362)
- "Sacral nerve stimulator has approximately 4 different programs; if symptoms return over time, the program can be changed within the implant to regain success." — Monica Holder (clinical) [Ep 1 · 40:05](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2405)
- "Constipation or fecal impaction puts pressure on urinary tract, causing urinary infections, improper emptying, urgency, and other symptoms; treating stool issues is often first step before urologic investigation." — Jason Frischer (clinical) [Ep 1 · 40:34](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2434)
- "New bedtime wetting in a patient previously clean on bowel management is suspected to be constipation; this is checked first before other evaluation." — Monica Holder (clinical) [Ep 1 · 41:31](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2491)
- "All anorectal malformation patients should be followed by urology long-term; more complex malformations have more associated urinary tract malformations, but even minor malformations require periodic follow-up to ensure kidney function and proper urinary tract emptying." — Jason Frischer (guideline) [Ep 1 · 41:58](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2518)
- "Urinary tract problems in anorectal malformation patients can cause diminished health with late-appearing signs/symptoms; regular urology checkups (exam, renal ultrasound, possibly further testing) are important even without visible problems." — Jason Frischer (clinical) [Ep 1 · 42:43](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2563)
- "Female anorectal malformation patients should see a gynecologist for reproductive health evaluation and examination." — Monica Holder (guideline) [Ep 1 · 43:14](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2594)
- "Cincinnati Children's has weekly meeting with colorectal, urology, and gynecology teams reviewing all patients to ensure comprehensive (not just focused) evaluation." — Jason Frischer (clinical) [Ep 1 · 43:37](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2617)
- "Long-term MiraLax literature is scant; many patients do fine on it. A class action lawsuit against MiraLax occurred 1–2 years ago but has not been heard about recently." — Jason Frischer (clinical) [Ep 1 · 44:12](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2652)
- "A couple of studies suggested MiraLax may have less-than-ideal neurodevelopmental outcomes, but these have not been reproduced; it is something to be thoughtful about when prescribing." — Jason Frischer (clinical) [Ep 1 · 45:00](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2700)
- "Any enema irritant (glycerin, castile soap) must be monitored; if patient produces mucus when stooling, consider if bowel is over-irritated and dial back additives or change product." — Monica Holder (clinical) [Ep 1 · 45:32](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2732)
- "Fleet phosphate enema causes the most irritation with long-term use, making colon look like a 'lead pipe' (very stiff, lacking mobility and pliability); it is used intermittently as rescue enema, not for long-term maintenance." — Jason Frischer (clinical) [Ep 1 · 46:05](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2765)
- "Fleet phosphate enema must be avoided in patients with any renal injury or kidney trouble." — Monica Holder (clinical) [Ep 1 · 46:55](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2815)
- "Solesta is not FDA approved for children; it is used in patients with patulous (open) anus as a filler to close the anal canal and help with fecal incontinence." — Jason Frischer (clinical) [Ep 1 · 47:14](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2834)
- "Solesta can be used in any age patient; Cincinnati has used it in patients 3–4 years old and older, with mixed results but little side effect (small infection risk)." — Jason Frischer (clinical) [Ep 1 · 48:13](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2893)
- "Solesta or sacral nerve stimulator may help patients transition from enemas to laxatives when prior attempts have failed, depending on individual anal canal anatomy and situation." — Jason Frischer (clinical) [Ep 1 · 48:31](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2911)
- "Sacral nerve stimulator results in spina bifida patients are mixed; some respond positively, others do not. Literature and research exist on this." — Jason Frischer (clinical) [Ep 1 · 49:17](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2957)
- "Sacral nerve stimulator in spina bifida requires adequate sacrum anatomy and presence of third sacral foramina (opening where third sacral nerve exits sacrum to innervate pelvis)." — Jason Frischer (clinical) [Ep 1 · 49:36](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=2976)
- "Patients with deformed sacrum have a range of anatomy; some still have continence potential despite sacral deformity on paper." — Monica Holder (clinical) [Ep 1 · 50:49](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3049)
- "For very deformed sacrum not suitable for sacral nerve stimulator, best option is enema (rectal, Malone, cecostomy, or Peristeen)." — Monica Holder (clinical) [Ep 1 · 51:15](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3075)
- "Botox is a muscle relaxant that relaxes the anal sphincter; it is used in Hirschsprung's disease patients with high anal resting pressures." — Jason Frischer (clinical) [Ep 1 · 51:56](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3116)
- "Solesta is hyaluronic acid polymer, a gel filling agent that closes a wide-open (patulous) anal canal; it acts very differently from Botox." — Jason Frischer (clinical) [Ep 1 · 52:19](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3139)
- "Children with normal anatomy typically potty train between 2.5 to 3.5 years, sometimes even 4 years; this varies by culture and location. Boys tend to potty train later than girls." — Monica Holder (clinical) [Ep 1 · 52:52](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3172)
- "Bowel management program starts when parent feels child needs to be in normal underwear (typically preschool/kindergarten age when peers are in underwear), not at a hard age cutoff; this can be age 3, 4, or later if child is home and not socially engaged yet." — Monica Holder (clinical) [Ep 1 · 53:33](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3213)
- "Some children are evaluated and can potty train with oral regimen; others without good continence potential start on enemas immediately. Some on enemas for years can later come off enemas and potty train when they have more maturity and buy-in, depending on anatomy." — Monica Holder (clinical) [Ep 1 · 54:22](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3262)
- "Hirschsprung's patients can potty train around the same age as other children; some will have harder time with continence depending on post-surgical anal canal anatomy and development." — Jason Frischer (clinical) [Ep 1 · 55:06](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3306)
- "Hirschsprung's evaluation requires contrast enema to assess surgical anatomy of anal canal and entire colon, plus repeat biopsy because initial frozen section may show adequate nerve cells but later those cells may be less abundant (transition zone)." — Jason Frischer (clinical) [Ep 1 · 55:30](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3330)
- "Patients with right anatomy for potty training may fail due to inadequate treatment; severe constipation causes stool leaking around impaction without sensation, so adequate treatment allows normal potty training." — Monica Holder (clinical) [Ep 1 · 56:14](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3374)
- "Anorectal malformation is abnormal development of where colon/rectum ends up (where it 'lands' in development); there is a wide spectrum in males and females." — Jason Frischer (clinical) [Ep 1 · 56:58](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3418)
- "In anorectal malformation, rectum can land outside anal canal/sphincter complex on skin just above that area, outside vagina in girls, anywhere along urinary tract in boys (with fistula causing stool to come out urinary tract), or connected to bladder in more complex cases." — Jason Frischer (clinical) [Ep 1 · 57:13](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3433)
- "Anorectal malformation diagnosis requires good physical exam and sometimes imaging." — Jason Frischer (clinical) [Ep 1 · 57:53](https://library.globalcastmd.com/watch/bowel-management-updates-innovations-with-live-q-a-april-2018-360?t=3473)
- "Many errors still happen in patients with Hirschsprung, resulting in complications and mortality" — Louis Delatorre (clinical) [Ep 28 · 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 28 · 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 28 · 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 28 · 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 28 · 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 28 · 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 28 · 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 28 · 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 28 · 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 28 · 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 28 · 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 28 · 0:00](https://library.globalcastmd.com/watch/error-traps-and-culture-of-safety-in-hirschsprung-disease-1726?t=0)
- "Every patient with cloaca history requires evaluation of three systems: urologic, gynecologic, and colorectal" — Jason Frischer (clinical) [Ep 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 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 87 · 20:14](https://library.globalcastmd.com/watch/colorectal-quiz-episode-47-13846?t=1214)
- "Every patient with cloaca history requires evaluation of three systems: urologic, gynecologic, and colorectal" — Marc Levitt (clinical) [Ep 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 88 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 89 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 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 90 · 28:04](https://library.globalcastmd.com/watch/colorectal-quiz-episode-46-13849?t=1684)
- "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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 91 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 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 92 · 10:53](https://library.globalcastmd.com/watch/colorectal-quiz-episode-40-13853?t=653)
- "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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 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 93 · 11:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-13861?t=701)
- "Suction rectal biopsy confirms the diagnosis of Hirschsprung's disease" (clinical) [Ep 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 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 94 · 17:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13864?t=1020)
- "Laparoscopic approach allows deep pelvic dissection minimizing transanal work and avoiding sphincter overstretching" — Aaron Garrison (clinical) [Ep 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 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 95 · 17:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-13866?t=1020)
- "Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period" — Marc Levitt (epidemiological) [Ep 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 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 96 · 46:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13872?t=2800)
- "Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period" — Marc Levitt (epidemiological) [Ep 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 97 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 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 98 · 46:40](https://library.globalcastmd.com/watch/anorectal-malformations-complications-13874?t=2800)
- "In the first two months of life, about 70% of volvulus cases occur, and by the first two years of life, 90% of volvulus cases that are going to occur do occur" (epidemiological) [Ep 3 · 27:23](https://library.globalcastmd.com/watch/malrotation-629?t=1643)
- "In 20% of cases with true malrotations of the fore and mid-gut, you have a normal barium enema" (clinical) [Ep 3 · 19:27](https://library.globalcastmd.com/watch/malrotation-629?t=1167)
- "A normal ultrasound does not rule out volvulus, supported by multiple studies" (clinical) [Ep 3 · 19:44](https://library.globalcastmd.com/watch/malrotation-629?t=1184)
- "Ladd's bands do not cause midgut volvulus" — Jack (clinical) [Ep 3 · 4:02](https://library.globalcastmd.com/watch/malrotation-629?t=242)
- "Ladd's bands are thought to be an attempt of the body to fuse the cecum to the lateral peritoneal wall" — Wit (clinical) [Ep 3 · 37:16](https://library.globalcastmd.com/watch/malrotation-629?t=2236)
- "The key reason to operate on an asymptomatic patient is to avoid midgut volvulus" — Jack (clinical) [Ep 3 · 3:52](https://library.globalcastmd.com/watch/malrotation-629?t=232)
- "The critical measurement is the distance between the ligament of Treitz and the ileocecal junction to prevent volvulus, though nobody knows the exact distance required" — Jack (clinical) [Ep 3 · 4:56](https://library.globalcastmd.com/watch/malrotation-629?t=296)
- "In patients with heterotaxy syndromes who have asymptomatic malrotations and undergo operations, the complication rate is remarkably high, between 30 and 50%" (epidemiological) [Ep 3 · 16:13](https://library.globalcastmd.com/watch/malrotation-629?t=973)
- "In a study from Edmonton on heterotaxy patients who underwent procedures for malrotation, the complication rate was about 50%" (host_summary) [Ep 3 · 24:59](https://library.globalcastmd.com/watch/malrotation-629?t=1499)
- "In a study by Papillon from Children's LA of about 200 heterotaxy patients, a quarter got screening upper GIs and three quarters did nothing; in 4 years there was only one case of volvulus, and in patients without bilious emesis and symptoms, no cases of volvulus" (host_summary) [Ep 3 · 25:12](https://library.globalcastmd.com/watch/malrotation-629?t=1512)
- "In the heterotaxy subgroup, the risk of volvulus in the early period (4-5 years) is actually very low if patients are not symptomatic" (epidemiological) [Ep 3 · 25:53](https://library.globalcastmd.com/watch/malrotation-629?t=1553)
- "When bowel loops are dilated, this will always give you a low-lying ligament of Treitz" — Todd Ponsky (clinical) [Ep 3 · 11:53](https://library.globalcastmd.com/watch/malrotation-629?t=713)
- "Atypical malrotation with a low-lying ligament of Treitz has some data showing lower risk of volvulus, though the data is not strong" (clinical) [Ep 3 · 16:35](https://library.globalcastmd.com/watch/malrotation-629?t=995)
- "In patients with rotation abnormalities, reversed mesenteric vessels may or may not be seen; it doesn't definitively indicate malrotation" — Jack (clinical) [Ep 3 · 41:01](https://library.globalcastmd.com/watch/malrotation-629?t=2461)
- "In Jack's series of several hundred patients, there was never a case where the vessels were normal in a patient who had risk for volvulus (narrow base mesentery), so they use it as a screening test in sick patients" — Jack (clinical) [Ep 3 · 41:15](https://library.globalcastmd.com/watch/malrotation-629?t=2475)
- "Upper GI is clearly better than ultrasound for diagnosing malrotation, but in a sick patient who can't get to radiology, ultrasound can be useful" — Jack (clinical) [Ep 3 · 41:54](https://library.globalcastmd.com/watch/malrotation-629?t=2514)
- "Laparoscopic Ladd's procedure can be very effective even in a newborn, though if there's too much twist and no room, conversion to open may be necessary" — Tim Kane (clinical) [Ep 3 · 8:18](https://library.globalcastmd.com/watch/malrotation-629?t=498)
- "In cardiac patients between first stage and Glenn procedure who get G-tubes, Nissen fundoplication is often requested because they vomit and are too small for PEGs" — Tim Kane (clinical) [Ep 3 · 14:42](https://library.globalcastmd.com/watch/malrotation-629?t=882)
- "A 45-minute Nissen at pressures of 8 is tolerated by cardiac patients between stages" — Tim Kane (clinical) [Ep 3 · 14:56](https://library.globalcastmd.com/watch/malrotation-629?t=896)
- "In a published study combining experience with Kansas City, the cardiac risk group did not stratify out to be at higher risk for reflux complications; neurologically impaired CP kids maybe, but not cardiac kids" — Todd Ponsky (host_summary) [Ep 3 · 15:15](https://library.globalcastmd.com/watch/malrotation-629?t=915)
- "Yama does not operate on asymptomatic malrotation as long as the patient has non-bilious vomiting, is gaining weight, and is clinically well" — Todd Ponsky (host_summary) [Ep 3 · 35:20](https://library.globalcastmd.com/watch/malrotation-629?t=2120)
- "If a patient has a narrow pedicle, the patient always has vomiting and is symptomatic" — Todd Ponsky (host_summary) [Ep 3 · 36:16](https://library.globalcastmd.com/watch/malrotation-629?t=2176)
- "Ladd's bands themselves are not risky; the risk is bilious vomiting and narrowing of the pedicle" — Todd Ponsky (host_summary) [Ep 3 · 36:39](https://library.globalcastmd.com/watch/malrotation-629?t=2199)
- "In situs inversus or ambiguous cases, measuring the distance between ligament of Treitz and ileocecal junction matters regardless of where the bowels are; if less than half the diameter of the abdominal cavity, intervention is needed" — Jack (clinical) [Ep 3 · 39:27](https://library.globalcastmd.com/watch/malrotation-629?t=2367)
- "Infant presented with delayed passage of meconium of more than 48 hours, but passed meconium after digital rectal examination and was kept for observation." — Jafar (clinical) [Ep 4 · 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 and tight rectum with passage of explosive stool after removing examining finger." — Jafar (clinical) [Ep 4 · 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 4 · 1:08](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=68)
- "At laparotomy for colostomy creation, 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 4 · 1:16](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=76)
- "Collapsed colon and dilated ileum with typical cone segment were observed at surgery." — Jafar (clinical) [Ep 4 · 1:38](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=98)
- "All bands were released and ileostomy was created; biopsies from appendix and terminal ileum confirmed total colonic aganglionosis." — Jafar (clinical) [Ep 4 · 1:48](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=108)
- "Postoperatively, infant was given IV fluids, antibiotics, and total parenteral nutrition; after bowel function returned, feeding was started with Ensure high-calorie formula with vitamin B12 supplementation." — Jafar (clinical) [Ep 4 · 2:03](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=123)
- "Infant developed multiple episodes of dehydration requiring hospital admission for IV fluid replacement." — Jafar (clinical) [Ep 4 · 2:28](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=148)
- "At 70 days of age (now 4 months at time of presentation), infant's weight was 3.5 kg, indicating slow weight gain." — Jafar (clinical) [Ep 4 · 2:37](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=157)
- "Only a few cases have been reported of total colonic aganglionosis associated with malrotation: Philone reported 4 patients, Kors reported 1 patient, and 3 patients were reported by others; no cases have been reported with all three anomalies (total colonic aganglionosis, malrotation, and congenital bands)." — Jafar (epidemiological) [Ep 4 · 3:39](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=219)
- "Congenital bands in this case are rare; etiology is unknown but could be attributed to abnormal bowel rotation or other developmental findings." — Jafar (clinical) [Ep 4 · 4:08](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=248)
- "The typical scenario for malrotation with Hirschsprung disease is a child with bilious vomiting who undergoes Ladd procedure for malrotation, but then fails to open up postoperatively, prompting investigation that reveals total colonic aganglionosis." (clinical) [Ep 4 · 5:42](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=342)
- "After Ladd procedure, if the baby does not open up, other potential causes for bilious vomiting must be considered, including Hirschsprung disease." (clinical) [Ep 4 · 6:06](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=366)
- "When malrotation is associated with Hirschsprung disease, the segments are usually short, not total colonic, following the same distribution as Hirschsprung disease in general." (epidemiological) [Ep 4 · 6:18](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=378)
- "For total colonic Hirschsprung disease, the preferred operation is Duhamel because it is simple, safe, and provides a reservoir at the bottom, which Soave does not." (opinion) [Ep 4 · 6:43](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=403)
- "Timing of definitive repair should be based on consistency of ileostomy output rather than age or weight; repair should be delayed until output firms up, which usually occurs when the infant starts solid food." (opinion) [Ep 4 · 7:05](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=425)
- "Infants do not do well if definitive repair is performed too early when ileostomy output is still very liquid." (clinical) [Ep 4 · 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 disease, Duhamel is the taught and used procedure, but the modern approach uses a relatively short piece of colon to create a small reservoir rather than the long Martin modification." (clinical) [Ep 4 · 7:28](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=448)
- "Good continence control in long-segment Hirschsprung disease is achieved in only about 50% of patients; the data on outcomes is not great." (epidemiological) [Ep 4 · 7:55](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=475)
- "When aganglionosis extends more than 50 cm proximal to the ileocecal valve into small bowel, it represents a much more progressive disease with a bigger dysmotility element, and classic operations are less likely to provide a simple fix." (clinical) [Ep 4 · 8:14](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=494)
- "There is no evidence in the literature that any particular procedure (Duhamel vs Soave) is superior for long-segment Hirschsprung disease; surgeons should use the procedure with which they have the best results." — Sharif (opinion) [Ep 4 · 8:54](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=534)
- "In infants with ileostomy who are not gaining weight despite adequate calories and normal blood tests, sodium loss should be investigated by checking sodium levels in the ileostomy effluent." — Sharif (clinical) [Ep 4 · 9:42](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=582)
- "Serum sodium will remain normal for many months before decreasing, so checking effluent sodium is necessary to detect losses early." — Sharif (clinical) [Ep 4 · 10:12](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=612)
- "If ileostomy effluent contains more than 5 to 7 mEq/L of sodium, the infant will not gain weight." — Sharif (clinical) [Ep 4 · 10:21](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=621)
- "The infant must be gaining weight and growing before proceeding with definitive surgical repair." — Sharif (clinical) [Ep 4 · 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 sodium replacement therapy in infants with ileostomy." (clinical) [Ep 4 · 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 receive sodium supplementation." (opinion) [Ep 4 · 10:49](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=649)
- "Iron deficiency is a significant long-term issue in children after any repair for Hirschsprung disease, though not an immediate concern in young infants." (clinical) [Ep 4 · 10:50](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=650)
- "For total colonic Hirschsprung disease, if Soave procedure is chosen, the surgeon should wait until the baby grows and the ileostomy is thicker before performing definitive repair." (opinion) [Ep 4 · 11:06](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=666)
- "After Soave or other procedures for total colonic disease, bulking agents or antidiarrheal agents can help manage stool consistency." (clinical) [Ep 4 · 11:29](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=689)
- "Some patients who underwent Duhamel abroad returned with problems including enterocolitis, obstruction, and distension of the Duhamel pouch." (clinical) [Ep 4 · 11:44](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=704)
- "Monitoring ileostomy output before deciding on definitive procedure is critically important." (clinical) [Ep 4 · 12:01](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=721)
- "Some patients who had ileoanal anastomosis developed severe perianal erosion requiring protective ileostomy and treatment before further procedures could be performed." (clinical) [Ep 4 · 12:05](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=725)
- "Patients with total colonic Hirschsprung disease should be managed with a long-term perspective rather than focusing only on immediate surgical decisions." (opinion) [Ep 4 · 12:38](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=758)
- "For regular (non-total colonic) Hirschsprung disease patients, Soave procedure does not result in incontinence if the procedure is performed correctly without damaging the sphincters." (opinion) [Ep 4 · 13:04](https://library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=784)
- "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 13 · 1:42](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=102)
- "The intestine of a newborn or fetus doubles in length in the last trimester of gestation." — Brad Warner (clinical) [Ep 13 · 3:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=183)
- "For a neonate with an ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for potential salvageability." — Brad Warner (clinical) [Ep 13 · 4:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=243)
- "Without the colon and ileocecal valve, at least 15 to 20 centimeters of small intestine would be needed for potential salvageability in neonates." — Brad Warner (clinical) [Ep 13 · 4:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=277)
- "In adult studies, adults with less than 50 centimeters of intestine have about 40% mortality after 5 to 10 years." — Brad Warner (epidemiological) [Ep 13 · 4:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=291)
- "According to Pediatric Intestinal Failure Research Consortium data, approximately 25% of children with short gut syndrome die, 25% need a transplant, and 50% can wean off TPN." — Brad Warner (epidemiological) [Ep 13 · 6:38](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=398)
- "The most common causes of death in intestinal failure include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access." — Brad Warner (clinical) [Ep 13 · 7:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=431)
- "Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection." — Brad Warner (clinical) [Ep 13 · 7:49](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=469)
- "Stool outputs of up to 40 cc per kilo per day are acceptable when advancing enteral feeding; beyond that threshold, enteral feeding should be reduced." — Brad Warner (clinical) [Ep 13 · 8:30](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=510)
- "The most common causes of short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias, with trauma and inflammatory bowel disease further down the list." — Brad Warner (epidemiological) [Ep 13 · 9:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=562)
- "For TPN, the goal is about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and the remainder from fat and protein." — Brad Warner (clinical) [Ep 13 · 10:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=622)
- "TPN should provide about 2 to 3 grams of protein per kilo per day and about 2 to 3 grams of fat per kilo per day." — Brad Warner (clinical) [Ep 13 · 10:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=645)
- "Babies should gain about 20 to 30 grams a day, which approximates in utero weight gain for a newborn." — Brad Warner (clinical) [Ep 13 · 12:05](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=725)
- "Lipid reduction strategy involves reducing fat from 2-3 g/kg/day given daily down to about 1 g/kg/day delivered twice or three times a week, which has been effective in reducing TPN-associated cholestasis." — Brad Warner (clinical) [Ep 13 · 12:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=773)
- "Omegaven is a fish oil-based fat containing primarily omega-3 fatty acids that are anti-inflammatory, in contrast to soybean-based intralipid which contains pro-inflammatory omega-6 fatty acids." — Brad Warner (clinical) [Ep 13 · 13:46](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=826)
- "SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has recently been FDA approved in the United States." — Brad Warner (clinical) [Ep 13 · 15:08](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=908)
- "Breast milk is the best choice for neonates because it contains proper fat composition plus growth factors such as epidermal growth factor and insulin-like growth factors that promote adaptation." — Brad Warner (opinion) [Ep 13 · 18:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1091)
- "Complex formulas fed enterally may stimulate adaptation better than elemental formulas because they cause secretion of enterotrophic hormones to a greater extent." — Brad Warner (opinion) [Ep 13 · 19:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1166)
- "There is a threshold percentage of enteral calories that prevents the onset of TPN-related liver damage, though the exact number is unknown; 90% enteral feeding carries far less risk than 10% enteral feeding." — Brad Warner (clinical) [Ep 13 · 20:56](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1256)
- "Surgical intervention should be considered when patients regress in enteral tolerance (e.g., tolerating 50% enteral a month ago but now down to 20%), when there are multiple episodes of sepsis with abdominal distention and dilated bowel loops, or when the child develops jaundice." — Brad Warner (clinical) [Ep 13 · 22:33](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1353)
- "Dilated bowel loops greater than 4 to 5 centimeters in diameter, combined with failure to advance enteral feeds or regression, is an indication for surgical intervention." — Brad Warner (clinical) [Ep 13 · 25:43](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1543)
- "Less than 5 to 10% of patients with over 100 centimeters of intestine should require TPN, suggesting an underlying motility or mucosal problem if they remain TPN-dependent." — Brad Warner (clinical) [Ep 13 · 27:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1673)
- "The STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation because it is easier to perform with less risk of injuring the mesenteric blood supply." — Brad Warner (clinical) [Ep 13 · 29:31](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1771)
- "The Bianchi procedure takes advantage of the bifurcating blood supply to the bowel wall, allowing longitudinal division to create two tubes of bowel, effectively doubling the length." — Brad Warner (clinical) [Ep 13 · 30:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1800)
- "STEP procedures can redilate and require redo operations, and outcomes are not as good when a STEP needs to be redone compared to never needing a redo." — Brad Warner (clinical) [Ep 13 · 32:54](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1974)
- "A Bianchi can be performed first, then a STEP can be done later if needed, but a Bianchi cannot be done after a STEP has been performed (unless the STEP was inadequate)." — Brad Warner (clinical) [Ep 13 · 33:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2006)
- "Tapering should be considered for children with dilated bowel who have at least 90 to 100 centimeters of intestinal length." — Brad Warner (clinical) [Ep 13 · 38:21](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2301)
- "Teduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1 to 2 liters per week." — Brad Warner (clinical) [Ep 13 · 43:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2625)
- "Growth hormone and glutamine combinations have been administered to patients, but results are primarily mixed and it hasn't been a huge advance in weaning TPN." — Brad Warner (clinical) [Ep 13 · 45:40](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2740)
- "Current 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 13 · 46:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?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 that increases risk for malignancies and infections." — Brad Warner (clinical) [Ep 13 · 47:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2831)
- "Ethanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters." — Brad Warner (clinical) [Ep 13 · 49:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2962)
- "Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival in intestinal failure patients, as demonstrated in series from Boston, Michigan, and Texas." — Brad Warner (clinical) [Ep 13 · 51:16](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=3076)
- "The infant presented with delayed passage of meconium of more than 48 hours, but passed meconium after examination." — Jafar (clinical) [Ep 23 · 0:18](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=18)
- "At day 7 of age, the infant presented with signs and symptoms of Hirschsprung disease including abdominal distension, tight rectum with passage of explosive stool after removing the examining finger." — Jafar (clinical) [Ep 23 · 0:30](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=30)
- "Full thickness rectal biopsy confirmed the absence of ganglion cells." — Jafar (clinical) [Ep 23 · 0:44](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=44)
- "On laparotomy for colostomy creation, 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 23 · 0:52](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=52)
- "Biopsy from the appendix and terminal ileum proved total colonic aganglionosis." — Jafar (clinical) [Ep 23 · 1:32](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=92)
- "Postoperatively, the infant received IV fluids, antibiotics, and total parenteral nutrition, then was started on high-calorie formula (Ensure) with vitamin B12 supplementation after bowel function returned." — Jafar (clinical) [Ep 23 · 1:39](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=99)
- "The infant developed multiple attacks of dehydration requiring hospital admission for IV fluid replacement." — Jafar (clinical) [Ep 23 · 2:04](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=124)
- "Only a few cases have been reported of total colonic Hirschsprung associated with malrotation: Philone reported 4 patients, one author reported 1 patient, and Zbra reported 3 patients, but no cases reported all three anomalies (total colonic Hirschsprung, malrotation, and congenital bands)." — Jafar (epidemiological) [Ep 23 · 3:16](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=196)
- "Congenital bands in this context are rare; the etiology is unknown but could be attributed to antenatal perforation of the bowel." — Jafar (clinical) [Ep 23 · 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 is a child with bilious vomiting who gets a contrast study showing malrotation, undergoes Ladd procedure, but then doesn't open up, prompting reconsideration of other causes." (clinical) [Ep 23 · 5:20](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=320)
- "Once a Ladd procedure is done, if the baby doesn't open up, you must think about other potential causes for bilious vomiting." (clinical) [Ep 23 · 5:42](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=342)
- "Hirschsprung associated with malrotation is usually short segment, not total colonic, but follows the same distribution as Hirschsprung in general." (epidemiological) [Ep 23 · 5:54](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=354)
- "For total colonic Hirschsprung, the preferred operation is Duhamel because it is simple, safe, and provides a reservoir at the bottom, which Soave does not." (opinion) [Ep 23 · 6:19](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=379)
- "Timing of definitive repair should be based on consistency of ileostomy output, not age or weight; patients don't do well if operated too early when output is still liquidy." (opinion) [Ep 23 · 6:41](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=401)
- "It is preferable to wait until ileostomy output firms up, which usually happens when the infant gets onto solid food." (opinion) [Ep 23 · 6:55](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=415)
- "For long segment or total colonic Hirschsprung, a relatively short piece of colon should be left, creating a small reservoir rather than the longer Martin modification element." (opinion) [Ep 23 · 7:07](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=427)
- "Good control in long segment Hirschsprung disease is really about 50% of patients; the data really isn't that great." (epidemiological) [Ep 23 · 7:32](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=452)
- "When long segment Hirschsprung involves more than 50 cm from the ileocecal valve, it is a much more progressive disease with a bigger dysmotility element." (clinical) [Ep 23 · 7:51](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=471)
- "There is no evidence in the literature that any particular procedure should be done just because the patient has long segment Hirschsprung; the best approach is to use whatever procedure the surgeon has had the best results with." — Sharif (opinion) [Ep 23 · 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 often has to do with sodium loss." — Sharif (clinical) [Ep 23 · 9:18](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=558)
- "Unless sodium levels in the effluent are checked, sodium loss will not be caught because serum sodium will be normal for many months before it starts to decrease." — Sharif (clinical) [Ep 23 · 9:49](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=589)
- "If ileostomy output contains more than 5 to 7 mEq per liter of sodium, the baby will not grow or gain weight." — Sharif (clinical) [Ep 23 · 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 23 · 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 how much sodium replacement to give." (opinion) [Ep 23 · 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 get sodium supplementation." (opinion) [Ep 23 · 10:10](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=610)
- "Iron deficiency is a big long-term issue with any repairs in these patients and is often forgotten." (clinical) [Ep 23 · 10:26](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=626)
- "For total colonic Hirschsprung, if doing Soave or other procedure, you must wait until the baby grows and the ileostomy is thicker, then can continue with bulking agents or antidiarrheal agents." (opinion) [Ep 23 · 10:46](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=646)
- "Some patients who had Duhamel done abroad came back with problems including enterocolitis, obstruction, and distension of the Duhamel pouch." (clinical) [Ep 23 · 11:20](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=680)
- "The baby should be monitored for ileostomy output before deciding on any procedure; some patients with ileoanal anastomosis developed severe perianal erosion requiring protective ileostomy before further procedures." (clinical) [Ep 23 · 11:42](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=702)
- "Soave for regular Hirschsprung disease patients (not total colonic) does not result in incontinence if the procedure is followed well and sphincters are not damaged." (opinion) [Ep 23 · 12:40](https://library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=760)
- "Failure of medical management is defined as appropriate treatment with no appropriate response" — Kahleb Graham (clinical) [Ep 39 · 2:51](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=171)
- "Patients who cannot take treatment (e.g., kids with autism or other cognitive problems) are considered to have failed medical management" — Kahleb Graham (clinical) [Ep 39 · 3:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=184)
- "Patients with persistent symptoms or pain with treatment, or failure to grow, are considered to have failed medical management" — Kahleb Graham (clinical) [Ep 39 · 3:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=184)
- "Failure of retrograde enemas is considered failure of medical management" — Kahleb Graham (clinical) [Ep 39 · 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 39 · 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 (MiraLax, lactulose) and stimulant laxatives (Senna, bisacodyl), but there are other medications GI specialists use that pediatricians are not accustomed to prescribing" — Anil Darbari (clinical) [Ep 39 · 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 don't completely evacuate" — Anil Darbari (clinical) [Ep 39 · 4:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=298)
- "Initial evaluation includes history (triggers, stooling frequency, sensation of complete emptying), physical exam (abdominal distension, palpable stool, rectal exam), and diagnostic imaging (abdominal X-ray, water-soluble contrast enema)" — Anil Darbari (clinical) [Ep 39 · 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 is diagnostic studies including contrast enema to assess colonic dilation, redundancy, and ensure normal ratio" — Kahleb Graham (clinical) [Ep 39 · 5:27](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=327)
- "Water-soluble contrast (not barium) is used for contrast enemas because it helps empty the colon and acts as a cleanout for patients starting new medical therapy" — Jason Frischer (clinical) [Ep 39 · 8:06](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=486)
- "Contrast studies are not great predictors of how patients will respond to medical or surgical management; normal-looking colons may not respond while abnormal-appearing colons may respond well" — Jason Frischer (clinical) [Ep 39 · 7:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=432)
- "The rectoanal inhibitory reflex (RAIR) is the response where the internal anal sphincter relaxes when the rectum becomes distended with stool" — Rod (host_summary) [Ep 39 · 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 39 · 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 a functional obstruction" — Anil Darbari (clinical) [Ep 39 · 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 39 · 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, comparing sensation to defecate with internal anal sphincter response" — Anil Darbari (clinical) [Ep 39 · 10:19](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=619)
- "Doctor Levitt states he doesn't know how he survived without anorectal manometry testing" — Marc Levitt (opinion) [Ep 39 · 10:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=647)
- "In the past, surgeons did not understand the major role the sphincter played in many patients" — Jason Frischer (opinion) [Ep 39 · 10:51](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=651)
- "Colonic motility assessment is critical because in the past, colons or sigmoid colons were resected based on appearance, but patients had motility disorders and did not need resection" — Marc Levitt (clinical) [Ep 39 · 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 39 · 7:54](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=474)
- "Anorectal manometry is critical for determining whether a patient needs surgery or resection, as patients with motility disorders do not need surgery" — Rod (host_summary) [Ep 39 · 12:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=723)
- "Historically, surgeons have been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have." — Gail Besner (opinion) [Ep 50 · 1:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=101)
- "The concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work." — Gail Besner (clinical) [Ep 50 · 2:55](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=175)
- "Nationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits." — Gail Besner (clinical) [Ep 50 · 3:07](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=187)
- "The Nationwide system kept work RVUs as part of the incentivization plan along with other goals that must be achievable." — Gail Besner (clinical) [Ep 50 · 3:27](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=207)
- "After implementing the academic RVU system, Nationwide had an increase in presentations, peer-reviewed publications, and external federal research funding." (host_summary) [Ep 50 · 3:44](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=224)
- "External federal research funding at Nationwide increased from $750,000 to $5.7 million, representing a 7.7-fold increase." — Rod Gerardo (host_summary) [Ep 50 · 3:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=238)
- "At Akron Children's Hospital under Bob Perry, the bonus structure required the entire group to reach a certain RVU threshold for everyone to receive 50% of their bonus, eliminating competition for cases." — Todd Ponsky (clinical) [Ep 50 · 5:03](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=303)
- "The BC Children's Hospital gastroschisis study was a retrospective review comparing outcomes before and after implementation of a protocol in 2012, covering patients from 2008 to 2019." (host_summary) [Ep 50 · 5:51](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=351)
- "At Saint Justine Hospital, the approach to gastroschisis differed from other institutions in that there was very low use of silos, with pretty much every patient having an attempt at immediate bedside sutureless closure following a protocol developed several years prior." — Charza Jaharifard (clinical) [Ep 50 · 6:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=418)
- "Before and after protocol implementation at BC Children's Hospital, approximately 75% of gastroschisis patients could be closed immediately, whether in the OR pre-implementation with fascial closure or at bedside post-implementation." — Charza Jaharifard (clinical) [Ep 50 · 7:57](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=477)
- "With silo management, parents look at their newborn's intestines through a silo for 5-6 days and cannot hold their baby until the silo is completely reduced." — Charza Jaharifard (clinical) [Ep 50 · 8:27](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=507)
- "With immediate closure of gastroschisis, if babies are extubated within 48 hours, parents can hold them within 48 hours, or immediately if managed without intubation." — Charza Jaharifard (clinical) [Ep 50 · 8:43](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=523)
- "In prior studies of placental mesenchymal stem cells for in utero MMC repair, two surgeries were performed on lambs: one to create the defect and one to repair it, both in utero, with PMSCs used during repair." (host_summary) [Ep 50 · 10:17](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=617)
- "In the current study, a single operation was performed at approximately 100 days gestational age where the MMC defect was created and repaired simultaneously, with PMSCs placed directly onto the spinal cord." (host_summary) [Ep 50 · 10:43](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=643)
- "The PMSCs did not persist in the placentas, uteri, or lambs at 3 months follow-up." (host_summary) [Ep 50 · 11:23](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=683)
- "There was no histological evidence of abnormal growth or tumor development in the ovine model at 3 months." (host_summary) [Ep 50 · 11:30](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=690)
- "Human trials using PMSCs for in utero myelomeningocele repair have been initiated with the first two patients enrolled." (host_summary) [Ep 50 · 11:52](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=712)
- "Allen et al. studied 277 children with Hirschsprung's disease, approximately half had Soave procedure, one-third had Duhamel, and the rest had Swenson procedure." — Britney Levy (host_summary) [Ep 58 · 0:47](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=47)
- "217 of the 277 Hirschsprung's disease patients had long-term outcome data available." — Britney Levy (host_summary) [Ep 58 · 0:47](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=47)
- "Duhamel procedure has the lowest risk of incontinence but the highest risk of constipation in school age children with Hirschsprung's disease." — Britney Levy (host_summary) [Ep 58 · 0:47](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=47)
- "Peters et al. retrospectively reviewed 55 pediatric patients with small bowel syndrome to examine whether presence or absence of ileocecal valve and/or colon can predict enteral autonomy." — Rod Gerardo (host_summary) [Ep 58 · 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 (host_summary) [Ep 58 · 1:35](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=95)
- "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 (host_summary) [Ep 58 · 1:35](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=95)
- "Olsen et al. systematic review analyzed 10 studies with 6,430 patients examining surgeon volume and pediatric thyroid surgery outcomes." — Cecilia Gigena (host_summary) [Ep 58 · 2:43](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=163)
- "The definition of a high volume surgeon varies widely, ranging from 9 thyroidectomies per year to over 200 thyroidectomies with at least 30 being in pediatric patients." — Cecilia Gigena (host_summary) [Ep 58 · 2:43](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=163)
- "Thyroidectomies performed by high volume surgeons show shorter length of stays." — Cecilia Gigena (host_summary) [Ep 58 · 2:43](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=163)
- "Tendon et al. conducted a prospective randomized control trial between 2017 and 2018 comparing three skin closure methods: sutures with tissue adhesive, sutures with adhesive tape, and sutures alone." — Ellen Encisco (host_summary) [Ep 58 · 3:35](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=215)
- "Wounds were assessed at two weeks, six weeks, and more than six months after operation by surveying clinicians and parents." — Ellen Encisco (host_summary) [Ep 58 · 3:35](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=215)
- "Wounds with tissue adhesive had poorer cosmesis at six weeks compared to other closure methods." — Em Tombash (host_summary) [Ep 58 · 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 disappears by six months." — Em Tombash (host_summary) [Ep 58 · 4:17](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=257)
- "At six months, there was no difference in wound outcomes between the three closure groups for either clinicians or parents." — Em Tombash (host_summary) [Ep 58 · 4:17](https://library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=257)
- "Malrotation occurs in about 1 in 200 to 500 live births." — Em Tombash (host_summary) [Ep 57 · 0:28](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=28)
- "In the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis." — Meera Kotagal (clinical) [Ep 57 · 1:17](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=77)
- "Normal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant." — Meera Kotagal (clinical) [Ep 57 · 1:44](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=104)
- "Intestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation." — Meera Kotagal (clinical) [Ep 57 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "In non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation." — Meera Kotagal (clinical) [Ep 57 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure." — Meera Kotagal (clinical) [Ep 57 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "Malrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus." — Meera Kotagal (clinical) [Ep 57 · 2:22](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "Complications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery)." — Meera Kotagal (clinical) [Ep 57 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "About 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus." — Meera Kotagal (epidemiological) [Ep 57 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "About 70% of those who will have a midgut volvulus will present in the first year of life." — Meera Kotagal (epidemiological) [Ep 57 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases." — Meera Kotagal (clinical) [Ep 57 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "Children with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy." — Meera Kotagal (clinical) [Ep 57 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses." — Meera Kotagal (clinical) [Ep 57 · 3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "In the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal." — Meera Kotagal (clinical) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension." — Meera Kotagal (clinical) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Late signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia." — Meera Kotagal (clinical) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "The differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis." — Meera Kotagal (clinical) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it." — Meera Kotagal (clinical) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Upper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned." — Meera Kotagal (clinical) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "On upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position." — Meera Kotagal (clinical) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Contrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test." — Meera Kotagal (clinical) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Midgut volvulus is considered the number one surgical emergency in pediatric surgery." — Meera Kotagal (opinion) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Surgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation." — Meera Kotagal (clinical) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability." — Meera Kotagal (clinical) [Ep 57 · 4:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "You can have malrotation without midgut volvulus, but you cannot have midgut volvulus without malrotation." — Em Tombash (host_summary) [Ep 57 · 8:33](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=513)
- "The Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible." — Meera Kotagal (clinical) [Ep 57 · 8:54](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=534)
- "The reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms." — Meera Kotagal (clinical) [Ep 57 · 8:54](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=534)
- "Some believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus." — Meera Kotagal (opinion) [Ep 57 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Laparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus." — Meera Kotagal (opinion) [Ep 57 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "About one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease." — Meera Kotagal (epidemiological) [Ep 57 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Laparoscopic approach may reduce the risk of postoperative bowel obstruction." — Meera Kotagal (opinion) [Ep 57 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Dr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically." — Meera Kotagal (opinion) [Ep 57 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "There is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach." — Meera Kotagal (opinion) [Ep 57 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "There is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications." — Meera Kotagal (opinion) [Ep 57 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly." — Meera Kotagal (clinical) [Ep 57 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Decisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion." — Meera Kotagal (opinion) [Ep 57 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "MMP-7 (matrix metalloproteinase 7) are proteolytic peptidases that break down peptide bonds for amino acids and are part of tissue remodeling processes, playing roles in tissue repair, arthritis, metastasis, and cirrhosis" — Em Gootee (host_summary) [Ep 71 · 1:25](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=85)
- "Higher levels of MMP-7 are associated with the diagnosis of biliary atresia" — Em Gootee (host_summary) [Ep 71 · 1:43](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=103)
- "In a cohort of 329 biliary atresia cases from July 2020 to December 2022, 40 were classified as low MMP-7" — Em Gootee (host_summary) [Ep 71 · 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 (gamma glutamyl transpeptidase) and direct bilirubin" — Em Gootee (host_summary) [Ep 71 · 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, and blood GGT levels are used to detect diseases of the liver and bile ducts" — Em Gootee (host_summary) [Ep 71 · 3:02](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=182)
- "Biliary atresia has variable outcomes even within one center, with patients who anatomically look similar having dramatically different outcomes" — Em Gootee (host_summary) [Ep 71 · 3:19](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=199)
- "Having lower MMP-7 levels within the cohort of biliary atresia patients is associated with worse prognosis" — Em Gootee (host_summary) [Ep 71 · 4:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=249)
- "The mechanism of why low MMP-7 levels in biliary atresia patients leads to worse prognosis is unknown" — Em Gootee (host_summary) [Ep 71 · 4:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=281)
- "In a Canadian cohort of 411 infants with gastroschisis treated at CAPSNET centers from 2014 to 2022, 144 were excluded due to gestational age, birth weight, other congenital anomalies, or complicated gastroschisis, leaving 267 participants" — Em Gootee (host_summary) [Ep 71 · 7:02](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=422)
- "Of 267 uncomplicated gastroschisis patients, 78% received exclusive breast milk in the first 28 days of life and 22% received supplemental or exclusive formula" — Em Gootee (host_summary) [Ep 71 · 7:43](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=463)
- "Patients with uncomplicated 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 71 · 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 exclusive breast milk and formula groups in time to reach full enteral feeds, duration of parenteral nutrition, or length of stay in uncomplicated gastroschisis" — Em Gootee (host_summary) [Ep 71 · 8:27](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=507)
- "Patients with uncomplicated gastroschisis who received some formula appeared to have slightly faster time getting to full feeds, likely related to timing of closure rather than feeding type" — Mike Livingston (clinical) [Ep 71 · 8:34](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=514)
- "Patients with uncomplicated gastroschisis who received exclusive breast milk in the first 28 days were far more likely to transition to exclusive breastfeeding: 73% compared to 11% in those with formula exposure" — Em Gootee (host_summary) [Ep 71 · 8:53](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=533)
- "A systematic review on transition from pediatric to adult care for colorectal conditions included 8 studies with patient, parent, and clinician perspectives, focusing on patients aged 10-30 years with anorectal malformation or Hirschsprung disease" — Em Gootee (host_summary) [Ep 71 · 12:46](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=766)
- "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 to adult care (around 25 years)" — Em Gootee (host_summary) [Ep 71 · 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 (opinion) [Ep 71 · 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 colorectal patients showed agreement with those for medical patients that existing guidelines were based on" — Sebastian King (clinical) [Ep 71 · 13:42](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=822)
- "Patients felt that 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 transitions smooth" — Sebastian King (clinical) [Ep 71 · 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 from pediatric to adult care happened in a timely or coordinated manner" — Whit Holcomb (clinical) [Ep 71 · 14:22](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=862)
- "No models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review" — Whit Holcomb (clinical) [Ep 71 · 14:38](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=878)
- "The Beotti et al. prospective study on postoperative calibrations in Hirschsprung disease took place 2021 to 2023 and included 33 patients under six months old who underwent endorectal pull-through surgeries." — Lizzie Lee (host_summary) [Ep 79 · 1:03](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=63)
- "In the Beotti study, patients were assigned to a new non-dilation protocol group or a traditional dilation group." — Lizzie Lee (host_summary) [Ep 79 · 1:14](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=74)
- "The Beotti study primary outcomes were anastomotic complications, enterocolitis, and constipation." — Lizzie Lee (host_summary) [Ep 79 · 1:20](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=80)
- "In the Beotti study, there was no significant difference in anastomotic complications between the two groups, but the non-dilation group had less enterocolitis and less constipation." — Lizzie Lee (host_summary) [Ep 79 · 1:27](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=87)
- "Choosing not to do postoperative anal dilations after Hirschsprung pull-through may be a good alternative with benefits like lower constipation and enterocolitis." — Lizzie Lee (host_summary) [Ep 79 · 1:36](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=96)
- "The APSA Outcomes and Evidence-based Practice Committee systematic review by Slidell et al. found that delivery after 37 weeks is optimal for gastroschisis." — Alex Halpern (host_summary) [Ep 79 · 2:11](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=131)
- "For gastroschisis, prophylactic antibiotics covering skin flora are adequate to reduce infection risk until closure." — Alex Halpern (host_summary) [Ep 79 · 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 (host_summary) [Ep 79 · 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 (host_summary) [Ep 79 · 2:28](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=148)
- "The APSA systematic review concluded that there is a need for high quality randomized controlled trials to help provide evidence-based care for gastroschisis infants." — Alex Halpern (host_summary) [Ep 79 · 2:42](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=162)
- "The Pefer et al. study is a retrospective study done in Texas using a state hospital database examining CDH outcomes by center volume." — Cecilia Gigena (host_summary) [Ep 79 · 3:16](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=196)
- "The Pefer study identified 1,314 CDH patients: 728 from high volume centers, 9 from mid-volume centers, and 79 from low volume centers." — Cecilia Gigena (host_summary) [Ep 79 · 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, even though they have significantly sicker patients." — Cecilia Gigena (host_summary) [Ep 79 · 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 (host_summary) [Ep 79 · 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 (host_summary) [Ep 79 · 4:00](https://library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=240)
- "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 30 · 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 30 · 3:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=183)
- "A 24-25 week premature infant with 20-25 cm of bowel will likely increase to at least 50 cm just on the basis of growth alone" — Brad Warner (clinical) [Ep 30 · 3:13](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=193)
- "For a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability" — Brad Warner (clinical) [Ep 30 · 4:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=243)
- "Without the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate" — Brad Warner (clinical) [Ep 30 · 4:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=277)
- "In adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years" — Brad Warner (epidemiological) [Ep 30 · 4:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=291)
- "According to Pediatric Intestinal Failure Research Consortium data, of children on TPN for more than several months due to short gut syndrome: 25% die, 25% need transplant, and 50% can wean off TPN" — Brad Warner (epidemiological) [Ep 30 · 6:38](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=398)
- "Common causes of death in intestinal failure include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access" — Brad Warner (clinical) [Ep 30 · 7:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=431)
- "Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection" — Brad Warner (clinical) [Ep 30 · 7:49](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=469)
- "The goal of management is to wean TPN and push enteral feeding, accepting stool outputs of up to 40 cc per kilo per day as the limit" — Brad Warner (clinical) [Ep 30 · 8:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=499)
- "The most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias" — Brad Warner (epidemiological) [Ep 30 · 9:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=562)
- "For TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein" — Brad Warner (clinical) [Ep 30 · 10:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=622)
- "Shoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN" — Brad Warner (clinical) [Ep 30 · 10:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=645)
- "Begin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip" — Brad Warner (clinical) [Ep 30 · 11:06](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=666)
- "With continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous" — Brad Warner (opinion) [Ep 30 · 11:23](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=683)
- "Want a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn" — Brad Warner (clinical) [Ep 30 · 12:05](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=725)
- "Lipid reduction strategy takes fat from 2-3 g per kilo per day given daily down to about 1 g per kilo per day delivered twice or 3 times a week, which has been effective in reducing TPN-associated cholestasis" — Brad Warner (clinical) [Ep 30 · 12:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=773)
- "Omegaven is a fish oil-based fat containing primarily 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 30 · 14:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=843)
- "When fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels" — Brad Warner (clinical) [Ep 30 · 14:38](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=878)
- "SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has recently been FDA approved in the United States" — Brad Warner (clinical) [Ep 30 · 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 proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation" — Brad Warner (opinion) [Ep 30 · 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 (opinion) [Ep 30 · 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, with 90% enteral feeding having far less risk of TPN-related cholestasis than 10% enteral" — Brad Warner (clinical) [Ep 30 · 21:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1279)
- "Time to consider surgical intervention is when enteral tolerance plateaus and then declines (going backward rather than forward), or with multiple sepsis episodes plus abdominal distention and dilated bowel loops, or when child starts getting jaundiced" — Brad Warner (clinical) [Ep 30 · 22:33](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1353)
- "Dilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function" — Brad Warner (clinical) [Ep 30 · 23:28](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1408)
- "More than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention" — Brad Warner (clinical) [Ep 30 · 25:43](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1543)
- "If a child has over 100 centimeters of intestine, less than 5-10% should require TPN, suggesting there may be an underlying motility or mucosal problem" — Brad Warner (clinical) [Ep 30 · 27:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1673)
- "For bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated" — Brad Warner (clinical) [Ep 30 · 28:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1717)
- "The STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation" — Brad Warner (epidemiological) [Ep 30 · 29:31](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1771)
- "The Bianchi procedure takes advantage of the V-shaped blood supply bifurcation before reaching the bowel wall, allowing creation of two tubes each supplied by one arm of the V" — Brad Warner (clinical) [Ep 30 · 30:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1800)
- "STEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles" — Brad Warner (clinical) [Ep 30 · 32:30](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1950)
- "STEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo" — Brad Warner (clinical) [Ep 30 · 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 30 · 33:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2006)
- "In a case where a STEP was acting as a brake causing dysmotility, removing the distal stepped bowel allowed the patient to completely wean off TPN" — Brad Warner (clinical) [Ep 30 · 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 90-100 centimeters of intestinal length" — Brad Warner (clinical) [Ep 30 · 38:23](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2303)
- "Strategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds" — Brad Warner (clinical) [Ep 30 · 39:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2340)
- "Dan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work" — Brad Warner (clinical) [Ep 30 · 39:23](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2363)
- "Dilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver" — Brad Warner (clinical) [Ep 30 · 39:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2391)
- "Medical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation" — Brad Warner (clinical) [Ep 30 · 40:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2426)
- "The gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion" — Brad Warner (clinical) [Ep 30 · 41:54](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2514)
- "In mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection" — Brad Warner (clinical) [Ep 30 · 42:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2539)
- "Teduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week" — Brad Warner (clinical) [Ep 30 · 43:57](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2637)
- "Teduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation" — Brad Warner (clinical) [Ep 30 · 44:34](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2674)
- "Growth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine" — Brad Warner (clinical) [Ep 30 · 45:13](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2713)
- "Growth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive" — Brad Warner (clinical) [Ep 30 · 45:46](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2746)
- "Survival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%" — Brad Warner (epidemiological) [Ep 30 · 46:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2811)
- "The intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression" — Brad Warner (clinical) [Ep 30 · 47:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2831)
- "Ethanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters" — Brad Warner (clinical) [Ep 30 · 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 specialists, and interventional radiologists improve survival in intestinal failure patients, as demonstrated in series from Boston, Michigan, and Texas" — Brad Warner (clinical) [Ep 30 · 51:20](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=3080)
- "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 (host_summary) [Ep 8 · 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 (host_summary) [Ep 8 · 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, trying to explain why the dilated portion was the cause rather than the consequence of the disease." — Andrea Bischoff (host_summary) [Ep 8 · 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 (host_summary) [Ep 8 · 8:52](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=532)
- "In 1946, Orvar Swenson finally recognized the finding of no ganglion cells in the narrow rectal sigmoid as the cause of Hirschsprung disease, whereas others before him had noted absent ganglion cells but thought it was an acquired condition." — Andrea Bischoff (host_summary) [Ep 8 · 10:08](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=608)
- "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 8 · 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 (host_summary) [Ep 8 · 12:38](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=758)
- "Barium enema technique became the standard diagnostic test for Hirschsprung disease in 1948, with Dr. Swenson involved in this publication." — Andrea Bischoff (host_summary) [Ep 8 · 13:23](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=803)
- "Barry Shandling, who worked in Canada, proposed punch biopsies for newborns that required no closure nor anesthesia." — Andrea Bischoff (host_summary) [Ep 8 · 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 (host_summary) [Ep 8 · 16:43](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=1003)
- "Dr. Swenson observed that when patients had a colostomy the obstruction was relieved, but after closing the colostomy the disease returned." — Andrea Bischoff (host_summary) [Ep 8 · 17:35](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=1055)
- "Dr. Swenson scoped from the rectum when the patient had a colostomy and saw there was no true obstruction." — Andrea Bischoff (host_summary) [Ep 8 · 17:57](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=1077)
- "Dr. Swenson used a probe on the proximal stoma and saw normal peristalsis, but when he put a probe in the distal stoma he saw there was no peristalsis." — Andrea Bischoff (host_summary) [Ep 8 · 18:09](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=1089)
- "Dr. Swenson performed a contrast study 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 (host_summary) [Ep 8 · 18:22](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=1102)
- "Hirschsprung disease is not only about ganglion cells or no ganglion cells; it is a much more complex condition." — Alberto Peña (opinion) [Ep 8 · 4:20](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=260)
- "The most serious challenge in Hirschsprung disease is the basic science approach to solve the problem of enterocolitis and many other problems affecting children with the disease." — Alberto Peña (opinion) [Ep 8 · 4:05](https://library.globalcastmd.com/watch/history-of-hirschsprung-disease-734?t=245)
- "Direct pancreatic function testing means obtaining function directly from the pancreas, not relying on stool testing for fecal elastase." (clinical) [Ep 15 · 0:05](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=5)
- "Endoscopic pancreatic function testing replaced the duodenal-tube (drilling) method by the end of the 1990s/early 2000s." (clinical) [Ep 15 · 2:07](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=127)
- "Dr. Conwell and colleagues at Tyler Stevens launched endoscopic function testing, showing comparable results to duodenal-tube testing for bicarbonate and lipase measurement." (clinical) [Ep 15 · 2:13](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=133)
- "Endoscopic collection became the standard because duodenal-tube testing requires the patient to be awake, placement of two tubes, and interventional radiology." (clinical) [Ep 15 · 2:39](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=159)
- "The Cincinnati protocol uses secretin 0.2 mcg/kg or CCK 0.04 mcg/kg at time zero, then collects duodenal aspirates every 5 minutes for three samples using an ERCP tapered catheter." (clinical) [Ep 15 · 3:05](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=185)
- "The lab at Cincinnati Children's Hospital measures activities for four enzymes: trypsin, amylase, lipase, and chemotrypsin." (clinical) [Ep 15 · 3:46](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=226)
- "Pancreatic function can be abnormal if checked around an acute attack." (clinical) [Ep 15 · 4:25](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=265)
- "Exocrine pancreatic maturation occurs over the first 2 to 3 years of life." (clinical) [Ep 15 · 4:33](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=273)
- "MR pancreatic function testing acquires identical imaging pre- and post-secretin to quantify the volume of fluid secreted into the gastrointestinal tract." — Andrew Trout (clinical) [Ep 15 · 5:18](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=318)
- "The delay between pre- and post-secretin MR imaging is about 15 minutes to allow fluid accumulation." — Andrew Trout (clinical) [Ep 15 · 6:27](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=387)
- "MR-PFT can threshold images and quantify secreted fluid volume by subtracting pre-secretin from post-secretin fluid volume." — Andrew Trout (clinical) [Ep 15 · 7:38](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=458)
- "Phantom studies have proven that MR can accurately quantitate fluid volume." — Andrew Trout (clinical) [Ep 15 · 8:13](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=493)
- "Preliminary data in about 35 patients are examining correlation between MR-PFT and endoscopic pancreatic function testing." — Andrew Trout (clinical) [Ep 15 · 8:28](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=508)
- "Qualitative MR exocrine assessment appears different between pediatric and adult patients, suggesting possible size or weight dependency." — Andrew Trout (opinion) [Ep 15 · 8:49](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=529)
- "In chronic or acute recurrent pancreatitis patients with ductal changes, the pancreatic duct is often dilated and abnormal at baseline, so secretin may not be needed to visualize the duct." — Andrew Trout (opinion) [Ep 15 · 9:41](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=581)
- "Low-fat diet, pancreatic enzyme replacement therapy (PERT), antioxidants, and steroids have never been shown to prevent recurrent pancreatitis episodes or pancreatic pain episodes." (clinical) [Ep 15 · 12:05](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=725)
- "The case patient was PRSS1-positive on genetic testing." (clinical) [Ep 15 · 12:43](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=763)
- "The case patient had low fecal elastase on two occasions and endoscopic PFTs showed low amylase and lipase, borderline low trypsin and chemotrypsin." (clinical) [Ep 15 · 12:47](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=767)
- "The case patient had normal hemoglobin A1C and normal mixed meal test for endocrine function." (clinical) [Ep 15 · 13:01](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=781)
- "The case patient showed evidence of ductal changes on ERCP, confirming chronic pancreatitis based on imaging and ERCP findings." (clinical) [Ep 15 · 13:09](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=789)
- "The case patient has been pain-free on PERT treatment for several months with catch-up growth." (clinical) [Ep 15 · 13:17](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=797)
- "The multidisciplinary pain consult at Cincinnati comprises three disciplines: pain physician (medical/psychosocial assessment, medication, interventional management), psychologist (100% of the time, not optional), and nurses." — Goldschneider (clinical) [Ep 15 · 15:00](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=900)
- "Cognitive-behavioral therapy is the standard, state-of-the-art therapy for pain management." — Goldschneider (guideline) [Ep 15 · 18:16](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=1096)
- "The 13-year-old pain case had extensive psychiatric disabilities: bipolar disorder, attention deficit disorder, oppositional defiant disorder." — Goldschneider (clinical) [Ep 15 · 16:37](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=997)
- "The 13-year-old's recurrent pancreatitis episodes were timed almost specifically with visits to his father, when he went off all medical regimen (diet, enzyme therapy)." — Goldschneider (clinical) [Ep 15 · 17:23](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=1043)
- "Topiramate was used for the 13-year-old's migraines and may have a role for visceral hyperalgesia where the gut has become sensitized by repeated inflammatory processes." — Goldschneider (clinical) [Ep 15 · 20:02](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=1202)
- "Low-dose methadone was used for about 2 years in the 13-year-old case, and weaning off was not a problem when the time was right." — Goldschneider (clinical) [Ep 15 · 20:22](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=1222)
- "In Ohio, informed consent is required for the use of opioids for chronic purposes in minors (law about a year old at time of recording)." — Goldschneider (guideline) [Ep 15 · 21:28](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=1288)
- "The 13-year-old's pain resolved for a couple of years without any surgical or endoscopic intervention, came off all pain medications, returned to school, and surgery was deferred indefinitely." — Goldschneider (clinical) [Ep 15 · 22:21](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=1341)
- "Discussing the neurobiology and neuropsychology of pain with families—using anecdotes like the paper-cut example (opening a lottery ticket vs. a bad report card)—helps destigmatize psychology referral." — Goldschneider (opinion) [Ep 15 · 24:04](https://library.globalcastmd.com/watch/function-tests-pain-management-pancreatic-disease-968?t=1444)
- "For a newborn with Hirschsprung disease and a transition zone at the descending colon level, laparoscopic biopsy and mobilization is the preferred approach among polled experts." — Mark (opinion) [Ep 16 · 1:35](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=95)
- "For the average pediatric surgeon performing primary transanal pull-through without biopsy, there is approximately a 1 in 10 to 1 in 15 chance of encountering disease higher than expected or total colonic aganglionosis during their career." (epidemiological) [Ep 16 · 2:09](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=129)
- "Surgeons performing transanal pull-through without prior biopsy should have a predetermined exit strategy for managing unexpectedly proximal disease." (opinion) [Ep 16 · 2:44](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=164)
- "The safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through." — Jason Frischer (opinion) [Ep 16 · 3:06](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=186)
- "Leveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable." — Jason Frischer (opinion) [Ep 16 · 3:46](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=226)
- "Leveling colostomy represents a three-stage procedure for Hirschsprung disease management." — Jason Frischer (clinical) [Ep 16 · 4:03](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=243)
- "Pure transanal pull-through may not be less invasive than laparoscopic approach, as prolonged torquing in the anal canal can be more traumatic than three small abdominal incisions." — Todd Ponsky (opinion) [Ep 16 · 4:22](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=262)
- "Transanal dissection attempting to reach high past the pelvic reflection involves significant pulling and stretching of the sphincters." — Belinda (clinical) [Ep 16 · 4:53](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=293)
- "Prolonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching." — Jason Frischer (opinion) [Ep 16 · 5:07](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=307)
- "Laparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases." — Jason Frischer (clinical) [Ep 16 · 5:30](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=330)
- "Standard rectosigmoid Hirschsprung disease (6-10 centimeters proximal) can be completed transanally in approximately 2 hours when the level is known from a good contrast study." — Jason Frischer (clinical) [Ep 16 · 5:46](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=346)
- "Complications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues." — Jason Frischer (clinical) [Ep 16 · 6:12](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=372)
- "Soiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence." — Jason Frischer (clinical) [Ep 16 · 6:31](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=391)
- "Obstructive symptoms after Hirschsprung surgery require differentiation between anatomic problems and pathologic problems." — Jason Frischer (clinical) [Ep 16 · 6:45](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=405)
- "True fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line." — Jason Frischer (clinical) [Ep 16 · 6:52](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=412)
- "Pseudo-incontinence after Hirschsprung surgery may be caused by underlying constipation." — Jason Frischer (clinical) [Ep 16 · 7:04](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=424)
- "Jack Langer published an algorithm for working up patients with problems after Hirschsprung disease." — Jason Frischer (host_summary) [Ep 16 · 7:08](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=428)
- "Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia evaluating dentate line position, stricture, stretched sphincter, and anatomic twists." — Jason Frischer (clinical) [Ep 16 · 7:25](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2015-1000?t=445)
- "Between 75 and 80% of the time, transanal dissection with sequential biopsies reaches normal ganglionic bowel; in the other 20%, conversion to abdominal approach is needed." — Alberto Peña (clinical) [Ep 17 · 3:42](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=222)
- "The concordance between pathology and radiology is 75% in rectosigmoid Hirschsprung disease patients, meaning 25% are discordant." — Todd Ponsky (host_summary) [Ep 17 · 5:30](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=330)
- "The concordance is only 25% for long-segment Hirschsprung disease between radiology and pathology." — Todd Ponsky (host_summary) [Ep 17 · 5:39](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=339)
- "If you start transanally and cannot mobilize more bowel, you simply go into the abdomen and continue the resection—this is not considered a complication." — Alberto Peña (opinion) [Ep 17 · 6:28](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=388)
- "When starting laparoscopically, if you break the peritoneum transanally first, it becomes hard to maintain pneumoperitoneum." — Todd Ponsky (clinical) [Ep 17 · 7:57](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=477)
- "Transanal approach results in absolutely no scar and minimal postoperative pain." — Andrea Bischoff (clinical) [Ep 17 · 8:59](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=539)
- "The main problems in Hirschsprung disease are not related to the surgical approach (laparoscopic vs. transanal) but to inexperience and technical incapacity of the surgeon that damages the patient permanently." — Alberto Peña (opinion) [Ep 17 · 11:10](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=670)
- "Patients complain about fecal incontinence, not about the size of the scar—that is the real problem." — Alberto Peña (opinion) [Ep 17 · 12:17](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=737)
- "More than 80% of Hirschsprung disease patients have rectosigmoid aganglionosis." — Luis de la Torre (epidemiological) [Ep 17 · 60:31](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3631)
- "The Lone Star retractor hooks should be placed at the pectinate line itself, not in the anal canal, to protect the anal canal by definition." — Alberto Peña (clinical) [Ep 17 · 14:23](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=863)
- "Surgeons should be careful not to stretch too much during transanal dissection because excessive stretching damages the sphincter mechanism by definition, potentially causing fecal incontinence." — Alberto Peña (clinical) [Ep 17 · 14:55](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=895)
- "The keys to avoiding strictures and retractions are: respecting the pectinate line and anal canal, not stretching the anus too much, mobilizing the rectum to ensure normal ganglionic bowel with good blood supply, and performing anastomosis with no tension." — Alberto Peña (clinical) [Ep 17 · 16:42](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1002)
- "Prone position is preferred over lithotomy position for transanal procedures because in lithotomy the surgeon is the only one who can see, the field is vertical causing instrument loss, and the scrub nurse has difficulty seeing." — Alberto Peña (opinion) [Ep 17 · 17:29](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1049)
- "Leaving 1-2 centimeters of aganglionosis does not explain why patients don't behave well—some patients operated with exactly the same technique do beautifully while others have enterocolitis symptoms, and we don't know why." — Alberto Peña (opinion) [Ep 17 · 18:30](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1110)
- "The majority of patients who come with symptoms of retention (enterocolitis or constipation) after pull-through do not have a portion of ganglionic bowel left—they simply behave like that and we do not know why." — Alberto Peña (clinical) [Ep 17 · 21:41](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1301)
- "When we remove the rectum of a human being, we are already seriously affecting the mechanisms of bowel control because we are removing the natural reservoir of the patient." — Alberto Peña (clinical) [Ep 17 · 22:39](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1359)
- "Even adult ulcerative colitis patients with perfect operations have problems with bowel control—they have accidents at night—because we are connecting a piece of colon that is constantly moving to where the rectum normally rests." — Alberto Peña (clinical) [Ep 17 · 22:50](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1370)
- "Even in patients with a very well preserved anal canal, some children have different degrees of fecal incontinence after Hirschsprung surgery." — Alberto Peña (clinical) [Ep 17 · 23:32](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1412)
- "Fecal incontinence in Hirschsprung disease is much more common than we believe, and we have not been discussing it enough in pediatric surgical meetings." — Alberto Peña (opinion) [Ep 17 · 23:44](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1424)
- "If you preserve the pectinate line, by definition you are preserving this crucial part of the bowel." — Alberto Peña (clinical) [Ep 17 · 24:43](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1483)
- "Patients are born with bowel control—we provoke the fecal incontinence through surgical technique." — Alberto Peña (opinion) [Ep 17 · 25:09](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1509)
- "The anterior dissection of the rectal wall must be conducted in a very meticulous way because the rectum has a common wall with the vagina and the prostatic urethra—fistulas to the vagina or urinary tract are unacceptable complications." — Alberto Peña (clinical) [Ep 17 · 26:24](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1584)
- "If you see fat around the rectum during full-thickness dissection, you can get closer to the rectum because that means you are not in the real rectal wall." — Alberto Peña (clinical) [Ep 17 · 27:06](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1626)
- "If you stay right on the bowel wall during dissection, you will not provoke denervation of the urinary tract." — Alberto Peña (clinical) [Ep 17 · 27:23](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=1643)
- "Patients who improve with rectal irrigation most probably suffer from Hirschsprung disease." — Luis de la Torre (clinical) [Ep 17 · 58:14](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3494)
- "To do a very good endorectal pull-through, you need to identify a very good plane of dissection and observe the circular fibers of the rectum that will become the rectal cuff." — Luis de la Torre (clinical) [Ep 17 · 42:18](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=2538)
- "If you are in the right plane of dissection during endorectal pull-through, the operation is almost bloodless." — Luis de la Torre (clinical) [Ep 17 · 42:36](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=2556)
- "When you leave a large muscular cuff, the patient will most probably have chronic obstruction, and this chronic obstruction will produce chronic colitis." — Luis de la Torre (clinical) [Ep 17 · 42:55](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=2575)
- "A posterior myectomy should be performed, resecting 1-2 centimeters in length of the muscular cuff to create a short muscular cuff from below." — Luis de la Torre (clinical) [Ep 17 · 44:37](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=2677)
- "Full-thickness biopsies should be sent for frozen section, not small seromuscular biopsies, because pathologists suffer when you send very small biopsies for frozen section." — Luis de la Torre (clinical) [Ep 17 · 51:39](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3099)
- "One of the most common problems in endorectal pull-through is leaving a large cuff, which causes obstruction." — Luis de la Torre (clinical) [Ep 17 · 52:57](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3177)
- "The anastomosis should be performed with the most perfect technique possible using fine sutures, 5-0 or 6-0 Vicryl." — Luis de la Torre (clinical) [Ep 17 · 53:59](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3239)
- "Long-segment Hirschsprung disease patients do not improve with irrigation—they are totally different and represent another big problem." — Luis de la Torre (clinical) [Ep 17 · 60:03](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3603)
- "Patients with long-segment disease and massive megacolon are not good candidates for primary transanal pull-through because we need to remove these huge segments of chronic dilation which have poor motility." — Luis de la Torre (clinical) [Ep 17 · 62:01](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3721)
- "The anal canal is composed of three clear zones: the anoderm with squamous epithelium, the area where the pectinate line lives, and the columnar zone." — Luis de la Torre (clinical) [Ep 17 · 64:05](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3845)
- "The columnar zone should be preserved for fecal control." — Luis de la Torre (clinical) [Ep 17 · 64:32](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3872)
- "Patients who have had the anal canal removed through different techniques are fecally incontinent, and interestingly, these patients also don't have enterocolitis." — Luis de la Torre (clinical) [Ep 17 · 64:53](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3893)
- "If you do the anastomosis below the columnar zone, the patient will be fecally incontinent—using 100% of that area results in full fecal incontinence, using 50% results in partial fecal incontinence." — Luis de la Torre (clinical) [Ep 17 · 66:27](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=3987)
- "Laparoscopy decreases the stretch of anal sphincters compared to pure transanal approach when going high, which could affect fecal continence." — Todd Ponsky (opinion) [Ep 17 · 94:53](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=5693)
- "With laparoscopy, you can dissect way down to the pelvic floor, so the actual transanal dissection is very short with very limited stretch on the sphincters." — Todd Ponsky (clinical) [Ep 17 · 95:11](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=5711)
- "Most common complications in total colonic aganglionosis include ileostomy prolapse, obstructive symptoms following pouch pull-through, wrong pathological diagnosis, anastomotic stricture or acquired atresia, severe diaper rash, and enterocolitis." — Andrea Bischoff (clinical) [Ep 17 · 70:18](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4218)
- "To avoid ileostomy prolapse, tack the bowel proximal to the stoma to the abdominal wall—whenever you open a stoma in a mobile portion of colon or intestine, you are at risk of prolapse." — Andrea Bischoff (clinical) [Ep 17 · 70:27](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4227)
- "For total colonic aganglionosis in a healthy newborn, perform colectomy with straight ileoanal anastomosis and ileostomy at presentation, then close the ileostomy only when the child is toilet trained for urine and willing to accept rectal irrigation." — Andrea Bischoff (clinical) [Ep 17 · 71:53](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4313)
- "Patients with total colonic aganglionosis have higher risk for enterocolitis, and the best treatment for enterocolitis is rectal irrigation." — Andrea Bischoff (clinical) [Ep 17 · 72:13](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4333)
- "You should not do an ileoanal anastomosis until the patient is toilet trained for urine because the patient needs to know how to go to the bathroom and evacuate in the toilet, otherwise you will have the worst unmanageable diaper rash." — Andrea Bischoff (clinical) [Ep 17 · 76:10](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4570)
- "If urinary sodium is less than 20 millimoles per liter in a patient with ileostomy, start oral sodium replacement." — Andrea Bischoff (clinical) [Ep 17 · 74:45](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4485)
- "Waiting until the patient is toilet trained for urine (usually around 3 years of age) before closing the ileostomy results in the baby becoming totally trained for stool soon after closure, provided you did a correct operation and preserved the anal canal." — Alberto Peña (clinical) [Ep 17 · 79:52](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4792)
- "If you take a child that has been traumatized with rectal maneuvers and try to do rectal irrigations, there will be problems, whereas if a patient has an ileostomy and the mother does rectal irrigations once in a while with a soft catheter, the baby will accept that." — Alberto Peña (clinical) [Ep 17 · 80:23](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4823)
- "Patients with total colonic aganglionosis have a high incidence of enterocolitis and will most likely need rectal irrigation, which is difficult to do in a 3-year-old with severe diaper rash who doesn't want anything near the anus." — Alberto Peña (clinical) [Ep 17 · 80:46](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=4846)
- "There are two big types of Hirschsprung disease: a benign type where patients never have enterocolitis and can go for years with huge megacolon, and a bad group with manifestations during the newborn period who have great tendency to suffer enterocolitis even with a good operation." — Alberto Peña (opinion) [Ep 17 · 120:20](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=7220)
- "The PHOX2B gene provides instructions for making a protein that acts early in development to help promote nerve cell formation and regulate neuron maturation, and is active in the neural crest cells that form parts of the autonomic nervous system controlling breathing, blood pressure, heart rate, and digestion." — Andrea Bischoff (host_summary) [Ep 17 · 121:44](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=7304)
- "PHOX2B mutation is associated with congenital central hypoventilation syndrome, neuroblastoma, and Hirschsprung disease." — Andrea Bischoff (host_summary) [Ep 17 · 122:24](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=7344)
- "Patients with congenital central hypoventilation syndrome (Ondine's curse) need tracheostomy and assisted ventilation during sleep because they stop breathing when they fall asleep." — Andrea Bischoff (clinical) [Ep 17 · 124:17](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=7457)
- "The association of Hirschsprung disease and anorectal malformation is very bad because every patient will be fecally incontinent—the patient has no anal canal by definition, and resection of the rectosigmoid removes the natural reservoir." — Andrea Bischoff (clinical) [Ep 17 · 126:22](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=7582)
- "For post-evacuation films in Hirschsprung patients, delayed evacuation is seen in those who do have Hirschsprung's, but this is not relied upon for diagnosis. In patients with equivocal findings, the Hirschsprung segment may be spastic and expel contrast, sometimes with huge expulsion." — Richard Krauss (clinical) [Ep 17 · 127:57](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=7677)
- "In chronic constipation patients (not Hirschsprung), about half of the contrast coming out on post-evacuation films is usually considered normal, though this is a gestalt assessment, not a precise measurement." — Richard Krauss (clinical) [Ep 17 · 128:28](https://library.globalcastmd.com/watch/hirschsprung-disease-surgical-procedures-1029?t=7708)
- "In the 1960s and 1970s fluoroscopy was done by everybody and done very well, but with the advent of MRI, CT, and ultrasound there has been a shift to more current modalities and fluoroscopy is almost a lost art." (opinion) [Ep 18 · 0:20](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=20)
- "In a newborn on plain radiograph you cannot tell the difference between colon and small bowel; you can only say there are multiple dilated loops suggesting distal bowel obstruction." (clinical) [Ep 18 · 2:38](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=158)
- "The differential diagnosis for neonatal distal bowel obstruction includes Hirschsprung disease, small left colon syndrome (meconium plug syndrome, immature colon), anorectal malformation, meconium ileus, and ileal atresia, which together account for about 99% of cases." (clinical) [Ep 18 · 3:12](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=192)
- "Seeing air in the rectum on plain radiograph does not rule out Hirschsprung disease." (clinical) [Ep 18 · 4:47](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=287)
- "The radiological diagnosis of enterocolitis is possible with a plain abdominal radiograph." (clinical) [Ep 18 · 4:58](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=298)
- "Air-fluid levels visible in the colon on cross-table or decubitus views are a sign of inflammatory process, potentially enterocolitis." (clinical) [Ep 18 · 6:13](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=373)
- "Enterocolitis in a newborn should be considered Hirschsprung disease until proven otherwise." (clinical) [Ep 18 · 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%." (host_summary) [Ep 18 · 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%." (host_summary) [Ep 18 · 10:35](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=635)
- "Radiologist agreement on transition zone location is fairly high at 90%." (host_summary) [Ep 18 · 10:47](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=647)
- "The concordance rate between radiologic and pathologic transition zone location is only about 62% overall." (host_summary) [Ep 18 · 11:02](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=662)
- "For short segment (rectosigmoid) Hirschsprung disease, the concordance between radiologic and pathologic transition zones is about 75%." (host_summary) [Ep 18 · 12:43](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=763)
- "For long segment Hirschsprung disease (descending colon, splenic flexure, or more proximal), the concordance between radiologic and pathologic transition zones is only about 25%." (host_summary) [Ep 18 · 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 provide better localization of the transition zone." (clinical) [Ep 18 · 13:44](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=824)
- "In patients with longer segment disease, surgeons should plan the operation assuming the transition may be high rather than relying on the enema findings." (clinical) [Ep 18 · 13:54](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=834)
- "Never use a Foley catheter inside the rectum for contrast enema in suspected Hirschsprung disease." — Rodrigo Ocelami (clinical) [Ep 18 · 15:57](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=957)
- "Insert the rectal tube only 2 to 3 centimeters into the rectum for contrast enema." — Rodrigo Ocelami (clinical) [Ep 18 · 15:49](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=949)
- "In the neonatal period, use water-soluble contrast diluted 50% with saline for contrast enema." — Rodrigo Ocelami (clinical) [Ep 18 · 16:19](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=979)
- "Inject contrast very slowly and gently via syringe (not gravity) to avoid distending the aganglionic segment and missing the diagnosis." — Rodrigo Ocelami (clinical) [Ep 18 · 16:31](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=991)
- "After the neonatal period, fill only up to the transverse colon; if the studied segment appears normal in distension, caliber, and mucosa, and the splenic flexure shows no suggestion of total colonic involvement, stop at the transverse colon." — Rodrigo Ocelami (clinical) [Ep 18 · 16:56](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1016)
- "Obtain two images in left lateral decubitus, two in right lateral decubitus, and two in AP position during contrast enema." — Rodrigo Ocelami (clinical) [Ep 18 · 17:25](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1045)
- "The inversion of the rectosigmoid index (rectum smaller than sigmoid) is very helpful in diagnosing Hirschsprung disease." — Rodrigo Ocelami (clinical) [Ep 18 · 18:18](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1098)
- "The affected (aganglionic) segment will be spastic, which is why contrast should not be given in large amounts or too fast, as this will cause you to miss the spasticity." — Rodrigo Ocelami (clinical) [Ep 18 · 18:33](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1113)
- "Always counsel families about good hydration after contrast enema to help the child evacuate the contrast and avoid dehydration." — Rodrigo Ocelami (clinical) [Ep 18 · 19:17](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1157)
- "Show the family the contrast material before and after the study so they know what to expect when white material comes out." — Rodrigo Ocelami (clinical) [Ep 18 · 19:31](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1171)
- "The water-soluble iodinated contrast used for enemas has an osmolality of about 400, similar to colon-cleansing agents, and is hyperosmotic." (clinical) [Ep 18 · 20:59](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1259)
- "The hyperosmotic contrast not only helps make the diagnosis but also attempts to clean the colon." (clinical) [Ep 18 · 21:11](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1271)
- "If contrast stays in the colon, neonates can become dehydrated, so the neonatal ICU must be informed." (clinical) [Ep 18 · 21:20](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1280)
- "Use gravity infusion from a bag with large IV tubing at a moderate pace (not slow) to rapidly show both distal and proximal segments and visualize the transition zone quickly." (clinical) [Ep 18 · 21:45](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1305)
- "Early maximal distention is best for seeing the transition zone; waiting too long can cause distention of the distal aganglionic segment because it is soft tissue, not a rigid pipe." (clinical) [Ep 18 · 22:18](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1338)
- "If the colon looks small in a neonate, fill the entire colon and attempt to reflux into the terminal ileum to make other diagnoses if present." (clinical) [Ep 18 · 22:45](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1365)
- "In a full-term infant, use a 12 to 14 French Foley catheter; in a premature infant, use a smaller size." (clinical) [Ep 18 · 23:02](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1382)
- "A true lateral image with femurs superimposed is essential to visualize the presacral space properly." (clinical) [Ep 18 · 23:18](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1398)
- "On frontal view, ensure the tube is visible but also visualize distal to it to avoid missing a very distal transition zone." (clinical) [Ep 18 · 23:26](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1406)
- "In a normal neonate, the proximal colon toward the splenic flexure is always a little smaller than the rectum." (clinical) [Ep 18 · 23:37](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1417)
- "If a Foley catheter balloon is inflated in the rectum to prevent leakage, it will miss very short segment Hirschsprung disease every single time." (clinical) [Ep 18 · 23:55](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1435)
- "Contrast enema in premature infants does not follow the rules; the colon can look immature and small, making it difficult to distinguish from Hirschsprung disease." (clinical) [Ep 18 · 25:02](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1502)
- "Contrast enema can be performed in premature infants as young as 35 to 36 weeks gestational age with reasonable diagnostic accuracy." (clinical) [Ep 18 · 25:18](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1518)
- "Below 35-36 weeks gestational age, when necrotizing enterocolitis becomes more prevalent, diagnostic accuracy of contrast enema decreases." (clinical) [Ep 18 · 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, if more proximal it is typical rectosigmoid." (clinical) [Ep 18 · 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 18 · 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 do not stop there—examine all the way up to the splenic flexure." (clinical) [Ep 18 · 28:48](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1728)
- "A case initially diagnosed radiologically as small left colon syndrome with transition at splenic flexure proved to be total colonic aganglionosis with transition in the terminal ileum." (clinical) [Ep 18 · 29:06](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1746)
- "If you have a proximal transition zone on enema, you cannot accurately determine where the pathologic transition actually is." (clinical) [Ep 18 · 30:14](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1814)
- "A proximal transition zone should prompt consideration of a more invasive surgical approach (laparoscopic or open) rather than transanal, because the true transition location is uncertain." (clinical) [Ep 18 · 30:22](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1822)
- "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." — Todd Ponsky (clinical) [Ep 18 · 31:01](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1861)
- "In clearly documented meconium ileus where reflux into terminal ileum is achieved and the patient clinically improves, rectal biopsy may not be necessary." — Todd Ponsky (clinical) [Ep 18 · 31:35](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=1895)
- "After Soave pull-through, contrast enema shows a wide presacral space due to the retained muscular cuff from partial-thickness dissection." (clinical) [Ep 18 · 33:27](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2007)
- "The widened presacral space after Soave is best seen on lateral view because the cuff extends circumferentially." (clinical) [Ep 18 · 34:05](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2045)
- "A true lateral view of the rectum is very important in post-surgical patients to assess for complications." (clinical) [Ep 18 · 34:14](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2054)
- "The Duhamel procedure creates a chimera of aganglionic segment distally with ganglionic segment proximally, not placed end-to-end or side-to-side but as a patchwork." (clinical) [Ep 18 · 35:06](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2106)
- "In symptomatic patients after Duhamel, an anterior pouch containing stool enlarges and impresses on the ganglionic bowel, causing obstruction." (clinical) [Ep 18 · 35:28](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2128)
- "In untreated Hirschsprung disease, even in patients 10, 12, 14, or 15 years old, a dilated rectum is never seen; by definition the aganglionic segment does not distend." (clinical) [Ep 18 · 36:09](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2169)
- "Patients who develop the characteristic Duhamel pouch with fecal impaction in the rectum may never have had true Hirschsprung disease, as the aganglionic rectum should not distend." (opinion) [Ep 18 · 36:33](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2193)
- "When resecting a Duhamel pouch, the specimen should be oriented and the pathologist alerted to determine whether ganglion cells are present in the rectum." (clinical) [Ep 18 · 36:56](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2216)
- "Resected Duhamel pouches have been observed to contain both ganglionic and aganglionic parts." (clinical) [Ep 18 · 37:20](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2240)
- "A contrast enema showing dilated, redundant colon filled with stool but normal rectum and presacral space represents idiopathic constipation, not Hirschsprung disease." (clinical) [Ep 18 · 37:43](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2263)
- "In a patient with a contrast enema showing dilated colon and normal rectum, rectal biopsy is a waste of time because the patient does not have Hirschsprung disease." (opinion) [Ep 18 · 39:43](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2383)
- "If a biopsy is taken in functional constipation, there is risk of obtaining an aganglionic result from the normal physiologic aganglionic zone, which does not mean the patient has Hirschsprung disease." (clinical) [Ep 18 · 39:54](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2394)
- "There is no way to differentiate so-called ultra-short segment Hirschsprung disease from idiopathic constipation." (opinion) [Ep 18 · 40:15](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2415)
- "The rectum has a normal area with ganglion cells, then a zone with no ganglion cells (normal physiologic aganglionosis), but the length of this aganglionic zone has never been accurately determined at different ages." (clinical) [Ep 18 · 40:28](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2428)
- "There is no accurate study defining the length of normal physiologic aganglionosis in preterm infants, full-term babies, 6-month-olds, or older children—this is a challenge for young pediatric surgeons." (opinion) [Ep 18 · 40:57](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2457)
- "A biopsy taken in the zone of normal physiologic aganglionosis will show no ganglion cells but does not indicate Hirschsprung disease." (clinical) [Ep 18 · 41:20](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2480)
- "The internal sphincter has been defined as a thickening of the circular layer of normal smooth muscle bowel, but this thickening has never been personally observed in opened normal rectums at different ages." (opinion) [Ep 18 · 41:29](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2489)
- "If the internal sphincter thickening exists, nobody has determined the exact limit of that thickening at different ages." (opinion) [Ep 18 · 41:56](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2516)
- "Achalasia of the internal sphincter is a manometric concept, not an anatomic concept." (opinion) [Ep 18 · 42:07](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2527)
- "Myectomies, myotomies, and botulinum toxin injections for internal sphincter achalasia are not recommended because no one knows what area of muscle they are actually treating." (opinion) [Ep 18 · 42:31](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2551)
- "Botulinum toxin injection paralyzes whatever muscle is present and facilitates stool passage, but it is not curing a condition of unknown origin." (opinion) [Ep 18 · 42:57](https://library.globalcastmd.com/watch/hirschsprung-disease-radiology-aspect-1030?t=2577)
- "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." (host_summary) [Ep 19 · 0:14](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=14)
- "Dr. Hirschsprung was a pediatrician who developed the hydrostatic reduction of ileocolonic intussusception, a contribution unrelated to Hirschsprung's disease." (host_summary) [Ep 19 · 1:06](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=66)
- "Early theories to explain Hirschsprung disease etiology included: obstruction (mechanical blockage from redundant colon or rectal valves), malformation (hypertrophied colon as primary congenital defect), and spastic distal colon causing functional obstruction." (host_summary) [Ep 19 · 1:25](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=85)
- "The malformation theory (hypertrophied colon as primary defect) came first among early theories, but all theories were wrong because they focused on the dilated portion as diseased rather than as a consequence of the disease." (host_summary) [Ep 19 · 2:28](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=148)
- "William Osler, one of the four founding professors of Johns Hopkins and creator of the residency system, proposed colostomy or rectal tube and irrigation as possible treatments for Hirschsprung's disease." (host_summary) [Ep 19 · 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 finally recognized as the cause of Hirschsprung disease in 1946 by Orvar Swenson." (host_summary) [Ep 19 · 5:20](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=320)
- "Others before Swenson, including Dr. Dalalé in 1920, recognized absent ganglion cells in the distal portion but thought it was an acquired condition rather than the cause of the disease." (host_summary) [Ep 19 · 5:26](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=326)
- "Treatments used for Hirschsprung disease prior to 1946 included anal sphincter dilation, rectosigmoid myotomy, spinal anesthesia, lumbar sympathectomy, and electric enemas, but not resection of the distal non-dilated portion." (host_summary) [Ep 19 · 5:58](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=358)
- "Electric enemas were described around 1908 and involved 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." (clinical) [Ep 19 · 6:50](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=410)
- "Barium enema technique became the standard diagnostic test for Hirschsprung's disease in 1948, with Dr. Swenson involved in this publication." (host_summary) [Ep 19 · 8:36](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=516)
- "Barry Shandling proposed punch biopsies for newborns that required no closure nor anesthesia." (host_summary) [Ep 19 · 10:46](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=646)
- "Barry Shandling worked in Canada." (clinical) [Ep 19 · 11:01](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=661)
- "Dr. Sydegaard from Sweden performed the first successful operation for total colonic aganglionosis in 1953, doing a colon resection with an ileoanal anastomosis." (host_summary) [Ep 19 · 11:56](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=716)
- "Dr. Lester Martin was the chief of pediatric surgery at Cincinnati Children's Hospital." (clinical) [Ep 19 · 11:34](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=694)
- "Swenson observed that when patients had a colostomy, the obstruction was relieved, but when the colostomy was closed, the disease returned." (host_summary) [Ep 19 · 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." (host_summary) [Ep 19 · 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, there was no peristalsis." (host_summary) [Ep 19 · 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 that the distal portion was the diseased one." (host_summary) [Ep 19 · 13:35](https://library.globalcastmd.com/watch/hirschsprung-disease-history-1032?t=815)
- "The contrast agent used is iodinated, water-soluble, and hyperosmotic with osmolality approximately 400." (clinical) [Ep 22 · 0:03](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=3)
- "The hyperosmotic contrast (osmolality ~400) is similar to agents used for colon cleansing and can help clean the colon in addition to making the diagnosis." (clinical) [Ep 22 · 0:17](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=17)
- "In neonates, retained hyperosmotic contrast can cause dehydration and clinical deterioration, requiring neonatal ICU awareness." (clinical) [Ep 22 · 0:26](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=26)
- "Gravity infusion is used rather than injection, with moderate-pace infusion to rapidly visualize distal and proximal segments and identify transition zones." (clinical) [Ep 22 · 0:41](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=41)
- "Lateral rectosigmoid imaging is performed to visualize the transition zone." (clinical) [Ep 22 · 1:24](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=84)
- "Early maximal distention is best for seeing the transition zone; delayed imaging can cause distention of the distal aganglionic segment because it is soft tissue, not a rigid lead pipe." (clinical) [Ep 22 · 1:31](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=91)
- "If the colon appears small in a neonate, the entire colon is filled with attempt to reflux into terminal ileum to identify other diagnoses." (clinical) [Ep 22 · 1:51](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=111)
- "In full-term neonates, a 12-14 French Foley catheter is used; in premature infants, a smaller size is used." (clinical) [Ep 22 · 2:08](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=128)
- "On normal contrast enema, the rectum is well distended, presacral space is well seen on true lateral image (femurs superimposed), and proximal colon toward splenic flexure is slightly smaller than rectum." (clinical) [Ep 22 · 2:21](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=141)
- "Very short-segment Hirschsprung disease can be missed if a Foley balloon is inflated in the distal rectum, blocking visualization of the transition zone." (clinical) [Ep 22 · 2:59](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=179)
- "Rectosigmoid transition zone Hirschsprung cases are usually concordant between radiologic and pathologic findings." (clinical) [Ep 22 · 3:25](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=205)
- "In long-segment Hirschsprung disease, the rectum is very small and there is irregular, spastic-appearing colon extending to the splenic flexure or beyond." (clinical) [Ep 22 · 3:34](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=214)
- "In total colonic Hirschsprung disease, the rectum is not larger than the rest of the colon, and the entire colon appears uniformly small." (clinical) [Ep 22 · 3:51](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=231)
- "In premature infants, the contrast enema does not follow the diagnostic rules because the colon may appear immature and small, making it impossible to distinguish from pathology." (clinical) [Ep 22 · 4:03](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=243)
- "Contrast enema can be performed in premature infants as young as 35-36 weeks gestational age with reasonable diagnostic accuracy." (clinical) [Ep 22 · 4:24](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=264)
- "Below 35-36 weeks gestational age, especially in the setting of necrotizing enterocolitis, diagnostic accuracy of contrast enema is reduced." (clinical) [Ep 22 · 4:36](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=276)
- "Rectosigmoid transition in Hirschsprung disease is located at approximately the S2 vertebral level; distal rectal disease is below S1-S2." (clinical) [Ep 22 · 5:47](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=347)
- "Small left colon syndrome typically has a transition at the splenic flexure that is very abrupt." (clinical) [Ep 22 · 6:20](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=380)
- "The rectosigmoid index (rectum larger than sigmoid) is a useful principle but not definitive; imaging must extend to the splenic flexure to avoid missing proximal disease." (clinical) [Ep 22 · 7:54](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=474)
- "A case initially interpreted as small left colon (small rectum, small colon to splenic flexure, meconium plugs) was proven to be total colonic aganglionosis with terminal ileum transition." (clinical) [Ep 22 · 8:08](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=488)
- "When the transition zone appears proximal (splenic flexure or beyond), the radiologic transition zone cannot accurately predict the histologic transition zone." (clinical) [Ep 22 · 9:20](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=560)
- "Proximal transition zones should prompt consideration of more invasive surgical approaches (laparoscopic or open) rather than transanal pull-through, because the true transition may be much more proximal than radiologically apparent." (opinion) [Ep 22 · 9:28](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=568)
- "One panelist performs rectal biopsy in almost any patient requiring contrast enema to rule out distal obstruction, including meconium plug, small left colon, and meconium ileus." (opinion) [Ep 22 · 10:12](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=612)
- "One panelist does not perform rectal biopsy in clear cases of meconium ileus with terminal ileum reflux and clinical improvement." (opinion) [Ep 22 · 10:44](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=644)
- "Dr. Pena would not perform rectal biopsy if certain the diagnosis is meconium ileus, but would perform biopsy for small left colon because it cannot be reliably distinguished from Hirschsprung disease radiologically." — Pena (opinion) [Ep 22 · 10:58](https://library.globalcastmd.com/watch/contrast-enema-for-hirschsprung-disease-1034?t=658)
- "Ganglion cells are present in the rectal submucosa at 28 weeks gestation normally, though they do not necessarily look like mature ganglion cells." — Collins (clinical) [Ep 20 · 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 20 · 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 20 · 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 20 · 4:26](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=266)
- "The failure rate for the suction rectal biopsy increases after one year of age." — Collins (clinical) [Ep 20 · 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, contributing to suction biopsy failure." — Collins (clinical) [Ep 20 · 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 20 · 4:57](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=297)
- "The anal canal becomes longer and thicker after infancy, contributing to suction biopsy difficulty." — Collins (clinical) [Ep 20 · 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 20 · 14:55](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=895)
- "A much better approach is to get a good full thickness rectal biopsy, not ask for a frozen section, allow the pathologist to do permanent sections and adjunctive studies if necessary, and then plan the surgical resection to begin at a future date." — Collins (opinion) [Ep 20 · 15:38](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=938)
- "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 20 · 16:36](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=996)
- "If a suction rectal biopsy confidently shows absent ganglion cells and the surgeon finds ganglion cells at the peritoneal reflection, the patient still has short segment disease and will lose a short length of rectum." — Raj Kapoor (clinical) [Ep 20 · 17:10](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1030)
- "If there is any equivocation or iffiness to the biopsy, clear communication with the surgeon is critical, and it may be necessary to rebiopsy or think of other strategies." — Raj Kapoor (opinion) [Ep 20 · 18:15](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1095)
- "A lot of confident diagnosis comes back to experience: an experienced pathologist can recognize immature ganglion cells, knows how to apply and interpret ancillary studies, and knows when material is suboptimal." — Raj Kapoor (opinion) [Ep 20 · 19:33](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1173)
- "Large nerves are not present in the submucosa of all cases of Hirschsprung disease, so it is possible to have a suction rectal biopsy that shows a lack of ganglion cells and does not demonstrate large nerves in the submucosa." — Collins (clinical) [Ep 20 · 23:04](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1384)
- "Total colonic aganglionosis is a classic example of Hirschsprung disease without large nerves in the submucosa." — Collins (clinical) [Ep 20 · 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 20 · 23:38](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1418)
- "The compulsion to do something immediately should be secondary to having a more firm diagnosis before going into the operating room." — Collins (opinion) [Ep 20 · 24:06](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1446)
- "Ancillary studies or ancillary findings are extremely helpful when you have conflicting or ambiguous results or suboptimal adequacy of a specimen." — Raj Kapoor (opinion) [Ep 20 · 25:05](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1505)
- "If a patient has no ganglion cells and adequate submucosa but no hypertrophic nerves, a convincing abnormality in calretinin immunoreactivity or acetylcholinesterase staining can be enough to discount the lack of hypertrophic nerves and make the diagnosis of Hirschsprung disease." — Raj Kapoor (clinical) [Ep 20 · 25:43](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1543)
- "An experienced pathologist gets a real feel for a gestalt of what are too many, too big nerves, rather than relying on nerve measurements with calipers." — Raj Kapoor (opinion) [Ep 20 · 26:20](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1580)
- "The 40 micron rule (that in a young infant under 6 months of age, you shouldn't see in the distal rectum nerves greater than 40 microns in diameter) is generally true at that young age, but there are rare exceptions, and in older age kids that rule does not hold." — Raj Kapoor (clinical) [Ep 20 · 26:29](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1589)
- "Complete communication between surgeon and pathologist is needed to reduce the number of difficulties and possible errors significantly." — Reyes Mujica (opinion) [Ep 20 · 27:55](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1675)
- "An operation for Hirschsprung disease is too big a deal to be made on a flimsy basis." — Reyes Mujica (opinion) [Ep 20 · 28:53](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1733)
- "Transition zone contains ganglion cells, but they're not in their normal distribution completely around the circumference of the bowel." — Collins (clinical) [Ep 20 · 31:39](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1899)
- "Transition zone has hypoganglionosis by definition." — Collins (clinical) [Ep 20 · 31:47](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1907)
- "Transition zone has hypertrophic nerves that can be evaluated or brought out by a glut one stain, more in the submucosa than in the myenteric plexus with or without associated ganglion cells." — Collins (clinical) [Ep 20 · 31:47](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1907)
- "A bit more controversial is submucosal hyperganglionosis with many ganglion cells in one ganglion (at least 10), in which case the submucosa can look like IND type B." — Collins (clinical) [Ep 20 · 32:09](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1929)
- "Ectopic ganglion cells can be present in what we think are normal biopsies and normally innervated bowels, so that's a bit more controversial." — Collins (clinical) [Ep 20 · 32:29](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1949)
- "A calretinin stain performed proximal to an aganglionic segment, if positive (showing nerve twigs in the lamina propria), is a sign that there are ganglion cells, even if they are not present in that particular section." — Collins (clinical) [Ep 20 · 32:58](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=1978)
- "The methodology used for IND diagnosis in Europe (15 micron thick sections, at least 3 times the thickness of normal sections) has not been adopted in the United States." — Collins (clinical) [Ep 20 · 33:34](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2014)
- "The histochemical stains used for IND diagnosis are not commonly used in the United States." — Collins (clinical) [Ep 20 · 33:57](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2037)
- "There have been inconsistent diagnostic criteria for IND; the definition for the various forms of IND have changed several times over the last several decades." — Collins (clinical) [Ep 20 · 34:05](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2045)
- "The most important issue with IND is inadequate control data: one cannot look at biopsies from constipated children and conclude that any of the features are responsible for the constipation without age-matched controls from children who are not constipated." — Collins (clinical) [Ep 20 · 34:17](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2057)
- "The recommendation is that the diagnosis of IND should not be made in infants." — Collins (guideline) [Ep 20 · 34:53](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2093)
- "IND is outgrown by the age of 4." — Collins (clinical) [Ep 20 · 34:57](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2097)
- "IND is not a disorder that requires surgical therapy; it is self-correcting." — Collins (clinical) [Ep 20 · 35:01](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2101)
- "Multiple papers and authors have challenged if the diagnostic criteria for IND represent one end of a normal spectrum." — Collins (host_summary) [Ep 20 · 35:12](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2112)
- "There is a question of whether the histopathological phenotype of IND is actually a consequence or an adaptation of downstream dysmotility rather than the cause of the dysmotility." — Collins (host_summary) [Ep 20 · 35:25](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2125)
- "Dr. Pena could not find a single paper or study with a topographic study of neurointestinal dysplasia showing the extension of the defect." — Pena (epidemiological) [Ep 20 · 36:30](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2190)
- "The concept of IND is still irrelevant from a clinical standpoint, though there may be many secrets in histological characterization of motility disorders to be studied in the future." — Pena (opinion) [Ep 20 · 37:36](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2256)
- "The problem with intestinal neuronal dysplasia arose out of the need to explain the subset of patients with symptoms after Hirschsprung surgery." — Reyes Mujica (clinical) [Ep 20 · 38:12](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2292)
- "IND was championed by a surgeon doing pathology, which is probably not appropriate." — Reyes Mujica (opinion) [Ep 20 · 38:34](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2314)
- "IND should be put in its right place as a probably transitional period of developing in a subset of patients, but not a condition that requires surgery." — Reyes Mujica (opinion) [Ep 20 · 38:50](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2330)
- "Dr. Kapoor is not as convinced as he once was that IND has been put to death, and remains open-minded as to whether there is an age-related change in the density of giant ganglia in the submucosa that is shifted in patients with Hirschsprung disease." — Raj Kapoor (opinion) [Ep 20 · 39:59](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2399)
- "The best way to diagnose hypoganglionosis is to only consider the myenteric ganglion cell density, which means one has to be dealing with a resected bowel, not just a suction biopsy." — Collins (clinical) [Ep 20 · 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 the myenteric plexus containing small ganglia (one or two ganglion cells per ganglion) with minimal neuropil." — Collins (clinical) [Ep 20 · 42:00](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2520)
- "For research purposes only, less severe forms of hypoganglionosis can be resolved with a dedicated count of ganglion cells using a particular antibody as a marker, but there is huge normal variation and a need to count large areas to get an accurate assessment, which limits the clinical value." — Collins (clinical) [Ep 20 · 42:14](https://library.globalcastmd.com/watch/hirschsprung-disease-pathology-aspect-1031?t=2534)
- "Jejunostomy chimney technique involves dividing bowel 2-3 cm distal to ligament of Treitz, bringing distal limb up as chimney over splenic flexure with side-to-end anastomosis, allowing Mickey button placement without luminal obstruction" (clinical) [Ep 21 · 3:00](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=180)
- "Placing balloon catheter directly in jejunal lumen creates obstruction; chimney technique avoids this by creating separate access limb" (clinical) [Ep 21 · 4:21](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=261)
- "Distal feeding can be provided through 3-4 French feeding tube placed in distal bowel and brought out as stent rather than matured mucous fistula, allowing easy refeeding without catheter access issues" (clinical) [Ep 21 · 0:57](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=57)
- "Refeeding distal bowel provides significant benefit for fluid/electrolyte absorption and allows bowel to dilate and mature, potentially decreasing technical problems at takedown" (clinical) [Ep 21 · 1:45](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=105)
- "When proximal and distal stomas are placed close together, takedown is less stressful on patient and surgeon than complete laparotomy to find and reconnect distant bowel segments" (opinion) [Ep 21 · 8:02](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=482)
- "Gastrostomy tubes in very small premature infants (700 grams) can be deferred by placing 3 French feeding tube coiled in stomach, then later dilating tract with wire and interventional radiology to place primary tube without second surgery" (clinical) [Ep 21 · 14:46](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=886)
- "Gastrostomy tube placement has costs including leakage issues if placed against costal margin in small infants; timing and location require careful consideration" (clinical) [Ep 21 · 20:41](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1241)
- "Prolapsed gastrostomy tubes can cause significant formula loss during feeds; removing dysfunctional gastrostomy allows some children to thrive better" (clinical) [Ep 21 · 22:46](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1366)
- "In 2-month-old with jejunal atresia unable to advance feeds beyond 20 mL/kg, if anastomosis appears patent at reoperation, would still revise it rather than leave it alone" (clinical) [Ep 21 · 24:16](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1456)
- "At end of intestinal failure operation, must ensure no kinking, restriction, or potential problems remain - cannot tolerate leaving anything that 'could be a problem but is probably all right'" (clinical) [Ep 21 · 25:29](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1529)
- "STEP procedure in first year of life, especially in infant who has not progressed with enteral feeds, is not beneficial unless specifically avoiding line infections and bacterial overgrowth" (clinical) [Ep 21 · 29:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1760)
- "Dysmotile bowel does not become motile because you did a STEP procedure on it; if bowel hasn't been fed and isn't functioning, STEP won't make it work" (clinical) [Ep 21 · 29:32](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1772)
- "The one thing that makes bowel adapt is feeding the bowel; procedures causing problems reinitiating feeds cause damage to patient" (clinical) [Ep 21 · 30:06](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1806)
- "In patient with 50% estimated bowel length, expectation is they will come off parenteral nutrition; should not overtry to salvage bad bowel when good bowel exists" (clinical) [Ep 21 · 28:07](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1687)
- "STEP registry paper showing procedures can be done safely in early neonatal period found only 3 patients came off parenteral nutrition, whereas natural data shows 80-90% of such patients off TPN at 12 months just by being fed" (epidemiological) [Ep 21 · 31:18](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1878)
- "Kids who had early STEP procedures have often redilated, undergone second STEPs, and had mechanical obstructions very detrimental to feeding ability" (clinical) [Ep 21 · 31:43](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1903)
- "Indication for lengthening procedure is complications from bacterial overgrowth (d-lactic acidosis) or ultra-short bowel with very dilated segment where tapering doesn't make sense - generally not decisions made at 2-3 months old but after first birthday" (clinical) [Ep 21 · 33:21](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2001)
- "Expectation of going from 10 mL/kg enteral feeds to off TPN in 3 months after STEP is a fairy tale that doesn't exist" (opinion) [Ep 21 · 34:06](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2046)
- "Surgical techniques for intestinal failure are not out of realm of any pediatric surgeon, but outcomes differ when done in isolation without multidisciplinary team consideration" (opinion) [Ep 21 · 34:46](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2086)
- "Since maturing multidisciplinary program, transplant candidates declined by 75% and internal transplants almost non-existent" (epidemiological) [Ep 21 · 40:47](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2447)
- "Patients should be referred to intestinal rehabilitation programs as soon as identified as needing comprehensive approach, not when complications exhausted local knowledge" (opinion) [Ep 21 · 44:23](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2663)
- "Programs do far better with children who do not already have complications of their disease than patients who come already suffering from current management" (clinical) [Ep 21 · 44:34](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2674)
- "In gastroschisis and surgical necrotizing enterocolitis, significant benefit to time to wean off parenteral nutrition based solely on breast milk (fortified or not) versus formula only" (clinical) [Ep 21 · 59:42](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3582)
- "Breast milk is not just formula but really a therapy with components that are anti-inflammatory and promotile" (clinical) [Ep 21 · 60:19](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3619)
- "Benefit to kids with spontaneous intestinal perforation is not seen with breast milk, suggesting specific anti-inflammatory and promotile components important for other conditions" (clinical) [Ep 21 · 60:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3620)
- "Donor breast milk is less advantageous than maternal breast milk; usually taken from mothers 10-14 months postpartum before weaning, has lower caloric density and protein, and freezing may inactivate trophic factors" (clinical) [Ep 21 · 62:25](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3745)
- "Express maternal breast milk is favorite approach; when patient predicted to do badly, go to elemental formulas as second line" (clinical) [Ep 21 · 63:19](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3799)
- "Free amino acid formulas are relatively hyperosmolar at 20 kcal/oz (osmolarity around 350-360); going higher increases osmolarity, so tend to avoid high caloric density formulas in very young infants" (clinical) [Ep 21 · 64:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3860)
- "In study by Joly et al in French adult cohort, hyperphagic adults with short bowel had 60% absorption coefficient with ad lib eating, 85% with continuous drip feeds, and 75% with half calories by mouth during day plus overnight drip feeds" (host_summary) [Ep 21 · 17:01](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1021)
- "Continuous drip feeding improves absorptive index, but combining daytime oral intake with nighttime drip feeds may offer best of both approaches" (host_summary) [Ep 21 · 17:40](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1060)
- "Prefer isotonic formulas (15-17 cal/oz) because digestion changes osmolarity in jejunum, and most bad kids don't have ileum so jejunum has no ability to absorb against concentration gradient" (clinical) [Ep 21 · 65:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3920)
- "Kids without upper GI dysmotility handle volume much better than concentration, so keep concentration low and advance volume" (clinical) [Ep 21 · 65:55](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3955)
- "Introduction of baby foods, meats, and vegetables remarkably helpful in adaptation process once kids get older" (clinical) [Ep 21 · 66:03](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3963)
- "TPN panel includes renal panel, liver panel, calcium/phosphorus/magnesium; no longer follow prealbumin or RBP as money-saving strategy, follow albumin instead for chronic changes" (clinical) [Ep 21 · 70:04](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4204)
- "Follow essential fatty acids monthly or every other month if on low lipid TPN; iron, ferritin, TIBC every 2-3 months; zinc, copper, ceruloplasmin every 3-6 months; selenium every 6 months" (clinical) [Ep 21 · 70:43](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4243)
- "About 60% of patients weaned off TPN have deficiencies in one micronutrient or another" (epidemiological) [Ep 21 · 71:36](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4296)
- "Follow B12 annually plus methylmalonic acid and homocysteine as more sensitive surrogate markers, since B12 can be synthesized by bacteria or falsely elevated with liver disease" (clinical) [Ep 21 · 72:03](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4323)
- "Breast milk has non-nutrient oligosaccharides (2FL, 3FL) that are not nutrient source to humans but affect microflora and dysbiosis; 80% of secretor mothers make 2FL which is immunomodulatory" (clinical) [Ep 21 · 85:56](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5156)
- "Dysbiosis in intestinal failure patients is profound and furthered by H2 blockers and antibiotics; how this affects adaptive process not well understood" (clinical) [Ep 21 · 86:24](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5184)
- "Older patient recommends prebiotics more and antibiotics less; almost all patients with substantial resection and lost ileocecal valve have element of small bowel contamination with colonic flora" (opinion) [Ep 21 · 83:13](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4993)
- "Want to encourage right flora (anaerobes) and discourage wrong flora (putrefactive bacteria like E. coli, Klebsiella); too many antibiotics kill bacteria you want present to break down starches into butyric acid" (clinical) [Ep 21 · 83:59](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5039)
- "Use antibiotics selectively: for d-lactic acidosis, hyperammonemia, or older child no longer thriving on previously adequate caloric intake; if used, finite period 2-3 weeks, and abandon if no improved growth velocity" (clinical) [Ep 21 · 85:06](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5106)
- "In recent data, probably 2/3 of bloodstream infections seen in patients on prophylactic Flagyl, because knocking out anaerobes facilitates aerobic overgrowth and presumably translocation" (clinical) [Ep 21 · 90:33](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5433)
- "Metronidazole has limited spectrum, knocks off anaerobes, facilitates growth of aerobes - absolutely the wrong choice for bacterial overgrowth" (opinion) [Ep 21 · 91:56](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5516)
- "If desperate for antibiotics, might use selective decontamination with non-absorbable aminoglycoside (Tobramycin) and Colistin" (clinical) [Ep 21 · 92:16](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5536)
- "Rifaximin may have role but not well studied in bacterial overgrowth, appropriate dose unknown, and no stable suspension available" (clinical) [Ep 21 · 92:37](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5557)
- "Use metronidazole to promote motility by decreasing overgrowth, improving mucosal quality, decreasing inflammation, and increasing tolerance and absorption - not to prevent bacterial infection" (clinical) [Ep 21 · 93:26](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5606)
- "When culture most bacteria causing overgrowth, get anaerobes qualitatively, which is reason for metronidazole use" (clinical) [Ep 21 · 94:29](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5669)
- "Lack of knowledge about microbiome in children with intestinal failure; tend to use antibiotics based on clinical findings - gram negatives or cholestasis suggests non-absorbable aminoglycoside; sudden distension with frothy diarrhea or lactic acidosis suggests Flagyl" (clinical) [Ep 21 · 95:24](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5724)
- "Patients seem to advance well once on solid food, likely due to more physiological exposure to complex proteins and oligosaccharides, but can't identify single causative factor yet" (clinical) [Ep 21 · 96:45](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5805)
- "Use antibiotics and not probiotics, only when forced to (d-lactic acidosis, stalling feeds with distension); metronidazole used because anaerobes are gas producers and cause lactic acidosis" (clinical) [Ep 21 · 97:56](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5876)
- "Metronidazole doesn't work for everyone; with lactic acidosis, very specific antibiotics seem to work and must find best one; try not to cycle, use once and see how long before recurrence" (clinical) [Ep 21 · 98:47](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5927)
- "Worry about probiotics getting in central lines through external contamination more than translocation; lactobacillus species extremely hard to clear, may require line removal" (clinical) [Ep 21 · 99:41](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5981)
- "One case established blood infection with same genotype as lactobacillus given as probiotic, which turned program away from probiotics in all kids with central lines" (clinical) [Ep 21 · 100:06](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6006)
- "First consideration with increased output is whether overfeeding and overtaxing gut, providing elements for osmotic diarrhea" (clinical) [Ep 21 · 101:17](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6077)
- "Reanastomosing colon helps with output; when colon involved, anti-motility drugs like loperamide become helpful" (clinical) [Ep 21 · 101:51](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6111)
- "Use soluble fibers to decrease high output; have tried octreotide but not found very useful and worry about chronic use with growth hormone suppression" (clinical) [Ep 21 · 102:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6140)
- "For patients with lot of gastric output, might use proton pump inhibitor to decrease gastric secretions, but must balance with potential medication risks" (clinical) [Ep 21 · 103:12](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6192)
- "Documented inflammation found on endoscopy in some kids; using anti-inflammatory agents (5-ASA products) seems to have impact, sometimes steroid-based enemas helpful depending on location" (clinical) [Ep 21 · 103:50](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6230)
- "Anti-inflammatories really helpful in challenging Hirschsprung's patients with dysbiosis and high stool frequency not well managed with other interventions" (clinical) [Ep 21 · 104:29](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6269)
- "Successfully managed some Hirschsprung's patients (8-9 years old, stooling 12 times daily, not responding to antibiotic cycling or prebiotics/formulas) with long-term anti-inflammatories and 5-ASA with remarkable success" (clinical) [Ep 21 · 104:49](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6289)
- "Avoid cholestyramine as much as possible; doses effective in firming stool usually bind nutrients, fat-soluble vitamins, and fats; slight risk for hyperchloremic acidosis and cholestyramine bezos" (clinical) [Ep 21 · 105:42](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6342)
- "Encountered patients on almost homeopathic cholestyramine doses whose parents/physicians believed stools looked better, but not sure stool volume actually declined" (clinical) [Ep 21 · 106:30](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6390)
- "Ursodiol in child with very short gut can contribute to diarrhea due to osmotic component with no real benefit preventing cholestasis" (clinical) [Ep 21 · 107:10](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6430)
- "Pancreatic enzymes not physiologic in humans until 5-7 months of age; worry about enzymes in dysmotile bowel areas especially with stomas - have seen strictures/stoma problems related to enzymes sitting in stenotic areas" (clinical) [Ep 21 · 108:12](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6492)
- "Only pancreatic enzyme present in adult quantities in young infants are proteases; amylases don't appear until 6-12 months, lipase doesn't reach adult levels until end of first year" (clinical) [Ep 21 · 109:23](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6563)
- "Short gut patients have high trypsinogen levels because they don't have enough enterokinase, but formal pancreatic stimulation shows proteases do appear" (clinical) [Ep 21 · 109:52](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6592)
- "Problem with pancreatic enzymes in short gut is they go through before releasing" (clinical) [Ep 21 · 110:47](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6647)
- "No upper number for acceptable stoma output that is hard and fast; have many patients with 40-50 cc/kg stoma output who continue feeding based on electrolyte profile" (clinical) [Ep 21 · 111:14](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6674)
- "Don't want patients acidotic (CO2 dropping to teens despite maximizing acetate) - that's the limit, not volume; electrolytes and acidosis drive decision, not volume" (clinical) [Ep 21 · 111:29](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6689)
- "Knee-jerk reactions to volume of output (unless otherwise sick with acidosis/abnormal electrolytes) should not be made; using nurse-callable number for output leads to variable feeding over longer time, very detrimental to weaning program" (opinion) [Ep 21 · 111:45](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6705)
- "Stoma output or stool output more relevant in guiding fluid and electrolyte replacement than making decisions about stopping or decreasing feeds" (clinical) [Ep 21 · 112:36](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6756)
- "Patients receiving GLP-2 analog therapies have dramatically decreased stomal output with benefit in fluid and electrolytes, though whether this gives sustainable benefit and whether use in kids is indicated not yet determined" (clinical) [Ep 21 · 113:12](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6792)
- "Adult GLP-2 analog studies suggest it is beneficial: can reduce fecal output in 60-70% of patients allowing 20% TPN reduction, and in extension study 20% of patients totally emancipated from TPN" (host_summary) [Ep 21 · 113:45](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6825)
- "Some patients do fine on GLP-2 analog while on it but regress when they come off, so jury still out" (clinical) [Ep 21 · 114:35](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6875)
- "Studies waiting until children have late intestinal failure not likely to give needed insight; multi-institutional trials following patients in areas where they can be monitored will provide better outcomes and insight for next 5-10 years" (opinion) [Ep 21 · 114:53](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6893)
- "Major advancements made in intestinal failure field in last 5-6 years not fully recognized; trajectory suggests remarkably different treatment paradigm in very short time" (opinion) [Ep 21 · 115:31](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6931)
- "When patients on long-term TPN, must monitor not just growth (weight and length) but micronutrient status - impacts neurodevelopmental/cognitive outcome and bone health" (clinical) [Ep 21 · 116:10](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6970)
- "In newborn bowel obstruction with distal air, contrast enema should precede upper GI unless clinical presentation strongly suggests malrotation" — Todd Ponsky (opinion) [Ep 24 · 1:59](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=119)
- "Tissue diagnosis is mandatory before surgery for Hirschsprung disease; contrast enema alone is insufficient" — Todd Ponsky (host_summary) [Ep 24 · 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" — Jacob Langer (clinical) [Ep 24 · 5:13](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=313)
- "In critically ill patients with enterocolitis, surgery may be necessary before pathology results are available (typically takes until Wednesday if specimen obtained Friday)" — Todd Ponsky (host_summary) [Ep 24 · 5:30](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=330)
- "In Mana Proctor's series, 8% of cases with apparent short transition zone on imaging had pathologically higher transition zones (long transition zone concept)" — Jacob Langer (epidemiological) [Ep 24 · 8:16](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=496)
- "Female patients may have higher risk of long-segment disease, with 50-50 incidence of long-segment in girls" — Jason Frischer (epidemiological) [Ep 24 · 8:56](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=536)
- "Prone positioning for pull-through is easier on surgeon's back and neck compared to lithotomy" — Todd Ponsky (opinion) [Ep 24 · 9:57](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=597)
- "Two definitions exist for ultra-short segment Hirschsprung: (1) absence of recto-anal inhibitory reflex with normal ganglion cells on biopsy (internal sphincter achalasia, not true Hirschsprung), and (2) very short segment of aganglionosis" — Jacob Langer (clinical) [Ep 24 · 15:23](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=923)
- "Manometry showing normal recto-anal inhibitory reflex rules out Hirschsprung disease in older children without need for biopsy" — Jacob Langer (clinical) [Ep 24 · 14:33](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=873)
- "Absence of recto-anal inhibitory reflex on manometry requires biopsy confirmation due to false positives" — Jacob Langer (clinical) [Ep 24 · 14:52](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=892)
- "For ultra-short segment with confirmed aganglionosis, pull-through is preferred over myectomy" — Jacob Langer (opinion) [Ep 24 · 16:36](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=996)
- "Most 16-year-olds with newly diagnosed Hirschsprung require diversion due to massive bowel dilation" — Jacob Langer (clinical) [Ep 24 · 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" — Jacob Langer (opinion) [Ep 24 · 17:05](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1025)
- "Adult anal canal is 3-4 centimeters long (possibly 5 cm), compared to 1 cm in infants; biopsies at 3 cm in adults may be from anal canal where ganglion cells are normally absent" — Garrison (clinical) [Ep 24 · 17:21](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1041)
- "Hypertrophic nerves should not be present in normal anal canal, even though ganglion cells are absent there" — Todd Ponsky (host_summary) [Ep 24 · 17:40](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1060)
- "Transitional epithelium (not normal rectal mucosa) should be seen on biopsy if specimen is truly from anal canal" — Jacob Langer (clinical) [Ep 24 · 17:53](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1073)
- "Most cecal perforations in Hirschsprung disease occur with shorter-segment disease (not total colonic), as cecum distends most and perforates like in rectal cancer" — Jacob Langer (clinical) [Ep 24 · 21:10](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1270)
- "For cecal perforation, close perforation and create loop ileostomy without frozen section of ileum, as total colonic disease is unlikely" — Jacob Langer (opinion) [Ep 24 · 21:10](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1270)
- "In long-segment disease, delay pull-through 6-12 months until stoma output thickens to prevent severe perianal excoriation" — Jacob Langer (clinical) [Ep 24 · 22:52](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1372)
- "Pull-throughs using only cecum (very short colonic segment) have poor outcomes with stasis and enterocolitis; ileal Duhamel may be preferable" — Jacob Langer (opinion) [Ep 24 · 23:50](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1430)
- "If transition zone is at hepatic flexure (not just cecum), preserve the colon and perform Duhamel" — Jacob Langer (opinion) [Ep 24 · 24:37](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1477)
- "When bringing right colon down, flip it over rather than rotating; preserve marginal artery and let anatomy determine orientation" — Jacob Langer (clinical) [Ep 24 · 25:47](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1547)
- "Manometry is not reliably performed until age 5-6 years" — Jacob Langer (clinical) [Ep 24 · 29:04](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1744)
- "In children over age 2-3 years, perform open rectal biopsy under general anesthesia rather than office suction biopsy due to patient cooperation issues" — Todd Ponsky (host_summary) [Ep 24 · 29:11](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1751)
- "For 3-year-old with massive dilation, divert and attempt bowel decompression; resect dilated segment if it does not collapse after 6-8 months" — Jacob Langer (opinion) [Ep 24 · 30:17](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1817)
- "Older children are less likely to have bowel shrinkage after diversion, but 3-year-olds may still respond" — Jacob Langer (clinical) [Ep 24 · 32:57](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1977)
- "Transanal resection of massively dilated colon in older children causes enormous sphincter stretch and impairs postoperative continence; laparoscopic dissection to pelvic floor is preferred" — Jason Frischer (clinical) [Ep 24 · 32:05](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=1925)
- "Colonoscopic biopsies can miss Hirschsprung disease; rectal biopsy is more reliable" — Jason Frischer (clinical) [Ep 24 · 33:42](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2022)
- "Manometry is reliable for diagnosing Hirschsprung in older children when biopsies may be unreliable" — Todd Ponsky (host_summary) [Ep 24 · 34:11](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2051)
- "For enterocolitis 6 months post-pull-through with fever, distention, and diarrhea but no peritonitis, treat with IV fluids, broad-spectrum antibiotics, and rectal irrigations" — Todd Ponsky (host_summary) [Ep 24 · 35:15](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2115)
- "Incidence of enterocolitis in children with trisomy 21 is double that of genetically normal children with Hirschsprung disease" — Todd Ponsky (host_summary) [Ep 24 · 36:20](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2180)
- "For recurrent enterocolitis, first rule out distal obstruction and residual aganglionosis with exam under anesthesia and biopsies" — Jacob Langer (guideline) [Ep 24 · 37:00](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2220)
- "Chronic oral metronidazole is used liberally for recurrent enterocolitis; some patients require it for months, and symptoms recur when discontinued" — Jacob Langer (clinical) [Ep 24 · 37:32](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2252)
- "Botox injection decreases number of hospitalizations for enterocolitis, though it does not work in all patients" — Jacob Langer (clinical) [Ep 24 · 38:03](https://library.globalcastmd.com/watch/hirschsprung-disease-update-course-2013-1061?t=2283)
- "For total colonic Hirschsprung disease, Duhamel procedure is preferred initially." — Alp Numoglu (clinical) [Ep 25 · 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, laparoscopic biopsy to establish the level, followed by laparoscopic-assisted pelvic dissection and perirectal dissection to join the dissection lines." — Alp Numoglu (clinical) [Ep 25 · 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 used for the last 40 cases, with laparoscopy in some cases to confirm ganglionosis level." — Stephanie (clinical) [Ep 25 · 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, delaying the pull-through and performing ileoanal anastomosis similar to total colectomy patients, with protective ileostomy." — Michael Alshaus (clinical) [Ep 25 · 1:40](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=100)
- "Pure transanal approach used for shorter-segment disease and some redo pull-throughs when ganglion cell location is accurately determined." — Michael Alshaus (clinical) [Ep 25 · 2:04](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=124)
- "In Spain, de la Torre technique is used; for total colonic aganglionosis, Lester Martin procedure is used." — Alberto Peña (clinical) [Ep 25 · 2:26](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=146)
- "About half of the 11 partners do Soave, the other half do Swenson procedures; laparoscopic leveling is performed, some use umbilical incisions depending on contrast enema findings." (clinical) [Ep 25 · 3:08](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=188)
- "Some partners doing Soave are switching to 'Soaven'—a very short Soave cuff transitioning to Swenson plane a couple centimeters above the dentate line." (clinical) [Ep 25 · 3:26](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=206)
- "In Italy, Soave approach was used initially, but switched to transanal approach in the last 2 years with laparoscopic biopsies; very satisfied with results." (host_summary) [Ep 25 · 4:08](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=248)
- "For a patient with total colonic aganglionosis, previously operated, suffering from fecal incontinence and severe diaper rash, with destroyed anal canal, treatment is a permanent stoma." (host_summary) [Ep 25 · 6:05](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=365)
- "When the anal canal is destroyed, the patient will not have bowel control; with total colonic aganglionosis producing liquid stool, there is no bowel management possible." — Alberto Peña (clinical) [Ep 25 · 6:52](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=412)
- "A permanent stoma is indicated when the anal canal is destroyed and the patient has total colonic aganglionosis." — Alberto Peña (clinical) [Ep 25 · 7:11](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=431)
- "Sometimes constipating diet and fiber are tried to convince parents that there is no other option except permanent stoma; this is one of the few indications for permanent stoma." — Alberto Peña (clinical) [Ep 25 · 7:27](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=447)
- "For a patient previously operated for Hirschsprung disease suffering from enterocolitis with normal rectal biopsy, rectal irrigation is the treatment." — Alp Numoglu (clinical) [Ep 25 · 8:24](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=504)
- "Before surgery, parents must demonstrate rectal irrigations to nursing staff on the floor and be signed off before proceeding to surgery." — Monica (clinical) [Ep 25 · 9:19](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=559)
- "For patients seen in clinic while waiting for surgical date, irrigation teaching and demonstration occur in clinic." — Monica (clinical) [Ep 25 · 9:43](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=583)
- "Parents are taught rectal irrigation on the ward by nurses; personal control is performed to ensure parents know how to irrigate before hospital discharge and before surgery." — Stephanie (clinical) [Ep 25 · 10:02](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=602)
- "Common irrigation problems: parents hesitant to advance catheter far enough, or not using enough saline to get clear return before finishing." — Monica (clinical) [Ep 25 · 10:27](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=627)
- "The only contraindication for irrigation is a recent operation; after a recent operation, the surgeon who operated should perform irrigation immediately post-op to avoid perforating the anastomosis." (host_summary) [Ep 25 · 10:59](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=659)
- "After a biopsy, wait 48 hours before starting rectal irrigation; patients are taught irrigation in clinic first, then biopsy is done later so it is not a fresh incision." (host_summary) [Ep 25 · 20:20](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1220)
- "In the background of Hirschsprung disease, enterocolitis is not simple gastroenteritis; children are often taken to other medical centers and treated as simple gastroenteritis by doctors unaware of enterocolitis." — Alp Numoglu (clinical) [Ep 25 · 11:34](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=694)
- "Parents are continuously taught to return to the specialist hospital for enterocolitis, not general hospitals." — Alp Numoglu (clinical) [Ep 25 · 12:02](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=722)
- "Families are made very comfortable with irrigations before going to the emergency room, because many places are uncomfortable with irrigations in general." — Monica (clinical) [Ep 25 · 12:31](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=751)
- "Most pediatricians worldwide do not know the difference between enterocolitis and gastroenteritis; they do not understand the entity called post-Hirschsprung enterocolitis." — Alberto Peña (opinion) [Ep 25 · 12:56](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=776)
- "Pediatricians do not understand why irrigations are necessary; they see dilated bowel on X-ray and think it is intestinal obstruction, not recognizing the entity itself." — Alberto Peña (opinion) [Ep 25 · 13:14](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=794)
- "When starting dissection 2 cm above the dentate line and pulling bowel through, the upper mucosa is often damaged, and the anastomosis ends up about 1 cm above the dentate line." — Alberto Peña (clinical) [Ep 25 · 14:25](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=865)
- "Dr. Pena does not believe that leaving 1-2 cm of rectal mucosa is the simple cause of enterocolitis." — Alberto Peña (opinion) [Ep 25 · 14:53](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=893)
- "A group in New York doing neonatal Soave primary procedures reported zero enterocolitis; when Dr. Pena followed some of those patients, many had fecal incontinence." — Alberto Peña (clinical) [Ep 25 · 15:12](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=912)
- "If you produce fecal incontinence in a patient, enterocolitis is zero; a patient with destroyed anal canal is equivalent to a stoma, and patients with stomas rarely have enterocolitis." — Alberto Peña (clinical) [Ep 25 · 15:48](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=948)
- "A good operation preserving the sphincter and anal canal creates sphincter closure, which creates stasis, and stasis produces enterocolitis." — Alberto Peña (clinical) [Ep 25 · 16:05](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=965)
- "Dr. Pena prefers to deal with enterocolitis rather than fecal incontinence; fecal incontinence is for life." — Alberto Peña (opinion) [Ep 25 · 16:30](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=990)
- "When re-biopsying patients suspected of having a transition zone or aganglionic pull-through, biopsy as high as possible above the anastomosis to avoid the problem of finding aganglionic tissue at the anastomosis level." (host_summary) [Ep 25 · 16:47](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1007)
- "GI doctors recently started doing more anorectal manometry; it is rare for a post-op Hirschsprung patient to have normal anorectal manometry, leading to misinformation." — Michael Alshaus (clinical) [Ep 25 · 17:33](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1053)
- "Some Hirschsprung patients are told by GI doctors they have chronic bacterial overgrowth syndrome and started on antibiotics, when they likely have enterocolitis; antibiotics alone are not the total solution." — Michael Alshaus (clinical) [Ep 25 · 17:58](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1078)
- "Young parents often feel irrigations are a chore and tough on their babies; it is crucial to instruct them, stress the importance, and teach excellent technique." — Michael Alshaus (clinical) [Ep 25 · 18:20](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1100)
- "Metronidazole (Flagyl) is given orally for better effect; when tapering, sometimes given with irrigation through the rectum." (host_summary) [Ep 25 · 18:42](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1122)
- "Always use saline for irrigations, not regular water; importantly, warm the saline, especially for neonatal babies, to keep body temperature normal." — Monica (clinical) [Ep 25 · 18:56](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1136)
- "Dr. Pena's incidence of enterocolitis in pull-through patients is about 30%." — Alberto Peña (epidemiological) [Ep 25 · 19:16](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1156)
- "Using Duhamel technique, there is a low incidence of enterocolitis, but no explanation for this." — Stephanie (epidemiological) [Ep 25 · 19:48](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1188)
- "Fecal incontinence is more frequently seen in Swenson and Soave operations compared to Duhamel and Rehbein." (host_summary) [Ep 25 · 21:21](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1281)
- "From operation until age 3 (when most kids potty-train for urine and stool), the goal is to establish regularity; if the child has bowel movements around the same time, 2-3 times daily, this is a good indication the patient will likely potty-train for stool." (host_summary) [Ep 25 · 22:12](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1332)
- "Resecting the rectosigmoid introduces a major pathophysiological change; children with perfect pull-throughs preserving the anal canal sometimes have toilet-training problems without explanation." — Alberto Peña (clinical) [Ep 25 · 23:02](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1382)
- "Hyperactive children with attention deficit disorder have more toilet-training problems because they have a piece of colon that does not act like a reservoir, connected to the rectum and moving constantly; significant cooperation from the child is required." — Alberto Peña (clinical) [Ep 25 · 23:30](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1410)
- "Even with a perfect operation, patients may have certain toilet-training problems; if the anal canal is destroyed, they will be totally incontinent; partial anal canal destruction causes more problems." — Alberto Peña (clinical) [Ep 25 · 24:01](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1441)
- "In manometry studies of the colon, migrating complexes or high-amplitude contractions stop in the sigmoid colon in most people and do not go to the rectum; after pull-through, these are moved down to the anus." — Michael Alshaus (clinical) [Ep 25 · 24:24](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1464)
- "Toilet-training Hirschsprung patients do not always get the same warning of impending bowel movement and do not have as much time; must factor this in and use the gastrocolic reflex." — Michael Alshaus (clinical) [Ep 25 · 24:47](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1487)
- "Dr. Pena does not find rectal manometry useful in Hirschsprung disease, constipation, or anorectal malformations after many years of experience." — Alberto Peña (opinion) [Ep 25 · 24:59](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1499)
- "Patients are discharged with three irrigations per day and metronidazole (Flagyl); every month the number of irrigations is decreased." — Alberto Peña (clinical) [Ep 25 · 26:25](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1585)
- "If decreasing irrigations causes recurrent enterocolitis and the patient does not tolerate lack of irrigation, and by 6 months post-op the patient is still on irrigations, parents become very nervous; at that point, other options are discussed." — Alberto Peña (clinical) [Ep 25 · 26:46](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1606)
- "For refractory enterocolitis, another option is further resection of normal ganglionic colon to remove more." — Alberto Peña (clinical) [Ep 25 · 27:07](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1627)
- "Hirschsprung disease is much more than ganglion cells vs. no ganglion cells; we do not know why some patients never have enterocolitis and toilet-train early, behaving like normal children, while others have severe enterocolitis from day one." — Alberto Peña (opinion) [Ep 25 · 27:17](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1637)
- "'Benign Hirschsprung disease' patients present at 8-10 years old with classic imaging and abdominal distention but never had enterocolitis, grew and developed normally, and do very well after surgery." — Alberto Peña (clinical) [Ep 25 · 27:45](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1665)
- "In the United States, earlier diagnosis is being made of patients with 'bad Hirschsprung'—enterocolitis from day one, very sick, and high incidence of enterocolitis after surgery." — Alberto Peña (epidemiological) [Ep 25 · 28:13](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1693)
- "There is much we do not know about Hirschsprung disease; the story is much more than absent ganglion cells, and taking bowel with normal ganglion cells down does not mean that bowel is 100% normal." — Alberto Peña (opinion) [Ep 25 · 28:30](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1710)
- "Some believe that ganglionic bowel may have neuronal intestinal dysplasia, but this is a very controversial histopathological diagnosis; we do not know what is wrong and must learn much more." — Alberto Peña (opinion) [Ep 25 · 28:46](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1726)
- "For an operated Soave patient with normal biopsy but a long muscular cuff: if no symptoms and doing fine, do nothing and let the patient grow; if obstructive symptoms and contrast enema shows narrow bowel then dilated bowel (obstructive cuff), do Swenson-type resection of the cuff full-thickness." (host_summary) [Ep 25 · 29:52](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1792)
- "Another option for obstructive Soave cuff is laparotomy or laparoscopy to split the cuff in front of the sacrum without resection." — Alp Numoglu (clinical) [Ep 25 · 30:55](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1855)
- "Dr. Pena is skeptical that the cuff produces obstruction; to believe it, he would need to see the cuff producing real obstruction manifested by very dilated colon above the cuff, which is very unusual." — Alberto Peña (opinion) [Ep 25 · 31:25](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1885)
- "Dr. Mark Levitt has experience dealing with obstructive cuffs transanally; laparoscopic approach is not a bad idea but Dr. Pena has never heard of it being done laparoscopically." — Alberto Peña (clinical) [Ep 25 · 32:02](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1922)
- "Botox is not used because it produces temporary effect and temporary incontinence; the treatment for enterocolitis must be a final solution, not temporary." (host_summary) [Ep 25 · 32:21](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1941)
- "Patients with total fecal incontinence have no enterocolitis; all operations moving toward fecal incontinence (myectomies, myotomies, Botox, massive dilatation, putting 3 fingers in the rectum) are temporary or permanent moves toward incontinence." — Alberto Peña (clinical) [Ep 25 · 32:48](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1968)
- "Patients subjected to myotomies, myectomies, or repeated Botox injections eventually develop more severe fecal incontinence." — Alberto Peña (clinical) [Ep 25 · 33:11](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=1991)
- "Dr. Pena does not believe in myectomy/myotomy/Botox procedures and does not use Botox." — Alberto Peña (opinion) [Ep 25 · 33:24](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=2004)
- "Hirschsprung disease and constipation are chronic diseases; offering Botox for constipation is simplistic—patients will not learn or overcome the problem and suddenly start defecating normally." (host_summary) [Ep 25 · 33:28](https://library.globalcastmd.com/watch/panel-discussion-and-case-presentation-part-ii-pediatric-bowel-management-2013-1068?t=2008)
- "A perineal fistula opens at or anterior to the fourchette, while a vestibular fistula opens posterior to the hymen in the vestibule." (clinical) [Ep 26 · 0:23](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=23)
- "Don's mobilization goal is to mobilize the rectum just enough to reach the perineal skin with a little bit of tension, not necessarily achieving complete separation from the vagina." — Don (clinical) [Ep 26 · 2:27](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=147)
- "Ivo advocates complete separation of rectum from vagina because incomplete separation may lead to retraction and wound problems, and redo cases often show an undissected plane between rectum and vagina." — Ivo (clinical) [Ep 26 · 2:46](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=166)
- "Complete rectal mobilization results in loss of some rudimentary internal sphincter tissue." — Ivo (clinical) [Ep 26 · 3:43](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=223)
- "Michael agrees with more mobilization to bring the rectum down without tension, and warns that dissecting too far from the rectal wall risks entering the posterior vagina even though there is a separate plane (compared to vestibular fistulas with a common wall)." — Michael (clinical) [Ep 26 · 4:10](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=250)
- "In every redo of a female anorectal malformation, the host finds areolar tissue that had never been dissected by the original surgeon, suggesting inadequate anterior rectal wall mobilization." (clinical) [Ep 26 · 5:30](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=330)
- "The host believes that inadequate anterior rectal wall mobilization creates tension that disrupts the perineal body, leading to reoperations." (opinion) [Ep 26 · 6:10](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=370)
- "Don suggests that many redo cases may have been done in the newborn period without a backup colostomy, which could contribute to complications." — Don (opinion) [Ep 26 · 6:49](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=409)
- "Many female redo cases were done with colostomy under all perfect conditions, but the surgeon did not dissect the anterior wall to the areolar plane." (clinical) [Ep 26 · 7:06](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=426)
- "Common perineal groove is a mucosal-lined channel between vagina and anus, associated with anorectal malformation, where the anus itself is normal in size and position." — Jonathan (clinical) [Ep 26 · 7:51](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=471)
- "Jonathan has not found patients with common perineal groove becoming symptomatic from the groove itself." — Jonathan (clinical) [Ep 26 · 8:06](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=486)
- "The vast majority of common perineal grooves, if observed, will become normal skin over time." (clinical) [Ep 26 · 10:36](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=636)
- "For common perineal grooves that produce mucus and do not resolve, a simple fix is to unroof the mucosa and suture it up." (clinical) [Ep 26 · 10:43](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=643)
- "Common perineal groove is often associated with a perineal fistula." (clinical) [Ep 26 · 10:51](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=651)
- "If a hole must be made during dissection, it is preferable to make it in the vagina rather than the rectum because the vagina heals very well with few complications." — Ivo (clinical) [Ep 26 · 12:47](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=767)
- "Rectal blood supply is intramural, so injuring the rectal wall hurts its blood supply." (clinical) [Ep 26 · 13:14](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=794)
- "Michael's key technique is to start laterally and find the lateral plane before attempting to separate or create two structures out of the common wall anteriorly." — Michael (clinical) [Ep 26 · 13:34](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=814)
- "The lateral plane defines the anterior plane during dissection." (clinical) [Ep 26 · 13:51](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=831)
- "Don's technique is to come in from lateral to anterior, and to start more proximally where the structures are easier to separate, then work from proximal to distal." — Don (clinical) [Ep 26 · 14:26](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=866)
- "The host performs vestibular fistula repair primarily without a colostomy, either in the newborn period or as a repair in the next 3-4 months depending on the child's condition." (clinical) [Ep 26 · 15:00](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=900)
- "The host does not believe these patients need a colostomy in the newborn period followed by repair and then colostomy closure (three stages)." (opinion) [Ep 26 · 15:30](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=930)
- "For primary vestibular repair without colostomy, the host waits until the perineal body is healed (around day 6 or 7) before feeding." (clinical) [Ep 26 · 16:27](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=987)
- "The host's practice of delayed feeding is based on experience doing many redo cases, many of which were in patients fed early." (opinion) [Ep 26 · 16:39](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=999)
- "By watching the perineal body carefully during the NPO period, the surgeon can intervene without a dehiscence by taking the patient back to the OR on day 6 or 7 to re-suture the perineal body if needed." (clinical) [Ep 26 · 16:50](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1010)
- "In patients who are fed early and sent home, perineal body disruption may go unnoticed until clinic follow-up at 3-4 weeks or later, or may not be noticed until potty training failure at age 4." (opinion) [Ep 26 · 17:09](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1029)
- "In settings without hyperalimentation, 10% dextrose can be used for NPO periods up to 7 days in healthy, robust children (not in undernourished or very young infants)." (clinical) [Ep 26 · 17:22](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1042)
- "Ivo performed a systematic review on perioperative nutrition showing that early enteral nutrition appears better than later nutrition in retrospective studies, similar to findings in adult surgery, but all studies are poor quality." — Ivo (epidemiological) [Ep 26 · 18:48](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1128)
- "Kate Deans describes rapid learning healthcare systems as a 10-year-old concept that allows continuous accrual of experience with rapid statistical modeling to provide real-time point-of-care results for rare diseases." — Kate (clinical) [Ep 26 · 22:13](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1333)
- "For delayed vestibular repairs (not newborns), the host performs a full GoLYTELY bowel prep until effluent is clear, plus or minus oral antibiotics." (clinical) [Ep 26 · 23:04](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1384)
- "The host's practice for primary vestibular repair includes PICC line placement, hyperalimentation for 7 days, and careful daily inspection of the perineum, with feeding and discharge on day 7 (Tuesday afternoon) if the perineal body is well healed." (clinical) [Ep 26 · 23:55](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1435)
- "About once or twice a year, the host observes early perineal body separation and returns the patient to the OR for reinforcing sutures." (clinical) [Ep 26 · 24:25](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1465)
- "The host does not use a Foley catheter for vestibular or perineal fistula repairs, believing that urine leaking on the perineum is not a big deal." (clinical) [Ep 26 · 25:31](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1531)
- "Jonathan uses a Foley catheter to keep alkaline urine away from the fresh wound." — Jonathan (clinical) [Ep 26 · 26:15](https://library.globalcastmd.com/watch/anorectal-malformation-management-of-female-patients-part-i-pediatric-1091?t=1575)
- "The PSARP approach, first utilized in 1980 by Dr. Peña, revolutionized pelvic surgery including anorectal malformations" (host_summary) [Ep 27 · 1:00](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=60)
- "The fundamental principles of ARM repair are: identify where the rectum ends, ligate the distal fistula without injuring other structures, mobilize the rectum to comfortably reach the perineum, and place it in the center of the sphincter" (host_summary) [Ep 27 · 2:26](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=146)
- "Opening the rectum too high during PSARP is safer than opening too low, because opening too low risks entering the urethra" (clinical) [Ep 27 · 5:24](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=324)
- "One advantage of laparoscopy is staying on the rectal wall from the beginning, preventing wandering into the urethra" — Keith (clinical) [Ep 27 · 6:34](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=394)
- "During PSARP, the lateral wall dissection defines the anterior plane and should be performed first, with medial dissection last because that is where the danger lies" — Keith (clinical) [Ep 27 · 6:59](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=419)
- "If the rectum is not mobilizing easily, you are not in the correct plane; this principle applies to both ARM and Hirschsprung surgery" (clinical) [Ep 27 · 7:52](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=472)
- "If you see fat on the rectal wall during dissection, you can get closer to the rectum" (clinical) [Ep 27 · 8:03](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=483)
- "Surgeons often stay too lateral thinking they are being safe, when in fact staying right on the rectal wall is safer" — Keith (clinical) [Ep 27 · 8:36](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=516)
- "In laparoscopic ARM repair, attaching the rectum to presacral fascia with 2-3 permanent sutures prevents prolapse" — Keith (clinical) [Ep 27 · 10:53](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=653)
- "Leaving too much laxity in the pulled-through rectum contributes to prolapse" — Keith (clinical) [Ep 27 · 11:06](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=666)
- "During laparoscopic mobilization, only mobilize enough rectum to get it down comfortably with slight tension remaining, rather than extensive mobilization followed by tacking" — Jack (clinical) [Ep 27 · 14:43](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=883)
- "Mucosal prolapse is not prevented by tacking the rectum and is preferable to stricture because it can be trimmed" — Jack (clinical) [Ep 27 · 15:30](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=930)
- "When assessing rectal length laparoscopically, desufflate the abdomen before final assessment because insufflation can make the rectum appear shorter than it actually is" (clinical) [Ep 27 · 16:01](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=961)
- "Opening the perineum too much during laparoscopic approach weakens the muscle complex; every bit of muscle helps prevent leakage" — Keith (clinical) [Ep 27 · 17:10](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1030)
- "The 'Gonzalez hernia' (presacral fat that pooches into the midline when fascia is violated) can be mobilized and used as a flap to cover the posterior vagina in recurrent fistula repairs" (clinical) [Ep 27 · 18:13](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1093)
- "During anoplasty, aggressively remove distal rectum so it retracts, then use sutures to pull it back down to perineal skin under tension" — Don (clinical) [Ep 27 · 19:47](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1187)
- "Over-dissection of the distal rectum leads to excessive looseness and increased prolapse risk; under-dissection leads to stricture" (clinical) [Ep 27 · 20:41](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1241)
- "The external skeletal muscle sphincter is probably more important for continence than the internal sphincter embedded in the rectal wall" (opinion) [Ep 27 · 22:24](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1344)
- "If a patient has good muscles, good sacrum, good spine, and good repair, they will be continent regardless of whether some internal sphincter tissue was removed" (opinion) [Ep 27 · 22:42](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1362)
- "Distal colostography requires both lateral and oblique/AP views with full distention and exact measurements to adequately assess fistula location and rectal length" — Greg Bates (clinical) [Ep 27 · 28:50](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1730)
- "Combining distal colostography with VCUG in the same setting provides complete anatomical information; the colostogram is done first, contrast removed, then VCUG performed" — Greg Bates (clinical) [Ep 27 · 28:31](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1711)
- "A properly done distal colostogram is essential to avoid misidentifying the bladder as rectum during PSARP, which can occur because the bladder can appear midline, white, and rectum-like" (clinical) [Ep 27 · 29:55](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1795)
- "Passing a flexible neonatal scope through the mucous fistula allows visualization of light transmission to confirm rectal location during PSARP" — Jack (clinical) [Ep 27 · 31:03](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1863)
- "Bladder-neck fistulas are distinguished from prostatic fistulas by location above the angle of the urethra; prostatic fistulas are at or below the urethral angle" — Greg Bates (clinical) [Ep 27 · 36:37](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2197)
- "Bladder-neck fistulas typically enter at right angles and narrow down, making them easier to define and ideal for laparoscopic approach" — Keith (clinical) [Ep 27 · 32:56](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1976)
- "If uncertain about fistula location during laparoscopic dissection, opening the rectum allows identification of the fistula from inside" — Keith (clinical) [Ep 27 · 33:14](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=1994)
- "The fistula typically narrows down significantly, and the correct level to divide it is where this narrowing occurs" — Jack (clinical) [Ep 27 · 33:52](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2032)
- "For laparoscopic fistula ligation, preload a Maryland dissector through an endo-loop, divide the fistula, then slide the loop over the Maryland for controlled ligation" — Keith (clinical) [Ep 27 · 34:40](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2080)
- "Metal clips for fistula closure tend to erode into the urethra; endo-loop ligation is preferred" — Keith (clinical) [Ep 27 · 34:42](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2082)
- "When ligating the fistula, the stick (Maryland) should be placed distally with the loop trailing behind for better control; placing the loop distally is harder to control" — Keith (clinical) [Ep 27 · 36:02](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2162)
- "Cystoscopy by an experienced urologist can identify the fistula in approximately 9 out of 10 cases, though prior surgical experience found only 3 out of 10 fistulas visible cystoscopically" — Greg Bates (clinical) [Ep 27 · 38:00](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2280)
- "Bulbar fistulas are often not visible on cystoscopy due to the tiny size of the opening" (clinical) [Ep 27 · 38:31](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2311)
- "A fistula at the urethral elbow or below is classified as bulbar; above the elbow is prostatic; at the bladder neck is bladder-neck" (clinical) [Ep 27 · 39:43](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2383)
- "Two critical characteristics from colostography are: exact fistula location and how low/bulbous the rectum is, which determines surgical approach feasibility" (clinical) [Ep 27 · 39:57](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2397)
- "A very low bulbar fistula can be missed if the surgeon performs anoplasty without addressing the fistula, resulting in a patient who urinates through the anus (persistent fistula)" (clinical) [Ep 27 · 40:33](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2433)
- "Fistulas at the same level can have very different rectal anatomy (bulbous vs. tapered), which determines whether PSARP or laparoscopy is more appropriate" (clinical) [Ep 27 · 42:25](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2545)
- "In ARM, the IMA cannot be taken because prior colostomy has divided marginal vessels; taking the IMA will allow the rectum to reach but leave it without blood supply" (clinical) [Ep 27 · 46:42](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2802)
- "ARM rectal mobilization depends on IMA branches and intramural blood supply in the rectal wall, requiring intimate wall dissection unlike Hirschsprung where the IMA can be safely divided" (clinical) [Ep 27 · 47:02](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2822)
- "A Heineke-Mikulicz plasty (cutting horizontally and suturing vertically) on a bulbous rectum can gain 2-3 additional centimeters of length while addressing dilation" (clinical) [Ep 27 · 47:30](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2850)
- "To assess adequate rectal length, the rectum should reach 2 finger-breadths (4 cm) below the pubic bone; marking this point on the perineum predicts successful pull-through" (clinical) [Ep 27 · 50:04](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=3004)
- "When mobilizing the rectum, use bulldogs on vessels to test which can be divided without compromising blood supply before making permanent divisions" — Don (clinical) [Ep 27 · 49:08](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2948)
- "A properly placed newborn colostomy (as proximal in the sigmoid as possible) prevents the need for colostomy takedown during definitive repair" (clinical) [Ep 27 · 49:26](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2966)
- "If the mucous fistula must be taken down to gain length, perform a colocolonic anastomosis at the time of repair rather than leaving a difficult Hartmann closure behind the bladder for later" (clinical) [Ep 27 · 49:47](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=2987)
- "For rectal atresia or stenosis, split the distal 360-degree anus into 180 degrees, then anastomose the mobilized proximal rectum (unfolded from circle to hemicircle) to preserve the dentate line without dissection" (clinical) [Ep 27 · 52:59](https://library.globalcastmd.com/watch/arms-in-male-patients-pediatric-colorectal-controversies-2014-1099?t=3179)
- "Hirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction." — Aaron Garrison (clinical) [Ep 29 · 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 29 · 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 29 · 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 29 · 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 29 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "There are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease." — Aaron Garrison (clinical) [Ep 29 · 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 29 · 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 29 · 1:03](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=63)
- "Hirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes." — Aaron Garrison (clinical) [Ep 29 · 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, but that transition zone can be located anywhere within the bowel." — Jason Frischer (clinical) [Ep 29 · 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, meaning the aganglionic bowel is contracted and narrow compared to the dilated ganglionated bowel more proximal." — Jason Frischer (clinical) [Ep 29 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema." — Jason Frischer (clinical) [Ep 29 · 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 (epidemiological) [Ep 29 · 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 29 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Typical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining." — Jason Frischer (clinical) [Ep 29 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "To be considered an adequate biopsy, it must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers." — Jason Frischer (clinical) [Ep 29 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Suction biopsy technique is typically used for patients less than six months of age." — Jason Frischer (clinical) [Ep 29 · 1:57](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=117)
- "Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate." — Jason Frischer (clinical) [Ep 29 · 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 29 · 4:23](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=263)
- "The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test." — Jason Frischer (clinical) [Ep 29 · 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 29 · 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 29 · 5:12](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=312)
- "NICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended." — Aaron Garrison (clinical) [Ep 29 · 5:12](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=312)
- "Older children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases." — Aaron Garrison (clinical) [Ep 29 · 5:12](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=312)
- "The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity." — Jason Frischer (clinical) [Ep 29 · 6:42](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=402)
- "The contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always." — Aaron Garrison (clinical) [Ep 29 · 6:59](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=419)
- "The goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line." — Aaron Garrison (clinical) [Ep 29 · 6:59](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=419)
- "In the Swenson procedure, you pull down the aganglionic bowel and perform a full thickness anastomosis one to two centimeters above the dentate line, leaving the most minimal amount of aganglionic bowel possible." — Jason Frischer (clinical) [Ep 29 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys." — Jason Frischer (clinical) [Ep 29 · 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 29 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum." — Jason Frischer (clinical) [Ep 29 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina." — Jason Frischer (opinion) [Ep 29 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction." — Jason Frischer (clinical) [Ep 29 · 7:36](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=456)
- "In the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel." — Aaron Garrison (clinical) [Ep 29 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "The Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures." — Aaron Garrison (opinion) [Ep 29 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "Children who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch." — Aaron Garrison (clinical) [Ep 29 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "In the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision." — Aaron Garrison (clinical) [Ep 29 · 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 29 · 10:15](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=615)
- "Early complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn." — Aaron Garrison (clinical) [Ep 29 · 11:49](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=709)
- "Anastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion." — Aaron Garrison (clinical) [Ep 29 · 11:49](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=709)
- "Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth." — Jason Frischer (clinical) [Ep 29 · 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 29 · 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 (clinical) [Ep 29 · 12:34](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=754)
- "For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation." — Jason Frischer (clinical) [Ep 29 · 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 29 · 13:54](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=834)
- "Most patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten." — Aaron Garrison (clinical) [Ep 29 · 13:54](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=834)
- "For patients not doing well after pull-through, if there is a stricture at the anastomosis, it needs to be addressed either through dilations or revising the pull through procedure." — Jason Frischer (clinical) [Ep 29 · 14:51](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=891)
- "Anatomic problems after pull-through can include a twist in the pull through, an obstructing cuff, a non-functioning Duhamel pouch, or a transition zone or continued aganglionic segment." — Jason Frischer (clinical) [Ep 29 · 14:51](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=891)
- "For patients with anatomic problems after pull-through, you typically have to revise the pull through." — Jason Frischer (clinical) [Ep 29 · 14:51](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=891)
- "For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies." — Jason Frischer (clinical) [Ep 29 · 14:51](https://library.globalcastmd.com/watch/hirschsprung-s-disease-3187?t=891)
- "Botox paralyzes skeletal muscle but clearly has some impact on smooth muscle" — Marc Levitt (clinical) [Ep 32 · 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, and if they hold stool in successfully, normal babies get constipated while Hirschsprung babies get enterocolitis" — Marc Levitt (clinical) [Ep 32 · 2:06](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=126)
- "After a perfectly done operation that preserves 1 centimeter of anal canal without hurting sphincters, high tone will occur in a baby that doesn't know how to relax" — Marc Levitt (clinical) [Ep 32 · 2:26](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=146)
- "Botox is valuable for babies coming back with enterocolitis episodes after ensuring no anatomic or pathologic problem with the pull-through" — Marc Levitt (clinical) [Ep 32 · 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, bad behavior by the patient can occur even with a perfectly done pull-through" — Marc Levitt (clinical) [Ep 32 · 3:27](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=207)
- "After one year of age, there may be an anatomic or pathologic problem, and Botox is not very valuable because the underlying problem must be identified" — Marc Levitt (clinical) [Ep 32 · 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 32 · 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 fail every 2 or 3 months" — Marc Levitt (clinical) [Ep 32 · 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 32 · 5:35](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=335)
- "Many pathologists are not measuring nerve caliber, and pediatric surgeons should demand that their pathologists do this to avoid doing a pull-through in the transition zone" — Marc Levitt (opinion) [Ep 32 · 5:43](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=343)
- "When anatomic and pathologic issues are completely ruled out (no twist, stricture, cuff, etc.), Botox may be done once or maybe twice and then the patient is done" — Marc Levitt (clinical) [Ep 32 · 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 (clinical) [Ep 32 · 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, cuff, duhamel pouch causing trouble, twist) with normal ganglion cells and nerves less than 40 microns who does not spontaneously empty, except rare patients under one year who have not learned to relax their anal canal" — Marc Levitt (opinion) [Ep 32 · 6:24](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=384)
- "If symptoms persist in an older child, there is an anatomic or pathologic problem that has not yet been identified" — Marc Levitt (clinical) [Ep 32 · 7:00](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=420)
- "Dr. Levitt's Botox technique: 100 units in 10 cc saline, injecting 2.5 cc submucosal into each quadrant with a very small gauge needle" — Marc Levitt (clinical) [Ep 32 · 7:07](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=427)
- "Dr. Levitt will never do internal sphincterotomy because it is permanent Botox and could cause permanent incontinence" — Marc Levitt (opinion) [Ep 32 · 7:30](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=450)
- "Most practitioners use between 60 and 100 units of Botox for Hirschsprung patients" — Scott Ingham (clinical) [Ep 32 · 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 (1 mL total with 0.25 mL per quadrant) compared to Dr. Levitt's 10 mL technique" — Scott Ingham (clinical) [Ep 32 · 8:44](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=524)
- "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 32 · 9:35](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=575)
- "Patients with dilated segment and no other anatomic abnormality who continue to misbehave may be offered redo surgery to remove the dilated segment, though this is exceedingly rare" — Marc Levitt (clinical) [Ep 32 · 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 32 · 10:13](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=613)
- "The workup for patients with dilated segments includes contrast study, examination under anesthesia, and rectal biopsy" — Marc Levitt (clinical) [Ep 32 · 10:34](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=634)
- "For redo pull-through, Dr. Levitt performs transanal approach saving the anal canal, delivers bowel into abdomen, then decides whether tapering is needed" — Marc Levitt (clinical) [Ep 32 · 11:11](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=671)
- "A tapered segment will be fairly dysmotile for many months" — Marc Levitt (clinical) [Ep 32 · 11:24](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=684)
- "Dr. Levitt always diverts patients with an ileostomy if tapering or redo is required" — Marc Levitt (clinical) [Ep 32 · 11:31](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=691)
- "Most likely the dilated segment can be removed and healthy segment brought down without tapering" — Marc Levitt (clinical) [Ep 32 · 11:37](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=697)
- "It is critical to ensure removal of any distal obstruction during redo surgery; Dr. Levitt has seen patients redone with Soave cuff left alone, requiring redo of the redo to remove the cuff before improvement" — Marc Levitt (clinical) [Ep 32 · 11:46](https://library.globalcastmd.com/watch/hirschsprung-disease-audience-q-a-with-dr-marc-levitt-3440?t=706)
- "A one-day-old full-term infant weighing 3.9 kilograms presented with significant abdominal distension and bilious emesis." — Todd Ponsky (host_summary) [Ep 35 · 0:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=40)
- "If a child is sick with bilious emesis and distension, resuscitation should be the first step before diagnostic workup." — Rod Gerardo (host_summary) [Ep 35 · 2:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=127)
- "The plain abdominal x-ray showed a big right colon, prominent transverse colon, and a compressed left colon with small lumen, along with possible small bowel dilation." (clinical) [Ep 35 · 3:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=196)
- "It is hard on a newborn film to really discern small and large bowel, and you can get fooled." — Frischer (clinical) [Ep 35 · 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 malrotation before contrast enema." — Todd Ponsky (clinical) [Ep 35 · 4:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=245)
- "A limited upper GI was performed and ruled out malrotation in this child." — Frischer (clinical) [Ep 35 · 4:43](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=283)
- "The contrast enema showed an impressive right colon with transverse colon tapering off, and a transition zone probably somewhere in the transverse colon." (clinical) [Ep 35 · 5:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=301)
- "Patients with proximal Hirschsprung disease are at risk of perforation, usually in the cecum." — Frischer (clinical) [Ep 35 · 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 35 · 5:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=320)
- "A baby that doesn't have a competent ileosecal valve might be saved from perforation because pressure can decompress into the small bowel." — Frischer (clinical) [Ep 35 · 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 in a patient with suspected Hirschsprung disease." — Frischer (clinical) [Ep 35 · 5:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=357)
- "If the transition zone is at the hepatic flexure, you can predict that enough pressure builds up in the right colon to have the cecum perforate." (clinical) [Ep 35 · 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 zone." (clinical) [Ep 35 · 6:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=364)
- "A suction rectal biopsy confirmed the diagnosis of Hirschsprung disease in this patient." (clinical) [Ep 35 · 6:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=418)
- "Proximal Hirschsprung disease and distal Hirschsprung disease require two different operative approaches." — Frischer (clinical) [Ep 35 · 7:14](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-3-5-proximal-hirschsprung-disease-3682?t=434)
- "Maternal magnesium sulfate used to slow delivery can cause neonatal abdominal distention that mimics Hirschsprung disease" — Levitt (clinical) [Ep 34 · 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 34 · 2:43](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=163)
- "Hypothyroidism can present with neonatal abdominal distention similar to Hirschsprung disease" — Levitt (clinical) [Ep 34 · 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 34 · 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 due to risk of perforation" — Levitt (clinical) [Ep 34 · 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 34 · 7:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=453)
- "The contrast study serves as a roadmap for surgery rather than a definitive diagnostic tool for Hirschsprung disease" — Levitt (clinical) [Ep 34 · 7:33](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=453)
- "In Hirschsprung disease, the aganglionic rectum appears narrow due to spasm and inability to relax, while the ganglionated proximal bowel is dilated, creating the recto-sigmoid ratio" — Frischer (clinical) [Ep 34 · 9:52](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=592)
- "Hyperperistalsis and tortuosity in the rectum on contrast enema is a classic finding in Hirschsprung disease, reflecting hypercontractility of the aganglionic segment" — Levitt (clinical) [Ep 34 · 10:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=630)
- "The exact location of the transition zone cannot be precisely determined on contrast study" — Levitt (clinical) [Ep 34 · 10:30](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=630)
- "Suction rectal biopsy is appropriate for neonates and does not require open biopsy in the operating room" — Levitt (clinical) [Ep 34 · 12:46](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=766)
- "Three good biopsy specimens should be obtained for pathologic evaluation" — Frischer (clinical) [Ep 34 · 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 34 · 13:03](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=783)
- "The diagnostic criteria for Hirschsprung disease at the Washington institution is absence of ganglion cells in 100 pathologic levels" — Levitt (clinical) [Ep 34 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "If a single ganglion cell is found on biopsy, the diagnosis is not Hirschsprung disease regardless of ganglion cell density" — Levitt (clinical) [Ep 34 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Nerve trunk hypertrophy is defined as nerve trunks greater than 40 microns in diameter" — Levitt (clinical) [Ep 34 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Pathologists should measure nerve trunks in rectal biopsies to confirm hypertrophy" — Levitt (clinical) [Ep 34 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "A pathology report showing no ganglion cells without comment on nerve hypertrophy is not satisfactory for surgical decision-making" — Levitt (clinical) [Ep 34 · 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 based on pathology reports showing no ganglion cells but lacking nerve hypertrophy documentation" — Levitt (clinical) [Ep 34 · 14:27](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=867)
- "Everyone is physiologically aganglionic in the zone of the anal canal" — Levitt (clinical) [Ep 34 · 15:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=940)
- "Hypertrophic nerves are not found in the anal canal zone, so absence of ganglion cells there without nerve hypertrophy does not indicate Hirschsprung disease" — Levitt (clinical) [Ep 34 · 15:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=940)
- "Presence of squamous epithelium in a rectal biopsy confirms the biopsy was taken too low (in the anal canal)" — Levitt (clinical) [Ep 34 · 15:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=940)
- "The optimal location for rectal biopsy is 0.5 to 1 cm above the crypts to ensure columnar epithelium" — Levitt (clinical) [Ep 34 · 15:40](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=940)
- "The crypts are located above the dentate line, so optimal biopsy location is at least 1-2 cm above the dentate line" — Frischer (clinical) [Ep 34 · 16:45](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=1005)
- "Infants presenting with Hirschsprung-like symptoms who have ganglion cells but numerous eosinophils on biopsy may have allergic colitis" — Levitt (clinical) [Ep 34 · 16:55](https://library.globalcastmd.com/watch/colorectal-quiz-episode-3-hirschsprung-disease-3649?t=1015)
- "The most important reason to use laparoscopy for Hirschsprung pull-through is to achieve deep pelvic dissection, minimizing transanal work and avoiding overstretching of the sphincters, which is a significant source of morbidity." — Marc Levitt (clinical) [Ep 36 · 6:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=361)
- "With proper laparoscopic dissection, the transanal portion of a primary Hirschsprung pull-through should take well under one hour." — Jason Frischer (clinical) [Ep 36 · 6:37](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=397)
- "For surgeons without laparoscopy available, an umbilical approach can accomplish significant dissection work." — Marc Levitt (clinical) [Ep 36 · 6:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=408)
- "Full-thickness biopsy should be cut as a cube with the seromuscular side equal to the mucosal side to ensure adequate tissue for pathology evaluation." — Marc Levitt (clinical) [Ep 36 · 7:37](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=457)
- "Surgeons should wait for frozen section confirmation before taking mesentery during Hirschsprung pull-through." — Aaron Garrison (clinical) [Ep 36 · 9:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=570)
- "Pathology must confirm presence of ganglion cells and nerves less than 40 microns in diameter before proceeding with pull-through." — Andrea Badillo (clinical) [Ep 36 · 10:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=608)
- "The biopsy must include submucosa because ganglion cells may be present in the seromuscular layer while hypertrophic nerves are present in the submucosal layer." — Marc Levitt (clinical) [Ep 36 · 10:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=620)
- "Mesenteric dissection should stay close to the bowel wall, not deep in the mesentery, as this plane tends to be less bloody." — Aaron Garrison (clinical) [Ep 36 · 11:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=673)
- "Staying close to the bowel during distal rectal dissection is critical because the old Swenson technique with wide dissection resulted in incontinence and urinary retention, likely from injury to the nerve erigentis." — Marc Levitt (clinical) [Ep 36 · 11:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=712)
- "For distal Hirschsprung disease, only distal branches of the IMA need to be taken, but for left colon involvement, the IMA itself may need to be taken to achieve adequate reach." — Jason Frischer (clinical) [Ep 36 · 12:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=746)
- "The transanal dissection should begin 1 cm above the dentate line to protect the dentate line and sphincters from injury." — Andrea Badillo (clinical) [Ep 36 · 13:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=784)
- "Lone Star retractor pins should be placed in three positions: first at the skin to identify the dentate line, then advanced to cover the dentate line, then moved to the mucosal opening site as dissection proceeds superiorly." — Andrea Badillo (clinical) [Ep 36 · 13:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=804)
- "The Swenson full-thickness dissection in the areolar plane is essentially bloodless and is preferred over submucosal dissection." — Marc Levitt (opinion) [Ep 36 · 14:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=852)
- "If a Soave submucosal dissection with cuff is performed, the cuff should be very short (approximately 1 cm) and must be split." — Marc Levitt (clinical) [Ep 36 · 14:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=872)
- "For standard rectosigmoid Hirschsprung cases, the patient can remain supine with legs wrapped and fastened to the ether screen, avoiding the need to flip prone." — Aaron Garrison (clinical) [Ep 36 · 15:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=903)
- "The resection margin should be approximately 5 cm above the biopsy site where the bowel appears healthy." — Andrea Badillo (clinical) [Ep 36 · 16:06](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=966)
- "Tacking sutures on the serosa to the pelvic sidewall at 3 and 9 o'clock positions help anchor the anastomosis in place, though this does not constitute a true two-layer anastomosis." — Aaron Garrison (clinical) [Ep 36 · 16:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=990)
- "The reinforcement layer of sutures is critical for lining up the two pieces of bowel to achieve mucosa-to-mucosa edge approximation." — Rod Gerardo (host_summary) [Ep 36 · 17:01](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-4-classic-hirschsprung-disease-surgical-technique-3704?t=1021)
- "Hypertrophic nerves are mainly a sacral nerve plexus entity, found in sigmoid and rectum, not in more proximal colon." (clinical) [Ep 37 · 5:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=348)
- "Frozen sections can rule out Hirschsprung disease but cannot definitively rule it in." — Rod Gerardo (host_summary) [Ep 37 · 5:23](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=323)
- "If frozen sections show no ganglion cells at the splenic flexure, do not proceed with pull-through that day; wait for permanent sections." (guideline) [Ep 37 · 9:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=572)
- "Ileostomy is preferred over colostomy when uncertain about transition zone level because ileostomy will almost definitely divert successfully." (opinion) [Ep 37 · 6:37](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=397)
- "When performing ileostomy for uncertain proximal disease, send a biopsy from the ileum to confirm it is ganglionic." (guideline) [Ep 37 · 6:49](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=409)
- "Mark biopsy sites with permanent suture using different numbers of tails for each site and document in operative report." (guideline) [Ep 37 · 7:29](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=449)
- "If you have even a little bit of colon, if you have your right colon, you can make one formed stool per day." (clinical) [Ep 37 · 10:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=620)
- "For mid-transverse colon transition zone, the pull-through blood supply is based on right colic vessels, and the middle colic must be ligated." — Andrea Badillo (clinical) [Ep 37 · 11:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=675)
- "To bring mid-transverse colon down for pull-through, the bowel must be de-rotated to avoid bringing the mesentery across the duodenum and creating obstruction." — Andrea Badillo (clinical) [Ep 37 · 11:21](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=681)
- "For transverse colon pull-through, ligate middle colic and very likely right colic; blood supply depends on ileocolic and the marginal artery paralleling the right colon." (clinical) [Ep 37 · 11:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=698)
- "De-rotation for transverse colon pull-through places the cecum at the liver bed, brings the pull-through down the right side, and puts small bowel on the left side — opposite rotation from Ladd's procedure." (clinical) [Ep 37 · 11:43](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=703)
- "When pulling transverse colon down, there is a slight twist in the mesentery, so ensuring adequate blood supply without kinking is critical." (clinical) [Ep 37 · 12:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=730)
- "Preference is to perform proximal Hirschsprung pull-through open, possibly through the ileostomy closure incision, though some do it laparoscopically." (opinion) [Ep 37 · 12:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=744)
- "There are functional outcome differences between pulling through transverse colon versus left-sided colon." (clinical) [Ep 37 · 9:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=585)
- "If planning to wait several months before pull-through and not diverting the colon, consider whether the colon needs to be beaten (decompressed), though the answer is uncertain." (opinion) [Ep 37 · 8:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=487)
- "Most defunctionalized colons can stay without needing irrigation access; only a small population will need the colon addressed if it becomes severely backed up with chalky stool." — Andrea Badillo (clinical) [Ep 37 · 8:46](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=526)
- "In settings without pathology support, empiric diversion in the dilated segment is a reasonable strategy; if that bowel works, that is where the pull-through will go." (guideline) [Ep 37 · 7:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=427)
- "If doing primary pull-through several days after mapping (waiting for permanent sections), ensure the child is doing well with irrigations and not having smoldering enterocolitis, which would warrant immediate diversion." (guideline) [Ep 37 · 6:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=369)
- "The nightmare scenario is not finding ganglion cells on frozen section (especially when not finding nerves) when in fact ganglion cells are present, leading to unnecessary resection of good colon." (clinical) [Ep 37 · 5:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=335)
- "For proximal disease, the key question on biopsy is whether ganglion cells are present, not whether nerves are hypertrophic." — Rod Gerardo (host_summary) [Ep 37 · 6:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-5-proximal-hirschsprung-disease-surgical-technique-3745?t=360)
- "After Hirschsprung pull-through, Dr. Durham brings patients back about 2 weeks after surgery to calibrate the anus and assess for cicatrix or narrowing at the anastomosis." — Megan Durham (clinical) [Ep 38 · 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 in the young child." — Megan Durham (clinical) [Ep 38 · 2:13](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=133)
- "Dr. Huang does not perform routine post-operative therapies initially after Hirschsprung pull-through because the anastomosis is healing and insertion of finger or dilator risks disrupting the anastomosis." — Eunice Huang (clinical) [Ep 38 · 2:23](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=143)
- "There is probably not a standard post-operative method for Hirschsprung patients because each patient is different, with some doing beautifully after identical surgery while others require frequent follow-up." — Eunice Huang (opinion) [Ep 38 · 2:46](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=166)
- "For a first episode of enterocolitis in a patient who has been doing well, Dr. Huang would be more likely to not intervene much beyond treating the enterocolitis and ensuring appropriate recovery." — Eunice Huang (clinical) [Ep 38 · 4:14](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=254)
- "For chronic or recurrent enterocolitis after Hirschsprung pull-through, concerns include anatomic problems, physiologic dysmotility of the ganglionic segment, or technical issues such as a twist." — Eunice Huang (clinical) [Ep 38 · 4:39](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=279)
- "At Children's Healthcare of Atlanta, acute Hirschsprung-associated enterocolitis management does not include fixed NPO time or immediate TPN initiation." — Megan Durham (clinical) [Ep 38 · 5:13](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=313)
- "Children's Healthcare of Atlanta protocol for enterocolitis includes rectal irrigations with about 10 cc/kg normal saline every 8 hours for at least the first 24 to 48 hours." — Megan Durham (clinical) [Ep 38 · 5:19](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=319)
- "IV Flagyl is typically started for Hirschsprung-associated enterocolitis at Children's Healthcare of Atlanta." — Megan Durham (clinical) [Ep 38 · 5:29](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=329)
- "Hirschsprung enterocolitis patients present across a spectrum from mild (slight white count elevation and concerning X-ray distention) to severe (gross distention with obvious shock), requiring different treatment approaches." — Rod Gerardo (host_summary) [Ep 38 · 5:32](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=332)
- "Dr. Durham would discharge a child after enterocolitis on Flagyl, laxatives, and rectal irrigations for some period of time, particularly for children who tend to dilate their colon." — Megan Durham (clinical) [Ep 38 · 6:18](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=378)
- "Teaching parents how to perform washouts at home and providing them the tools allows them freedom to do initial washout when their child is getting sick, improving quality of life at home." — Eunice Huang (clinical) [Ep 38 · 6:48](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=408)
- "Children's Healthcare of Atlanta has developed a standardized teaching regimen for rectal irrigations across different campuses and a regular education process for floor nurses." — Megan Durham (clinical) [Ep 38 · 7:05](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=425)
- "Nursing staff commonly have different levels of education regarding rectal irrigations and enemas because this is not an everyday common occurrence." — Megan Durham (clinical) [Ep 38 · 7:13](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=433)
- "A standardized order form with links to policy has been implemented to make rectal irrigation procedures clearer for nurses." — Megan Durham (clinical) [Ep 38 · 7:37](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=457)
- "Dr. Langer published a guideline with the APSA Hirschsprung Disease Research Interest Group for diagnosis and management of obstructive symptoms after Hirschsprung pull-through." — Megan Durham (guideline) [Ep 38 · 8:10](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=490)
- "The APSA algorithm for post-pull-through obstruction includes decision points starting with rectal exam and contrast enema, potentially moving to rectal biopsy, botulinum toxin injection, and ultimately motility workup that determines need for further colonic resection versus bowel management, stoma, or ACE." — Rod Gerardo (host_summary) [Ep 38 · 8:33](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=513)
- "Obstructed Hirschsprung patients are easier to identify because not passing stool is an easy sign for parents to see, whereas hypermodal patients with fecal incontinence present a more difficult diagnostic challenge." — Megan Durham (clinical) [Ep 38 · 9:37](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=577)
- "In Case 2, exam under anesthesia revealed intact sphincters and intact dentate line." — Megan Durham (clinical) [Ep 38 · 10:52](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=652)
- "The patient in Case 2 had high-amplitude propagating contractions (HAPCs) on manometry with pressures upwards of 400 mmHg all the way down to the anus." — Megan Durham (clinical) [Ep 38 · 10:56](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=656)
- "Nobody can control the type of pressure (400 mmHg HAPCs) coming down to the anus." — Megan Durham (opinion) [Ep 38 · 11:11](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=671)
- "The patient in Case 2 was diagnosed with pseudo-incontinence with hypermotility." — Rod Gerardo (host_summary) [Ep 38 · 11:14](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=674)
- "Adjusting fiber intake, daily Imodium, and adding cholestyramine successfully managed the hypermotility patient, allowing return to school with other kids within about a year." — Rod Gerardo (host_summary) [Ep 38 · 11:21](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-1-3801?t=681)
- "Rectal prolapse is a relatively unusual problem in pediatric surgery." — Eunice Huang (epidemiological) [Ep 40 · 0:59](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=59)
- "Children develop rectal prolapse because of their anatomy: they have a very weak pelvic floor and the rectum is very low, so it tends to pop out easily if they strain hard enough." — Eunice Huang (clinical) [Ep 40 · 2:44](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=164)
- "The majority of pediatric rectal prolapse cases do not need surgery." — em gootee or todd ponsky (host_summary) [Ep 40 · 2:26](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=146)
- "The most common reasons for rectal prolapse in children are constipation, sitting on the potty too long, or sitting on it incorrectly." — em gootee or todd ponsky (host_summary) [Ep 40 · 2:33](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=153)
- "Physical exam is key to distinguish rectal prolapse from intussusception, polyps, and rectal hemorrhoids." — em gootee or todd ponsky (host_summary) [Ep 40 · 2:55](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=175)
- "Conservative treatment includes managing constipation, teaching proper toilet sitting with a smaller seat so children don't fall through, providing a step for proper upright posture, and limiting time on the toilet without distractions like iPads." — Eunice Huang (clinical) [Ep 40 · 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." — em gootee or todd ponsky (host_summary) [Ep 40 · 3:39](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=219)
- "Dr. Sean St. Peter's sclerotherapy technique uses 5 ccs of Sotradechol injected in 4 quadrants with any remaining volume injected in between." — Shawn St. Peter (clinical) [Ep 40 · 4:28](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=268)
- "Sclerotherapy has a low threshold for use because it is simple, innocuous, and can provide a window of a couple months without prolapse that allows younger children to see less frequent episodes." — Shawn St. Peter (opinion) [Ep 40 · 4:11](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=251)
- "A systematic review in the Journal of Pediatric Surgery included 27 publications with 900 patients: 300 underwent sclerotherapy (8 studies, 3 sclerosing agents) and 600 underwent operative management (22 studies, 17 different procedures)." — Eunice Huang (epidemiological) [Ep 40 · 5:10](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=310)
- "The large number of different operative procedures (17 procedures across studies) indicates uncertainty about which is the best procedure for rectal prolapse." — Eunice Huang (opinion) [Ep 40 · 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 rectal prolapse based on published data." — Eunice Huang (clinical) [Ep 40 · 5:56](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=356)
- "A 2019 Journal of Pediatric Surgery review of sclerotherapy publications found that alcohol is the most popular sclerosing agent and is pretty effective." — em gootee or todd ponsky (host_summary) [Ep 40 · 6:31](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=391)
- "Alcohol as a sclerosing agent is probably really easy to obtain in the hospital setting." — em gootee or todd ponsky (opinion) [Ep 40 · 7:04](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=424)
- "The complication rate of sclerotherapy is mostly negligible, complications are acute, and there is minimal risk of long-term problems." — Eunice Huang (clinical) [Ep 40 · 7:14](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=434)
- "Patients with rectal prolapse should be evaluated to rule out underlying diseases, especially cystic fibrosis." — Eunice Huang (guideline) [Ep 40 · 7:41](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=461)
- "Sclerotherapy with ethyl alcohol is the recommended first option after failed conservative management, can be performed up to 3 times, and has an estimated cumulative success rate of a little bit over 80%." — em gootee or todd ponsky (host_summary) [Ep 40 · 8:04](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=484)
- "Laparoscopic rectopexy is the recommended operative approach for patients who fail sclerotherapy because it has the lowest complication rate and the highest success rate." — em gootee or todd ponsky (host_summary) [Ep 40 · 8:12](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=492)
- "Some patients with rectal prolapse and anxiety develop a feedback loop where prolapse becomes an emotional release mechanism for evacuating stool." — Eunice Huang (clinical) [Ep 40 · 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, when combined with sclerotherapy and support for anxiety, leads to more durable outcomes." — Eunice Huang (clinical) [Ep 40 · 9:34](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=574)
- "Patients with rectal prolapse may benefit from a multidisciplinary team approach including behavioral therapy and physical therapy." — em gootee or todd ponsky (host_summary) [Ep 40 · 9:20](https://library.globalcastmd.com/watch/update-course-rewind-2020-colorectal-part-2-3834?t=560)
- "10% of newborns with meconium plug have Hirschsprung disease" — Marc Levitt (epidemiological) [Ep 42 · 3:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=193)
- "Newborns with meconium plug should receive biopsy for Hirschsprung disease to avoid missing the diagnosis and having the child suffer months of constipation, poor feeding, and distension" — Marc Levitt (clinical) [Ep 42 · 3:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=193)
- "In a newborn with meconium plug and Hirschsprung disease, the initial contrast enema shows what appears to be a meconium plug but is actually a segment of Hirschsprung disease" — Marc Levitt (clinical) [Ep 42 · 3:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=210)
- "After meconium passage, obtaining another contrast image will show the characteristic appearance of Hirschsprung disease" — Amanda Jensen (host_summary) [Ep 42 · 3:53](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=233)
- "Common causes of failure to pass meconium include Hirschsprung disease, meconium plug syndrome, meconium ileus, and anorectal malformation" — Rod Gerardo (host_summary) [Ep 42 · 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 from maternal preterm labor treatment, milk protein allergy, and microcolon intestinal hypoperistalsis syndrome" — Amanda Jensen (host_summary) [Ep 42 · 4:19](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=259)
- "In total colonic Hirschsprung disease, contrast enema shows an amorphous, cylindrical colon without the classic narrowing at the rectum compared to the sigmoid seen in typical Hirschsprung disease" — Marc Levitt (clinical) [Ep 42 · 6:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=393)
- "The age cutoff for switching from suction rectal biopsy to full-thickness biopsy is around 6 months" — Jason Frischer (clinical) [Ep 42 · 7:26](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=446)
- "At 10 months of age, full-thickness biopsy is preferred over suction biopsy to ensure a definitive diagnosis" — Marc Levitt (clinical) [Ep 42 · 7:39](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=459)
- "Suction biopsies are problematic when they do not provide a definitive diagnosis, requiring a subsequent trip to the OR for formal biopsy" — Marc Levitt (clinical) [Ep 42 · 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 preoperatively before proceeding to the operating room" — Amanda Jensen (host_summary) [Ep 42 · 8:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=483)
- "If the patient is doing well and can be managed with irrigations, it is preferable to have final pathology diagnosis of Hirschsprung disease from rectal biopsy before entering the abdomen" — Jason Frischer (clinical) [Ep 42 · 8:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=518)
- "If the patient is not doing well with irrigations, a procedure such as ileostomy or leveling colostomy is necessary to relieve pressure" — Amanda Jensen (host_summary) [Ep 42 · 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 will likely spill into the non-functional part of the colon" — Amanda Jensen (host_summary) [Ep 42 · 9:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=544)
- "Standard biopsy locations during operative mapping include rectosigmoid, proximal sigmoid around the left colon, splenic flexure/transverse colon, and right colon or hepatic flexure area" — Jason Frischer (clinical) [Ep 42 · 9:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=553)
- "A transition zone can often be visualized during surgery (open or laparoscopic), but when it cannot be seen, biopsies should be obtained at multiple levels" — Amanda Jensen (host_summary) [Ep 42 · 9:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=575)
- "It is acceptable to not perform a definitive procedure if only frozen section is available and there is uncertainty about the frozen section diagnosis" — Amanda Jensen (host_summary) [Ep 42 · 10:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=609)
- "Surgeons can wait for final pathology and return another day to perform the pull-through procedure if needed" — Amanda Jensen (host_summary) [Ep 42 · 10:21](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-10-total-colonic-hirschsprung-disease-part-1-3893?t=621)
- "The case patient is a 10-year-old male with chronic constipation, soiling, poor appetite, and a water-soluble contrast enema showing a tortuous, redundant, dilated colon full of stool." — Amanda Jensen (host_summary) [Ep 41 · 0:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=35)
- "Anorectal manometry in this patient showed an absent rectoanal inhibitory reflex (RAIR)." (host_summary) [Ep 41 · 1:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=63)
- "Colonic transit and colonic function must be assessed in this patient; it is not purely a sphincter issue." — Anil Darbari (clinical) [Ep 41 · 1:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=105)
- "The massively dilated colon is a result of colonic dysfunction, with dilatation predominantly in the rectosigmoid." — Anil Darbari (clinical) [Ep 41 · 2:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=124)
- "A Sitz marker study is recommended to assess colonic transit." — Kahleb Graham (clinical) [Ep 41 · 2:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=144)
- "Anorectal manometry should assess resting pressure; high resting pressure may indicate a patient amenable to anal Botox." — Kahleb Graham (clinical) [Ep 41 · 2:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=155)
- "Conscious rectal sensitivity threshold is tested by gradually inflating a balloon to determine when the patient has a sensation to defecate." — Kahleb Graham (clinical) [Ep 41 · 2:49](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=169)
- "Normal defecation physiology involves pushing from the belly (increasing intraabdominal pressure) and relaxing the anal sphincter, creating a positive pressure gradient." — Kahleb Graham (clinical) [Ep 41 · 3:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=180)
- "Motility disorder patients may have a negative pressure gradient during defecation, termed dyssynergia, and may benefit from pelvic floor physical therapy or biofeedback." — Kahleb Graham (clinical) [Ep 41 · 3:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=189)
- "Sitz marker study is performed by having the patient ingest markers and obtaining an X-ray at day 5." — Kahleb Graham (clinical) [Ep 41 · 3:39](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=219)
- "Sitz marker study is used as a screening test; if markers are scattered throughout the colon or predominantly on the right side, colonic manometry may be indicated." — Kahleb Graham (clinical) [Ep 41 · 3:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=228)
- "If all Sitz markers are at the bottom of the colon, it suggests an outlet issue rather than a transit problem." (host_summary) [Ep 41 · 4:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=247)
- "If all Sitz markers have disappeared on day-5 X-ray, the patient has stooled, even if they report not having done so; the markers do not dissolve." — Kahleb Graham (clinical) [Ep 41 · 4:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=253)
- "Sitz marker study should be available in most settings worldwide." — Marc Levitt (opinion) [Ep 41 · 4:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=275)
- "Colonic manometry is not available everywhere in the world." — Marc Levitt (epidemiological) [Ep 41 · 4:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=285)
- "Sitz markers can be used as a colonic transit study by obtaining X-rays at days 0, 1, 2, and 4 to visualize marker transit through the colon." — Anil Darbari (clinical) [Ep 41 · 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 (host_summary) [Ep 41 · 5:17](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=317)
- "Nuclear scintigraphy is an alternative to colonic manometry in centers without manometry capability but with nuclear medicine capacity." — Marc Levitt (clinical) [Ep 41 · 5:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=332)
- "From a surgeon's perspective, three colonic motility scenarios must be distinguished: (1) diffusely slow but functional, (2) normal motility with a segmental problem, and (3) severely slow throughout." — Marc Levitt (clinical) [Ep 41 · 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 for diagnosing motility disorders, but it is expensive and not available everywhere." (host_summary) [Ep 41 · 6:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=394)
- "Colonic manometry provides information on peristaltic activity, specifically the motion of the colon." — Anil Darbari (clinical) [Ep 41 · 7:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=427)
- "Normal colonic physiology includes two strong contractions per day, called high-amplitude propagating contractions (HAPCs)." — Anil Darbari (clinical) [Ep 41 · 7:21](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=441)
- "HAPCs start in the cecum and progress distally in a coordinated manner." — Anil Darbari (clinical) [Ep 41 · 7:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=452)
- "Presence of two HAPCs during an 18- or 24-hour colonic manometry study rules out colonic dysmotility." — Anil Darbari (clinical) [Ep 41 · 7:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=465)
- "Many patients undergoing colonic manometry have normal results, meaning they have slow transit but normal HAPCs." — Jason Frischer (clinical) [Ep 41 · 8:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=482)
- "If HAPCs are present throughout the colon, antegrade flush therapy is likely to work well." — Marc Levitt (clinical) [Ep 41 · 8:22](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=502)
- "Some patients have a true outlet issue with a normal colon on manometry." — Kahleb Graham (clinical) [Ep 41 · 8:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=518)
- "Colonic manometry can characterize whether contractions are well coordinated (neuropathic problem) or low amplitude (myopathic problem)." — Kahleb Graham (clinical) [Ep 41 · 8:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=527)
- "Contractions should propagate from the right colon to the rectum; the rectum does not have the same contractions as the colon." — Kahleb Graham (clinical) [Ep 41 · 9:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=543)
- "In Hirschsprung patients status post pull-through, the rectosigmoid brake is removed, and contractions may be seen extending from the right colon all the way to the sphincters." — Kahleb Graham (clinical) [Ep 41 · 9:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=552)
- "Even if HAPCs are present and colonic motility appears normal, absence of response to stimulants on manometry indicates abnormal colonic motility." — Anil Darbari (clinical) [Ep 41 · 9:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=576)
- "In this case, the team concluded the patient did not have Hirschsprung disease; the absent RAIR was a sampling error, and calretinin staining was positive." — Marc Levitt (clinical) [Ep 41 · 10:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=611)
- "Anorectal manometry showed the colon was diffusely slow, and the problem was primarily the sphincter." (host_summary) [Ep 41 · 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 antegrade continence enema (MACE) for antegrade flushes, in combination with Botox and biofeedback physiotherapy." (host_summary) [Ep 41 · 10:38](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=638)
- "Over time, the colon may rehabilitate, and the patient may eventually need only laxatives, but mechanical emptying of the colon is a perfectly acceptable endpoint." — Marc Levitt (opinion) [Ep 41 · 10:50](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=650)
- "Enemas from below or from above (via Malone or cecostomy) are acceptable management; failure of this conservative therapy may then require resection." — Marc Levitt (clinical) [Ep 41 · 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." (host_summary) [Ep 41 · 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 enemas only and do not need resection." — Marc Levitt (clinical) [Ep 41 · 11:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=692)
- "Historically, colons were resected in patients who, in retrospect, likely had only motility disorders and did not need surgery." (host_summary) [Ep 41 · 12:03](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=723)
- "Hirschsprung disease is a congenital condition affecting the lower most aspect of the intestine (rectum or sigmoid), characterized by missing ganglion cells in the submucosal and myenteric plexus that allow the intestine to relax." — Nelson Rosen (clinical) [Ep 43 · 1:05](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=65)
- "In Hirschsprung disease, the rectum and lowest part of the colon are always affected, with the aganglionosis always ending right above the anus." — Nelson Rosen (clinical) [Ep 43 · 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 43 · 2:25](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=145)
- "In about 10% of Hirschsprung cases, the entire colon is affected." — Nelson Rosen (epidemiological) [Ep 43 · 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 43 · 2:52](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=172)
- "The first sign of Hirschsprung disease in newborns is usually failure to pass stool (meconium) within the first 24 to 48 hours." — Patty Curran (clinical) [Ep 43 · 3:00](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=180)
- "After failure to pass meconium, newborns with Hirschsprung disease develop bloating, continued failure to pass stool, and vomiting." — Patty Curran (clinical) [Ep 43 · 3:15](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=195)
- "In newborns with suspected Hirschsprung disease, the initial workup includes a water-soluble contrast enema looking for a narrower distal segment (rectum) with dilation above." — Nelson Rosen (clinical) [Ep 43 · 3:30](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=210)
- "If contrast enema raises concern for Hirschsprung disease, a suction rectal biopsy is performed to examine tissue for the presence of ganglion cells." — Nelson Rosen (clinical) [Ep 43 · 4:05](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=245)
- "In older children, Hirschsprung disease can be missed and typically presents with failure to thrive (small for age) and significant constipation." — Nelson Rosen (clinical) [Ep 43 · 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 43 · 5:00](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=300)
- "In older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess degree of constipation, followed by contrast rectal enema, and then biopsy depending on findings." — Nelson Rosen (clinical) [Ep 43 · 5:20](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=320)
- "In older children with low-risk presentations (normal early years, then worsening constipation), biopsy should usually be done only after routine constipation management measures are tried and fail." — Nelson Rosen (clinical) [Ep 43 · 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, specifically looking for the rectoanal inhibitory reflex." — Nelson Rosen (clinical) [Ep 43 · 6:25](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=385)
- "The normal rectoanal inhibitory reflex causes the anal sphincter to relax when a balloon is inflated in the rectum, but this reflex is absent in Hirschsprung disease." — Nelson Rosen (clinical) [Ep 43 · 7:05](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=425)
- "Anorectal manometry is not sufficiently sensitive to rule out Hirschsprung disease; a normal manometry does not completely exclude the diagnosis." — Nelson Rosen (clinical) [Ep 43 · 7:33](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=453)
- "Even with suggestive manometry findings, a biopsy is still required before surgical intervention; no surgeon would operate on manometry alone." — Rod Gerardo (host_summary) [Ep 43 · 7:50](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=470)
- "Suction rectal biopsy can be performed at the bedside in newborns and is reliable up to one year of age." — Patty Curran (clinical) [Ep 43 · 8:20](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=500)
- "After one year of age, biopsy should be performed in the operating room under anesthesia to obtain tissue from higher in the rectum." — Patty Curran (clinical) [Ep 43 · 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 (distal-most) part of the rectum." — Rod Gerardo (host_summary) [Ep 43 · 8:41](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=521)
- "In children over one year old, the suction biopsy tool cannot obtain adequate tissue depth because the tissue is thicker, necessitating surgical biopsy in the OR." — Rod Gerardo (host_summary) [Ep 43 · 9:05](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=545)
- "Surgical rectal biopsy in older children is a simple 20-minute procedure with same-day discharge." — Rod Gerardo (host_summary) [Ep 43 · 9:40](https://library.globalcastmd.com/watch/hirschsprung-disease-workup-4411?t=580)
- "Harold Hirschsprung identified that a baby could be sick due to this problem but did not understand the pathology." — Marc Levitt (clinical) [Ep 45 · 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' without an apostrophe S." — Marc Levitt (guideline) [Ep 45 · 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 discovering the absence of ganglion cells in the pathology lab." — Marc Levitt (clinical) [Ep 45 · 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 45 · 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 45 · 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 by making only a 1-centimeter cuff, which Dan von Almen describes as 'basically Swensons with a 1-centimeter cuff.'" — Marc Levitt (host_summary) [Ep 45 · 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 few people read." — Marc Levitt (clinical) [Ep 45 · 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 45 · 2:34](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=154)
- "The Suave and Duhamel procedures were developed because surgeons believed the Swenson operation caused fecal and urinary incontinence or voiding dysfunction." — Marc Levitt (clinical) [Ep 45 · 2:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=160)
- "Doctor Swenson argued that complications attributed to his operation were due to improper technique—specifically, dissecting too wide—rather than the operation itself." — Marc Levitt (host_summary) [Ep 45 · 2:56](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=176)
- "A proper Swenson dissection should be performed right on the bowel wall (similar to a PSARP); if fat is visible, the dissection can be closer, as the nerves are in the fatty layer." — Marc Levitt (clinical) [Ep 45 · 3:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=210)
- "Dissecting too wide during a Swenson procedure will injure the nervi erigentes." — Marc Levitt (clinical) [Ep 45 · 3:44](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=224)
- "Orvar Swenson lived to age 105 and wrote letters to Dr. Levitt and Alberto Pena asking them to promote the Swenson operation." — Marc Levitt (clinical) [Ep 45 · 3:46](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=226)
- "Duhamel's technique involves leaving the original rectum behind, performing a pull-through next to it, and then mating the two lumens." — Marc Levitt (clinical) [Ep 45 · 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 ileo-Duhamel, though Dr. Levitt would still perform an ileoanal anastomosis." — Marc Levitt (opinion) [Ep 45 · 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 45 · 4:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=275)
- "Some patients who underwent Rabine's procedure did well, with ganglionated bowel functioning through 6 centimeters of aganglionic bowel, but the operation is no longer performed." — Marc Levitt (clinical) [Ep 45 · 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 perform a primary coloanal anastomosis of a Suave procedure, eliminating the need to leave the bowel hanging out and return at day 7." — Marc Levitt (clinical) [Ep 45 · 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 Suave technique is 'the Suave technique with the Boley modification' or 'Suave-Boley.'" — Marc Levitt (guideline) [Ep 45 · 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 perform a primary pull-through for Hirschsprung disease without a preceding stoma." — Marc Levitt (clinical) [Ep 45 · 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 out of desperation because in the Philippines, babies with stomas faced such severe social stigma that families would leave them to die." — Marc Levitt (clinical) [Ep 45 · 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 extended Duhamel procedure that leaves a longer aganglionic segment of rectum for long-segment Hirschsprung disease." — Jason Frischer (clinical) [Ep 45 · 10:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=608)
- "In 1977, Doctor Martin was the first to apply the endorectal pull-through technique used in Hirschsprung disease to the surgical treatment of ulcerative colitis, performing total proctocolectomy with ileoanal anastomosis." — Jason Frischer (clinical) [Ep 45 · 10:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=640)
- "Doctor Martin's ulcerative colitis technique predated the J-pouch, which later modified his approach." — Jason Frischer (clinical) [Ep 45 · 11:19](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=679)
- "The transanal dissection used in the Suave procedure is the same concept as the mucosectomy performed in ulcerative colitis surgery." — Marc Levitt (clinical) [Ep 45 · 11:28](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=688)
- "Helen Noblett from Melbourne, Australia, developed the suction rectal biopsy technique." — Marc Levitt (clinical) [Ep 45 · 12:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=752)
- "Keith Jorgeson performed the first laparoscopic version of the Suave procedure." — Marc Levitt (clinical) [Ep 45 · 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 the laparoscopic Suave (co-authored with Tom Inge), they described leaving a 5-centimeter cuff, which would now be considered too long." — Marc Levitt (clinical) [Ep 45 · 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 approaches to perform rectosigmoid resection with or without laparoscopy or laparotomy." — Marc Levitt (clinical) [Ep 45 · 13:17](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=797)
- "Some centers around the world now perform transanal-only approaches for Hirschsprung disease, which Dr. Levitt uses in certain circumstances." — Marc Levitt (clinical) [Ep 45 · 13:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=815)
- "Dan Teitelbaum performed significant research on enterocolitis in Hirschsprung disease before his death from a brain tumor." — Marc Levitt (clinical) [Ep 45 · 13:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-21-the-history-of-hirschsprung-disease-4512?t=827)
- "For exam under anesthesia in Hirschsprung's patients, digital exam should assess for circumferential stricture at the anastomosis" — Hira Ahmad (clinical) [Ep 44 · 1:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=96)
- "Hagar dilator can be used to size the anastomotic opening to ensure adequate caliber" — Hira Ahmad (clinical) [Ep 44 · 1:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=117)
- "Foley catheter passage can determine if there is a twist in the pull-through segment" — Hira Ahmad (clinical) [Ep 44 · 2:04](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=124)
- "Swabe cuff presents as a 1-2 centimeter circumferential narrowing that is not the anastomosis itself" — Hira Ahmad (clinical) [Ep 44 · 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 44 · 2:33](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=153)
- "In Duhamel procedure, rectal exam should assess for two lumens and a spur between them, as stool can flow into the Duhamel pouch, fill it, and compress the ganglionated pull-through" — Marc Levitt (clinical) [Ep 44 · 3:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=180)
- "Treatment for problematic Duhamel spur is to take out the common wall; occasionally the Duhamel pouch itself needs excision" — Marc Levitt (clinical) [Ep 44 · 3:25](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=205)
- "Before anesthesia induction, it is important to examine the anus for sphincteric contraction vs. patulous appearance" — Marc Levitt (clinical) [Ep 44 · 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 44 · 3:48](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=228)
- "During exam and biopsy, close examination is needed to ensure the dentate line was preserved at the original pull-through" — Marc Levitt (clinical) [Ep 44 · 3:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=237)
- "If the dentate line has been lost at original pull-through or sphincters have been overstretched, the patient will not have enterocolitis but will have fecal incontinence" — Marc Levitt (clinical) [Ep 44 · 4:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=252)
- "Botox is being studied to prevent enterocolitis with the theory of chemo-denervating nerves in the area instead of permanent stretch or anatomic destruction from surgery" — Jason Frischer (clinical) [Ep 44 · 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 to obtain a circumferential view of the anastomotic area during exam under anesthesia" — Rebecca Rentia (clinical) [Ep 44 · 4:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=297)
- "To palpate for Swabe cuff, place finger against the sacrum and pull down to feel rubbery tissue outside the pull-through" — Marc Levitt (clinical) [Ep 44 · 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 aganglionotic or transition zone pull-through, though sampling error must be considered" — Marc Levitt (clinical) [Ep 44 · 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; some surgeons offer redo for significantly obstructive patients with this finding" — Marc Levitt (opinion) [Ep 44 · 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, and may develop in Hirschsprung's patients not emptying well due to sphincter dysfunction" — Marc Levitt (clinical) [Ep 44 · 8:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=532)
- "Until comparing original and repeat pathology, it is unclear whether hypertrophic nerves represent original pathology error or secondary changes that evolved over time" — Marc Levitt (clinical) [Ep 44 · 9:46](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=586)
- "The Swenson procedure was the first Hirschsprung's operation and is the purest, leaving the least amount of Hirschsprung's tissue behind" — Marc Levitt (clinical) [Ep 44 · 13:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=785)
- "The Swabe and Duhamel procedures were developed because surgeons were doing the Swenson in too wide a plane and injuring the nervi erigentes in the mesorectum" — Marc Levitt (clinical) [Ep 44 · 13:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=795)
- "If you stay right on the bowel wall during Swenson dissection, you avoid nerve injury" — Marc Levitt (clinical) [Ep 44 · 13:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=804)
- "In the original laparoscopic Swabe described by Keith Jorgeson, a 5 centimeter cuff was recommended, which is too long" — Marc Levitt (opinion) [Ep 44 · 12:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=760)
- "Many Swabe surgeons are now approaching a Swenson technique or have transitioned to Swenson, using a mini-cuff (approximately 1 centimeter)" — Marc Levitt (clinical) [Ep 44 · 12:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=750)
- "Sometimes the Swabe cuff fuses back together or is not cut all the way, creating an aganglionotic obstructive ring around the pull-through" — Marc Levitt (clinical) [Ep 44 · 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 aganglionotic cases, the approach is total body prep, then transanal dissection in prone position first, going as far as possible; if healthy bowel cannot reach, be prepared for laparoscopy or laparotomy" — Marc Levitt (clinical) [Ep 44 · 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 44 · 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 must include rectal irrigation, done early" — Jason Frischer (guideline) [Ep 44 · 17:23](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1043)
- "Every institution should have a protocol for obstructed Hirschsprung's patients to ensure quick and efficient response" — Jason Frischer (guideline) [Ep 44 · 17:28](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1048)
- "Systematic workup for obstructed Hirschsprung's includes: resuscitation, imaging studies, and comprehensive rectal exam under anesthesia" — Jason Frischer (guideline) [Ep 44 · 17:41](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1061)
- "Gastroenterologists and surgeons must know the anatomy of the original pull-through procedure (Swabe, Swenson, or Duhamel) when evaluating obstructed patients" — Marc Levitt (guideline) [Ep 44 · 18:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-20-hirschsprung-disease-obstruction-part-2-4461?t=1112)
- "In the Petcova et al. study published in Annals of Surgery 2020, children with uncomplicated appendicitis were randomized to medical management with antibiotics or surgery, with 5-year follow-up." — Ellen Encisco (host_summary) [Ep 46 · 0:43](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=43)
- "In the Petcova et al. appendicitis study, the surgery group had no complications, while 46% of patients in the non-surgical management group required appendectomy during follow-up." (host_summary) [Ep 46 · 1:11](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=71)
- "Medical management of acute uncomplicated appendicitis may be safe but is associated with a high failure rate, with many children ultimately requiring laparoscopic appendectomy." — Ellen Encisco (host_summary) [Ep 46 · 1:22](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=82)
- "Metastectomy for osteosarcoma lung metastases improves survival and can make patients long-term survivors." (host_summary) [Ep 46 · 2:15](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=135)
- "Approximately 10% of 1 millimeter lung nodules in osteosarcoma patients contain malignant disease." (host_summary) [Ep 46 · 2:24](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=144)
- "The Children's Oncology Group is starting a study to determine whether thoracotomy or thoracoscopy is superior for resection of pulmonary metastases in osteosarcoma, with enrollment expected late 2021 or early 2022." (host_summary) [Ep 46 · 2:40](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=160)
- "The Flourish device is a catheter-based device that places magnets in proximal and distal esophageal pouches to create a compression anastomosis by causing ischemia of tissue between the magnets, which then sloughs off." (host_summary) [Ep 46 · 3:16](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=196)
- "Inclusion criteria for the Flourish device are: atretic gap less than 4 centimeters long, fistula repaired or absent, and G-tube able to accommodate an 18 French catheter." (host_summary) [Ep 46 · 3:39](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=219)
- "The Flourish device is associated with a high stricture rate and known serious life-threatening complications, and should only be used by centers with capabilities to treat the many issues associated with esophageal atresia." (host_summary) [Ep 46 · 3:57](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=237)
- "Indocyanine green (ICG) has become a topic of interest in the last few years for use in pediatric surgery, especially in minimally invasive procedures to improve visualization of structures." — Ellen Encisco (host_summary) [Ep 46 · 4:43](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=283)
- "For laparoscopic cholecystectomy, ICG must be administered intravenously 12 to 18 hours prior to surgery to allow time for accumulation in the extrahepatic ducts, or can be injected directly into the gallbladder during surgery." — Ellen Encisco (host_summary) [Ep 46 · 5:32](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=332)
- "ICG applications in pediatric surgery include laparoscopic cholecystectomies, varicocele repairs, partial nephrectomies, and tumor excisions." — Ellen Encisco (host_summary) [Ep 46 · 5:48](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=348)
- "For anorectal malformations with rectal-perineal or rectal-vestibular fistula, outcomes including complications are similar whether the procedure is done before or after 14 days of life." (host_summary) [Ep 46 · 6:37](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=397)
- "A PCPLC consortium study comparing endorectal pull-through for Hirschsprung disease at less than 31 days versus greater than 31 days found that preoperative enterocolitis, postoperative enterocolitis, constipation, and incontinence were the same between both groups." (host_summary) [Ep 46 · 6:54](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=414)
- "Delayed pull-through with irrigations is a safe alternative to an operation in the neonatal period for Hirschsprung disease." (host_summary) [Ep 46 · 7:14](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=434)
- "Cryoanalgesia is probably effective at improving post-operative pain and decreasing length of stay for pectus patients, with length of stay reduced from 4 days to 1 day." (host_summary) [Ep 46 · 8:11](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=491)
- "There are no long-term studies on the effects of cryoanalgesia for pectus repair." (host_summary) [Ep 46 · 8:34](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=514)
- "The double rim sign or halo sign on X-ray indicates a child has swallowed a button battery rather than a coin." — Ellen Encisco (host_summary) [Ep 46 · 9:48](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=588)
- "The main goal of button battery ingestion treatment is to remove the battery within 2 hours of ingestion." — Ellen Encisco (host_summary) [Ep 46 · 10:13](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=613)
- "Sucralfate or honey can help reduce damage from button batteries on the child's esophagus as temporizing measures." — Ellen Encisco (host_summary) [Ep 46 · 10:20](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=620)
- "Children less than 1 year old should not receive honey due to risk of botulism and should instead receive 10 mL of sucralfate every 10 minutes for up to 3 doses for button battery ingestion." — Ellen Encisco (host_summary) [Ep 46 · 10:35](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=635)
- "Children over age 1 with button battery ingestion should receive honey 10 mL every 10 minutes for up to 6 doses." — Ellen Encisco (host_summary) [Ep 46 · 10:51](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=651)
- "New ATLS recommendations for pediatric trauma patients in hemorrhagic shock call for earlier transfusion: after 1 bolus of 20 cc per kilogram of crystalloid fluid, blood should be given." (host_summary) [Ep 46 · 11:28](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=688)
- "Balanced transfusion protocol for pediatric hemorrhagic shock typically includes 10 to 20 mLs per kilogram of packed red blood cells, plus inclusion of FFP and platelets." (host_summary) [Ep 46 · 11:38](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=698)
- "Earlier transfusion in pediatric trauma was associated with shorter median time to transfusion and a decrease in total fluid volume administered." (host_summary) [Ep 46 · 11:46](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=706)
- "Whole blood in trauma patients requires less volume compared to component therapy." (host_summary) [Ep 46 · 11:59](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=719)
- "Research shows that observation of spontaneous pneumothorax in adults is non-inferior to immediate intervention with tube thoracostomy." (host_summary) [Ep 46 · 12:42](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=762)
- "The Midwest Pediatric Surgery Consortium study on spontaneous pneumothorax management with simple aspiration showed 48% success rate, but 44% of patients in the simple aspiration group recurred." (host_summary) [Ep 46 · 12:53](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=773)
- "83% of patients who failed simple aspiration for spontaneous pneumothorax ultimately ended up with VATS or blebectomy." (host_summary) [Ep 46 · 13:16](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=796)
- "Greenwood et al. showed that mortality amongst black newborns is 3 times that of white newborns." — Ellen Encisco (host_summary) [Ep 46 · 14:10](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=850)
- "When black newborns are treated by black physicians, their mortality is reduced by 58% compared to black newborns treated by white physicians." — Ellen Encisco (host_summary) [Ep 46 · 14:19](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=859)
- "Bias exists within medicine and can change outcomes; representation matters and can make a difference." — Ellen Encisco (host_summary) [Ep 46 · 14:30](https://library.globalcastmd.com/watch/update-course-rewind-2021-top-ten-key-takeaways-4578?t=870)
- "There are two types of problematic post-pull-through Hirschsprung's patients: obstructed patients (not emptying, distention, enterocolitis, failure to thrive) and soiling patients (pooping constantly, never distended, minimal constipation)." — Marc Levitt (clinical) [Ep 47 · 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, though some need medical treatment to manage constipation." — Marc Levitt (clinical) [Ep 47 · 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; if they are, investigation is needed to identify and fix the problem." — Marc Levitt (clinical) [Ep 47 · 4:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=280)
- "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 47 · 5:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=307)
- "A pull-through can decompensate if the patient does not have adequate medical management or sphincter management, potentially leading to nerve hypertrophy." — Marc Levitt (clinical) [Ep 47 · 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? This question is often neglected." — Marc Levitt (clinical) [Ep 47 · 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 (sometimes too strong and non-relaxing, but not lax) and intact dentate line with preserved anal canal sensation." — Marc Levitt (clinical) [Ep 47 · 7:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=429)
- "When a Hirschsprung's patient has an intact dentate line and intact sphincters, they have full potential for voluntary bowel movements and bowel control." — Marc Levitt (clinical) [Ep 47 · 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, the patient may have lost their potential for bowel control." — Marc Levitt (clinical) [Ep 47 · 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 objectively assess whether sphincters are intact, whether the patient has a good squeeze, and whether that squeeze is concentric." — Marc Levitt (clinical) [Ep 47 · 9:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=555)
- "Sphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function." — Jason Frischer (clinical) [Ep 47 · 9:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=598)
- "Sphincters become overstretched from transanal approach with deep dissection, wrong plane, or retractors placed in the anus; overstretched sphincters will not return to normal." — Marc Levitt (clinical) [Ep 47 · 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 (like anorectal malformation with poor spine/sacrum or spina bifida) need to be in a dedicated bowel management program with enemas or antegrade options." — Hira Ahmad (clinical) [Ep 47 · 12:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=740)
- "Patients with lost potential for bowel control (injured sphincters or lost dentate line) need a mechanical emptying program." — Marc Levitt (clinical) [Ep 47 · 12:39](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=759)
- "A mechanical program can get borderline patients clean and psychologically motivated to be clean, making them more likely to successfully potty train." — Marc Levitt (clinical) [Ep 47 · 12:53](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=773)
- "Mark Levitt's current routine is to perform 3D anorectal manometry in all soiling Hirschsprung's patients to assess squeeze quality and dentate line presence, then decide whether to attempt potty training with laxatives or start mechanical cleaning." — Marc Levitt (clinical) [Ep 47 · 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 47 · 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; it results from overstretched sphincters becoming patulous to the point of laxity." — Marc Levitt (clinical) [Ep 47 · 15:02](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=902)
- "During normal bowel movements, sphincters relax and the anus opens with some mucosal descent, but as soon as sphincters tighten, the mucosa retracts back in; prolapse at rest indicates damaged muscles and/or mucosa brought too low at anastomosis." — Jason Frischer (clinical) [Ep 47 · 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, Mark Levitt would offer sphincter reconstruction and perform a Malone at the same time, as the Malone can serve as a bridge to continence by allowing patients to practice holding and releasing flushes on command." — Marc Levitt (clinical) [Ep 47 · 17:13](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-22-hirschsprung-disease-the-soiling-patient-part-1-4616?t=1033)
- "The three components of continence are quality of sphincters, quality of dentate line, and motility." (clinical) [Ep 48 · 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's disease there are two sphincters of concern: the external sphincter (which patients have voluntary control of) and the internal sphincter (which tends not to relax due to absent recto-anal inhibitory reflex)." (clinical) [Ep 48 · 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)
- "If a patient has voluntary bowel movements during the day but accidents at night when sleeping, their external sphincters are working but internal sphincters are not—when sleeping they relax the external sphincter and lose control." — Hira Ahmad (clinical) [Ep 48 · 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)
- "Nocturnal soiling with daytime control can occur if the dentate line is lost (from overstretching) with some preservation of the external sphincter." — Amanda Jensen (host_summary) [Ep 48 · 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)
- "The dentate (or pectinate) line is the transition from squamous epithelium to columnar epithelium, occurring about two-thirds of the way up the anal canal, with associated changes in blood supply (splenic versus systemic) and innervation." (clinical) [Ep 48 · 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)
- "The nerves in the dentate line region tell you gas versus liquid versus solid, how hard to squeeze, how long to squeeze, and how tight to squeeze—preserving this region is key to continence." (clinical) [Ep 48 · 4:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=240)
- "The rectum (not the anal canal) has proprioception capacity to detect stretch, which signals stool accumulation and triggers external sphincter contraction to hold stool until a bathroom is found." (clinical) [Ep 48 · 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 the stretch—they just have loose stool flowing; they are better off with bulk kicked out by a laxative than a stool softener that slowly oozes out." (clinical) [Ep 48 · 5:40](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=340)
- "For children with anorectal malformation, Hirschsprung's disease, or spinal conditions, their ability to sense stool in the rectum or neorectum is so sensitive to success that the right consistency and bulk of stool is very important." (clinical) [Ep 48 · 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)
- "If clinicians make stool too soft or too loose through medications, they throw a child with borderline control over the edge into failure." (clinical) [Ep 48 · 6:50](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=410)
- "Loose stool is the enemy of borderline continence because you don't know for sure that it's there—we are very dependent on the stretch and bulk of stool in the rectum to trigger the external sphincter and relax the internal sphincter." (clinical) [Ep 48 · 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)
- "Patients with Hirschsprung's disease with absolutely intact sphincters are dependent on rectal stretch; they don't have a rectum (it's been removed) and their sigmoid has taken over that job—if they have injured sphincters they are particularly in trouble." (clinical) [Ep 48 · 8:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=490)
- "A patient with missing dentate line (from dissection started too low) loses all anal canal sensation but can still develop bowel control if sphincters are working, though they will be very sensitive to loose stool and need bulk to detect stool presence." (clinical) [Ep 48 · 10:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=630)
- "A patient with missing dentate line but intact sphincters is similar to an anorectal malformation anastomosis (rectum or colon mucosa to skin) and should be able to achieve continence if muscle is intact." (clinical) [Ep 48 · 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)
- "On contrast study, a colon that moves too fast shows smaller caliber with many haustrations (appearing as contractions), while a colon that moves too slow shows dilation with lack of haustrations." — Hira Ahmad (clinical) [Ep 48 · 13:55](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=835)
- "For a hypomotile (slow-moving) colon with intact sphincters and dentate line, treatment can start with mechanical emptying then switch to laxative program; if sphincters and dentate line are deficient, mechanical enema program is needed." — Hira Ahmad (clinical) [Ep 48 · 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 hypermotile patients (7-8 stools daily), treatment involves constipating them and then ensuring timed emptying—either spontaneous if sphincters intact or mechanical if deficient." — Hira Ahmad (clinical) [Ep 48 · 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)
- "The treatment approach for hypermotile patients is to constipate them, then figure out how to empty them in a time-controlled fashion to maintain mechanical or social continence, depending on sphincter function." (clinical) [Ep 48 · 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's is an obstruction problem that has been solved by surgery; the separate challenge is getting patients clean, which depends on whether they are too slow or too fast and whether they have the mechanisms for continence (sphincters and dentate line)." (clinical) [Ep 48 · 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)
- "For hypermotile patients, treatment escalates through: skin care with cyanoacrylate barrier, proton pump inhibitor to reduce stool acidity, small volume enemas, water-soluble fiber for bulk, loperamide (0.5-0.8 mg/kg divided daily), cholestyramine, hyoscyamine (0.125 mg every 6 hours), and rarely diphenoxylate-atropine (which has cardiac side effects)." (clinical) [Ep 48 · 19:49](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1189)
- "Tincture of opium is useful for slowing hypermotility but is a controlled substance and difficult to prescribe." (clinical) [Ep 48 · 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)
- "Botox may be needed for patients with good pull-through who are not emptying, to help them train and control non-relaxing sphincters and stop being withholders." (clinical) [Ep 48 · 22:06](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1326)
- "Some Hirschsprung's patients with good operations have super-strong sphincters that need relaxation (via Botox) to allow stool passage until they learn proper external and internal sphincter coordination for evacuation." (clinical) [Ep 48 · 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 can provide objective data showing that resting pressures in some Hirschsprung's patients are on the higher end of normal, indicating need for relaxation therapy." (clinical) [Ep 48 · 23:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1390)
- "Patients with Hirschsprung's disease are very sensitive to some foods, particularly lactose, and paying attention to diet (from breastfed infants through older children) is important." (clinical) [Ep 48 · 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)
- "Every soiling patient can be made to do well with appropriate help (mechanical evacuations, Botox, etc.) and can be gotten on the right track." (opinion) [Ep 48 · 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)
- "Of all soiling populations (anorectal malformation, Hirschsprung's, functional constipation, and spinal), Hirschsprung's is the hardest group because the sphincters are so troublesome." (opinion) [Ep 48 · 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)
- "Within Hirschsprung's soiling patients, the hypermotile group is much harder to manage than the hypomotile group." (opinion) [Ep 48 · 25:20](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-part-2-the-dentate-line-and-motility-4739?t=1520)
- "The three components of continence are quality of sphincters, quality of dentate line, and motility." — Marc Levitt (clinical) [Ep 49 · 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)." — Marc Levitt (clinical) [Ep 49 · 1:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=90)
- "If both internal and external sphincters have been overstretched, both become problematic." — Marc Levitt (clinical) [Ep 49 · 1:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=105)
- "A patient who has voluntary bowel movements during the day but soils at night indicates working external sphincters but non-functioning internal sphincters; when sleeping, they relax the external sphincter and lose control." — Marc Levitt (clinical) [Ep 49 · 1:57](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=117)
- "Loss of dentate line can occur with overstretching and some preservation of external sphincter, resulting in daytime control but nighttime soiling." — Marc Levitt (clinical) [Ep 49 · 2:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=155)
- "The dentate (or pectinate) line is the transition from squamous epithelium to columnar epithelium, located about 2/3 of the way up the anal canal." — Jason Frischer (clinical) [Ep 49 · 3:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=188)
- "Blood supply changes occur at the dentate line (splanchnic versus systemic), and there is also innervation in that area." — Jason Frischer (clinical) [Ep 49 · 3:25](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=205)
- "The nerves located at the dentate line region tell you gas, liquid, solid; how hard, how long, and how tight to squeeze." — Jason Frischer (clinical) [Ep 49 · 3:54](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=234)
- "Preserving the dentate line region is key because injury to that region affects a patient's ability to be continent." — Jason Frischer (clinical) [Ep 49 · 4:15](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=255)
- "The rectum (not the anal canal) has proprioception capacity to detect stretch, which is the signal that stool is accumulating and it's time to hold stool and find a bathroom." — Marc Levitt (clinical) [Ep 49 · 4:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=298)
- "In anorectal malformation patients, the rectum should be preserved because rectal stretch provides proprioception." — Marc Levitt (clinical) [Ep 49 · 5:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=307)
- "When the internal sphincter is functioning properly, it relaxes at the time of rectal stretch." — Marc Levitt (clinical) [Ep 49 · 5:36](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=336)
- "Giving anorectal malformation patients stool softeners is problematic because they never feel the stretch; loose stool just flows and they will never have control of that." — Marc Levitt (clinical) [Ep 49 · 5:43](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=343)
- "ARM patients are much better off with bulk (kicked out by a laxative) than a stool softener that slowly oozes out." — Marc Levitt (clinical) [Ep 49 · 5:58](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=358)
- "In children with anorectal malformation, Hirschsprung disease, spinal conditions, or combinations thereof, the ability to sense stool in the rectum or neorectum region is critical to success; the right consistency and bulk of stool is very important." — Jason Frischer (clinical) [Ep 49 · 6:11](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=371)
- "If clinicians make stool too soft or too loose with medications, they put a child on the edge of having control or not and throw them over that edge, preventing success." — Jason Frischer (clinical) [Ep 49 · 6:45](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=405)
- "Loose stool is the enemy if you have borderline continence or even completely normal continence, because you don't know for sure that it's there." — Marc Levitt (clinical) [Ep 49 · 7:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=467)
- "We are very dependent on the stretch and bulk of stool in the rectum; that's when the external sphincter goes into motion and the internal sphincter relaxes." — Marc Levitt (clinical) [Ep 49 · 8:07](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=487)
- "Hirschsprung patients with absolutely intact sphincters are dependent on that stretch; they don't have a rectum (it's been removed) and their sigmoid has taken over that job." — Marc Levitt (clinical) [Ep 49 · 8:19](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=499)
- "Hirschsprung patients with injured sphincters are particularly in trouble regarding dependence on stool bulk and stretch." — Marc Levitt (clinical) [Ep 49 · 8:32](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=512)
- "A patient with missing dentate line can develop bowel control provided their sphincters are working, but they will be very sensitive to loose stool." — Marc Levitt (clinical) [Ep 49 · 10:44](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=644)
- "Patients with missing dentate line won't be good at detecting that something is there unless they have bulk, but with the right diet, right stool consistency, and intact sphincters, they can achieve control." — Marc Levitt (clinical) [Ep 49 · 11:00](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=660)
- "A Hirschsprung patient with missing dentate line and intact muscle should be able to achieve continence, similar to an anorectal malformation anastomosis (rectum or colon mucosa to skin)." — Jason Frischer (clinical) [Ep 49 · 11:16](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=676)
- "Patients with no dentate line and patulous sphincters who are soiling develop severe skin irritation from sitting in pull-ups or diapers." — Jason Frischer (clinical) [Ep 49 · 12:08](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=728)
- "Patients with horrific diaper rash and perineal excoriation related to no dentate line and no intact sphincters need temporary stomas; some may need permanent stomas." — Marc Levitt (clinical) [Ep 49 · 12:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=755)
- "In a soiling Hirschsprung patient with no obstruction, no distention, no enterocolitis, and 3 stools a day, that's a patient who needs management of a slow-moving colon." — Marc Levitt (clinical) [Ep 49 · 15:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=909)
- "In both scenarios (intact or deficient sphincters/dentate line), patients with slow-moving colon need a bowel management program; if sphincters are poor and dentate line deficient, mechanical emptying with enema program is needed; if intact, can start mechanical and potentially switch to laxative program." — Hira Ahmad (clinical) [Ep 49 · 15:50](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=950)
- "For hypermotile patients (stooling 7-8 times a day), the approach is to constipate them first, then figure out how to empty them in a time-controlled fashion." — Jason Frischer (clinical) [Ep 49 · 18:17](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1097)
- "Whether hypermotile patients can empty on their own versus needing mechanical emptying to maintain social continence depends on their sphincter function." — Jason Frischer (clinical) [Ep 49 · 18:35](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1115)
- "Hirschsprung disease is an obstruction problem; once that's solved, the tough part is getting patients clean—two separate and independent challenges." — Marc Levitt (clinical) [Ep 49 · 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." — Marc Levitt (clinical) [Ep 49 · 19:22](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1162)
- "Clinicians need to determine if Hirschsprung patients are too slow or too fast, how to manipulate their motility, and understand if they have the mechanisms needed for continence (sphincters and dentate line)." — Marc Levitt (clinical) [Ep 49 · 19:30](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1170)
- "For hypermotile patients, skin care is vitally important; a cyanoacrylate-based barrier is very helpful." — Marc Levitt (clinical) [Ep 49 · 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 or any hypermotile patient have dramatically improved over the last 4-5 years." — Marc Levitt (clinical) [Ep 49 · 20:12](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1212)
- "Proton pump inhibitors are helpful to reduce the acidity of stool in hypermotile patients." — Marc Levitt (clinical) [Ep 49 · 20:27](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1227)
- "Some antacid products can be taken orally as liquid and put on the skin to reduce acidity and help excoriation." — Marc Levitt (clinical) [Ep 49 · 20:37](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1237)
- "Small volume enemas are a very helpful maneuver for hypermotile patients." — Marc Levitt (clinical) [Ep 49 · 20:47](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1247)
- "Water-soluble fiber (not water-insoluble) produces bulky stool and is helpful for hypermotile patients." — Marc Levitt (clinical) [Ep 49 · 20:52](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1252)
- "Loperamide is very helpful medicine for hypermotile patients; the maximum dose is 0.5 to 0.8 mg per kilogram divided daily based on patient weight." — Marc Levitt (clinical) [Ep 49 · 21:05](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1265)
- "Cholestyramine is the next level of treatment after loperamide for hypermotile patients." — Marc Levitt (clinical) [Ep 49 · 21:24](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1284)
- "Hyoscyamine (Levsin) 0.125 mg tablet every six hours has been used for hypermotile patients." — Marc Levitt (clinical) [Ep 49 · 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." — Marc Levitt (clinical) [Ep 49 · 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 for slowing stool but is a controlled substance and difficult to get prescribed." — Marc Levitt (clinical) [Ep 49 · 21:55](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1315)
- "If everything checks out with the pull-through and patients are still not emptying, Botox may be needed to help patients train and control their non-relaxing sphincters rather than being withholders." — Marc Levitt (clinical) [Ep 49 · 22:06](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1326)
- "Some Hirschsprung patients who have a good operation have super strong sphincters that just need a little relaxation to allow passage of stool until they learn proper sphincter coordination for evacuation." — Jason Frischer (clinical) [Ep 49 · 22:42](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1362)
- "Botox helps train sphincters in Hirschsprung patients; anorectal manometry can provide objective data showing resting pressures are usually on the higher end of normal, and some patients need extra relaxation to allow them to go." — Jason Frischer (clinical) [Ep 49 · 23:10](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1390)
- "Nutrition in Hirschsprung patients is very important; some patients are very sensitive to certain foods, particularly lactose." — Jason Frischer (clinical) [Ep 49 · 23:31](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1411)
- "Paying attention to diet (whether breastfed infants or older children) is important because lactose is particularly problematic in some Hirschsprung patients." — Jason Frischer (clinical) [Ep 49 · 23:50](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1430)
- "Every Hirschsprung patient should be able to do well; they might need help and might need mechanical evacuations or Botox, but all should be able to get on the right track." — Jason Frischer (opinion) [Ep 49 · 24:29](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1469)
- "Of all soiling patients (anorectal malformation, Hirschsprung, functional constipation, spinal), the hardest group is definitely Hirschsprung without question, because the sphincters are so troublesome." — Marc Levitt (opinion) [Ep 49 · 24:49](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1489)
- "Of Hirschsprung patients, the hypermotile are much harder to manage than the hypomotile." — Marc Levitt (opinion) [Ep 49 · 25:09](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1509)
- "With systematic strategies—knowing if patients have potential for bowel control and manipulating motility accordingly—many Hirschsprung patients who were told they could never be clean can achieve cleanliness." — Marc Levitt (opinion) [Ep 49 · 25:14](https://library.globalcastmd.com/watch/the-colorectal-quiz-episode-23-hirschsprung-disease-the-soiling-patient-5056?t=1514)
- "A single institution prospective randomized controlled trial found that anal dilations after PSARP may not be needed." — Rebecca Rentia (host_summary) [Ep 51 · 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, psychological dissociation in children on later testing related to anal dilations." — Ellen Encisco (host_summary) [Ep 51 · 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 (host_summary) [Ep 51 · 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 (host_summary) [Ep 51 · 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 (host_summary) [Ep 51 · 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, so a size 10 is 2 deviations less." — Todd Ponsky (host_summary) [Ep 51 · 1:57](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=117)
- "In the dilation study with 25 children, the types of malformations were evenly distributed and complexity was about equal." — Todd Ponsky (host_summary) [Ep 51 · 2:16](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=136)
- "Strictures were non-significant between both groups (dilation vs no dilation), and a Heineke-Mikulicz anoplasty (longitudinal incision closed transversely to widen diameter) was able to be performed for stricture management." — Rebecca Rentia (host_summary) [Ep 51 · 2:26](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=146)
- "The number of strictures, number needing anoplasties, and number of redo operations were the same between dilation and no-dilation groups." — Ellen Encisco (host_summary) [Ep 51 · 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 (host_summary) [Ep 51 · 3:04](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=184)
- "Dr. Rentia currently sizes the anus at 2 weeks and 1 month in practice to understand the diameter of the anoplasty so that stooling is not obstructed by an unrecognized strictured anoplasty." — Rebecca Rentia (opinion) [Ep 51 · 3:19](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=199)
- "Dr. Rentia would only consider initiating full dilations for slightly older children where dilations are more traumatic and if concerned about needing general anesthesia, given that HM anoplasty is an option." — Rebecca Rentia (opinion) [Ep 51 · 3:38](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=218)
- "About 5 to 8% of patients require a strictureplasty at the two-month period." — Rebecca Rentia (epidemiological) [Ep 51 · 4:04](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=244)
- "Dr. Rentia is a fan of doing dilations in the neonatal period for low malformations and having the family discharged as soon as possible to home." — Rebecca Rentia (opinion) [Ep 51 · 5:03](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=303)
- "A study of 30-day outcomes for ARM with perineal or rectovaginal fistulas divided patients into early repair (before 6 days old) and late repair (6-8 weeks), with 66 early and 231 late repairs among 291 patients." — Ellen Encisco (host_summary) [Ep 51 · 5:20](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=320)
- "30-day complications are not statistically different between early and late repair groups for perineal and rectovaginal fistulas." — Caitlin Smith (host_summary) [Ep 51 · 5:40](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=340)
- "A second study defined early repair as 14 days or younger and late as after 14 days, with 31 early and 133 late repairs among 164 patients, also showing no difference in 30-day complications." — Caitlin Smith (host_summary) [Ep 51 · 5:45](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=345)
- "Dr. Smith finds that for neonates and infants up to several months old, dilations are really well tolerated, but avoids them in older age groups." — Caitlin Smith (opinion) [Ep 51 · 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, while breastfed infants can delay until 2-3 months." — Caitlin Smith (clinical) [Ep 51 · 6:32](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=392)
- "Repair should be done before infants start solids because that makes the dilation strategy at home much more difficult." — Caitlin Smith (clinical) [Ep 51 · 6:47](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=407)
- "Long segment Hirschsprung disease is defined as any disease proximal to the rectosigmoid colon for the majority of reviewed articles." — Rebecca Rentia (host_summary) [Ep 51 · 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 (host_summary) [Ep 51 · 7:42](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=462)
- "There was no superior or more common operation for long segment Hirschsprung, although Duhamel and Swenson-Soave were the top operations." — Rebecca Rentia (host_summary) [Ep 51 · 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, though there is potential for stem cell therapy which is still in its infancy." — Rebecca Rentia (host_summary) [Ep 51 · 8:13](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=493)
- "A hypermotility and skin rash protocol for total colonic Hirschsprung disease outlines why an early operation (around 5 months old) is possible." — Rebecca Rentia (host_summary) [Ep 51 · 8:31](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=511)
- "If a child with an ileostomy is adequately prepared and the family can learn to thicken stool, they can have a pull-through that does not result in complete perineal skin breakdown and learn techniques helpful for this difficult-to-toilet-train group." — Rebecca Rentia (host_summary) [Ep 51 · 8:49](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=529)
- "Dr. Rentia performs pull-through when the child is toilet trained for urine, typically at age 4, because waiting too long can result in horrible anal sphincter spasm and pelvic disease that makes keeping a pull-through challenging." — Rebecca Rentia (opinion) [Ep 51 · 9:25](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=565)
- "A PCPLC study on bowel management strategies in children with anorectal malformations looked at 624 patients in the 5-12 year old age group." — Caitlin Smith (host_summary) [Ep 51 · 10:36](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=636)
- "Even mild and moderate anorectal malformation patients in the 5-12 year old group need to rely on enemas and other bowel management strategies to stay clean when heading into school age." — Caitlin Smith (host_summary) [Ep 51 · 10:45](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=645)
- "The majority of ARM patients had constipation as their primary complaint, and only 40% were toilet trained." — Caitlin Smith (host_summary) [Ep 51 · 11:14](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=674)
- "A study on timing of pull-through for Hirschsprung disease required all infants to be diagnosed under 1 month of age, with primary pull-throughs performed either less than or greater than 31 days." — Rebecca Rentia (host_summary) [Ep 51 · 11:38](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=698)
- "Preoperative enterocolitis was the same between both timing groups (before and after 31 days), postoperative enterocolitis was the same, and transition zone was the marker if a child needed treatment for constipation." — Rebecca Rentia (host_summary) [Ep 51 · 11:46](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=706)
- "A PCPLC consortium study of 525 ARM patients found that public insurance was associated with decreased rates of urinary incontinence." — Caitlin Smith (host_summary) [Ep 51 · 12:15](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=735)
- "Dr. Smith wonders if the PCPLC, being made up of specialty centers, may miss some race and ethnic disparities since patients who can afford to travel to these centers may be captured while those without means are not." — Caitlin Smith (opinion) [Ep 51 · 12:40](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=760)
- "Urethral length of about 2.5 centimeters has been measured in VCUGs of normal females, and about 1.5 centimeters is needed for cloacal reconstruction." — Rebecca Rentia (host_summary) [Ep 51 · 13:26](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=806)
- "If a urethra that is too short is pulled past the bladder neck, there is a risk for incontinence." — Rebecca Rentia (host_summary) [Ep 51 · 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 (host_summary) [Ep 51 · 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 cloacal anatomy." — Rebecca Rentia (host_summary) [Ep 51 · 14:03](https://library.globalcastmd.com/watch/update-course-rewind-pediatric-colorectal-consortium-2021-5357?t=843)
- "A single-institution prospective randomized controlled trial from Nationwide compared routine anal dilations versus no dilations following PSARP, with 25 patients in each arm and 12-month follow-up." — Rebecca Rentia (host_summary) [Ep 52 · 3:35](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=215)
- "Stricture was defined as a Hagar dilator size of less than 10, which is 2 standard deviations below the newborn standard of Hagar size 12." — Rebecca Rentia (host_summary) [Ep 52 · 4:36](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=276)
- "In the dilation versus non-dilation arms, strictures occurred in 3 versus 8 patients (non-significant difference), and the number of Heineke-Mikulicz anoplasties needed was equivalent between groups." — Rebecca Rentia (host_summary) [Ep 52 · 5:29](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=329)
- "The number of re-operative surgeries was equivalent between dilation and non-dilation groups (about 2 in each group)." — Rebecca Rentia (host_summary) [Ep 52 · 6:12](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=372)
- "Literature documents a component of psychological dissociation in children who undergo routine anal dilations, measured on later testing." — Rebecca Rentia (host_summary) [Ep 52 · 4:00](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=240)
- "The Heineke-Mikulicz anoplasty should be performed at the skin level; long strictures extending through the sphincter complex are not suitable for this technique." — Rebecca Rentia (clinical) [Ep 52 · 9:35](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=575)
- "Current practice shows approximately 5-8% of patients require strictureplasty at the two-month follow-up period when dilations are not routinely performed." — Rebecca Rentia (clinical) [Ep 52 · 10:25](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=625)
- "The Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) is a multi-institutional consortium across the United States comprised of 17 institutions including free-standing children's hospitals." — Rebecca Rentia (clinical) [Ep 52 · 11:07](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=667)
- "An NSQIP-P study of 291 patients (66 early repair under 6 days, 231 late repair 6 weeks to 8 months) found no statistically significant difference in 30-day complications between early and delayed repair of perineal and rectovesibular fistulas." — Caitlin Smith (host_summary) [Ep 52 · 14:55](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=895)
- "A PCPLC study of 164 patients (31 early repair under 14 days, 133 late repair after 14 days) found no difference in 30-day outcomes for perineal and rectovesibular fistula repairs." — Caitlin Smith (host_summary) [Ep 52 · 15:53](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=953)
- "Neonates and infants under about 3 months of age tolerate anal dilations well, but for older patients dilations become a greater psychological stressor for parents and patients." — Caitlin Smith (opinion) [Ep 52 · 17:39](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1059)
- "The optimal timing for repair of low anorectal malformations is around 2-3 months, balancing the goal of keeping the fistula open without trying to increase size, while managing constipation with MiraLax to keep stool soft." — Rebecca Rentia (opinion) [Ep 52 · 18:17](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1097)
- "Formula-fed infants requiring caloric concentration have thicker stools and may need earlier repair, while breastfed infants can safely wait until 2-3 months; repair should be completed before starting solid foods." — Caitlin Smith (clinical) [Ep 52 · 18:54](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1134)
- "Long-segment Hirschsprung disease is defined as any disease proximal to the rectosigmoid colon in the majority of reviewed articles." — Rebecca Rentia (host_summary) [Ep 52 · 22:57](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1377)
- "Contrast studies are very inaccurate for determining the transition zone in Hirschsprung disease; colonic mapping with biopsies is needed." — Rebecca Rentia (host_summary) [Ep 52 · 23:38](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1418)
- "For long-segment Hirschsprung disease, no superior operation was identified, though Duhamel and Swenson-Soave were the most commonly performed procedures." — Rebecca Rentia (host_summary) [Ep 52 · 23:55](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1435)
- "A European study demonstrated that early operation for total colonic Hirschsprung (around 5 months) is possible if the child with an ileostomy is adequately prepared and the family learns to thicken stool, preventing complete perineal skin breakdown." — Rebecca Rentia (host_summary) [Ep 52 · 24:23](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1463)
- "Water-soluble fiber and Imodium can be used to thicken and slow ileostomy effluent before pull-through in total colonic Hirschsprung patients." — Rebecca Rentia (clinical) [Ep 52 · 25:32](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1532)
- "Delaying pull-through too long in total colonic Hirschsprung can result in horrible anal sphincter spasm and pelvic disease that makes maintaining a pull-through challenging." — Rebecca Rentia (clinical) [Ep 52 · 26:23](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1583)
- "A PCPLC study of 624 anorectal malformation patients found that 418 (two-thirds) were enrolled in bowel management programs, with constipation as the primary complaint." — Caitlin Smith (host_summary) [Ep 52 · 28:58](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1738)
- "In the PCPLC bowel management study, only 40% of anorectal malformation patients were toilet trained, and about half reported daytime stool accidents." — Caitlin Smith (host_summary) [Ep 52 · 29:18](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1758)
- "Even patients with mild and moderate anorectal malformations in the 5-12 year age group frequently require enemas and multiple bowel management strategies to maintain cleanliness for school." — Caitlin Smith (host_summary) [Ep 52 · 28:16](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1696)
- "A PCPLC study comparing early (under 31 days) versus late (over 31 days) endorectal pull-through for Hirschsprung diagnosed under 1 month found preoperative enterocolitis rates were equivalent (about 2 in each group)." — Rebecca Rentia (host_summary) [Ep 52 · 30:06](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1806)
- "Post-operative enterocolitis rates were equivalent between early and late pull-through groups (40-50% experiencing at least one episode in both groups)." — Rebecca Rentia (host_summary) [Ep 52 · 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 equivalent between early and late pull-through groups for Hirschsprung disease." — Rebecca Rentia (host_summary) [Ep 52 · 30:46](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1846)
- "Transition zone level, rather than timing of pull-through, was the primary marker determining whether a Hirschsprung patient needed treatment for constipation." — Rebecca Rentia (host_summary) [Ep 52 · 30:55](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1855)
- "Delayed pull-through with rectal irrigations and sending the family home is a safe alternative to neonatal operation for Hirschsprung disease when there is adequate family support." — Rebecca Rentia (clinical) [Ep 52 · 31:12](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1872)
- "In spina bifida patients, Hispanic ethnicity and public insurance are associated with lower overall continence rates." — Caitlin Smith (host_summary) [Ep 52 · 32:12](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1932)
- "A PCPLC study of 525 anorectal malformation patients found public insurance was associated with decreased rates of urinary incontinence, independent of clinical factors including ARM type, spine, and sacrum." — Caitlin Smith (host_summary) [Ep 52 · 32:32](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=1952)
- "The urethral length in normal females has been measured at about 2.5 centimeters, and approximately 1.5 centimeters is needed to avoid incontinence; pulling a urethra that is too short past the bladder neck creates risk for incontinence." — Rebecca Rentia (host_summary) [Ep 52 · 35:19](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=2119)
- "A short vagina may require vaginal replacement even in an otherwise short common channel cloaca operation." — Rebecca Rentia (host_summary) [Ep 52 · 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 (host_summary) [Ep 52 · 36:05](https://library.globalcastmd.com/watch/update-course-2021-peds-colorectal-consortium-conclusions-5413?t=2165)
- "Motor vehicle collisions and firearm violence represent the leading causes of morbidity and mortality in the pediatric age group." — Brittany Levy (host_summary) [Ep 53 · 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." — Brittany Levy (host_summary) [Ep 53 · 1:48](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=108)
- "After adjusting for confounding factors, children who were shot were 7.8 times more likely to die than those injured in motor vehicle collisions." — Brittany Levy (host_summary) [Ep 53 · 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, which is twice as high as institutional mortality rate and 49 times higher than the statewide case fatality rate for motor vehicle collisions." — Brittany Levy (host_summary) [Ep 53 · 2:27](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=147)
- "The case fatality rate for children injured by firearms rose from 13% to almost 17% over the study period, while the case fatality rate for motor vehicle related injuries decreased over time." — Brittany Levy (host_summary) [Ep 53 · 2:51](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=171)
- "The rate of self-inflicted pediatric gunshot wounds doubled over the study period from 2% to 4.4% of all pediatric firearm injuries." — Brittany Levy (host_summary) [Ep 53 · 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%." — Brittany Levy (host_summary) [Ep 53 · 3:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=193)
- "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, which suggests that guns became more dangerous." — Brittany Levy (opinion) [Ep 53 · 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." — Brittany Levy (host_summary) [Ep 53 · 5:49](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=349)
- "Policy level changes need to be made around the country to reduce access to firearms and increase safety." — Brittany Levy (host_summary) [Ep 53 · 5:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=358)
- "Clinicians can make an individual difference by talking to families about firearm safety and safe storage every time they see a child who is injured." — Brittany Levy (host_summary) [Ep 53 · 6:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=369)
- "The Hirschsprung study looked at 75 patients with Hirschsprung disease matched with a 10 to 1 control cohort using the Manitoba Center for Health Policy provincial data repository." — Brittany Levy (host_summary) [Ep 53 · 7:48](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=468)
- "Hirschsprung patients performed just as well as the control cohort from grade 3 onwards until grade 12 graduation on standardized testing." — Brittany Levy (host_summary) [Ep 53 · 8:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=534)
- "In the preschool age, much closer to their treatment timeline, some differences in neurodevelopmental performance can be seen in Hirschsprung patients." — Brittany Levy (host_summary) [Ep 53 · 9:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=545)
- "Children with Hirschsprung disease going into school may still have some challenges around potty training, bowels, and abdominal discomfort." — Brittany Levy (host_summary) [Ep 53 · 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 this data." — Brittany Levy (host_summary) [Ep 53 · 10:25](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=625)
- "In the Miami bicycle injury study of 77 cases over eight years, only one patient was wearing a helmet." — Em Gootee (host_summary) [Ep 53 · 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." — Em Gootee (host_summary) [Ep 53 · 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." — Em Gootee (host_summary) [Ep 53 · 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." — Em Gootee (host_summary) [Ep 53 · 13:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=793)
- "Free helmet programs going through a pediatrician's office are useful but need to be sustained." — Em Gootee (host_summary) [Ep 53 · 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 have implemented multidisciplinary approaches including free helmet programs, changing laws, and public education, sustained over several years." — Em Gootee (host_summary) [Ep 53 · 13:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-may-2022-caps-issue-5787?t=838)
- "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 54 · 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 54 · 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 (patulous anus and absent dentate line) result from an overstretching of the anal sphincters and a dissection started too low during the initial procedure." (clinical) [Ep 54 · 0:25](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=25)
- "To manage his incontinence, a Malone appendicostomy was given for antegrade flushes." (clinical) [Ep 54 · 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 appendicostomy." (clinical) [Ep 54 · 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 patient's ability to squeeze the anus closed and enable voluntary bowel movements." (clinical) [Ep 54 · 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 54 · 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 54 · 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 54 · 1:40](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=100)
- "Dissection is started at the skin edge, staying in the plane between the bowel wall and the surrounding sphincter muscle." (clinical) [Ep 54 · 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 54 · 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 is visible between the bowel and muscle, and the external sphincter muscle is seen circumferentially." (clinical) [Ep 54 · 2:29](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=149)
- "The surrounding external sphincter muscles need to be more firmly attached to the distal pull-through to provide adequate squeeze to close the anus." (clinical) [Ep 54 · 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 54 · 3:02](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=182)
- "The plan is for the patient to practice voluntary squeeze during their antegrade flushes, with the anticipation they will get better and better at holding in their flush." (clinical) [Ep 54 · 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; deeper to this location is ischiorectal fat." (clinical) [Ep 54 · 3:18](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=198)
- "The muscle is tacked to the bowel circumferentially, starting anteriorly, which was the most problematic area noted on the manometry." (clinical) [Ep 54 · 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 placed from the seromuscular bowel layer to the muscle." (clinical) [Ep 54 · 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 54 · 4:12](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=252)
- "Post-operatively, the anus is more closed; digital exam confirms the anus is supple and easily distensible, but now compressed by the surrounding external sphincter." (clinical) [Ep 54 · 4:25](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=265)
- "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 voluntary control." (clinical) [Ep 54 · 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 54 · 4:54](https://library.globalcastmd.com/watch/sphincter-reconstruction-for-patients-with-soiling-after-a-pull-through-for-hirschsprung-disease-6096?t=294)
- "In Poland, thoracoscopic esophageal atresia repair has been performed exclusively since 2005" — Ellen Encisco (host_summary) [Ep 55 · 1:38](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=98)
- "The first thoracoscopic esophageal atresia procedure took almost 4 hours, but with experience it became a 1-hour procedure" — Ellen Encisco (host_summary) [Ep 55 · 1:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=114)
- "Dr. Patkowski's team has had no conversions from thoracoscopic to open approach since beginning the technique" — Ellen Encisco (host_summary) [Ep 55 · 1:59](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=119)
- "All esophageal atresia cases in Dr. Patkowski's center have been managed by one team using only the thoracoscopic approach since the beginning" — Ellen Encisco (host_summary) [Ep 55 · 2:06](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=126)
- "Centralizing care for esophageal atresia patients is important even if transportation costs are higher, because complication costs are much higher" — Ellen Encisco (host_summary) [Ep 55 · 2:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=178)
- "Dr. Patkowski's center handles 15 to 20 esophageal atresia cases per year, which provides sufficient volume for good experience" — Ellen Encisco (host_summary) [Ep 55 · 3:06](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=186)
- "The Centre in Rocklaw has become the referral center for esophageal atresia and long gap esophageal atresia cases from the whole of Poland" — Mark Davenport (clinical) [Ep 55 · 3:38](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=218)
- "Centers of excellence for esophageal atresia are showing better outcomes" — Todd Ponsky (clinical) [Ep 55 · 4:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=253)
- "Centralization of esophageal atresia care would be difficult to implement in the United States healthcare system" — Todd Ponsky (opinion) [Ep 55 · 4:26](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=266)
- "In the Sheffield study, 47% of Hirschsprung disease patients needed a stoma before primary pull-through" — Govind Murti (epidemiological) [Ep 55 · 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 remaining had colostomies" — Ellen Encisco (host_summary) [Ep 55 · 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 in Hirschsprung disease was washout failure, accounting for nearly 40% of cases" — Ellen Encisco (host_summary) [Ep 55 · 5:46](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=346)
- "Of 20 patients who needed post-pull-through stoma formation, 7 occurred within 30 days and 13 occurred after 30 days" — Govind Murti (epidemiological) [Ep 55 · 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 55 · 6:28](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=388)
- "The Sheffield study represents real life surgical reporting and reflects overall management of Hirschsprung's disease within the UK" — Mark Davenport (opinion) [Ep 55 · 6:35](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=395)
- "The Sheffield Hirschsprung management sequence does not reflect typical practice in the United States" — Beth Rymeski (opinion) [Ep 55 · 7:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=429)
- "In US practice, most Hirschsprung patients undergo either neonatal pull-through or are sent home on irrigations for pull-through in the first couple of months of life" — Beth Rymeski (clinical) [Ep 55 · 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 only done for delayed presentation with perforation or complicated cardiac babies" — Beth Rymeski (clinical) [Ep 55 · 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 for Hirschsprung disease" — Ellen Encisco (host_summary) [Ep 55 · 8:10](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=490)
- "The Tanzania soap bathing study included 252 patients, with 114 receiving a preoperative bath with plain soap" — Cecilia Gigena (host_summary) [Ep 55 · 9:23](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=563)
- "In the soap bathing group, 11.4% developed surgical site infections compared to 40.6% in the control group" — Cecilia Gigena (host_summary) [Ep 55 · 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%" — Cecilia Gigena (host_summary) [Ep 55 · 9:43](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=583)
- "Length of stay in the soap bathing intervention group was 12 days compared to 22 days in the non-intervention group" — Mark Davenport (host_summary) [Ep 55 · 9:53](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=593)
- "The Tanzania study used trained carers to direct the method of cleansing, concentrating on areas known to harbor commensal and pathogenic bacteria" — Mark Davenport (clinical) [Ep 55 · 9:04](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=544)
- "Before implementing preoperative bathing in Tanzania, almost every pediatric surgery patient developed a wound infection" — Beth Rymeski (clinical) [Ep 55 · 10:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=641)
- "After implementing preoperative baths in Tanzania, wound infection rates dropped to nearly zero" — Beth Rymeski (clinical) [Ep 55 · 10:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=656)
- "The Tanzania soap bathing trial was well designed, analyzed in substantial detail, and has implications for low to middle income countries where surgical site infections are a major problem" — Mark Davenport (opinion) [Ep 55 · 11:04](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=664)
- "The original Swenson operation for Hirschsprung disease was a full-thickness rectal dissection performed transabdominally." — Mimi Denning (host_summary) [Ep 56 · 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)
- "Surgeons performing wide rectal dissection for Hirschsprung disease were injuring the nervi erigentes, leading to fecal incontinence, bladder dysfunction, and sexual dysfunction." — Marc Levitt (host_summary) [Ep 56 · 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 and pulling ganglionated bowel through." — Mimi Denning (host_summary) [Ep 56 · 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)
- "Dr. Suave in Italy developed a submucosal dissection technique staying within the rectal wall to avoid nerve injury, eventually breaking through full thickness for the pull-through." — Mimi Denning (host_summary) [Ep 56 · 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)
- "Dr. Henri Ford's 2018 APSA presidential address revealed that Dr. A.C. Yancey had described the submucosal dissection technique 12 years before Suave." — Marc Levitt (clinical) [Ep 56 · 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. Yancey published his submucosal dissection technique in the Journal of the National Medical Association in 1952." — Marc Levitt (clinical) [Ep 56 · 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." — Marc Levitt (clinical) [Ep 56 · 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. Yancey's and Dr. Suave's articles demonstrate essentially an identical submucosal dissection technique." — Marc Levitt (clinical) [Ep 56 · 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)
- "In 1951-1952, Black academics could not publish their work in mainstream surgical journals." — Erika Newman (epidemiological) [Ep 56 · 7:05](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=425)
- "Dr. Yancey did not express anger about Dr. Suave's later publication of the same technique, instead emphasizing the value and purpose of the National Medical Association." — Carolyn Yancey (opinion) [Ep 56 · 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 (clinical) [Ep 56 · 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 established the first postgraduate academic training program in the state of Alabama for Black surgeons at the Tuskegee VA." — Carolyn Yancey (clinical) [Ep 56 · 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 conducted preliminary preclinical work for the pull-through technique at the veterinarian hospital in Tuskegee." — Carolyn Yancey (clinical) [Ep 56 · 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)
- "Three of Dr. Yancey's four children went into medicine." — Carolyn Yancey (epidemiological) [Ep 56 · 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. Newman brought Dr. Yancey's story to the attention of the Hirschsprung interest group at APSA." — Jason Frischer (clinical) [Ep 56 · 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 write papers, review manuscripts for journals, write board questions, and influence CPT coding." — Erika Newman (clinical) [Ep 56 · 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)
- "When reviewing articles for journals, Dr. Newman now sends back revisions to ensure correct references to Dr. Yancey's work are included." — Erika Newman (clinical) [Ep 56 · 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)
- "A fellow at Children's National wrote an operative note describing a patient as status post a 'Yancey-Suave procedure,' indicating the terminology has become part of standard practice." — Jason Frischer (clinical) [Ep 56 · 15:06](https://library.globalcastmd.com/watch/colorectal-quiz-episode-37-the-yancey-soave-story-of-the-original-surgical-descriptions-for-hirschsprung-disease-6597?t=906)
- "The National Medical Association was created in the basement of First Congregational Church in Atlanta because Black doctors had no other place to publish their work during segregation." — Carolyn Yancey (epidemiological) [Ep 56 · 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's only career options after training were the military or the VA system due to segregation." — Carolyn Yancey (epidemiological) [Ep 56 · 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 traveled back and forth to Grady Memorial Hospital." — Carolyn Yancey (epidemiological) [Ep 56 · 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)
- "Around 1964, Dr. Yancey gained privileges to see colored patients at Emory University Hospital on the main campus." — Carolyn Yancey (epidemiological) [Ep 56 · 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)
- "Emily Rice is a nurse with the Division of Colorectal and Pelvic Reconstruction at Children's National Hospital." — Emily Rice (clinical) [Ep 59 · 0:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=0)
- "Rectal irrigations can help a child empty their colon of stool and gas." — Emily Rice (clinical) [Ep 59 · 1:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=60)
- "Children who suffer from Hirschsprung disease or functional constipation have colons that may not move stool through the body as quickly as it should, a condition called dysmotility." — Emily Rice (clinical) [Ep 59 · 1:08](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=68)
- "When stool sits in the colon for too long, it can cause bacteria to grow and can lead to enterocolitis, which is an inflammation of the colon." — Emily Rice (clinical) [Ep 59 · 1:25](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=85)
- "Rectal irrigations help keep a child healthy and safe by preventing and treating enterocolitis." — Emily Rice (clinical) [Ep 59 · 1:40](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=100)
- "Irrigations put salt water (saline) into the colon to help clean the stool out and prevent infection." — Emily Rice (clinical) [Ep 59 · 1:50](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=110)
- "If a child has a history of Hirschsprung disease and is showing signs of enterocolitis or dehydration, caregivers should perform an irrigation and immediately contact the medical team or pediatrician." — Emily Rice (guideline) [Ep 59 · 2:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=120)
- "A 24-french silicone Foley catheter is used for rectal irrigations in children one year of age or older." — Emily Rice (clinical) [Ep 59 · 2:40](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=160)
- "A 20-french silicone catheter is used for children under one year of age." — Emily Rice (clinical) [Ep 59 · 2:52](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=172)
- "The irrigation procedure uses 20 milliliters of saline per flush." — Emily Rice (clinical) [Ep 59 · 3:10](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=190)
- "The child should be positioned on their back with knees bent and pulled up towards their chest to visualize the anus and allow stool and gas to exit the colon." — Emily Rice (clinical) [Ep 59 · 3:25](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=205)
- "The Foley catheter should be gently inserted into the rectum about 4-6 inches." — Emily Rice (clinical) [Ep 59 · 3:50](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=230)
- "Slowly turning and moving the catheter back and forth in the rectum may help find pockets of stool that are stuck in the colon." — Emily Rice (clinical) [Ep 59 · 4:10](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=250)
- "It is important to wait between each flush for fluid to drain out of the rectum and to ensure 20 milliliters is returned from each flush before repeating." — Emily Rice (clinical) [Ep 59 · 4:35](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=275)
- "Irrigation can continue until the fluid draining from the catheter is clear." — Emily Rice (clinical) [Ep 59 · 4:48](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=288)
- "The catheter should not be inserted all the way to the end and should not be forced; when gently advanced, it will easily follow the pathway or curve of the colon." — Emily Rice (clinical) [Ep 59 · 4:55](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=295)
- "If saline is pushed in but no water or stool comes back out, the catheter should be pulled out a little bit then gently pushed back in." — Emily Rice (clinical) [Ep 59 · 5:15](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=315)
- "If no saline or stool returns with irrigation, check the catheter for blockage by food or thick stool, as stool can block the tiny holes at the tip of the catheter." — Emily Rice (clinical) [Ep 59 · 5:25](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=325)
- "Massaging the child's belly or having them change positions may help if there is no return of fluid." — Emily Rice (clinical) [Ep 59 · 5:40](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=340)
- "If there is still no return after troubleshooting, caregivers should contact the medical team or pediatrician." — Emily Rice (guideline) [Ep 59 · 5:48](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=348)
- "Signs of enterocolitis include fever, a swollen or large belly, foul-smelling stool, or no stool output in 24 hours." — Emily Rice (clinical) [Ep 59 · 6:05](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=365)
- "Signs of dehydration include not urinating as much as normal, fewer wet diapers than usual, a 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 59 · 6:20](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=380)
- "If a child develops signs of enterocolitis or dehydration, caregivers should call the medical team or pediatrician immediately." — Emily Rice (guideline) [Ep 59 · 6:00](https://library.globalcastmd.com/watch/how-to-administer-a-rectal-irrigation-at-home-6744?t=360)

## Changelog
- Sep 9: Summaries and takeaways published for 3 audiences
- Sep 7: Audit reverted — short clips unhidden
- Sep 7: Claimed as a curated collection
- Sep 7: 23 items added automatically
- Sep 7: 75 items added automatically

---
Educational content from recorded physician discussions — not medical advice. Cite the canonical URL or the ?t= deep link. Policy: https://library.globalcastmd.com/ai