One of the failings of, and you need specialized equipment to do this, that most visualization companies offer, and you can do this thoracoscopically, laparoscopically, or a lot of the companies also have open detectors. And so what I'm trying to do here is look for any residual tumor, knowing that one of ICG's kind of limitations is that it's not specific, it's highly sensitive.
We didn't put an NG in, so we're paying the price for that. But what we typically will do, or what some of the old school anesthetists, and I would assume that they've taught the fellows and their junior partners is you will suction the baby while awake in 3 different positions, head down, turn to the right, turn to the left to make sure you've sucked out that big atonic bag.
The first pyloomyotomy was done actually the year before by someone else, but Ramstead was the one who popularized it and the spreader bears his name. He used a coffee spoon and he actually intended to do a pyloroplasty, but ended up doing myotomy only because the baby got unstable or, you know, they couldn't do it appropriately, so we only did the myotomy.
There is also some data to suggest that you get the maximal bang for your buck after the first block or cycle of C5VD in intermediate risk patients or the first block after of Cyopel 4, you typically won't get as much shrinkage or contraction of the tumor after your subsequent blocks.
if a cyst was diagnosed prenatally, and it was larger than four and a half centimeters at the 20 week anatomy scan, there was a higher rate of postnatal symptomatology. And the authors, therefore, made the conclusion that perhaps these patients may benefit from earlier intervention.
if a cyst was diagnosed prenatally, and it was larger than four and a half centimeters at the 20 week anatomy scan, there was a higher rate of postnatal symptomatology. And the authors, therefore, made the conclusion that perhaps these patients may benefit from earlier intervention.
clinicalThe Taiwanese published in the Journal of Pediatrics in 2006 that they send all their kids home with stool color cards↗
▶Ep 8 · 9:59
clinicalMMP7 was identified as a serum marker of epithelial injury in biliary atresia through large-scale proteomic analysis of 30 children with biliary atresia in 2017↗
▶Ep 8 · 10:40
clinicalMMP7 using a cutoff value of 52-53 nanograms per ml demonstrated a sensitivity of diagnosing biliary atresia of about 98% with a specificity of about 95% in 135 consecutive infants in China↗
▶Ep 8 · 13:10
opinionMMP7 has the potential to eliminate a lot of other testing and eliminate things like a liver biopsy if confidence grows in its impact↗
▶Ep 8 · 14:44
clinicalA combination of blood tests and laparoscopy can diagnose biliary atresia promptly and accurately↗
▶Ep 8 · 17:09
clinicalBile duct proliferation and portal edema may not appear on very early liver biopsies and may delay diagnosis by up to 30 days↗
▶Ep 8 · 26:20
clinicalCystic biliary atresia patients get to surgery earlier, potentially because of prenatal diagnosis and heightened level of suspicion↗
Choledochal Cyst Podcast
▶Ep 9 · 0:29
quotea choledocal cyst ray is a congenital cystic dilation of the biliary tree↗
▶Ep 9 · 0:29
clinicalCholedochal cyst is a congenital cystic dilation of the biliary tree↗
▶Ep 9 · 0:36
epidemiologicalIn the Western world, the incidence is about 1 in 100,000↗
▶Ep 9 · 0:36
quoteIn the Western world, the incidence is about 1 in 100,000. But in Asia, specifically Eastern Asia, it's quite a bit more common, 1 in 13,000.↗
▶Ep 9 · 0:50
epidemiologicalIn Asia, specifically Eastern Asia, incidence is 1 in 13,000↗
▶Ep 9 · 0:58
quoteIt's actually three to four times more likely in females than in males.↗
▶Ep 9 · 0:58
clinicalThere are some genes that have been identified in limited studies, possibly including PKD1 for type 5 choledochal cysts↗
▶Ep 9 · 0:58
epidemiologicalCholedochal cysts are three to four times more likely in females than in males↗
▶Ep 9 · 1:10
clinicalFor types 1 and 4, etiology is likely embryologic, relating to the pancreaticobiliary duct junction (pancreaticobiliary malunion), which creates a long common channel↗
▶Ep 9 · 1:40
quotereflux of pancreatic enzymes from, obviously, the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 9 · 1:40
clinicalReflux of pancreatic enzymes from the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes↗
▶Ep 9 · 2:05
clinicalType 1 is a dilation of the extrahepatic common bile duct only, either fusiform or saccular↗
▶Ep 9 · 2:25
clinicalType 2 is a small diverticulum off of the common bile duct↗
▶Ep 9 · 2:35
clinicalType 3 is a choledochocele affecting the portion of the common bile duct in the wall of the duodenum↗
▶Ep 9 · 2:45
clinicalType 4a is multiple cysts in both the intra- and extrahepatic biliary tree; type 4b is multiple cysts in the extrahepatic biliary tree only↗
▶Ep 9 · 3:00
clinicalType 5 is intrahepatic only and diffusely throughout, called Caroli's disease↗
▶Ep 9 · 3:25
clinicalIn younger children such as infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound for other causes↗
▶Ep 9 · 3:45
clinicalIn children, patients often present with symptoms consistent with cholangitis, such as jaundice or fever, and can have a palpable right upper quadrant mass↗
▶Ep 9 · 4:05
quoteCharcot's triad, but actually, this is incredibly uncommon as far as presentations are concerned.↗
▶Ep 9 · 4:05
clinicalCharcot's triad (jaundice, fever, palpable RUQ mass) is incredibly uncommon as a presentation↗
▶Ep 9 · 4:20
clinicalGiant cysts that children are born with can perforate and present with biliary ascites↗
▶Ep 9 · 4:35
clinicalGiant choledochal cysts can be diagnosed prenatally on week 20 ultrasounds↗
▶Ep 9 · 4:45
quoteif a cyst was diagnosed prenatally, and it was larger than four and a half centimeters at the 20 week anatomy scan, there was a higher rate of postnatal symptomatology. And the authors, therefore, made the conclusion that perhaps these patients may benefit from earlier intervention.↗
▶Ep 9 · 4:45
clinicalIf a cyst was diagnosed prenatally and was larger than 4.5 cm at the 20-week anatomy scan, there was a higher rate of postnatal symptomatology, suggesting these patients may benefit from earlier intervention↗
▶Ep 9 · 5:12
clinicalDifferential diagnosis for a one-year-old with jaundice includes choledocholithiasis, cholelithiasis, gallstone pancreatitis, choledochal cyst, and biliary atresia (though the child is a little old for biliary atresia)↗
▶Ep 9 · 5:46
clinicalPhysical exam should look for jaundice or scleral icterus and a palpable abdominal mass in younger children↗
▶Ep 9 · 6:05
clinicalLabs to check include liver function tests with total, direct, and indirect bilirubin levels, plus or minus a CBC to look for evidence of cholangitis or infection↗
▶Ep 9 · 6:22
clinicalThe major initial screening imaging test is an abdominal ultrasound↗
▶Ep 9 · 6:25
clinicalA liver biopsy is not typically needed if the patient is older and you have reliable ultrasound imaging, but becomes critical in a neonate or newborn to rule out cystic biliary atresia↗
clinicalCT scan is commonly used because of the ease with which you can scan young children↗
▶Ep 9 · 7:05
clinicalMRCP is useful if there are questions about anatomic details, specifically hilar or intrahepatic disease, to understand how extensive the cystic change is and to identify variant biliary anatomy (present in 15-20% of patients)↗
▶Ep 9 · 7:40
clinicalERCP can be both diagnostic and therapeutic depending on what is seen on prior scans and the type of choledochal cyst↗
▶Ep 9 · 8:00
clinicalThere are no non-surgical treatment options for choledochal cysts↗
▶Ep 9 · 8:10
clinicalThe anomalous anatomy related to the cyst puts the patient at risk for episodes of cholangitis due to biliary stasis and superinfection, which can be life-threatening↗
▶Ep 9 · 8:30
quotethere is, as we can best estimate, about an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma↗
▶Ep 9 · 8:30
clinicalFor type 1 and type 4 cysts with pancreaticobiliary malunion, there is about an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma and gallbladder cancer↗
▶Ep 9 · 9:00
epidemiologicalStudies estimate lifetime malignancy risk anywhere from 6% to 30%↗
▶Ep 9 · 9:08
quoteeven after surgical resection of these cysts, some studies suggest that there is still about a 4% lifetime risk of malignancy, which means that these patients need to be surveilled through their lifetime.↗
▶Ep 9 · 9:08
clinicalEven after surgical resection of these cysts, some studies suggest there is still about a 4% lifetime risk of malignancy, requiring lifelong surveillance↗
▶Ep 9 · 9:16
clinicalIf a patient presents actively infected with pancreatitis, cholangitis, or in some acute way, cool them off and treat the underlying process, then schedule surgery after sufficient recovery↗
▶Ep 9 · 9:50
opinionFor incidentally found lesions, schedule surgery sooner than later when it makes sense for the family schedule, but not waiting too long↗
▶Ep 9 · 11:13
clinicalSurgical goals for type 1 and type 4 are to remove as much of the duct as possible, taking the duct all the way down behind or into the head of the pancreas to where it tapers, so as not to leave remnant cyst↗
▶Ep 9 · 11:50
clinicalFor type 1 and type 4 cysts, reconstruction of the biliary drainage system often includes a Roux-en-Y hepaticojejunostomy, but a hepaticoduodenostomy is also an option↗
▶Ep 9 · 12:15
clinicalType 2 can be simply removal of the diverticulum at its neck with repair of the common bile duct↗
▶Ep 9 · 12:30
clinicalType 3 can be treated with ERCP and sphincterotomy if it is a limited choledochocele, or transduodenal resection if it involves the duodenal wall↗
▶Ep 9 · 12:50
clinicalBiopsy of the mucosa of the choledochocele is important because if it is biliary epithelium constantly exposed to intestinal secretions, it could become malignant↗
▶Ep 9 · 13:10
clinicalType 5 management depends on how diffuse the disease is: if limited to an anatomic part of the liver, resection may be possible; if diffuse throughout with inadequate functional liver remnant, transplantation may be necessary↗
▶Ep 9 · 13:19
clinicalIn a younger child (less than 2 years), a transverse or right subcostal incision is preferred; in older children, an upper midline incision is also viable↗
▶Ep 9 · 14:40
clinicalIntraoperative cholangiogram through the gallbladder helps understand where the tapering of the distal cyst occurs to avoid leaving remnant cyst↗
▶Ep 9 · 15:50
clinicalRoux-en-Y limb is constructed about 15 to 20 cm distal from the ligament of Treitz, brought retrocolic, and hepaticojejunostomy is performed with interrupted 5-0 or 6-0 Maxon suture↗
▶Ep 9 · 16:47
clinicalFor type 2 cyst, resect the neck and repair the common bile duct with interrupted absorbable suture; T-tube is not typically left↗
▶Ep 9 · 17:30
clinicalType 3 cyst can be approached endoscopically with ERCP and sphincterotomy, or transduodenally if large and obstructing, sometimes with preoperative stents↗
▶Ep 9 · 18:10
clinicalType 5 (Caroli's disease) management depends on extent: if limited to one hemi-liver with adequate remnant and preserved biliary outflow, liver resection is possible; if diffuse, liver transplantation may be necessary↗
▶Ep 9 · 18:45
clinicalPostoperatively, place drains to assess for biliary leaks from the hepatoenteric anastomosis and remove them once the patient is tolerating a regular diet↗
▶Ep 9 · 19:20
clinicalInstitutionally, patients are placed on a choleretic like Actigall and cholangitis prophylaxis with daily Bactrim for 3 to 6 months after surgery↗
▶Ep 9 · 19:50
clinicalShort-term to long-term surgical complications can include anastomotic stricture, small bowel obstruction, reflux gastritis, and recurrent cholangitis↗
▶Ep 9 · 20:15
clinicalLifelong follow-up is needed because of the possibility of developing future malignancy even after resection of the cyst↗
quotea choledocal cyst ray is a congenital cystic dilation of the biliary tree↗
▶Ep 1 · 0:29
clinicalCholedochal cyst is a congenital cystic dilation of the biliary tree↗
▶Ep 1 · 0:36
epidemiologicalIn the Western world, the incidence is about 1 in 100,000↗
▶Ep 1 · 0:36
quoteIn the Western world, the incidence is about 1 in 100,000. But in Asia, specifically Eastern Asia, it's quite a bit more common, 1 in 13,000.↗
▶Ep 1 · 0:50
epidemiologicalIn Asia, specifically Eastern Asia, incidence is 1 in 13,000↗
▶Ep 1 · 0:58
clinicalThere are some genes that have been identified in limited studies, possibly including PKD1 for type 5 choledochal cysts↗
▶Ep 1 · 0:58
quoteIt's actually three to four times more likely in females than in males.↗
▶Ep 1 · 0:58
epidemiologicalCholedochal cysts are three to four times more likely in females than in males↗
▶Ep 1 · 1:10
clinicalFor types 1 and 4, etiology is likely embryologic, relating to the pancreaticobiliary duct junction (pancreaticobiliary malunion), which creates a long common channel↗
▶Ep 1 · 1:40
clinicalReflux of pancreatic enzymes from the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes↗
▶Ep 1 · 1:40
quotereflux of pancreatic enzymes from, obviously, the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 1 · 2:05
clinicalType 1 is a dilation of the extrahepatic common bile duct only, either fusiform or saccular↗
▶Ep 1 · 2:25
clinicalType 2 is a small diverticulum off of the common bile duct↗
▶Ep 1 · 2:35
clinicalType 3 is a choledochocele affecting the portion of the common bile duct in the wall of the duodenum↗
▶Ep 1 · 2:45
clinicalType 4a is multiple cysts in both the intra- and extrahepatic biliary tree; type 4b is multiple cysts in the extrahepatic biliary tree only↗
▶Ep 1 · 3:00
clinicalType 5 is intrahepatic only and diffusely throughout, called Caroli's disease↗
▶Ep 1 · 3:25
clinicalIn younger children such as infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound for other causes↗
▶Ep 1 · 3:45
clinicalIn children, patients often present with symptoms consistent with cholangitis, such as jaundice or fever, and can have a palpable right upper quadrant mass↗
▶Ep 1 · 4:05
quoteCharcot's triad, but actually, this is incredibly uncommon as far as presentations are concerned.↗
▶Ep 1 · 4:05
clinicalCharcot's triad (jaundice, fever, palpable RUQ mass) is incredibly uncommon as a presentation↗
▶Ep 1 · 4:20
clinicalGiant cysts that children are born with can perforate and present with biliary ascites↗
▶Ep 1 · 4:35
clinicalGiant choledochal cysts can be diagnosed prenatally on week 20 ultrasounds↗
▶Ep 1 · 4:45
quoteif a cyst was diagnosed prenatally, and it was larger than four and a half centimeters at the 20 week anatomy scan, there was a higher rate of postnatal symptomatology. And the authors, therefore, made the conclusion that perhaps these patients may benefit from earlier intervention.↗
▶Ep 1 · 4:45
clinicalIf a cyst was diagnosed prenatally and was larger than 4.5 cm at the 20-week anatomy scan, there was a higher rate of postnatal symptomatology, suggesting these patients may benefit from earlier intervention↗
▶Ep 1 · 5:12
clinicalDifferential diagnosis for a one-year-old with jaundice includes choledocholithiasis, cholelithiasis, gallstone pancreatitis, choledochal cyst, and biliary atresia (though the child is a little old for biliary atresia)↗
▶Ep 1 · 5:46
clinicalPhysical exam should look for jaundice or scleral icterus and a palpable abdominal mass in younger children↗
▶Ep 1 · 6:05
clinicalLabs to check include liver function tests with total, direct, and indirect bilirubin levels, plus or minus a CBC to look for evidence of cholangitis or infection↗
▶Ep 1 · 6:22
clinicalThe major initial screening imaging test is an abdominal ultrasound↗
▶Ep 1 · 6:25
clinicalA liver biopsy is not typically needed if the patient is older and you have reliable ultrasound imaging, but becomes critical in a neonate or newborn to rule out cystic biliary atresia↗
clinicalCT scan is commonly used because of the ease with which you can scan young children↗
▶Ep 1 · 7:05
clinicalMRCP is useful if there are questions about anatomic details, specifically hilar or intrahepatic disease, to understand how extensive the cystic change is and to identify variant biliary anatomy (present in 15-20% of patients)↗
▶Ep 1 · 7:40
clinicalERCP can be both diagnostic and therapeutic depending on what is seen on prior scans and the type of choledochal cyst↗
▶Ep 1 · 8:00
clinicalThere are no non-surgical treatment options for choledochal cysts↗
▶Ep 1 · 8:10
clinicalThe anomalous anatomy related to the cyst puts the patient at risk for episodes of cholangitis due to biliary stasis and superinfection, which can be life-threatening↗
▶Ep 1 · 8:30
quotethere is, as we can best estimate, about an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma↗
▶Ep 1 · 8:30
clinicalFor type 1 and type 4 cysts with pancreaticobiliary malunion, there is about an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma and gallbladder cancer↗
▶Ep 1 · 9:00
epidemiologicalStudies estimate lifetime malignancy risk anywhere from 6% to 30%↗
▶Ep 1 · 9:08
clinicalEven after surgical resection of these cysts, some studies suggest there is still about a 4% lifetime risk of malignancy, requiring lifelong surveillance↗
▶Ep 1 · 9:08
quoteeven after surgical resection of these cysts, some studies suggest that there is still about a 4% lifetime risk of malignancy, which means that these patients need to be surveilled through their lifetime.↗
▶Ep 1 · 9:16
clinicalIf a patient presents actively infected with pancreatitis, cholangitis, or in some acute way, cool them off and treat the underlying process, then schedule surgery after sufficient recovery↗
▶Ep 1 · 9:50
opinionFor incidentally found lesions, schedule surgery sooner than later when it makes sense for the family schedule, but not waiting too long↗
▶Ep 1 · 11:13
clinicalSurgical goals for type 1 and type 4 are to remove as much of the duct as possible, taking the duct all the way down behind or into the head of the pancreas to where it tapers, so as not to leave remnant cyst↗
▶Ep 1 · 11:50
clinicalFor type 1 and type 4 cysts, reconstruction of the biliary drainage system often includes a Roux-en-Y hepaticojejunostomy, but a hepaticoduodenostomy is also an option↗
▶Ep 1 · 12:15
clinicalType 2 can be simply removal of the diverticulum at its neck with repair of the common bile duct↗
▶Ep 1 · 12:30
clinicalType 3 can be treated with ERCP and sphincterotomy if it is a limited choledochocele, or transduodenal resection if it involves the duodenal wall↗
▶Ep 1 · 12:50
clinicalBiopsy of the mucosa of the choledochocele is important because if it is biliary epithelium constantly exposed to intestinal secretions, it could become malignant↗
▶Ep 1 · 13:10
clinicalType 5 management depends on how diffuse the disease is: if limited to an anatomic part of the liver, resection may be possible; if diffuse throughout with inadequate functional liver remnant, transplantation may be necessary↗
▶Ep 1 · 13:19
clinicalIn a younger child (less than 2 years), a transverse or right subcostal incision is preferred; in older children, an upper midline incision is also viable↗
▶Ep 1 · 14:40
clinicalIntraoperative cholangiogram through the gallbladder helps understand where the tapering of the distal cyst occurs to avoid leaving remnant cyst↗
▶Ep 1 · 15:50
clinicalRoux-en-Y limb is constructed about 15 to 20 cm distal from the ligament of Treitz, brought retrocolic, and hepaticojejunostomy is performed with interrupted 5-0 or 6-0 Maxon suture↗
▶Ep 1 · 16:47
clinicalFor type 2 cyst, resect the neck and repair the common bile duct with interrupted absorbable suture; T-tube is not typically left↗
▶Ep 1 · 17:30
clinicalType 3 cyst can be approached endoscopically with ERCP and sphincterotomy, or transduodenally if large and obstructing, sometimes with preoperative stents↗
▶Ep 1 · 18:10
clinicalType 5 (Caroli's disease) management depends on extent: if limited to one hemi-liver with adequate remnant and preserved biliary outflow, liver resection is possible; if diffuse, liver transplantation may be necessary↗
▶Ep 1 · 18:45
clinicalPostoperatively, place drains to assess for biliary leaks from the hepatoenteric anastomosis and remove them once the patient is tolerating a regular diet↗
▶Ep 1 · 19:20
clinicalInstitutionally, patients are placed on a choleretic like Actigall and cholangitis prophylaxis with daily Bactrim for 3 to 6 months after surgery↗
▶Ep 1 · 19:50
clinicalShort-term to long-term surgical complications can include anastomotic stricture, small bowel obstruction, reflux gastritis, and recurrent cholangitis↗
▶Ep 1 · 20:15
clinicalLifelong follow-up is needed because of the possibility of developing future malignancy even after resection of the cyst↗
Choledochal Cysts: In Brief with Dr. Alexander Bondoc
▶Ep 2 · 8:03
clinicalThe risk for developing cholangiocarcinoma can be as high as 26 percent↗
▶Ep 2 · 8:22
clinicalEven after surgical resection of these cysts some studies suggest there is still about a four percent lifetime risk of malignancy↗
▶Ep 2 · 8:45
clinicalPatients presenting acutely can have pancreatitis or cholangitis↗
clinicalFor type 1 and type 4 cysts the goal is to remove as much of the duct as possible taking the duct all the way down to where it tapers behind the head of the pancreas or into the head of the pancreas↗
▶Ep 2 · 9:40
clinicalReconstruction can include a hepaticoduodenostomy or a hepaticojejunostomy↗
Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations
▶Ep 15 · 0:26
clinicalCincinnati Children's Hospital handles the bulk of complex vascular access and all catheter-based access for dialysis↗
▶Ep 15 · 2:09
opinionChest and neck central venous access is preferred from a purely logistical standpoint↗
▶Ep 15 · 2:09
quoteFrom a purely logistical standpoint, um, chest and neck, central venous access is preferred.↗
▶Ep 15 · 2:39
clinicalContraindications for central access include thrombosis, collateralization, and central stenosis of the SVC↗
▶Ep 15 · 3:09
opinionRoutine ultrasound is not necessary unless the patient has a congenital anomaly, usually cardiovascular↗
▶Ep 15 · 3:20
clinicalFor patients with multiple prior lines, Doppler venous ultrasound of the jugulars is the preferred first screening test↗
▶Ep 15 · 3:37
clinicalImaging may escalate to contrast-enhanced MR or CT venogram, and sometimes intraoperative venography with fluoroscopy↗
▶Ep 15 · 4:02
clinicalPositioning over a vertically oriented shoulder roll is the most versatile approach for neonates and infants↗
▶Ep 15 · 4:02
quoteThe more versatile way to position the patient is over a vertically oriented shoulder roll.↗
▶Ep 15 · 4:12
clinicalA vertical shoulder roll provides hyperextension of the neck and allows shoulders to drop posteriorly, giving access to bilateral subclavians and jugulars↗
▶Ep 15 · 4:55
clinicalA micropuncture kit with a 21 gauge finder needle is preferred over the 18 gauge needle in standard kits for small neonates↗
▶Ep 15 · 5:25
clinicalUsing ultrasound for internal jugular central line placement is the number one preferred method, with lowest risk of pneumothorax and carotid injury↗
▶Ep 15 · 5:25
quoteUsing an ultrasound for an IJ, um, central line, uh, attempt is the number one preferred way of doing things.↗
▶Ep 15 · 5:52
opinionFor large bore access like dialysis catheters, sticking the patient as low as possible on the neck is recommended↗
▶Ep 15 · 6:00
clinicalLevering the ultrasound probe (12mm diameter) against the clavicle provides a reasonable low puncture site↗
▶Ep 15 · 6:22
opinionSticking low on the neck leaves less catheter to curve in the neck, reducing problems with catheter displacement when patients turn their heads↗
▶Ep 15 · 6:36
clinicalCatheters have been observed to spit out of the SVC with excessive laxity in the neck↗
▶Ep 15 · 6:36
quoteI've seen catheter spit out of the, of the SVC. It's strange, but I've seen it a couple of times.↗
▶Ep 15 · 6:56
clinicalFor subclavian access, puncture at least 1 finger breadth (almost 1cm) inferior and lateral to the junction of median and medial aspects of the clavicle↗
▶Ep 15 · 7:14
clinicalWhen approaching the clavicle during subclavian access, keep the needle flat and push down on skin rather than angling at 30 degrees↗
▶Ep 15 · 7:34
clinicalFor subclavian access, aim directly at the sternal notch, then angle wider toward the angle of mandible in a radial motion if unsuccessful↗
▶Ep 15 · 8:04
clinicalThe right triangle technique uses the trachea as midline and the right mainstem bronchus as hypotenuse; catheter tip in this triangle will always be at the atrial-caval junction↗
▶Ep 15 · 8:26
quoteIf you leave the tip of your catheter in that triangle, in the area of that triangle, that will always be the atrial cable junction.↗
▶Ep 15 · 8:38
opinionRoutine post-procedural X-rays are not ordered for single-stick, uncomplicated procedures using fluoroscopy↗
▶Ep 15 · 9:06
clinicalPost-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rarely chylothorax or thoracic duct injury↗
▶Ep 15 · 9:41
clinicalThe first clinical decision for line infection is determining if the patient is septic from the line↗
▶Ep 15 · 9:41
quoteYour first clinical decision point is, is the patient septic from this line?↗
▶Ep 15 · 9:46
clinicalIf the patient is septic from the line, source control requires bedside removal under light sedation↗
▶Ep 15 · 10:04
clinicalFor non-septic line-dependent patients with complex vascular access, treatment involves identifying the organism, assessing sensitivity, and performing serial blood cultures to achieve sustained culture negativity for line salvage↗
▶Ep 15 · 12:19
clinicalTranslumbar line placement through back musculature into intrahepatic IVC is considered when femoral, IJ, and subclavian options are exhausted↗
▶Ep 15 · 12:48
clinicalEmergency facial vein cutdown involves horizontal incision lateral to sternocleidomastoid at angle of mandible with the head turned↗
▶Ep 15 · 13:04
clinicalFor facial vein cutdown, beveling the catheter hard helps it follow a path when blindly passing without a wire↗
Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations
▶Ep 63 · 0:26
clinicalCincinnati Children's Hospital handles the bulk of complex vascular access and all catheter-based access for dialysis↗
▶Ep 63 · 2:09
opinionChest and neck central venous access is preferred from a purely logistical standpoint↗
▶Ep 63 · 2:09
quoteFrom a purely logistical standpoint, um, chest and neck, central venous access is preferred.↗
▶Ep 63 · 2:39
clinicalContraindications for central access include thrombosis, collateralization, and central stenosis of the SVC↗
▶Ep 63 · 3:09
opinionRoutine ultrasound is not necessary unless the patient has a congenital anomaly, usually cardiovascular↗
▶Ep 63 · 3:20
clinicalFor patients with multiple prior lines, Doppler venous ultrasound of the jugulars is the preferred first screening test↗
▶Ep 63 · 3:37
clinicalImaging may escalate to contrast-enhanced MR or CT venogram, and sometimes intraoperative venography with fluoroscopy↗
▶Ep 63 · 4:02
quoteThe more versatile way to position the patient is over a vertically oriented shoulder roll.↗
▶Ep 63 · 4:02
clinicalPositioning over a vertically oriented shoulder roll is the most versatile approach for neonates and infants↗
▶Ep 63 · 4:12
clinicalA vertical shoulder roll provides hyperextension of the neck and allows shoulders to drop posteriorly, giving access to bilateral subclavians and jugulars↗
▶Ep 63 · 4:55
clinicalA micropuncture kit with a 21 gauge finder needle is preferred over the 18 gauge needle in standard kits for small neonates↗
▶Ep 63 · 5:25
clinicalUsing ultrasound for internal jugular central line placement is the number one preferred method, with lowest risk of pneumothorax and carotid injury↗
▶Ep 63 · 5:25
quoteUsing an ultrasound for an IJ, um, central line, uh, attempt is the number one preferred way of doing things.↗
▶Ep 63 · 5:52
opinionFor large bore access like dialysis catheters, sticking the patient as low as possible on the neck is recommended↗
▶Ep 63 · 6:00
clinicalLevering the ultrasound probe (12mm diameter) against the clavicle provides a reasonable low puncture site↗
▶Ep 63 · 6:22
opinionSticking low on the neck leaves less catheter to curve in the neck, reducing problems with catheter displacement when patients turn their heads↗
▶Ep 63 · 6:36
quoteI've seen catheter spit out of the, of the SVC. It's strange, but I've seen it a couple of times.↗
▶Ep 63 · 6:36
clinicalCatheters have been observed to spit out of the SVC with excessive laxity in the neck↗
▶Ep 63 · 6:56
clinicalFor subclavian access, puncture at least 1 finger breadth (almost 1cm) inferior and lateral to the junction of median and medial aspects of the clavicle↗
▶Ep 63 · 7:14
clinicalWhen approaching the clavicle during subclavian access, keep the needle flat and push down on skin rather than angling at 30 degrees↗
▶Ep 63 · 7:34
clinicalFor subclavian access, aim directly at the sternal notch, then angle wider toward the angle of mandible in a radial motion if unsuccessful↗
▶Ep 63 · 8:04
clinicalThe right triangle technique uses the trachea as midline and the right mainstem bronchus as hypotenuse; catheter tip in this triangle will always be at the atrial-caval junction↗
▶Ep 63 · 8:26
quoteIf you leave the tip of your catheter in that triangle, in the area of that triangle, that will always be the atrial cable junction.↗
▶Ep 63 · 8:38
opinionRoutine post-procedural X-rays are not ordered for single-stick, uncomplicated procedures using fluoroscopy↗
▶Ep 63 · 9:06
clinicalPost-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rarely chylothorax or thoracic duct injury↗
▶Ep 63 · 9:41
clinicalThe first clinical decision for line infection is determining if the patient is septic from the line↗
▶Ep 63 · 9:41
quoteYour first clinical decision point is, is the patient septic from this line?↗
▶Ep 63 · 9:46
clinicalIf the patient is septic from the line, source control requires bedside removal under light sedation↗
▶Ep 63 · 10:04
clinicalFor non-septic line-dependent patients with complex vascular access, treatment involves identifying the organism, assessing sensitivity, and performing serial blood cultures to achieve sustained culture negativity for line salvage↗
▶Ep 63 · 12:19
clinicalTranslumbar line placement through back musculature into intrahepatic IVC is considered when femoral, IJ, and subclavian options are exhausted↗
▶Ep 63 · 12:48
clinicalEmergency facial vein cutdown involves horizontal incision lateral to sternocleidomastoid at angle of mandible with the head turned↗
▶Ep 63 · 13:04
clinicalFor facial vein cutdown, beveling the catheter hard helps it follow a path when blindly passing without a wire↗
Clinical & Research Update: Pediatric Liver Tumors - A Case-Based Discussion with Drs. Katherine Somers & Alex Bondoc
▶Ep 17 · 23:04
epidemiologicalTumor board presentation and multidisciplinary conference approach is associated with improved success and long-term outcomes for pediatric liver tumor patients↗
▶Ep 17 · 24:34
clinicalMaximum tumor shrinkage typically occurs after the first block or cycle of chemotherapy; subsequent blocks produce less shrinkage↗
▶Ep 17 · 24:34
quoteThere is also some data to suggest that you get the maximal bang for your buck after the first block or cycle of C5VD in intermediate risk patients or the first block after of Cyopel 4, you typically won't get as much shrinkage or contraction of the tumor after your subsequent blocks.↗
▶Ep 17 · 25:49
quoteOne of the failings of, and you need specialized equipment to do this, that most visualization companies offer, and you can do this thoracoscopically, laparoscopically, or a lot of the companies also have open detectors. And so what I'm trying to do here is look for any residual tumor, knowing that one of ICG's kind of limitations is that it's not specific, it's highly sensitive.↗
▶Ep 17 · 26:05
clinicalICG fluorescence is highly sensitive but not specific for tumor detection; it can help find multifocal disease and assess margins↗
▶Ep 17 · 26:21
clinicalIn approximately 15% of lung resections, ICG fluorescence identifies lesions not visible on high-resolution axial imaging↗
▶Ep 17 · 52:15
guidelinePRETEXT IV multifocal disease requires liver transplantation; patients should be referred early to transplant program↗
▶Ep 17 · 59:46
guidelineIn the United States, children with hepatoblastoma automatically receive Status 1B categorization on deceased donor list, the second highest stratum for organ allocation↗
quoteReflux, G E R, reflux, right? Reflux is really common in the first year of life.↗
▶Ep 24 · 3:05
epidemiologicalPyloric stenosis occurs in about 4 to 5 in 1000 live births with heavy male preponderance.↗
▶Ep 24 · 4:00
quoteAnd is it a cause and effect relationship? Perhaps not, but we're talking adversity. This is a patient population you have to be aware of. Perhaps they're not seeking care as soon or they've been placed in the waiting room. They're not being seen as fast. Hard to say.↗
▶Ep 24 · 4:55
quoteAs you're rolling the hypertrophied muscle over the retroperitoneum or even over the spine, so they tell you to warm up your hands, have mom or dad holding them tight so that they're not upset, and then maybe sometimes you can elicit it, especially if it's particularly large.↗
▶Ep 24 · 6:01
clinicalThere is an association between Gilbert's syndrome and pyloric stenosis; some patients are incidentally diagnosed with Gilbert's when labs are checked for pyloric stenosis.↗
▶Ep 24 · 7:34
quoteYou could aggressively observe the patient. But atropin is a traditional medical management, and it's essentially fallen out of favor because how good pediatric anesthetists are and there isn't necessarily a high concordance rate between congenital anomalies that would make a patient, a baby, a high anesthetic risk.↗
▶Ep 24 · 7:34
opinionAtropine is traditional medical management for pyloric stenosis but has fallen out of favor because pediatric anesthetists are skilled and there is not high concordance between congenital anomalies that would make a baby high anesthetic risk.↗
▶Ep 24 · 8:40
clinicalThe first pyloromyotomy was done the year before Ramstedt, but Ramstedt popularized it and the spreader bears his name; he used a coffee spoon and intended to do pyloroplasty but ended up doing myotomy only because the baby became unstable.↗
▶Ep 24 · 8:40
quoteThe first pyloomyotomy was done actually the year before by someone else, but Ramstead was the one who popularized it and the spreader bears his name. He used a coffee spoon and he actually intended to do a pyloroplasty, but ended up doing myotomy only because the baby got unstable or, you know, they couldn't do it appropriately, so we only did the myotomy.↗
▶Ep 24 · 9:09
guidelineGastric suction prior to induction is essential; anesthetists suction the baby while awake in three positions (head down, turn right, turn left) to empty the atonic stomach and prevent aspiration during induction.↗
▶Ep 24 · 9:16
quoteWe didn't put an NG in, so we're paying the price for that. But what we typically will do, or what some of the old school anesthetists, and I would assume that they've taught the fellows and their junior partners is you will suction the baby while awake in 3 different positions, head down, turn to the right, turn to the left to make sure you've sucked out that big atonic bag.↗
▶Ep 24 · 9:36
quoteWhy is this step so important? Because again, you relax the baby. You have no NG. The baby vomits and aspirates. So it's very specific to paroxysmosis because of what's happened metabolically, physiologically with the stomach.↗
▶Ep 24 · 10:57
clinicalThe surgeon should know the channel length from ultrasound because a 3-millimeter Maryland grasper when fully opened is 13 millimeters; if the channel is 15-18 millimeters and only a 13-millimeter myotomy is made, it will be incomplete.↗
▶Ep 24 · 10:57
quoteThis is why you should know how long the channel is, because if it's 1518 millimeters. The 3 millimeter Maryland grass for when you open it completely is 13 millimeters. If you only make a 13 millimeter myotomy on a 15 or an 18 millimeter channel. You're going to have an incomplete myotomy.↗
▶Ep 24 · 11:23
clinicalThe technique involves scoring the serosal surface, finding entry with the bovie blade, twisting to crack the muscle, then using a serrated spreader to grip and separate the muscle; both ends should move independently when complete.↗
▶Ep 24 · 12:05
clinicalThe anesthetist can put air down a suction catheter to look for bubbles if mucosal violation is suspected; a piece of omentum is laid on top of the myotomy.↗
▶Ep 24 · 12:27
clinicalOpen pyloromyotomy can be done through a periumbilical incision with tunneling up to the right upper quadrant by stretching the baby's skin.↗
▶Ep 24 · 13:06
clinicalIncisional hernias can occur because the fascia on stab incisions in the left and right upper quadrant is typically not closed; omental hernias have been observed.↗
▶Ep 24 · 13:23
opinionComplication rates after pyloromyotomy are equivalent or better with open approach because laparoscopic pyloromyotomy is an experience and feel operation.↗
▶Ep 24 · 13:54
quoteI tell them that it is very common for babies to vomit afterwards, and it doesn't necessarily mean that the operation didn't work. Why does this happen? My theory is that the stomach is still atonic, right? It's not going to remodel itself immediately. Sometimes if you're challenging the baby, they still will vomit, and that's OK.↗
▶Ep 24 · 13:54
clinicalPost-operative vomiting is very common and does not necessarily mean the operation did not work; the stomach is still atonic and will not remodel immediately.↗
▶Ep 24 · 14:13
clinicalComplete intolerance of feeds lasting into days post-operatively raises concern for incomplete myotomy.↗
