MRSA or methicillin resistant Staph aureus, it's a lot of times kind of in the lay press. It's the bacteria that people have been really concerned about for the last decade as being a very resistant Staph aureus that can cause a lot of problems with infection.
a lot of other surgical practices that have published papers about using screening and treatment programs, they often look at high risk patient populations as being kind of 8 to 10% of the patient population as having MRSA.
If we can, we like to use a NIM tube as part of trying to prevent potential injury to recurrent nerves or at least make you aware when you're Getting close to them.
We like to use 30 prolenes and we like to place all the stitches before we actually secure them down, and it's important to do this under spontaneous conditions.
We like to use 3 Orolines and we like to place all the stitches before we actually secure them down, and it's important to do this under spontaneous conditions.
We will sometimes place stitches in the trachea to pull it up and out of the way so you can visualize that posterior aspect of where you see the spine.
QUAD #1: Cervical Tracheopexy with Dr. Alessandro de Alarcon
▶Ep 15 · 0:49
clinicalCincinnati Children's typically uses a combined cervical and thoracic approach for esophageal atresia cases.↗
▶Ep 15 · 0:49
quoteIn Cincinnati we typically use a combined approach looking at the thoracic approach as well as with the cervical approach.↗
▶Ep 15 · 1:15
clinicalRequired intraoperative equipment includes a neck tray, MLB tray, and Maloney dilators or NG tubes.↗
▶Ep 15 · 1:15
quoteYou need a neck tray, and MLB tray, and Maloney dilators versus NG tubes in the operating room and you do it.↗
▶Ep 15 · 1:21
clinicalFlexible bronchoscopy during the operation is key, and endotracheal tube placement must allow visualization during the procedure.↗
▶Ep 15 · 1:21
quoteThe flexible bronchoscopy is really key and Placing your endotracheal tube is really important so they can look as you were doing the operation.↗
▶Ep 15 · 1:29
clinicalNasotracheal intubation is often used with the cuff positioned high, sometimes almost at the glottis.↗
▶Ep 15 · 1:33
quoteAnd sometimes that means your cuff is super high and it's almost at the glottis.↗
▶Ep 15 · 1:39
quoteIf we can, we like to use a NIM tube as part of trying to prevent potential injury to recurrent nerves or at least make you aware when you're Getting close to them.↗
▶Ep 15 · 1:39
clinicalA NIM tube is preferred when possible to prevent injury to recurrent nerves or provide awareness when approaching them.↗
▶Ep 15 · 1:55
clinicalThe surgical approach uses subplatysmal flaps and addresses anterior compression as needed.↗
▶Ep 15 · 2:09
clinicalAortopexy and innominate artery pexy can be added at the same time as the cervical procedure.↗
▶Ep 15 · 2:29
quoteAnd then it's thinking about your approach to mobilize the esophagus and the experience of working with our team in Cincinnati, we have learned how to not be afraid of the esophagus.↗
▶Ep 15 · 2:29
opinionThe Cincinnati team has learned not to be afraid of mobilizing the esophagus, which is important for the procedure.↗
▶Ep 15 · 2:54
quoteWe will sometimes place stitches in the trachea to pull it up and out of the way so you can visualize that posterior aspect of where you see the spine.↗
▶Ep 15 · 2:54
clinicalStitches are sometimes placed in the trachea to pull it up and out of the way for visualization of the posterior aspect and spine.↗
▶Ep 15 · 3:15
clinicalSuture placement is performed under spontaneous ventilation conditions.↗
▶Ep 15 · 3:15
clinicalThe team uses 3-0 prolene sutures and places all stitches before securing them down.↗
▶Ep 15 · 3:15
quoteWe like to use 30 prolenes and we like to place all the stitches before we actually secure them down, and it's important to do this under spontaneous conditions.↗
▶Ep 15 · 3:33
clinicalA patient who had prior thoracoscopic tracheopexy with dysphagia from torqued esophagus underwent the combined approach and became symptom-free.↗
▶Ep 15 · 4:00
clinicalOutcome measures include follow-up endoscopy, pulmonary function tests when patients are old enough, and imaging.↗
▶Ep 15 · 4:09
quoteAnd when you look 36 months later, it may still look like there's some malaysia, but symptomatically, they're better.↗
▶Ep 15 · 4:09
clinicalAt 36 months follow-up, imaging may still show tracheomalacia, but patients can be symptomatically better.↗
▶Ep 15 · 4:15
opinionThe team is still learning what measures should define good versus bad outcomes.↗
▶Ep 15 · 4:15
quoteSo it's important to pair that piece and understand that we're still trying to learn exactly what are those measures that we want to use to be able to say that they are a good outcome versus a bad outcome.↗
▶Ep 15 · 4:26
clinicalManaging complications including swallowing dysfunction and vocal fold paralysis is part of postoperative care.↗
Alessandro's statements about Esophageal Atresia26 statements
QUAD #1: Cervical Tracheopexy with Dr. Alessandro de Alarcon
▶Ep 25 · 0:49
quoteIn Cincinnati we typically use a combined approach looking at the thoracic approach as well as with the cervical approach.↗
▶Ep 25 · 0:49
clinicalCincinnati Children's typically uses a combined cervical and thoracic approach for esophageal atresia cases.↗
▶Ep 25 · 1:15
quoteYou need a neck tray, and MLB tray, and Maloney dilators versus NG tubes in the operating room and you do it.↗
▶Ep 25 · 1:15
clinicalRequired intraoperative equipment includes a neck tray, MLB tray, and Maloney dilators or NG tubes.↗
▶Ep 25 · 1:21
clinicalFlexible bronchoscopy during the operation is key, and endotracheal tube placement must allow visualization during the procedure.↗
▶Ep 25 · 1:21
quoteThe flexible bronchoscopy is really key and Placing your endotracheal tube is really important so they can look as you were doing the operation.↗
▶Ep 25 · 1:29
clinicalNasotracheal intubation is often used with the cuff positioned high, sometimes almost at the glottis.↗
▶Ep 25 · 1:33
quoteAnd sometimes that means your cuff is super high and it's almost at the glottis.↗
▶Ep 25 · 1:39
clinicalA NIM tube is preferred when possible to prevent injury to recurrent nerves or provide awareness when approaching them.↗
▶Ep 25 · 1:39
quoteIf we can, we like to use a NIM tube as part of trying to prevent potential injury to recurrent nerves or at least make you aware when you're Getting close to them.↗
▶Ep 25 · 1:55
clinicalThe surgical approach uses subplatysmal flaps and addresses anterior compression as needed.↗
▶Ep 25 · 2:09
clinicalAortopexy and innominate artery pexy can be added at the same time as the cervical procedure.↗
▶Ep 25 · 2:29
quoteAnd then it's thinking about your approach to mobilize the esophagus and the experience of working with our team in Cincinnati, we have learned how to not be afraid of the esophagus.↗
▶Ep 25 · 2:29
opinionThe Cincinnati team has learned not to be afraid of mobilizing the esophagus, which is important for the procedure.↗
▶Ep 25 · 2:54
clinicalStitches are sometimes placed in the trachea to pull it up and out of the way for visualization of the posterior aspect and spine.↗
▶Ep 25 · 2:54
quoteWe will sometimes place stitches in the trachea to pull it up and out of the way so you can visualize that posterior aspect of where you see the spine.↗
▶Ep 25 · 3:15
clinicalThe team uses 3-0 prolene sutures and places all stitches before securing them down.↗
▶Ep 25 · 3:15
clinicalSuture placement is performed under spontaneous ventilation conditions.↗
▶Ep 25 · 3:15
quoteWe like to use 30 prolenes and we like to place all the stitches before we actually secure them down, and it's important to do this under spontaneous conditions.↗
▶Ep 25 · 3:33
clinicalA patient who had prior thoracoscopic tracheopexy with dysphagia from torqued esophagus underwent the combined approach and became symptom-free.↗
▶Ep 25 · 4:00
clinicalOutcome measures include follow-up endoscopy, pulmonary function tests when patients are old enough, and imaging.↗
▶Ep 25 · 4:09
clinicalAt 36 months follow-up, imaging may still show tracheomalacia, but patients can be symptomatically better.↗
▶Ep 25 · 4:09
quoteAnd when you look 36 months later, it may still look like there's some malaysia, but symptomatically, they're better.↗
▶Ep 25 · 4:15
quoteSo it's important to pair that piece and understand that we're still trying to learn exactly what are those measures that we want to use to be able to say that they are a good outcome versus a bad outcome.↗
▶Ep 25 · 4:15
opinionThe team is still learning what measures should define good versus bad outcomes.↗
▶Ep 25 · 4:26
clinicalManaging complications including swallowing dysfunction and vocal fold paralysis is part of postoperative care.↗
Alessandro's statements about Esophageal Atresia50 statements
QUAD #1: Cervical Tracheopexy with Dr. Alessandro de Alarcon
▶Ep 48 · 0:49
clinicalCincinnati Children's typically uses a combined cervical and thoracic approach for esophageal atresia cases.↗
▶Ep 48 · 0:49
quoteIn Cincinnati we typically use a combined approach looking at the thoracic approach as well as with the cervical approach.↗
▶Ep 48 · 1:15
quoteYou need a neck tray, and MLB tray, and Maloney dilators versus NG tubes in the operating room and you do it.↗
▶Ep 48 · 1:15
clinicalRequired intraoperative equipment includes a neck tray, MLB tray, and Maloney dilators or NG tubes.↗
▶Ep 48 · 1:21
clinicalFlexible bronchoscopy during the operation is key, and endotracheal tube placement must allow visualization during the procedure.↗
▶Ep 48 · 1:21
quoteThe flexible bronchoscopy is really key and Placing your endotracheal tube is really important so they can look as you were doing the operation.↗
▶Ep 48 · 1:29
clinicalNasotracheal intubation is often used with the cuff positioned high, sometimes almost at the glottis.↗
▶Ep 48 · 1:33
quoteAnd sometimes that means your cuff is super high and it's almost at the glottis.↗
▶Ep 48 · 1:39
clinicalA NIM tube is preferred when possible to prevent injury to recurrent nerves or provide awareness when approaching them.↗
▶Ep 48 · 1:39
quoteIf we can, we like to use a NIM tube as part of trying to prevent potential injury to recurrent nerves or at least make you aware when you're Getting close to them.↗
▶Ep 48 · 1:55
clinicalThe surgical approach uses subplatysmal flaps and addresses anterior compression as needed.↗
▶Ep 48 · 2:09
clinicalAortopexy and innominate artery pexy can be added at the same time as the cervical procedure.↗
▶Ep 48 · 2:29
quoteAnd then it's thinking about your approach to mobilize the esophagus and the experience of working with our team in Cincinnati, we have learned how to not be afraid of the esophagus.↗
▶Ep 48 · 2:29
opinionThe Cincinnati team has learned not to be afraid of mobilizing the esophagus, which is important for the procedure.↗
▶Ep 48 · 2:54
clinicalStitches are sometimes placed in the trachea to pull it up and out of the way for visualization of the posterior aspect and spine.↗
▶Ep 48 · 2:54
quoteWe will sometimes place stitches in the trachea to pull it up and out of the way so you can visualize that posterior aspect of where you see the spine.↗
▶Ep 48 · 3:15
clinicalThe team uses 3-0 prolene sutures and places all stitches before securing them down.↗
▶Ep 48 · 3:15
quoteWe like to use 30 prolenes and we like to place all the stitches before we actually secure them down, and it's important to do this under spontaneous conditions.↗
▶Ep 48 · 3:15
clinicalSuture placement is performed under spontaneous ventilation conditions.↗
▶Ep 48 · 3:33
clinicalA patient who had prior thoracoscopic tracheopexy with dysphagia from torqued esophagus underwent the combined approach and became symptom-free.↗
▶Ep 48 · 4:00
clinicalOutcome measures include follow-up endoscopy, pulmonary function tests when patients are old enough, and imaging.↗
▶Ep 48 · 4:09
quoteAnd when you look 36 months later, it may still look like there's some malaysia, but symptomatically, they're better.↗
▶Ep 48 · 4:09
clinicalAt 36 months follow-up, imaging may still show tracheomalacia, but patients can be symptomatically better.↗
▶Ep 48 · 4:15
opinionThe team is still learning what measures should define good versus bad outcomes.↗
▶Ep 48 · 4:15
quoteSo it's important to pair that piece and understand that we're still trying to learn exactly what are those measures that we want to use to be able to say that they are a good outcome versus a bad outcome.↗
▶Ep 48 · 4:26
clinicalManaging complications including swallowing dysfunction and vocal fold paralysis is part of postoperative care.↗
Combined cervical and thoracic approach for esophageal atresia with tracheopexy
▶Ep 78 · 0:49
clinicalCincinnati Children's typically uses a combined cervical and thoracic approach for esophageal atresia cases.↗
▶Ep 78 · 0:49
quoteIn Cincinnati we typically use a combined approach we're looking at the thoracic approach as well as with the cervical approach.↗
▶Ep 78 · 1:15
quoteYou need a neck tray, and MLB tray, and Maloney dilators versus NG tubes in the operating room and you do it.↗
▶Ep 78 · 1:15
clinicalRequired intraoperative equipment includes a neck tray, MLB tray, and Maloney dilators versus NG tubes.↗
▶Ep 78 · 1:21
clinicalFlexible bronchoscopy during the operation is key, with the endotracheal tube placed exactly where needed for visualization.↗
▶Ep 78 · 1:21
quoteThe flexible bronchoscopy is really key and Placing your endotracheal tube is really important, so they can look as you were doing the operation.↗
▶Ep 78 · 1:29
clinicalNasotracheal intubation is often used with the cuff positioned very high, sometimes almost at the glottis.↗
▶Ep 78 · 1:34
quoteAnd sometimes that means your cuff is super high and it's almost at the glottis, you just have to be aware of that.↗
▶Ep 78 · 1:39
quoteIf we can, we like to use a NIM tube as part of trying to prevent potential injury to recurrent nerves or at least make you aware when you're Getting close to them.↗
▶Ep 78 · 1:39
clinicalA NIM tube is used when possible to prevent potential injury to recurrent nerves or provide awareness when getting close to them.↗
▶Ep 78 · 1:55
clinicalThe standard neck approach involves raising subplatysmal flaps and dealing with anterior compression as needed.↗
▶Ep 78 · 2:09
clinicalAortopexy and mopexy can be added at the same time as the cervical approach.↗
▶Ep 78 · 2:13
clinicalThe straps are separated to expose the airway and find the esophagus.↗
▶Ep 78 · 2:29
opinionThe Cincinnati team has learned not to be afraid of the esophagus, being able to find it, move it, and get it out of the way.↗
▶Ep 78 · 2:35
quoteWe have learned how to not be afraid of the esophagus.↗
▶Ep 78 · 2:54
clinicalStitches are sometimes placed in the trachea to pull it up and out of the way to visualize the posterior aspect where the spine is visible.↗
▶Ep 78 · 3:15
quoteWe like to use 3 Orolines and we like to place all the stitches before we actually secure them down, and it's important to do this under spontaneous conditions.↗
▶Ep 78 · 3:15
clinical3-0 Prolene sutures are used, with all stitches placed before securing them down, under spontaneous ventilation conditions.↗
▶Ep 78 · 3:33
clinicalA patient who had prior thoracoscopic tracheopexy developed dysphagia from a torqued esophagus, was treated with the combined approach, achieved a good airway, and is now symptom-free.↗
▶Ep 78 · 4:00
clinicalOutcome measures include follow-up endoscopy, pulmonary function tests when patients are old enough to perform them, and imaging.↗
▶Ep 78 · 4:09
quoteAnd when you look 36 months later, it may still look like there's some malaysia, but symptomatically, they're better.↗
▶Ep 78 · 4:09
clinicalAt 36 months follow-up, imaging may still show some malacia, but patients are symptomatically better.↗
▶Ep 78 · 4:15
opinionThe team is still learning what measures should be used to define good versus bad outcomes.↗
▶Ep 78 · 4:26
clinicalManaging complications including swallowing dysfunction and vocal fold paralysis is part of the care process.↗
Alessandro's statements about Pediatric Airway Reconstruction & Stenosis Management29 statements
Screening and treatment of MRSA colonization in pediatric airway surgery patients
▶Ep 35 · 0:35
quoteMRSA or methicillin resistant Staph aureus, it's a lot of times kind of in the lay press. It's the bacteria that people have been really concerned about for the last decade as being a very resistant Staph aureus that can cause a lot of problems with infection.↗
▶Ep 35 · 0:35
clinicalMRSA (methicillin-resistant Staph aureus) can cause serious infections in the skin and wound sites after surgery.↗
▶Ep 35 · 0:58
epidemiologicalStudies in the last decade show an increasing number of MRSA infections both in the community and during surgical procedures globally.↗
▶Ep 35 · 1:14
opinionThe increase in resistant bacterial strains is thought to be due to more frequent antibiotic use than in the past.↗
▶Ep 35 · 1:27
clinicalAt Cincinnati Children's, several patients had severe MRSA infections that led to failure of their airway reconstruction.↗
▶Ep 35 · 1:27
quotesome of my co-authors noted they had a series of several patients that had pretty severe MRSA infections that led to actually failure of their airways.↗
▶Ep 35 · 1:46
clinicalCincinnati Children's protocol screens patients for MRSA prior to airway surgery and treats colonized patients before and during surgery with appropriate antibiotics.↗
▶Ep 35 · 2:00
quotecolonized, that means that they have it either in their skin or some site. Their body where they're growing it, but it's not causing an infection↗
▶Ep 35 · 3:00
epidemiologicalMRSA surgical site infections can increase the cost of admission by up to approximately $62,000.↗
▶Ep 35 · 3:06
quoteStudies show it increased costs up to about $62,000 for a single surgical site infection, which is not insignificant↗
▶Ep 35 · 3:19
clinicalMRSA infections can cause rib grafts used in airway reconstructions to die, leading to complete surgical failure.↗
▶Ep 35 · 3:26
quotewhen we use rib grafts for airway reconstructions, those rib grafts can actually die and the whole operation. Itself will be a failure↗
▶Ep 35 · 3:34
epidemiologicalA typical airway reconstruction runs around $90,000 in hospital charges.↗
▶Ep 35 · 3:34
quotea typical airway reconstruction in me, you know, if you're just looking at charges to a hospital or cost, runs around $90,000.↗
▶Ep 35 · 3:58
clinicalHospital stays for airway reconstruction range from a couple of weeks to about a month.↗
▶Ep 35 · 4:31
clinicalCincinnati Children's is working on protocols to reduce or eliminate surgical site infections by identifying preventable harm.↗
▶Ep 35 · 4:31
opinionSurgical site infections have historically been looked at as accidents or something not preventable.↗
▶Ep 35 · 5:19
epidemiologicalAbout one-third of children with tracheostomies screened at Cincinnati Children's are colonized with MRSA.↗
▶Ep 35 · 5:19
quotea lot of other surgical practices that have published papers about using screening and treatment programs, they often look at high risk patient populations as being kind of 8 to 10% of the patient population as having MRSA.↗
▶Ep 35 · 5:19
quoteif you look at just the overall Numbers of children that we screen here with tracheostomies, about a third of them will have will be colonized with MRSA↗
▶Ep 35 · 5:19
epidemiologicalOther surgical practices typically define high-risk patient populations as having 8 to 10% MRSA colonization rates.↗
▶Ep 35 · 5:59
clinicalCincinnati Children's airway surgery program focuses on improving outcomes beyond tracheostomy removal, including voice outcomes and long-term quality of life.↗
▶Ep 35 · 5:59
clinicalRobin Cotton is one of the forefathers of airway reconstruction in children.↗
▶Ep 35 · 6:48
clinicalMany children with tracheostomies will be MRSA positive from the tracheostomy site or an additional site.↗
▶Ep 35 · 7:07
opinionThe study design could not prove that Cincinnati Children's protocol is the perfect protocol.↗
▶Ep 35 · 7:07
quoteIn our study, we couldn't really prove that our protocol is the perfect protocol. Partly just the nature of the design of the study↗
▶Ep 35 · 7:24
clinicalThe study showed no increase in MRSA infections in patients who were MRSA positive and treated according to the protocol.↗
▶Ep 35 · 7:24
guidelineCenters performing significant airway reconstruction should have a clinical protocol for MRSA screening before surgery and treatment.↗
▶Ep 35 · 7:40
quotewe did show that there wasn't any increase in MRSA infections in the patients that were MRSA positive, which was pretty fantastic↗
Alessandro's statements about Tracheomalacia26 statements
QUAD #1: Cervical Tracheopexy with Dr. Alessandro de Alarcon
▶Ep 4 · 0:49
clinicalCincinnati Children's typically uses a combined cervical and thoracic approach for esophageal atresia cases.↗
▶Ep 4 · 0:49
quoteIn Cincinnati we typically use a combined approach looking at the thoracic approach as well as with the cervical approach.↗
▶Ep 4 · 1:15
clinicalRequired intraoperative equipment includes a neck tray, MLB tray, and Maloney dilators or NG tubes.↗
▶Ep 4 · 1:15
quoteYou need a neck tray, and MLB tray, and Maloney dilators versus NG tubes in the operating room and you do it.↗
▶Ep 4 · 1:21
quoteThe flexible bronchoscopy is really key and Placing your endotracheal tube is really important so they can look as you were doing the operation.↗
▶Ep 4 · 1:21
clinicalFlexible bronchoscopy during the operation is key, and endotracheal tube placement must allow visualization during the procedure.↗
▶Ep 4 · 1:29
clinicalNasotracheal intubation is often used with the cuff positioned high, sometimes almost at the glottis.↗
▶Ep 4 · 1:33
quoteAnd sometimes that means your cuff is super high and it's almost at the glottis.↗
▶Ep 4 · 1:39
clinicalA NIM tube is preferred when possible to prevent injury to recurrent nerves or provide awareness when approaching them.↗
▶Ep 4 · 1:39
quoteIf we can, we like to use a NIM tube as part of trying to prevent potential injury to recurrent nerves or at least make you aware when you're Getting close to them.↗
▶Ep 4 · 1:55
clinicalThe surgical approach uses subplatysmal flaps and addresses anterior compression as needed.↗
▶Ep 4 · 2:09
clinicalAortopexy and innominate artery pexy can be added at the same time as the cervical procedure.↗
▶Ep 4 · 2:29
quoteAnd then it's thinking about your approach to mobilize the esophagus and the experience of working with our team in Cincinnati, we have learned how to not be afraid of the esophagus.↗
▶Ep 4 · 2:29
opinionThe Cincinnati team has learned not to be afraid of mobilizing the esophagus, which is important for the procedure.↗
▶Ep 4 · 2:54
clinicalStitches are sometimes placed in the trachea to pull it up and out of the way for visualization of the posterior aspect and spine.↗
▶Ep 4 · 2:54
quoteWe will sometimes place stitches in the trachea to pull it up and out of the way so you can visualize that posterior aspect of where you see the spine.↗
▶Ep 4 · 3:15
clinicalSuture placement is performed under spontaneous ventilation conditions.↗
▶Ep 4 · 3:15
quoteWe like to use 30 prolenes and we like to place all the stitches before we actually secure them down, and it's important to do this under spontaneous conditions.↗
▶Ep 4 · 3:15
clinicalThe team uses 3-0 prolene sutures and places all stitches before securing them down.↗
▶Ep 4 · 3:33
clinicalA patient who had prior thoracoscopic tracheopexy with dysphagia from torqued esophagus underwent the combined approach and became symptom-free.↗
▶Ep 4 · 4:00
clinicalOutcome measures include follow-up endoscopy, pulmonary function tests when patients are old enough, and imaging.↗
▶Ep 4 · 4:09
clinicalAt 36 months follow-up, imaging may still show tracheomalacia, but patients can be symptomatically better.↗
▶Ep 4 · 4:09
quoteAnd when you look 36 months later, it may still look like there's some malaysia, but symptomatically, they're better.↗
▶Ep 4 · 4:15
quoteSo it's important to pair that piece and understand that we're still trying to learn exactly what are those measures that we want to use to be able to say that they are a good outcome versus a bad outcome.↗
▶Ep 4 · 4:15
opinionThe team is still learning what measures should define good versus bad outcomes.↗
▶Ep 4 · 4:26
clinicalManaging complications including swallowing dysfunction and vocal fold paralysis is part of postoperative care.↗