# Midgut Volvulus — GCMD Library living collection

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

Updated: n/a · 5 episodes · 97 cited statements

## Episodes
### Nutritional Management
- [Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227) — podcast · 12:05 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227.md)

### Evidence & Research
- [Update Course 2021: TOP PUBLICATIONS IN NON - PED SURG JOURNALS](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404) — video · 22:13 · [machine version](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404.md)

### Case-Based Learning
- [Malrotation](https://library.globalcastmd.com/watch/malrotation-629) — video · 42:31 · [machine version](https://library.globalcastmd.com/watch/malrotation-629.md)
- [Malrotation and Volvulus with Trinity](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941) — video · 8:02 · [machine version](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941.md)

### In-Depth Reviews
- [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)

## Chapters
- [0:02](https://library.globalcastmd.com/watch/malrotation-629?t=2) Case 1: Teenager with transient symptoms and malrotation on imaging (Ep 1)
- [2:58](https://library.globalcastmd.com/watch/malrotation-629?t=178) Management options and risk stratification for asymptomatic malrotation (Ep 1)
- [9:51](https://library.globalcastmd.com/watch/malrotation-629?t=591) Case 2: Cardiac infant with feeding difficulties and possible malrotation (Ep 1)
- [16:56](https://library.globalcastmd.com/watch/malrotation-629?t=1016) Imaging interpretation and mesenteric width assessment (Ep 1)
- [19:57](https://library.globalcastmd.com/watch/malrotation-629?t=1197) Case 3: Same cardiac infant with clear malrotation on imaging (Ep 1)
- [24:20](https://library.globalcastmd.com/watch/malrotation-629?t=1460) Case 4: Toddler with non-bilious emesis and redundant duodenum (Ep 1)
- [33:32](https://library.globalcastmd.com/watch/malrotation-629?t=2012) International perspective on asymptomatic malrotation management (Ep 1)
- [37:56](https://library.globalcastmd.com/watch/malrotation-629?t=2276) Case 5: Situs inversus with malrotation and technical challenges (Ep 1)
- [0:05](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=5) Introduction to Non-Core Journal Review by Dr. Jose Campos (Ep 2)
- [1:53](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=113) Malrotation Diagnosis: Ultrasound versus Upper GI (Ep 2)
- [9:19](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=559) Non-Operative Management of Appendicitis (Ep 2)
- [13:01](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=781) Complete Resection in High-Risk Neuroblastoma (Ep 2)
- [15:04](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=904) Fetal Tracheal Occlusion for Severe CDH (Ep 2)
- [17:10](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1030) Whole Blood Transfusion in Pediatric Trauma (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=0) Introduction and Overview of Malrotation Epidemiology (Ep 3)
- [1:17](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=77) Embryologic Development and Anatomic Spectrum of Rotation Abnormalities (Ep 3)
- [3:49](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229) Complications, Clinical Presentation, and Diagnostic Approach (Ep 3)
- [8:33](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=513) Surgical Management: Detorsion and Ladd Procedure (Ep 3)
- [12:17](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=737) Summary and Closing (Ep 3)
- [0:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=0) Introduction and Context for Older Patient Refeeding (Ep 4)
- [1:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=110) Oral Feeding Strategy and Diet Composition (Ep 4)
- [3:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=223) Hydration Management and Fluid Replacement (Ep 4)
- [5:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=351) Growth Monitoring Through Puberty and Long-term Follow-up (Ep 4)
- [8:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=514) Growth Assessment Methods and Troubleshooting (Ep 4)
- [10:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=625) Summary and Conclusion (Ep 4)
- [0:00](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=0) Case presentation and initial findings (Ep 5)
- [0:59](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=59) Division of Ladd's bands and reduction of volvulus (Ep 5)
- [4:29](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=269) Complete bowel run and mesenteric base widening (Ep 5)
- [6:49](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=409) Final bowel run and appendectomy (Ep 5)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "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 1 · 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 1 · 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 1 · 19:44](https://library.globalcastmd.com/watch/malrotation-629?t=1184)
- "Ladd's bands do not cause midgut volvulus" — Jack (clinical) [Ep 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 39:27](https://library.globalcastmd.com/watch/malrotation-629?t=2367)
- "Malrotation occurs in about 1 in 200 to 500 live births." — Em Tombash (host_summary) [Ep 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 10:01](https://library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Older patients (ages 8-16) who experience volvulus can lose 90+% of their bowel." — Michael Helmrath (clinical) [Ep 4 · 1:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=71)
- "The benefit and curse in older patients with bowel loss is that they already know how to eat and have established that behavior." — Paul Wales (clinical) [Ep 4 · 1:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=84)
- "In older children, normal feeding behavior is important in many social aspects of life, not just nutrition." — Cecilia Gigena (host_summary) [Ep 4 · 1:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=90)
- "Even if you cannot cure the patient and get them off TPN, it is important to make compromises to optimize quality of life." — Paul Wales (opinion) [Ep 4 · 1:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=110)
- "The general strategy is to push the macronutrient modules of protein and fat, which are well tolerated." — Paul Wales (clinical) [Ep 4 · 2:14](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=134)
- "Most patients with short bowel do not tolerate simple sugars very well." — Paul Wales (clinical) [Ep 4 · 2:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=141)
- "The general concept of pushing solids and minimizing fluid intake helps prevent dumping." — Paul Wales (clinical) [Ep 4 · 2:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=145)
- "Smaller meals more frequently of solids separated from liquids, with minimization of simple sugars, reduces dumping tendency." — Paul Wales (clinical) [Ep 4 · 2:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=151)
- "Patients who have transitioned off TPN often come back with problems when diet history reveals they have gotten loose with diet choices, particularly increased sugars." — Paul Wales (clinical) [Ep 4 · 2:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=172)
- "Minimizing sugars reduces symptoms related to bacterial overgrowth, making patients less bloated and gassy." — Paul Wales (clinical) [Ep 4 · 3:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=211)
- "In older children with fluid losses (by stoma or other source), if they are on parenteral support, some fluid can be replaced IV." — Paul Wales (clinical) [Ep 4 · 3:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=228)
- "As you try to get patients off IV support, keeping them hydrated by replenishing losses through enteral replacements is important." — Paul Wales (clinical) [Ep 4 · 4:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=241)
- "Transport requires sodium and glucose, so the rehydration solution must contain some glucose and some salt." — Paul Wales (clinical) [Ep 4 · 4:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=251)
- "There are homemade recipes for oral rehydration solutions and over-the-counter preparations available." — Paul Wales (clinical) [Ep 4 · 4:39](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=279)
- "Gatorade does not always work well for rehydration because it has too much sugar in it." — Paul Wales (clinical) [Ep 4 · 4:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=288)
- "Some patients can come off TPN but still need a central line for IV fluids; without IV fluids they end up sleeping most of the day and lack energy." — Michael Helmrath (clinical) [Ep 4 · 4:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=295)
- "Being in a hydrated state is extremely important to making the bowel work well." — Michael Helmrath (clinical) [Ep 4 · 5:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=308)
- "Sometimes patients cannot drink rehydration solution, but the GI tract can use it (via G-tube)." — Michael Helmrath (clinical) [Ep 4 · 5:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=331)
- "Energy use goes up dramatically during puberty." — Michael Helmrath (clinical) [Ep 4 · 5:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=351)
- "Children who are doing well often hit the wall when they start puberty because their energy needs overcome their nutrient input." — Michael Helmrath (clinical) [Ep 4 · 6:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=370)
- "The goal is always healthy growth, and it is important to be proactive, add supplements, and hope they will take extra nutritional support." — Michael Helmrath (opinion) [Ep 4 · 6:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=370)
- "It is all about normal growth parameters and getting patients through puberty." — Paul Wales (opinion) [Ep 4 · 6:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=383)
- "Some kids end up back on parenteral support to get through puberty." — Paul Wales (clinical) [Ep 4 · 6:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=388)
- "When patients are not growing anymore as adults, borderline or marginal gut function is often enough to sustain them." — Paul Wales (clinical) [Ep 4 · 6:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=393)
- "Clinicians should look at the growth chart for both weight and height, and not accept a 3rd percentile." — Michael Helmrath (opinion) [Ep 4 · 6:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=417)
- "There are very few conditions with intestinal failure that have restricted growth." — Michael Helmrath (clinical) [Ep 4 · 7:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=426)
- "Patients need to be monitored for micronutrient deficiencies after getting off TPN, as this is when they often get into trouble." — Paul Wales (clinical) [Ep 4 · 7:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=442)
- "Long-term growth and outcome need to be followed, highlighting the importance of multidisciplinary teams." — Paul Wales (opinion) [Ep 4 · 7:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=451)
- "Weight is tracked as a major metric for growth, but it has to be balanced with height." — Paul Wales (clinical) [Ep 4 · 8:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=531)
- "What is commonly seen in this population is round babies where their weight for height is elevated." — Paul Wales (clinical) [Ep 4 · 8:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=537)
- "There is increasing data looking at quality of weight: how much is fat weight versus lean body mass." — Paul Wales (clinical) [Ep 4 · 9:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=541)
- "For any child not meeting growth potential, numerous other diagnoses can be responsible, ranging from endocrine issues to pancreatic insufficiency to micronutrient issues." — Michael Helmrath (clinical) [Ep 4 · 9:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=574)
- "The concept is that patients are capable of having normal growth, and as you address issues and improve something, you need reasonable follow-up time on the order of weeks, not months." — Michael Helmrath (opinion) [Ep 4 · 9:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=588)
- "Much of the growth monitoring can be done remotely; patients do not need to travel for assessment, but you cannot wait until the next appointment." — Michael Helmrath (opinion) [Ep 4 · 10:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=615)
- "The curation process filters approximately 1200 articles per month from 33 pediatric and general surgical journals plus 3 top clinical journals (NEJM, Lancet, JAMA) down to 25-50 relevant pediatric surgery articles, then further narrows to 10-15 through specialty filtering, quality ranking, methodology assessment, and popularity polling among general surgeons." — Todd Ponsky (host_summary) [Ep 2 · 1:53](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=113)
- "Upper GI contrast study is operator-dependent and requires direct communication with radiologist, readily available at high-volume centers but requires more coordination at community hospitals." — Todd Ponsky (clinical) [Ep 2 · 5:30](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=330)
- "Ultrasound for malrotation diagnosis is very dependent on the person who performs the ultrasound, making it less reliable than upper GI contrast study." (opinion) [Ep 2 · 8:08](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=488)
- "Reversal of vessels at the root of the mesentery on ultrasound is not a very reliable way to make the diagnosis of malrotation." (clinical) [Ep 2 · 8:35](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=515)
- "In the Annals of Surgery 5-year follow-up study of non-operative appendicitis management, 46% of patients randomized to non-surgical management required appendectomy during follow-up, while the surgical group had no complications or readmissions." — Todd Ponsky (host_summary) [Ep 2 · 11:52](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=712)
- "Half of the non-surgical appendicitis management group presented to the emergency room during 5-year follow-up." — Todd Ponsky (host_summary) [Ep 2 · 12:08](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=728)
- "The presence of an appendicolith in appendicitis has about a 50% failure rate with non-operative management, making it a contraindication for non-surgical treatment." — Todd Ponsky (clinical) [Ep 2 · 10:22](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=622)
- "In the Journal of Clinical Oncology study of 1,531 patients with stage 4 high-risk neuroblastoma, 5-year event-free survival and overall survival were significantly higher with complete resection compared to incomplete microscopic resection." (host_summary) [Ep 2 · 14:20](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=860)
- "Local progression in stage 4 neuroblastoma was lower with complete resection when compared with incomplete resection." (host_summary) [Ep 2 · 14:36](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=876)
- "In the New England Journal of Medicine randomized controlled trial of 80 women carrying fetuses with severe isolated left-sided congenital diaphragmatic hernia, fetal endoscopic tracheal occlusion (FETO) at 27-29 weeks resulted in 40% survival to discharge versus 15% with expectant care." (host_summary) [Ep 2 · 16:30](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=990)
- "At 6 months of age, survival was the same between FETO and expectant care groups in severe CDH." (host_summary) [Ep 2 · 16:44](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1004)
- "FETO was associated with an increased risk of pre-labor rupture of membranes and preterm labor." (host_summary) [Ep 2 · 16:47](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1007)
- "In the Journal of Trauma study of 135 children aged 1-17 years who received whole blood as adjunct to component therapy, matched to 270 children receiving only component therapy, the whole blood group had decreased transfusion volume at 24 hours and required fewer ventilation days, though mortality, length of stay, and major complications were the same." — Todd Ponsky (host_summary) [Ep 2 · 18:16](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1096)
- "Current ATLS protocols recommend initial bolus with normal saline or crystalloid solution before moving to blood products in pediatric trauma." — Todd Ponsky (guideline) [Ep 2 · 19:40](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1180)
- "Nationwide in adults, ambulance rigs are starting to travel with whole blood capabilities and people are using whole blood even earlier in trauma resuscitation." — Todd Ponsky (clinical) [Ep 2 · 19:40](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1180)
- "The challenge for whole blood in pediatrics is availability, and thankfully for children, we don't use a lot of massive transfusion protocols compared to adults." — Todd Ponsky (clinical) [Ep 2 · 20:28](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1228)
- "Some centers are limiting whole blood use to males and some to children older than 15, depending on institutional protocols and blood bank partnerships." — Todd Ponsky (clinical) [Ep 2 · 21:13](https://library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1273)
- "A 12-year-old female presented with a three-month history of intermittent pain and weight loss with acute worsening of symptoms." (host_summary) [Ep 5 · 0:08](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=8)
- "CT scan showed evidence of midgut volvulus." (host_summary) [Ep 5 · 0:15](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=15)
- "Patient was positioned in dorsal lithotomy position with surgeon positioned between patient's legs." (host_summary) [Ep 5 · 0:18](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=18)
- "5 millimeter ports were used for the procedure." (host_summary) [Ep 5 · 0:29](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=29)
- "Upon entering abdomen, there was clear disorientation of the bowel with an internal hernia and complete twist of the bowel." (host_summary) [Ep 5 · 0:36](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=36)
- "The anatomy was confusing because of 360-degree twist of the bowel as well as the internal hernia." (host_summary) [Ep 5 · 2:38](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=158)
- "The key to this operation is to operate in front of the camera and run the bowel in front of the camera instead of chasing the bowel around the abdomen, which prevents disorientation and allows the surgeon to keep a clear view." (opinion) [Ep 5 · 2:52](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=172)
- "The superior mesenteric vessels were engorged because they had been twisted." (host_summary) [Ep 5 · 3:13](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=193)
- "It is critical that the bowel be completely run from the duodenojejunal junction all the way to the ileocecal valve to ensure that all bands have been released." (opinion) [Ep 5 · 4:00](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=240)
- "The key to this operation is making sure that the mesentery has been broadly widened to prevent a twist in the future." (opinion) [Ep 5 · 6:29](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=389)
- "One should be able to see the superior mesenteric artery and vein coming straight down into the middle of the abdomen with no twists or obstruction." (opinion) [Ep 5 · 6:39](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=399)
- "Running the bowel from proximal to distal places all the small bowel on the patient's right and the colon on the patient's left." (host_summary) [Ep 5 · 7:11](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=431)
- "Using a 5mm stapler for appendix division allows keeping all ports at 5mm and not upsizing to a 12mm port for a larger stapler." (host_summary) [Ep 5 · 7:37](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=457)
- "The operation took approximately 90 minutes and the patient did well." (host_summary) [Ep 5 · 7:58](https://library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=478)

## Changelog
- Sep 10: 1 item no longer name midgut volvulus
- Sep 7: 3 items added automatically
- Sep 7: 3 items added automatically

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