You can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.
You can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.
You can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.
You can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.
Our method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap.
Our method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap.
quoteSo in the younger patients, they're oftentimes picked up either prenatally on ultrasound, or in younger kids, say two-year-old or three-year-old, it might be picked up as a solid abdominal mass.↗
▶Ep 1 · 0:41
clinicalWhen neuroblastoma patients have metastatic disease, they may present with either bony pain or potentially neurologic symptoms from cord compression.↗
▶Ep 1 · 0:41
clinicalIn younger patients, neuroblastoma is often picked up either prenatally on ultrasound, or in younger kids (two-year-old or three-year-old) as a solid abdominal mass.↗
▶Ep 1 · 1:07
clinicalWhen considering neuroblastoma as part of the differential diagnosis, it is important to get catecholamines (either urine or serum) as one of the most diagnostic laboratory tests for this tumor.↗
▶Ep 1 · 1:39
clinicalThe MIBG study is helpful for confirming the diagnosis of neuroblastoma and can also demonstrate metastatic disease.↗
▶Ep 1 · 1:39
clinicalMost children with suspected neuroblastoma would get a cross-sectional imaging study, either a CT scan or an MRI.↗
▶Ep 1 · 1:39
clinicalIf imaging suggests neuroblastoma (central abdominal mass or adrenal mass rather than kidney mass), the next test would be a nuclear medicine study, typically an MIBG study.↗
▶Ep 1 · 2:20
clinicalSome centers, including Cincinnati Children's Hospital, would get a PET scan looking for tumor uptake as well as potential metastatic disease.↗
▶Ep 1 · 2:20
clinicalAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 1 · 2:20
quoteAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 1 · 2:45
guidelineThere is a special category MS for children less than 18 months of age who have metastases to either the bone marrow or the skin.↗
▶Ep 1 · 2:45
guidelineIn the INRGSS system, tumors that are localized are categorized as L1; if localized but have image-defined risk factors (encasing nerves or vessels), they are L2; if they have metastatic disease, they are M.↗
▶Ep 1 · 2:45
guidelineBased on the most recent iteration of the neuroblastoma staging system (INRGSS), it is possible to assign a stage before any invasive procedure is performed.↗
▶Ep 1 · 3:36
guidelineThe prior neuroblastoma staging system required tissue diagnosis before assigning a stage.↗
▶Ep 1 · 3:36
guidelineThe INRGSS pre-biopsy staging system was specifically created to allow studies from different centers in different countries to be compared based on the pre-surgical staging of the patient.↗
▶Ep 1 · 4:06
opinionSome surgeons would approach resection of a localized neuroblastoma with laparoscopy depending on the size of the tumor.↗
▶Ep 1 · 4:06
clinicalA child with an adrenal mass on the right side and a positive MIBG scan but no evidence of metastases could potentially be treated with a primary resection of the mass via laparotomy.↗
▶Ep 1 · 4:44
clinicalFor very large masses that encase the aorta, cava, or other major vasculature, all you really want is tissue for diagnosis, which can be obtained through open biopsy, laparoscopic biopsy, or core needle biopsies done by an interventional radiologist.↗
▶Ep 1 · 5:14
clinicalThe most important biologic risk determinant to obtain from neuroblastoma biopsy tissue is the NMIC status.↗
▶Ep 1 · 5:14
clinicalIn addition to NMIC status, you want to look for 1P and 11Q deletions and Shimada histology in neuroblastoma biopsy tissue.↗
▶Ep 1 · 5:45
epidemiologicalNeuroblastoma risk is divided about 50-50 between the low risk categories and the high risk category, with a smaller percentage being intermediate risk.↗
▶Ep 1 · 5:45
clinicalBiologic risk determinants from biopsy will tell you what risk category the patient falls into: very low risk, low risk, intermediate risk, or high risk.↗
▶Ep 1 · 6:11
clinicalNMIC amplification and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 1 · 6:11
clinicalPatients with high risk neuroblastoma receive aggressive chemotherapy including peripheral stem cell transplant times 2, aggressive surgery with the goal of greater than 90% resection of the tumor, followed by radiation, immunotherapy after chemotherapy, and potentially retinoic acid therapy.↗
▶Ep 1 · 6:11
quoteNMIC and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 1 · 6:51
clinicalFor intermediate risk neuroblastoma, the goal at the time of debulking or resecting the primary tumor is to achieve at least a 50% response from the initial volume of the primary tumor through the combination of neoadjuvant chemotherapy and surgical resection.↗
▶Ep 1 · 6:51
clinicalIntermediate risk neuroblastoma tumors get varying cycles of chemotherapy based on the biologic risk factors they have.↗
▶Ep 1 · 7:22
clinicalThe low risk neuroblastoma group, depending on the actual age of the patient and how it is diagnosed, could potentially be followed simply with observation.↗
▶Ep 1 · 7:22
clinicalJed Nocturne led a study through the Children's Oncology Group looking at patients less than six months of age with either a prenatally diagnosed or shortly postnatally diagnosed localized mass, showing these patients can be observed with the expectation that the vast majority will avoid any type of surgical procedure.↗
▶Ep 1 · 7:55
clinicalMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow (specifically not bone, not cortical bone) and is less than 18 months of age.↗
▶Ep 1 · 7:55
clinicalIf the tumor and metastatic disease are responding to neoadjuvant chemotherapy, one would attack the primary tumor site with a resection, with many advocating for attempting a greater than 90% resection.↗
▶Ep 1 · 7:55
clinicalPatients with metastatic neuroblastoma typically receive four or five cycles of neoadjuvant chemotherapy and then are reassessed.↗
▶Ep 1 · 7:55
quoteMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow, specifically not bone, not cortical bone, and is less than 18 months of age.↗
▶Ep 1 · 7:55
clinicalIn patients with MS disease, simple observation can be the treatment path.↗
▶Ep 1 · 7:55
clinicalIf the metastatic disease is progressing on neoadjuvant chemotherapy, then surgery is not indicated.↗
▶Ep 1 · 7:55
clinicalIf MS disease patients progress or develop respiratory issues because of an enlarging liver mass, treatment might be elected because of the complication of the size of the tumor, but the tumor itself usually does not have to be treated.↗
▶Ep 1 · 8:55
clinicalYou can biopsy the skin lesions in MS disease and that will give you the diagnosis.↗
Neuroblastoma
▶Ep 2 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 2 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 2 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 2 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 2 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 2 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 2 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 2 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 2 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 2 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 2 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 2 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 2 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 2 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 2 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 2 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 2 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 2 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 2 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
▶Ep 2 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
▶Ep 2 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
▶Ep 2 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula
▶Ep 2 · 9:58
clinicalIf a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse.↗
▶Ep 2 · 9:58
clinicalIf a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse.↗
▶Ep 2 · 14:02
clinicalRoutine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues.↗
▶Ep 2 · 14:02
clinicalRoutine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues.↗
▶Ep 2 · 19:37
clinicalDual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings.↗
▶Ep 2 · 19:37
clinicalDual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings.↗
quoteThe tissue damage extends beyond what you can appreciate with the naked eye, and the progression of it probably extends beyond what you would think is the normal time frame.↗
▶Ep 2 · 56:27
quoteThe tissue damage extends beyond what you can appreciate with the naked eye, and the progression of it probably extends beyond what you would think is the normal time frame.↗
▶Ep 2 · 1:52:36
clinicalIn a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured.↗
▶Ep 2 · 1:52:36
clinicalIn a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 2 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 2 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 2 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 2 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 2 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 2 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 2 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 2 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 2 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 2 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 2 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 2 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 2 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 4 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 4 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 4 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 4 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 4 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 4 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 4 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 4 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 4 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 4 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 4 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 4 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 6 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 6 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 6 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 6 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 6 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 6 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 6 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 6 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 6 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 6 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 6 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 6 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 6 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 10 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 10 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 10 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 10 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 10 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 10 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 10 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 10 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 10 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 10 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 10 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 10 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 10 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 74 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 74 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 74 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 74 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 74 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 74 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 74 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 74 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 74 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 74 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 74 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 74 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 74 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 74 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 74 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 74 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 74 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 74 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
▶Ep 74 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
▶Ep 74 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
▶Ep 74 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 76 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 76 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 76 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 76 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 76 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 76 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 76 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 76 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 76 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 76 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 76 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 76 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 76 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
clinicalBaseline chest X-ray may be useful if patient later presents with respiratory symptoms and consolidation, providing comparison↗
▶Ep 22 · 6:34
clinicalBaseline chest X-ray may be useful if patient later presents with respiratory symptoms and consolidation, providing comparison↗
▶Ep 22 · 25:54
clinicalIf crura come together easily during paraesophageal hernia repair, primary closure without mesh is preferred↗
▶Ep 22 · 25:54
clinicalIf crura come together easily during paraesophageal hernia repair, primary closure without mesh is preferred↗
▶Ep 22 · 29:25
clinicalPosterior defect is the usual problem site in paraesophageal hernia; mesh should cover the posterior repair↗
▶Ep 22 · 29:25
clinicalPosterior defect is the usual problem site in paraesophageal hernia; mesh should cover the posterior repair↗
▶Ep 22 · 33:35
clinicalWaiting only 3-4 weeks for revision risks operating during maximal inflammation period↗
▶Ep 22 · 33:35
clinicalWaiting only 3-4 weeks for revision risks operating during maximal inflammation period↗
▶Ep 22 · 44:09
opinionFundoplication attempts mechanical fix for physiologic problem, making it inherently difficult operation↗
▶Ep 22 · 44:09
quoteI hate this operation, whether it's open or laparoscopic, because you're trying to do a mechanical fix to a physiologic problem, and it's uh miserable.↗
▶Ep 22 · 44:09
quoteI hate this operation, whether it's open or laparoscopic, because you're trying to do a mechanical fix to a physiologic problem, and it's uh miserable.↗
▶Ep 22 · 44:09
opinionFundoplication attempts mechanical fix for physiologic problem, making it inherently difficult operation↗
▶Ep 22 · 45:22
clinicalGastric disconnect is excellent operation in cognitively impaired patients who don't eat much and have refractory reflux or multiple failed fundoplications↗
▶Ep 22 · 45:22
clinicalGastric disconnect is excellent operation in cognitively impaired patients who don't eat much and have refractory reflux or multiple failed fundoplications↗
▶Ep 22 · 49:43
clinicalDextrocardia makes thoracoscopic visualization challenging for EA/TEF repair↗
▶Ep 22 · 49:43
clinicalDextrocardia makes thoracoscopic visualization challenging for EA/TEF repair↗
▶Ep 22 · 49:56
clinicalFor unstable EA/TEF patient, laparotomy with G-tube and vessel loop around GE junction allows fistula control and ventilation, deferring thoracic repair until patient stabilizes↗
▶Ep 22 · 49:56
clinicalFor unstable EA/TEF patient, laparotomy with G-tube and vessel loop around GE junction allows fistula control and ventilation, deferring thoracic repair until patient stabilizes↗
▶Ep 22 · 54:34
clinicalBronchoscopy should be performed in all EA/TEF cases to identify additional fistulas↗
▶Ep 22 · 54:34
clinicalBronchoscopy should be performed in all EA/TEF cases to identify additional fistulas↗
▶Ep 22 · 58:19
clinicalTracheal reconstruction for esophageal lung can be performed via median sternotomy: divide trachea, repair esophagus posteriorly, reconstruct trachea and fish-mouth abnormal bronchus to create lung connection↗
▶Ep 22 · 58:19
clinicalTracheal reconstruction for esophageal lung can be performed via median sternotomy: divide trachea, repair esophagus posteriorly, reconstruct trachea and fish-mouth abnormal bronchus to create lung connection↗
▶Ep 22 · 59:03
clinicalIf initial TEF ligation is performed too far from trachea (2cm), significant esophageal length is lost, potentially preventing primary anastomosis↗
▶Ep 22 · 59:03
clinicalIf initial TEF ligation is performed too far from trachea (2cm), significant esophageal length is lost, potentially preventing primary anastomosis↗
▶Ep 22 · 59:24
clinicalMagnet anastomosis can be attempted when esophageal ends are tacked together but gap prevents primary anastomosis↗
▶Ep 22 · 59:24
clinicalMagnet anastomosis can be attempted when esophageal ends are tacked together but gap prevents primary anastomosis↗
clinicalBaseline chest X-ray may be useful if patient later presents with respiratory symptoms and consolidation, providing comparison↗
▶Ep 17 · 25:54
clinicalIf crura come together easily during paraesophageal hernia repair, primary closure without mesh is preferred↗
▶Ep 17 · 29:25
clinicalPosterior defect is the usual problem site in paraesophageal hernia; mesh should cover the posterior repair↗
▶Ep 17 · 33:35
clinicalWaiting only 3-4 weeks for revision risks operating during maximal inflammation period↗
▶Ep 17 · 44:09
opinionFundoplication attempts mechanical fix for physiologic problem, making it inherently difficult operation↗
▶Ep 17 · 44:09
quoteI hate this operation, whether it's open or laparoscopic, because you're trying to do a mechanical fix to a physiologic problem, and it's uh miserable.↗
▶Ep 17 · 45:22
clinicalGastric disconnect is excellent operation in cognitively impaired patients who don't eat much and have refractory reflux or multiple failed fundoplications↗
▶Ep 17 · 49:43
clinicalDextrocardia makes thoracoscopic visualization challenging for EA/TEF repair↗
▶Ep 17 · 49:56
clinicalFor unstable EA/TEF patient, laparotomy with G-tube and vessel loop around GE junction allows fistula control and ventilation, deferring thoracic repair until patient stabilizes↗
▶Ep 17 · 54:34
clinicalBronchoscopy should be performed in all EA/TEF cases to identify additional fistulas↗
▶Ep 17 · 58:19
clinicalTracheal reconstruction for esophageal lung can be performed via median sternotomy: divide trachea, repair esophagus posteriorly, reconstruct trachea and fish-mouth abnormal bronchus to create lung connection↗
▶Ep 17 · 59:03
clinicalIf initial TEF ligation is performed too far from trachea (2cm), significant esophageal length is lost, potentially preventing primary anastomosis↗
▶Ep 17 · 59:24
clinicalMagnet anastomosis can be attempted when esophageal ends are tacked together but gap prevents primary anastomosis↗
Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula
▶Ep 1 · 9:58
clinicalIf a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse.↗
▶Ep 1 · 14:02
clinicalRoutine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues.↗
▶Ep 1 · 19:37
clinicalDual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings.↗
quoteThe tissue damage extends beyond what you can appreciate with the naked eye, and the progression of it probably extends beyond what you would think is the normal time frame.↗
▶Ep 1 · 1:52:36
clinicalIn a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured.↗
Complications and Beyond
▶Ep 2 · 6:34
clinicalBaseline chest X-ray may be useful if patient later presents with respiratory symptoms and consolidation, providing comparison↗
▶Ep 2 · 25:54
clinicalIf crura come together easily during paraesophageal hernia repair, primary closure without mesh is preferred↗
▶Ep 2 · 29:25
clinicalPosterior defect is the usual problem site in paraesophageal hernia; mesh should cover the posterior repair↗
▶Ep 2 · 33:35
clinicalWaiting only 3-4 weeks for revision risks operating during maximal inflammation period↗
▶Ep 2 · 44:09
quoteI hate this operation, whether it's open or laparoscopic, because you're trying to do a mechanical fix to a physiologic problem, and it's uh miserable.↗
▶Ep 2 · 44:09
opinionFundoplication attempts mechanical fix for physiologic problem, making it inherently difficult operation↗
▶Ep 2 · 45:22
clinicalGastric disconnect is excellent operation in cognitively impaired patients who don't eat much and have refractory reflux or multiple failed fundoplications↗
▶Ep 2 · 49:43
clinicalDextrocardia makes thoracoscopic visualization challenging for EA/TEF repair↗
▶Ep 2 · 49:56
clinicalFor unstable EA/TEF patient, laparotomy with G-tube and vessel loop around GE junction allows fistula control and ventilation, deferring thoracic repair until patient stabilizes↗
▶Ep 2 · 54:34
clinicalBronchoscopy should be performed in all EA/TEF cases to identify additional fistulas↗
▶Ep 2 · 58:19
clinicalTracheal reconstruction for esophageal lung can be performed via median sternotomy: divide trachea, repair esophagus posteriorly, reconstruct trachea and fish-mouth abnormal bronchus to create lung connection↗
▶Ep 2 · 59:03
clinicalIf initial TEF ligation is performed too far from trachea (2cm), significant esophageal length is lost, potentially preventing primary anastomosis↗
▶Ep 2 · 59:24
clinicalMagnet anastomosis can be attempted when esophageal ends are tacked together but gap prevents primary anastomosis↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 26 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 26 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 26 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 26 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 26 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 26 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 26 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 26 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 26 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 26 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 26 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 26 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 26 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
▶Ep 18 · 0:46
quoteOur method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap.↗
▶Ep 18 · 0:46
clinicalAt Cincinnati Children's, if a child has no gas in the abdomen, they place a G-tube and may put something up the distal esophagus for a fluoro shot, then wait a couple of weeks for a protocol gap measurement in interventional radiology.↗
▶Ep 18 · 0:46
clinicalAt Cincinnati Children's, if a child has no gas in the abdomen, they place a G-tube and may put something up the distal esophagus for a fluoro shot, then wait a couple of weeks for a protocol gap measurement in interventional radiology.↗
▶Ep 18 · 0:46
quoteOur method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap.↗
▶Ep 18 · 2:10
quoteThe physiology, which I believe in intensely, is that stretch is a very strong promoter of growth. And then if you put things on tension, they will actually grow over time. That's how the cardiovascular system develops in utero.↗
▶Ep 18 · 2:10
clinicalThe philosophy of traction-based elongation is that with traction, you can get the two ends of the esophagus to grow, and if you can get them to grow far enough, you can put them together.↗
▶Ep 18 · 2:10
clinicalStretch is a very strong promoter of growth, and if you put things on tension they will actually grow over time, which is how the cardiovascular system develops in utero.↗
▶Ep 18 · 2:10
quoteBut the philosophy here is that with traction, you can get the two ends of the esophagus to grow. And if you can get them to grow far enough, you can put them together.↗
▶Ep 18 · 2:10
clinicalThe philosophy of traction-based elongation is that with traction, you can get the two ends of the esophagus to grow, and if you can get them to grow far enough, you can put them together.↗
▶Ep 18 · 2:10
clinicalStretch is a very strong promoter of growth, and if you put things on tension they will actually grow over time, which is how the cardiovascular system develops in utero.↗
▶Ep 18 · 2:10
quoteBut the philosophy here is that with traction, you can get the two ends of the esophagus to grow. And if you can get them to grow far enough, you can put them together.↗
▶Ep 18 · 2:10
quoteThe physiology, which I believe in intensely, is that stretch is a very strong promoter of growth. And then if you put things on tension, they will actually grow over time. That's how the cardiovascular system develops in utero.↗
▶Ep 18 · 3:15
host_summaryIn the Boston Group 2015 study, the primary group (de novo cases) achieved an intact esophagus in 96% of patients, while the secondary group (patients with previous operations) achieved this in about two thirds of patients.↗
▶Ep 18 · 3:15
quoteBut these procedures are not without some morbidity. And you look at the ICU stay is a median of 70 days with a couple of weeks being paralyzed for the primary group and 110 days for the secondary group with a month of being paralyzed.↗
▶Ep 18 · 3:15
quoteThere was a great article published by the Boston Group 2015. Divides the cases into two groups, a primary group and a secondary group. Secondary being patients who had had operations previously in the primary group, being cases that they saw de novo.↗
▶Ep 18 · 3:15
host_summaryIn the Boston Group 2015 study, about two thirds of patients with primary repair were able to get full oral nutrition and about 10% of patients who had secondary repair achieved full oral nutrition.↗
▶Ep 18 · 3:15
host_summaryIn the Boston Group 2015 study, the primary group had a median ICU stay of 70 days with a couple of weeks being paralyzed, and the secondary group had a median ICU stay of 110 days with a month of being paralyzed.↗
▶Ep 18 · 3:15
quoteAbout two thirds of patients with the primary repair were able to get the full oral nutrition and about 10% of the patients who had the secondary repair.↗
▶Ep 18 · 3:15
quoteObviously, you look at the result of getting the esophagus together and intact esophagus in 96% of patients in the primary group, about two thirds of patients in the secondary group.↗
▶Ep 18 · 3:15
quoteObviously, you look at the result of getting the esophagus together and intact esophagus in 96% of patients in the primary group, about two thirds of patients in the secondary group.↗
▶Ep 18 · 3:15
quoteThere was a great article published by the Boston Group 2015. Divides the cases into two groups, a primary group and a secondary group. Secondary being patients who had had operations previously in the primary group, being cases that they saw de novo.↗
▶Ep 18 · 3:15
epidemiologicalIn the Boston Group 2015 study, about two thirds of patients with primary repair were able to get full oral nutrition and about 10% of patients who had secondary repair achieved full oral nutrition.↗
▶Ep 18 · 3:15
epidemiologicalIn the Boston Group 2015 study, the primary group had a median ICU stay of 70 days with a couple of weeks being paralyzed, and the secondary group had a median ICU stay of 110 days with a month of being paralyzed.↗
▶Ep 18 · 3:15
epidemiologicalIn the Boston Group 2015 study, the primary group (de novo cases) achieved an intact esophagus in 96% of patients, while the secondary group (patients with previous operations) achieved this in about two thirds of patients.↗
▶Ep 18 · 3:15
quoteBut these procedures are not without some morbidity. And you look at the ICU stay is a median of 70 days with a couple of weeks being paralyzed for the primary group and 110 days for the secondary group with a month of being paralyzed.↗
▶Ep 18 · 3:15
quoteAbout two thirds of patients with the primary repair were able to get the full oral nutrition and about 10% of the patients who had the secondary repair.↗
▶Ep 18 · 4:36
clinicalThe colon can be used as an interposition for esophageal replacement.↗
▶Ep 18 · 4:36
quoteYou could use the stomach. That would be called a gastric transposition. The surgical group from the INOEA, their recommendation, the recommendation for the first option is a gastric pull up.↗
▶Ep 18 · 4:36
guidelineThe surgical group from INOEA recommends gastric pull up as the first option for esophageal replacement, dividing the esophageal stump at the esophageal hiatus and mobilizing the fundus to pull it up in either the anterior or posterior mediastinum.↗
▶Ep 18 · 4:36
quoteYou can actually use the colon as an interposition as well. I personally was trained to do colon interpositions.↗
▶Ep 18 · 4:36
quoteYou divide the esophageal stump at the esophageal hiatus and mobilize the fundus and pull the fundus up and you can pull it up either in the anterior or posterior mediastinum.↗
▶Ep 18 · 4:36
host_summaryThe surgical group from INOEA recommends gastric pull up as the first option for esophageal replacement, dividing the esophageal stump at the esophageal hiatus and mobilizing the fundus to pull it up in either the anterior or posterior mediastinum.↗
▶Ep 18 · 4:36
quoteYou can actually use the colon as an interposition as well. I personally was trained to do colon interpositions.↗
▶Ep 18 · 4:36
quoteYou divide the esophageal stump at the esophageal hiatus and mobilize the fundus and pull the fundus up and you can pull it up either in the anterior or posterior mediastinum.↗
▶Ep 18 · 4:36
quoteYou could use the stomach. That would be called a gastric transposition. The surgical group from the INOEA, their recommendation, the recommendation for the first option is a gastric pull up.↗
▶Ep 18 · 4:36
clinicalThe colon can be used as an interposition for esophageal replacement.↗
▶Ep 18 · 8:00
quoteCommon problems with this are that they dilate and they can become tortuous. It's not uncommon to get kind of a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 18 · 8:00
clinicalCommon problems with colonic interposition are that the colon can dilate and become tortuous, and it's not uncommon to get a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 18 · 8:00
clinicalCommon problems with colonic interposition are that the colon can dilate and become tortuous, and it's not uncommon to get a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 18 · 8:00
quoteCommon problems with this are that they dilate and they can become tortuous. It's not uncommon to get kind of a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 18 · 8:17
opinionVon Allman was initially taught that sigmoid redundancy in colonic interposition can't be fixed and that it's too dangerous because it will risk the blood supply, but he found that this is not really true.↗
▶Ep 18 · 8:17
clinicalVon Allman passes the colonic interposition posterior to the stomach, which leaves the vascular pedicle along the spine, allowing mobilization of the colon by dividing the gastric duodenotomy and colon attachment to the stomach, then mobilizing the sigmoid redundancy transhiatally and reanastomosing the colon to the stomach.↗
▶Ep 18 · 8:17
quoteI was taught initially that you can't fix that and that it's too dangerous and that you'll risk the blood supply to the colon interposition. But I found that actually that's not really true.↗
▶Ep 18 · 8:17
quoteI pass the interposition posterior to the stomach, which leaves the vascular pedicle along the spine. And you can mobilize the colon. You can divide the gastric dual aporotomy, divide the colon attachment to the stomach, and then mobilize that sigmoid redundancy transhiatally, and then reinestimose the colon to the stomach.↗
▶Ep 18 · 8:17
quoteSo I wouldn't pretend to say that these don't need to be revised sometimes, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 18 · 8:17
opinionColonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 18 · 8:17
clinicalVon Allman passes the colonic interposition posterior to the stomach, which leaves the vascular pedicle along the spine, allowing mobilization of the colon by dividing the gastric duodenotomy and colon attachment to the stomach, then mobilizing the sigmoid redundancy transhiatally and reanastomosing the colon to the stomach.↗
▶Ep 18 · 8:17
opinionColonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 18 · 8:17
quoteI was taught initially that you can't fix that and that it's too dangerous and that you'll risk the blood supply to the colon interposition. But I found that actually that's not really true.↗
▶Ep 18 · 8:17
opinionVon Allman was initially taught that sigmoid redundancy in colonic interposition can't be fixed and that it's too dangerous because it will risk the blood supply, but he found that this is not really true.↗
▶Ep 18 · 8:17
quoteSo I wouldn't pretend to say that these don't need to be revised sometimes, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 18 · 8:17
quoteI pass the interposition posterior to the stomach, which leaves the vascular pedicle along the spine. And you can mobilize the colon. You can divide the gastric dual aporotomy, divide the colon attachment to the stomach, and then mobilize that sigmoid redundancy transhiatally, and then reinestimose the colon to the stomach.↗
▶Ep 18 · 9:03
clinicalYou can get extraordinary length with colonic interposition, allowing treatment of cases with caustic injuries extending to the pharynx by sewing the colon to the pharynx and down to the stomach, which is tough to do with a gastric pull-up.↗
▶Ep 18 · 9:03
quoteYou can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.↗
▶Ep 18 · 9:03
quoteYou can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.↗
▶Ep 18 · 9:03
clinicalYou can get extraordinary length with colonic interposition, allowing treatment of cases with caustic injuries extending to the pharynx by sewing the colon to the pharynx and down to the stomach, which is tough to do with a gastric pull-up.↗
▶Ep 18 · 9:56
opinionVon Allman states we don't know whether esophageal elongation is growth or stretch and should do studies to understand that, but notes that tension is a very good physiologic growth promoter in other organs, making this an area ripe for more basic science.↗
▶Ep 18 · 9:56
quoteAnd yet there's very good physiologic data that tension is a growth promoter, not necessarily in the esophagus, but in other organs. So I think that it's an area ripe for a little more basic science.↗
▶Ep 18 · 9:56
quoteI don't think we know we should do the studies to understand that. But I would say that this gets back to David van der Zee's comment about, go have a cup of coffee and come back and it'll be fine. Clearly, that's not growth, that's stretch.↗
▶Ep 18 · 9:56
opinionVon Allman states we don't know whether esophageal elongation is growth or stretch and should do studies to understand that, but notes that tension is a very good physiologic growth promoter in other organs, making this an area ripe for more basic science.↗
▶Ep 18 · 9:56
quoteAnd yet there's very good physiologic data that tension is a growth promoter, not necessarily in the esophagus, but in other organs. So I think that it's an area ripe for a little more basic science.↗
▶Ep 18 · 9:56
quoteI don't think we know we should do the studies to understand that. But I would say that this gets back to David van der Zee's comment about, go have a cup of coffee and come back and it'll be fine. Clearly, that's not growth, that's stretch.↗
quoteI think that the, the main controversy, at least from my perspective, that still persists is what to do with the high-risk patients.↗
▶Ep 2 · 0:42
epidemiologicalSurvival rate for high-risk neuroblastoma patients is in the 38 to 40% range↗
▶Ep 2 · 6:31
quoteThe difference between what a surgeon says they did in the operating room and and what the postoperative imaging says they did in the operating room, and those are not necessarily the same.↗
▶Ep 2 · 6:52
clinicalSurgeon-reported degree of resection showed only 66% concordance with radiologist assessment of postoperative imaging in tandem transplant pilot study↗
▶Ep 2 · 7:33
clinicalRepeat study in recent COG high-risk trial showed same 66% concordance rate between surgeon op notes and postoperative imaging, with surgeons underestimating and radiologists overcalling resection completeness↗
▶Ep 2 · 8:16
quoteWe don't have a very good definition of what is a greater than 90% resection.↗
▶Ep 2 · 10:00
host_summaryMemorial Sloan Kettering data suggests biggest volume response of neuroblastoma tumor occurs with first two cycles of chemotherapy, with very little response after that↗
▶Ep 2 · 10:17
quoteThe more chemotherapy you give or other agents, and now things like MIBG, which is local radiation, um. Uh, that you actually make the tumor more fibrotic, and it makes that technique of getting down on the vessels and splitting it off much more difficult.↗
▶Ep 2 · 10:17
opinionMore chemotherapy or other agents like MIBG may make tumor more fibrotic and make subadventitial dissection more difficult↗
▶Ep 2 · 13:07
epidemiologicalComplication rate for aggressive neuroblastoma resection is approximately 30% morbidity with mortality less than 1%↗
▶Ep 2 · 15:10
clinicalHigh-risk neuroblastoma treatment includes tandem peripheral blood stem cell transplants, with second transplant given as soon as patient recovers from first, followed by immunotherapy and Retin-A↗
▶Ep 2 · 16:48
host_summaryGerman study of 278 stage 4 high-risk neuroblastoma patients achieved complete resection in almost half and >90% resection in another quarter (75% total with >90% resection)↗
▶Ep 2 · 17:13
host_summaryGerman study showed overall survival 45%, event-free survival 33%, and local progression-free survival 58% in stage 4 neuroblastoma↗
▶Ep 2 · 17:32
host_summaryGerman study showed no difference in overall survival, event-free survival, or local progression-free survival based on completeness of resection in stage 4 neuroblastoma↗
▶Ep 2 · 17:51
host_summaryGerman study concluded aggressive surgery is not justified in stage 4 neuroblastoma, that limited operations decrease complications, and there is limited impact on patient outcome↗
▶Ep 2 · 18:14
host_summaryEuropean study included 1,324 high-risk neuroblastoma patients (stages 2, 3, and 4) and achieved 76% with >95% resection↗
▶Ep 2 · 19:02
host_summaryEuropean neuroblastoma study showed 0.5% mortality and 10% morbidity (30% including lesser complications)↗
▶Ep 2 · 19:17
host_summaryEuropean study showed significant improvement in event-free survival and overall survival with aggressive resection in high-risk neuroblastoma - first study to show overall survival benefit↗
▶Ep 2 · 19:37
quoteThis is very important to support the aggressive approach that everybody in this room has suggested that they would, uh, that they would pursue. There actually now is some data to support that.↗
▶Ep 2 · 20:17
host_summaryEuropean study concluded >95% resection results in improvement in event-free survival in high-risk neuroblastoma↗
▶Ep 2 · 21:24
host_summaryCOG 3973 study of approximately 230 high-risk neuroblastoma patients showed significant improvement in local relapse-free survival and event-free survival but not overall survival↗
▶Ep 2 · 21:56
opinionCOG 3973 study's inability to demonstrate overall survival benefit may be type 2 error due to smaller sample size (230 vs 1,300 patients in European study)↗
▶Ep 2 · 23:30
quoteIf you're not comfortable taking care of them, you should send them to somebody that is.↗
▶Ep 2 · 23:33
host_summaryEuropean neuroblastoma procedures are performed in more than 200 hospitals yet still demonstrated survival improvements↗
▶Ep 2 · 24:03
host_summaryOlder data shows worse survival in neuroblastoma when kidney is removed, likely because single kidney limits chemotherapy dosing↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 3 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 3 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 3 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 3 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 3 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 3 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 3 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 3 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 3 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 3 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 3 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 3 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 3 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 7 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 7 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 7 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 7 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 7 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 7 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 7 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 7 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 7 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 7 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 7 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 7 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 7 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 14 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 14 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 14 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 14 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 14 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 14 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 14 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 14 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 14 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 14 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 14 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 14 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 14 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 35 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 35 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 35 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 35 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 35 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 35 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 35 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 35 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 35 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 35 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 35 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 35 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 35 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 2:48
host_summaryThe START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 4 · 3:32
host_summaryThe primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 4 · 4:01
host_summaryHigh-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 4 · 4:39
host_summarySurvival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 4 · 4:55
host_summaryAdverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 4 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 4 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 4 · 7:11
quoteThe authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 4 · 7:11
host_summaryThe authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 4 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 4 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 4 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 4 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
▶Ep 2 · 0:46
quoteOur method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap.↗
▶Ep 2 · 0:46
clinicalAt Cincinnati Children's, if a child has no gas in the abdomen, they place a G-tube and may put something up the distal esophagus for a fluoro shot, then wait a couple of weeks for a protocol gap measurement in interventional radiology.↗
▶Ep 2 · 2:10
clinicalThe philosophy of traction-based elongation is that with traction, you can get the two ends of the esophagus to grow, and if you can get them to grow far enough, you can put them together.↗
▶Ep 2 · 2:10
clinicalStretch is a very strong promoter of growth, and if you put things on tension they will actually grow over time, which is how the cardiovascular system develops in utero.↗
▶Ep 2 · 2:10
quoteBut the philosophy here is that with traction, you can get the two ends of the esophagus to grow. And if you can get them to grow far enough, you can put them together.↗
▶Ep 2 · 2:10
quoteThe physiology, which I believe in intensely, is that stretch is a very strong promoter of growth. And then if you put things on tension, they will actually grow over time. That's how the cardiovascular system develops in utero.↗
▶Ep 2 · 3:15
host_summaryIn the Boston Group 2015 study, about two thirds of patients with primary repair were able to get full oral nutrition and about 10% of patients who had secondary repair achieved full oral nutrition.↗
▶Ep 2 · 3:15
quoteObviously, you look at the result of getting the esophagus together and intact esophagus in 96% of patients in the primary group, about two thirds of patients in the secondary group.↗
▶Ep 2 · 3:15
quoteThere was a great article published by the Boston Group 2015. Divides the cases into two groups, a primary group and a secondary group. Secondary being patients who had had operations previously in the primary group, being cases that they saw de novo.↗
▶Ep 2 · 3:15
host_summaryIn the Boston Group 2015 study, the primary group had a median ICU stay of 70 days with a couple of weeks being paralyzed, and the secondary group had a median ICU stay of 110 days with a month of being paralyzed.↗
▶Ep 2 · 3:15
host_summaryIn the Boston Group 2015 study, the primary group (de novo cases) achieved an intact esophagus in 96% of patients, while the secondary group (patients with previous operations) achieved this in about two thirds of patients.↗
▶Ep 2 · 3:15
quoteBut these procedures are not without some morbidity. And you look at the ICU stay is a median of 70 days with a couple of weeks being paralyzed for the primary group and 110 days for the secondary group with a month of being paralyzed.↗
▶Ep 2 · 3:15
quoteAbout two thirds of patients with the primary repair were able to get the full oral nutrition and about 10% of the patients who had the secondary repair.↗
▶Ep 2 · 4:36
host_summaryThe surgical group from INOEA recommends gastric pull up as the first option for esophageal replacement, dividing the esophageal stump at the esophageal hiatus and mobilizing the fundus to pull it up in either the anterior or posterior mediastinum.↗
▶Ep 2 · 4:36
quoteYou divide the esophageal stump at the esophageal hiatus and mobilize the fundus and pull the fundus up and you can pull it up either in the anterior or posterior mediastinum.↗
▶Ep 2 · 4:36
quoteYou could use the stomach. That would be called a gastric transposition. The surgical group from the INOEA, their recommendation, the recommendation for the first option is a gastric pull up.↗
▶Ep 2 · 4:36
clinicalThe colon can be used as an interposition for esophageal replacement.↗
▶Ep 2 · 4:36
quoteYou can actually use the colon as an interposition as well. I personally was trained to do colon interpositions.↗
▶Ep 2 · 8:00
clinicalCommon problems with colonic interposition are that the colon can dilate and become tortuous, and it's not uncommon to get a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 2 · 8:00
quoteCommon problems with this are that they dilate and they can become tortuous. It's not uncommon to get kind of a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 2 · 8:17
quoteI was taught initially that you can't fix that and that it's too dangerous and that you'll risk the blood supply to the colon interposition. But I found that actually that's not really true.↗
▶Ep 2 · 8:17
quoteSo I wouldn't pretend to say that these don't need to be revised sometimes, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 2 · 8:17
quoteI pass the interposition posterior to the stomach, which leaves the vascular pedicle along the spine. And you can mobilize the colon. You can divide the gastric dual aporotomy, divide the colon attachment to the stomach, and then mobilize that sigmoid redundancy transhiatally, and then reinestimose the colon to the stomach.↗
▶Ep 2 · 8:17
opinionVon Allman was initially taught that sigmoid redundancy in colonic interposition can't be fixed and that it's too dangerous because it will risk the blood supply, but he found that this is not really true.↗
▶Ep 2 · 8:17
clinicalVon Allman passes the colonic interposition posterior to the stomach, which leaves the vascular pedicle along the spine, allowing mobilization of the colon by dividing the gastric duodenotomy and colon attachment to the stomach, then mobilizing the sigmoid redundancy transhiatally and reanastomosing the colon to the stomach.↗
▶Ep 2 · 8:17
opinionColonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 2 · 9:03
clinicalYou can get extraordinary length with colonic interposition, allowing treatment of cases with caustic injuries extending to the pharynx by sewing the colon to the pharynx and down to the stomach, which is tough to do with a gastric pull-up.↗
▶Ep 2 · 9:03
quoteYou can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.↗
▶Ep 2 · 9:56
quoteI don't think we know we should do the studies to understand that. But I would say that this gets back to David van der Zee's comment about, go have a cup of coffee and come back and it'll be fine. Clearly, that's not growth, that's stretch.↗
▶Ep 2 · 9:56
opinionVon Allman states we don't know whether esophageal elongation is growth or stretch and should do studies to understand that, but notes that tension is a very good physiologic growth promoter in other organs, making this an area ripe for more basic science.↗
▶Ep 2 · 9:56
quoteAnd yet there's very good physiologic data that tension is a growth promoter, not necessarily in the esophagus, but in other organs. So I think that it's an area ripe for a little more basic science.↗
quoteSo in the younger patients, they're oftentimes picked up either prenatally on ultrasound, or in younger kids, say two-year-old or three-year-old, it might be picked up as a solid abdominal mass.↗
▶Ep 1 · 0:41
clinicalIn younger patients, neuroblastoma is often picked up either prenatally on ultrasound, or in younger kids (two-year-old or three-year-old) as a solid abdominal mass.↗
▶Ep 1 · 0:41
clinicalWhen neuroblastoma patients have metastatic disease, they may present with either bony pain or potentially neurologic symptoms from cord compression.↗
▶Ep 1 · 1:07
clinicalWhen considering neuroblastoma as part of the differential diagnosis, it is important to get catecholamines (either urine or serum) as one of the most diagnostic laboratory tests for this tumor.↗
▶Ep 1 · 1:39
clinicalThe MIBG study is helpful for confirming the diagnosis of neuroblastoma and can also demonstrate metastatic disease.↗
▶Ep 1 · 1:39
clinicalIf imaging suggests neuroblastoma (central abdominal mass or adrenal mass rather than kidney mass), the next test would be a nuclear medicine study, typically an MIBG study.↗
▶Ep 1 · 1:39
clinicalMost children with suspected neuroblastoma would get a cross-sectional imaging study, either a CT scan or an MRI.↗
▶Ep 1 · 2:20
quoteAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 1 · 2:20
clinicalAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 1 · 2:20
clinicalSome centers, including Cincinnati Children's Hospital, would get a PET scan looking for tumor uptake as well as potential metastatic disease.↗
▶Ep 1 · 2:45
guidelineThere is a special category MS for children less than 18 months of age who have metastases to either the bone marrow or the skin.↗
▶Ep 1 · 2:45
guidelineIn the INRGSS system, tumors that are localized are categorized as L1; if localized but have image-defined risk factors (encasing nerves or vessels), they are L2; if they have metastatic disease, they are M.↗
▶Ep 1 · 2:45
guidelineBased on the most recent iteration of the neuroblastoma staging system (INRGSS), it is possible to assign a stage before any invasive procedure is performed.↗
▶Ep 1 · 3:36
guidelineThe INRGSS pre-biopsy staging system was specifically created to allow studies from different centers in different countries to be compared based on the pre-surgical staging of the patient.↗
▶Ep 1 · 3:36
guidelineThe prior neuroblastoma staging system required tissue diagnosis before assigning a stage.↗
▶Ep 1 · 4:06
opinionSome surgeons would approach resection of a localized neuroblastoma with laparoscopy depending on the size of the tumor.↗
▶Ep 1 · 4:06
clinicalA child with an adrenal mass on the right side and a positive MIBG scan but no evidence of metastases could potentially be treated with a primary resection of the mass via laparotomy.↗
▶Ep 1 · 4:44
clinicalFor very large masses that encase the aorta, cava, or other major vasculature, all you really want is tissue for diagnosis, which can be obtained through open biopsy, laparoscopic biopsy, or core needle biopsies done by an interventional radiologist.↗
▶Ep 1 · 5:14
clinicalThe most important biologic risk determinant to obtain from neuroblastoma biopsy tissue is the NMIC status.↗
▶Ep 1 · 5:14
clinicalIn addition to NMIC status, you want to look for 1P and 11Q deletions and Shimada histology in neuroblastoma biopsy tissue.↗
▶Ep 1 · 5:45
epidemiologicalNeuroblastoma risk is divided about 50-50 between the low risk categories and the high risk category, with a smaller percentage being intermediate risk.↗
▶Ep 1 · 5:45
clinicalBiologic risk determinants from biopsy will tell you what risk category the patient falls into: very low risk, low risk, intermediate risk, or high risk.↗
▶Ep 1 · 6:11
quoteNMIC and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 1 · 6:11
clinicalPatients with high risk neuroblastoma receive aggressive chemotherapy including peripheral stem cell transplant times 2, aggressive surgery with the goal of greater than 90% resection of the tumor, followed by radiation, immunotherapy after chemotherapy, and potentially retinoic acid therapy.↗
▶Ep 1 · 6:11
clinicalNMIC amplification and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 1 · 6:51
clinicalIntermediate risk neuroblastoma tumors get varying cycles of chemotherapy based on the biologic risk factors they have.↗
▶Ep 1 · 6:51
clinicalFor intermediate risk neuroblastoma, the goal at the time of debulking or resecting the primary tumor is to achieve at least a 50% response from the initial volume of the primary tumor through the combination of neoadjuvant chemotherapy and surgical resection.↗
▶Ep 1 · 7:22
clinicalThe low risk neuroblastoma group, depending on the actual age of the patient and how it is diagnosed, could potentially be followed simply with observation.↗
▶Ep 1 · 7:22
clinicalJed Nocturne led a study through the Children's Oncology Group looking at patients less than six months of age with either a prenatally diagnosed or shortly postnatally diagnosed localized mass, showing these patients can be observed with the expectation that the vast majority will avoid any type of surgical procedure.↗
▶Ep 1 · 7:55
quoteMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow, specifically not bone, not cortical bone, and is less than 18 months of age.↗
▶Ep 1 · 7:55
clinicalIf MS disease patients progress or develop respiratory issues because of an enlarging liver mass, treatment might be elected because of the complication of the size of the tumor, but the tumor itself usually does not have to be treated.↗
▶Ep 1 · 7:55
clinicalIn patients with MS disease, simple observation can be the treatment path.↗
▶Ep 1 · 7:55
clinicalMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow (specifically not bone, not cortical bone) and is less than 18 months of age.↗
▶Ep 1 · 7:55
clinicalPatients with metastatic neuroblastoma typically receive four or five cycles of neoadjuvant chemotherapy and then are reassessed.↗
▶Ep 1 · 7:55
clinicalIf the metastatic disease is progressing on neoadjuvant chemotherapy, then surgery is not indicated.↗
▶Ep 1 · 7:55
clinicalIf the tumor and metastatic disease are responding to neoadjuvant chemotherapy, one would attack the primary tumor site with a resection, with many advocating for attempting a greater than 90% resection.↗
▶Ep 1 · 8:55
clinicalYou can biopsy the skin lesions in MS disease and that will give you the diagnosis.↗
quoteI think that the, the main controversy, at least from my perspective, that still persists is what to do with the high-risk patients.↗
▶Ep 2 · 0:34
quoteI think that the, the main controversy, at least from my perspective, that still persists is what to do with the high-risk patients.↗
▶Ep 2 · 0:42
epidemiologicalSurvival rate for high-risk neuroblastoma patients is in the 38 to 40% range↗
▶Ep 2 · 0:42
epidemiologicalSurvival rate for high-risk neuroblastoma patients is in the 38 to 40% range↗
▶Ep 2 · 6:31
quoteThe difference between what a surgeon says they did in the operating room and and what the postoperative imaging says they did in the operating room, and those are not necessarily the same.↗
▶Ep 2 · 6:31
quoteThe difference between what a surgeon says they did in the operating room and and what the postoperative imaging says they did in the operating room, and those are not necessarily the same.↗
▶Ep 2 · 6:52
clinicalSurgeon-reported degree of resection showed only 66% concordance with radiologist assessment of postoperative imaging in tandem transplant pilot study↗
▶Ep 2 · 6:52
clinicalSurgeon-reported degree of resection showed only 66% concordance with radiologist assessment of postoperative imaging in tandem transplant pilot study↗
▶Ep 2 · 7:33
clinicalRepeat study in recent COG high-risk trial showed same 66% concordance rate between surgeon op notes and postoperative imaging, with surgeons underestimating and radiologists overcalling resection completeness↗
▶Ep 2 · 7:33
clinicalRepeat study in recent COG high-risk trial showed same 66% concordance rate between surgeon op notes and postoperative imaging, with surgeons underestimating and radiologists overcalling resection completeness↗
▶Ep 2 · 8:16
quoteWe don't have a very good definition of what is a greater than 90% resection.↗
▶Ep 2 · 8:16
quoteWe don't have a very good definition of what is a greater than 90% resection.↗
▶Ep 2 · 10:00
host_summaryMemorial Sloan Kettering data suggests biggest volume response of neuroblastoma tumor occurs with first two cycles of chemotherapy, with very little response after that↗
▶Ep 2 · 10:00
clinicalMemorial Sloan Kettering data suggests biggest volume response of neuroblastoma tumor occurs with first two cycles of chemotherapy, with very little response after that↗
▶Ep 2 · 10:17
opinionMore chemotherapy or other agents like MIBG may make tumor more fibrotic and make subadventitial dissection more difficult↗
▶Ep 2 · 10:17
quoteThe more chemotherapy you give or other agents, and now things like MIBG, which is local radiation, um. Uh, that you actually make the tumor more fibrotic, and it makes that technique of getting down on the vessels and splitting it off much more difficult.↗
▶Ep 2 · 10:17
quoteThe more chemotherapy you give or other agents, and now things like MIBG, which is local radiation, um. Uh, that you actually make the tumor more fibrotic, and it makes that technique of getting down on the vessels and splitting it off much more difficult.↗
▶Ep 2 · 10:17
opinionMore chemotherapy or other agents like MIBG may make tumor more fibrotic and make subadventitial dissection more difficult↗
▶Ep 2 · 13:07
epidemiologicalComplication rate for aggressive neuroblastoma resection is approximately 30% morbidity with mortality less than 1%↗
▶Ep 2 · 13:07
epidemiologicalComplication rate for aggressive neuroblastoma resection is approximately 30% morbidity with mortality less than 1%↗
▶Ep 2 · 15:10
clinicalHigh-risk neuroblastoma treatment includes tandem peripheral blood stem cell transplants, with second transplant given as soon as patient recovers from first, followed by immunotherapy and Retin-A↗
▶Ep 2 · 15:10
clinicalHigh-risk neuroblastoma treatment includes tandem peripheral blood stem cell transplants, with second transplant given as soon as patient recovers from first, followed by immunotherapy and Retin-A↗
▶Ep 2 · 16:48
host_summaryGerman study of 278 stage 4 high-risk neuroblastoma patients achieved complete resection in almost half and >90% resection in another quarter (75% total with >90% resection)↗
▶Ep 2 · 16:48
clinicalGerman study of 278 stage 4 high-risk neuroblastoma patients achieved complete resection in almost half and >90% resection in another quarter (75% total with >90% resection)↗
▶Ep 2 · 17:13
epidemiologicalGerman study showed overall survival 45%, event-free survival 33%, and local progression-free survival 58% in stage 4 neuroblastoma↗
▶Ep 2 · 17:13
host_summaryGerman study showed overall survival 45%, event-free survival 33%, and local progression-free survival 58% in stage 4 neuroblastoma↗
▶Ep 2 · 17:32
host_summaryGerman study showed no difference in overall survival, event-free survival, or local progression-free survival based on completeness of resection in stage 4 neuroblastoma↗
▶Ep 2 · 17:32
clinicalGerman study showed no difference in overall survival, event-free survival, or local progression-free survival based on completeness of resection in stage 4 neuroblastoma↗
▶Ep 2 · 17:51
guidelineGerman study concluded aggressive surgery is not justified in stage 4 neuroblastoma, that limited operations decrease complications, and there is limited impact on patient outcome↗
▶Ep 2 · 17:51
host_summaryGerman study concluded aggressive surgery is not justified in stage 4 neuroblastoma, that limited operations decrease complications, and there is limited impact on patient outcome↗
▶Ep 2 · 18:14
host_summaryEuropean study included 1,324 high-risk neuroblastoma patients (stages 2, 3, and 4) and achieved 76% with >95% resection↗
▶Ep 2 · 18:14
clinicalEuropean study included 1,324 high-risk neuroblastoma patients (stages 2, 3, and 4) and achieved 76% with >95% resection↗
▶Ep 2 · 19:02
epidemiologicalEuropean neuroblastoma study showed 0.5% mortality and 10% morbidity (30% including lesser complications)↗
▶Ep 2 · 19:02
host_summaryEuropean neuroblastoma study showed 0.5% mortality and 10% morbidity (30% including lesser complications)↗
▶Ep 2 · 19:17
host_summaryEuropean study showed significant improvement in event-free survival and overall survival with aggressive resection in high-risk neuroblastoma - first study to show overall survival benefit↗
▶Ep 2 · 19:17
clinicalEuropean study showed significant improvement in event-free survival and overall survival with aggressive resection in high-risk neuroblastoma - first study to show overall survival benefit↗
▶Ep 2 · 19:37
quoteThis is very important to support the aggressive approach that everybody in this room has suggested that they would, uh, that they would pursue. There actually now is some data to support that.↗
▶Ep 2 · 19:37
quoteThis is very important to support the aggressive approach that everybody in this room has suggested that they would, uh, that they would pursue. There actually now is some data to support that.↗
▶Ep 2 · 20:17
clinicalEuropean study concluded >95% resection results in improvement in event-free survival in high-risk neuroblastoma↗
▶Ep 2 · 20:17
host_summaryEuropean study concluded >95% resection results in improvement in event-free survival in high-risk neuroblastoma↗
▶Ep 2 · 21:24
host_summaryCOG 3973 study of approximately 230 high-risk neuroblastoma patients showed significant improvement in local relapse-free survival and event-free survival but not overall survival↗
▶Ep 2 · 21:24
clinicalCOG 3973 study of approximately 230 high-risk neuroblastoma patients showed significant improvement in local relapse-free survival and event-free survival but not overall survival↗
▶Ep 2 · 21:56
opinionCOG 3973 study's inability to demonstrate overall survival benefit may be type 2 error due to smaller sample size (230 vs 1,300 patients in European study)↗
▶Ep 2 · 21:56
opinionCOG 3973 study's inability to demonstrate overall survival benefit may be type 2 error due to smaller sample size (230 vs 1,300 patients in European study)↗
▶Ep 2 · 23:30
quoteIf you're not comfortable taking care of them, you should send them to somebody that is.↗
▶Ep 2 · 23:30
quoteIf you're not comfortable taking care of them, you should send them to somebody that is.↗
▶Ep 2 · 23:33
host_summaryEuropean neuroblastoma procedures are performed in more than 200 hospitals yet still demonstrated survival improvements↗
▶Ep 2 · 23:33
clinicalEuropean neuroblastoma procedures are performed in more than 200 hospitals yet still demonstrated survival improvements↗
▶Ep 2 · 24:03
clinicalOlder data shows worse survival in neuroblastoma when kidney is removed, likely because single kidney limits chemotherapy dosing↗
▶Ep 2 · 24:03
host_summaryOlder data shows worse survival in neuroblastoma when kidney is removed, likely because single kidney limits chemotherapy dosing↗
clinicalImmunotherapy is effective in neuroblastoma in the setting of minimal residual disease↗
▶Ep 2 · 25:38
clinicalImmunotherapy is effective in neuroblastoma in the setting of minimal residual disease↗
Neuroblastoma
▶Ep 3 · 2:11
clinicalOther differential diagnoses for suprarenal mass include neuroblastoma, pulmonary sequestration below the diaphragm, and misdiagnosed renal anomaly↗
▶Ep 3 · 2:11
clinicalAdrenal hemorrhage is the most common differential diagnosis for prenatal suprarenal mass, more common with history of fetal stress↗
▶Ep 3 · 6:02
guidelineMIBG scan is the next step if catecholamines are elevated↗
▶Ep 3 · 6:02
opinionRadiologists are quite good at identifying adrenal hemorrhage on ultrasound↗
▶Ep 3 · 8:14
clinicalIn perinatal phase, most common metastatic sites are liver, bone, skin, and lymph nodes↗
▶Ep 3 · 8:44
guidelineNocktern study data supports observation of prenatal neuroblastoma with careful ultrasound surveillance↗
▶Ep 3 · 12:27
quoteThe only caution I would raise is that we had a case of a child who presented with exactly this scenario, was observed, the adrenal mass went away and age at age three she presented with widely metastatic high risk neuroblastoma.↗
▶Ep 3 · 12:27
clinicalCase report: child with observed prenatal adrenal mass that resolved presented at age 3 with widely metastatic high-risk neuroblastoma↗
▶Ep 3 · 16:36
clinicalLymph node status in neuroblastoma is not as important for therapy changes as in Wilms tumor↗
▶Ep 3 · 17:58
clinicalPrimary concern in stage MS with liver involvement is mass effect causing respiratory compromise↗
▶Ep 3 · 17:58
quoteThe most common thing that we worry about is is the mass, is the mass effect of the tumor in the liver, which can be really dramatic and causes respiratory compromise.↗
▶Ep 3 · 19:06
opinionClassic findings of stage MS (high catecholamines, blue blebs on skin, liver metastasis, adrenal mass) may not require biopsy↗
▶Ep 3 · 25:06
epidemiological10% of neuroblastomas are not MIBG avid↗
▶Ep 3 · 25:06
clinicalPET scan may detect metastases in MIBG-negative neuroblastomas↗
Topics in 10: Neuroblastoma
▶Ep 5 · 0:41
clinicalWhen neuroblastoma patients have metastatic disease, they may present with either bony pain or potentially neurologic symptoms from cord compression.↗
▶Ep 5 · 0:41
clinicalIn younger patients, neuroblastoma is often picked up either prenatally on ultrasound, or in younger kids (two-year-old or three-year-old) as a solid abdominal mass.↗
▶Ep 5 · 0:41
quoteSo in the younger patients, they're oftentimes picked up either prenatally on ultrasound, or in younger kids, say two-year-old or three-year-old, it might be picked up as a solid abdominal mass.↗
▶Ep 5 · 0:41
clinicalWhen neuroblastoma patients have metastatic disease, they may present with either bony pain or potentially neurologic symptoms from cord compression.↗
▶Ep 5 · 0:41
clinicalIn younger patients, neuroblastoma is often picked up either prenatally on ultrasound, or in younger kids (two-year-old or three-year-old) as a solid abdominal mass.↗
▶Ep 5 · 0:41
quoteSo in the younger patients, they're oftentimes picked up either prenatally on ultrasound, or in younger kids, say two-year-old or three-year-old, it might be picked up as a solid abdominal mass.↗
▶Ep 5 · 1:07
clinicalWhen considering neuroblastoma as part of the differential diagnosis, it is important to get catecholamines (either urine or serum) as one of the most diagnostic laboratory tests for this tumor.↗
▶Ep 5 · 1:07
clinicalWhen considering neuroblastoma as part of the differential diagnosis, it is important to get catecholamines (either urine or serum) as one of the most diagnostic laboratory tests for this tumor.↗
▶Ep 5 · 1:39
clinicalThe MIBG study is helpful for confirming the diagnosis of neuroblastoma and can also demonstrate metastatic disease.↗
▶Ep 5 · 1:39
clinicalMost children with suspected neuroblastoma would get a cross-sectional imaging study, either a CT scan or an MRI.↗
▶Ep 5 · 1:39
clinicalIf imaging suggests neuroblastoma (central abdominal mass or adrenal mass rather than kidney mass), the next test would be a nuclear medicine study, typically an MIBG study.↗
▶Ep 5 · 1:39
clinicalThe MIBG study is helpful for confirming the diagnosis of neuroblastoma and can also demonstrate metastatic disease.↗
▶Ep 5 · 1:39
clinicalMost children with suspected neuroblastoma would get a cross-sectional imaging study, either a CT scan or an MRI.↗
▶Ep 5 · 1:39
clinicalIf imaging suggests neuroblastoma (central abdominal mass or adrenal mass rather than kidney mass), the next test would be a nuclear medicine study, typically an MIBG study.↗
▶Ep 5 · 2:20
clinicalAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 5 · 2:20
clinicalAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 5 · 2:20
quoteAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 5 · 2:20
clinicalSome centers, including Cincinnati Children's Hospital, would get a PET scan looking for tumor uptake as well as potential metastatic disease.↗
▶Ep 5 · 2:20
clinicalSome centers, including Cincinnati Children's Hospital, would get a PET scan looking for tumor uptake as well as potential metastatic disease.↗
▶Ep 5 · 2:20
quoteAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 5 · 2:45
guidelineIn the INRGSS system, tumors that are localized are categorized as L1; if localized but have image-defined risk factors (encasing nerves or vessels), they are L2; if they have metastatic disease, they are M.↗
▶Ep 5 · 2:45
guidelineBased on the most recent iteration of the neuroblastoma staging system (INRGSS), it is possible to assign a stage before any invasive procedure is performed.↗
▶Ep 5 · 2:45
guidelineBased on the most recent iteration of the neuroblastoma staging system (INRGSS), it is possible to assign a stage before any invasive procedure is performed.↗
▶Ep 5 · 2:45
guidelineIn the INRGSS system, tumors that are localized are categorized as L1; if localized but have image-defined risk factors (encasing nerves or vessels), they are L2; if they have metastatic disease, they are M.↗
▶Ep 5 · 2:45
guidelineThere is a special category MS for children less than 18 months of age who have metastases to either the bone marrow or the skin.↗
▶Ep 5 · 2:45
guidelineThere is a special category MS for children less than 18 months of age who have metastases to either the bone marrow or the skin.↗
▶Ep 5 · 3:36
guidelineThe INRGSS pre-biopsy staging system was specifically created to allow studies from different centers in different countries to be compared based on the pre-surgical staging of the patient.↗
▶Ep 5 · 3:36
guidelineThe prior neuroblastoma staging system required tissue diagnosis before assigning a stage.↗
▶Ep 5 · 3:36
guidelineThe prior neuroblastoma staging system required tissue diagnosis before assigning a stage.↗
▶Ep 5 · 3:36
guidelineThe INRGSS pre-biopsy staging system was specifically created to allow studies from different centers in different countries to be compared based on the pre-surgical staging of the patient.↗
▶Ep 5 · 4:06
clinicalA child with an adrenal mass on the right side and a positive MIBG scan but no evidence of metastases could potentially be treated with a primary resection of the mass via laparotomy.↗
▶Ep 5 · 4:06
opinionSome surgeons would approach resection of a localized neuroblastoma with laparoscopy depending on the size of the tumor.↗
▶Ep 5 · 4:06
opinionSome surgeons would approach resection of a localized neuroblastoma with laparoscopy depending on the size of the tumor.↗
▶Ep 5 · 4:06
clinicalA child with an adrenal mass on the right side and a positive MIBG scan but no evidence of metastases could potentially be treated with a primary resection of the mass via laparotomy.↗
▶Ep 5 · 4:44
clinicalFor very large masses that encase the aorta, cava, or other major vasculature, all you really want is tissue for diagnosis, which can be obtained through open biopsy, laparoscopic biopsy, or core needle biopsies done by an interventional radiologist.↗
▶Ep 5 · 4:44
clinicalFor very large masses that encase the aorta, cava, or other major vasculature, all you really want is tissue for diagnosis, which can be obtained through open biopsy, laparoscopic biopsy, or core needle biopsies done by an interventional radiologist.↗
▶Ep 5 · 5:14
clinicalThe most important biologic risk determinant to obtain from neuroblastoma biopsy tissue is the NMIC status.↗
▶Ep 5 · 5:14
clinicalIn addition to NMIC status, you want to look for 1P and 11Q deletions and Shimada histology in neuroblastoma biopsy tissue.↗
▶Ep 5 · 5:14
clinicalIn addition to NMIC status, you want to look for 1P and 11Q deletions and Shimada histology in neuroblastoma biopsy tissue.↗
▶Ep 5 · 5:14
clinicalThe most important biologic risk determinant to obtain from neuroblastoma biopsy tissue is the NMIC status.↗
▶Ep 5 · 5:45
epidemiologicalNeuroblastoma risk is divided about 50-50 between the low risk categories and the high risk category, with a smaller percentage being intermediate risk.↗
▶Ep 5 · 5:45
clinicalBiologic risk determinants from biopsy will tell you what risk category the patient falls into: very low risk, low risk, intermediate risk, or high risk.↗
▶Ep 5 · 5:45
epidemiologicalNeuroblastoma risk is divided about 50-50 between the low risk categories and the high risk category, with a smaller percentage being intermediate risk.↗
▶Ep 5 · 5:45
clinicalBiologic risk determinants from biopsy will tell you what risk category the patient falls into: very low risk, low risk, intermediate risk, or high risk.↗
▶Ep 5 · 6:11
quoteNMIC and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 5 · 6:11
clinicalPatients with high risk neuroblastoma receive aggressive chemotherapy including peripheral stem cell transplant times 2, aggressive surgery with the goal of greater than 90% resection of the tumor, followed by radiation, immunotherapy after chemotherapy, and potentially retinoic acid therapy.↗
▶Ep 5 · 6:11
clinicalNMIC amplification and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 5 · 6:11
clinicalPatients with high risk neuroblastoma receive aggressive chemotherapy including peripheral stem cell transplant times 2, aggressive surgery with the goal of greater than 90% resection of the tumor, followed by radiation, immunotherapy after chemotherapy, and potentially retinoic acid therapy.↗
▶Ep 5 · 6:11
clinicalNMIC amplification and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 5 · 6:11
quoteNMIC and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 5 · 6:51
clinicalFor intermediate risk neuroblastoma, the goal at the time of debulking or resecting the primary tumor is to achieve at least a 50% response from the initial volume of the primary tumor through the combination of neoadjuvant chemotherapy and surgical resection.↗
▶Ep 5 · 6:51
clinicalIntermediate risk neuroblastoma tumors get varying cycles of chemotherapy based on the biologic risk factors they have.↗
▶Ep 5 · 6:51
clinicalFor intermediate risk neuroblastoma, the goal at the time of debulking or resecting the primary tumor is to achieve at least a 50% response from the initial volume of the primary tumor through the combination of neoadjuvant chemotherapy and surgical resection.↗
▶Ep 5 · 6:51
clinicalIntermediate risk neuroblastoma tumors get varying cycles of chemotherapy based on the biologic risk factors they have.↗
▶Ep 5 · 7:22
clinicalThe low risk neuroblastoma group, depending on the actual age of the patient and how it is diagnosed, could potentially be followed simply with observation.↗
▶Ep 5 · 7:22
clinicalJed Nocturne led a study through the Children's Oncology Group looking at patients less than six months of age with either a prenatally diagnosed or shortly postnatally diagnosed localized mass, showing these patients can be observed with the expectation that the vast majority will avoid any type of surgical procedure.↗
▶Ep 5 · 7:22
clinicalThe low risk neuroblastoma group, depending on the actual age of the patient and how it is diagnosed, could potentially be followed simply with observation.↗
▶Ep 5 · 7:22
clinicalJed Nocturne led a study through the Children's Oncology Group looking at patients less than six months of age with either a prenatally diagnosed or shortly postnatally diagnosed localized mass, showing these patients can be observed with the expectation that the vast majority will avoid any type of surgical procedure.↗
▶Ep 5 · 7:55
clinicalIn patients with MS disease, simple observation can be the treatment path.↗
▶Ep 5 · 7:55
clinicalIf MS disease patients progress or develop respiratory issues because of an enlarging liver mass, treatment might be elected because of the complication of the size of the tumor, but the tumor itself usually does not have to be treated.↗
▶Ep 5 · 7:55
clinicalIf the metastatic disease is progressing on neoadjuvant chemotherapy, then surgery is not indicated.↗
▶Ep 5 · 7:55
clinicalIf the tumor and metastatic disease are responding to neoadjuvant chemotherapy, one would attack the primary tumor site with a resection, with many advocating for attempting a greater than 90% resection.↗
▶Ep 5 · 7:55
clinicalPatients with metastatic neuroblastoma typically receive four or five cycles of neoadjuvant chemotherapy and then are reassessed.↗
▶Ep 5 · 7:55
clinicalMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow (specifically not bone, not cortical bone) and is less than 18 months of age.↗
▶Ep 5 · 7:55
clinicalIf the tumor and metastatic disease are responding to neoadjuvant chemotherapy, one would attack the primary tumor site with a resection, with many advocating for attempting a greater than 90% resection.↗
▶Ep 5 · 7:55
clinicalIf MS disease patients progress or develop respiratory issues because of an enlarging liver mass, treatment might be elected because of the complication of the size of the tumor, but the tumor itself usually does not have to be treated.↗
▶Ep 5 · 7:55
clinicalIn patients with MS disease, simple observation can be the treatment path.↗
▶Ep 5 · 7:55
quoteMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow, specifically not bone, not cortical bone, and is less than 18 months of age.↗
▶Ep 5 · 7:55
clinicalPatients with metastatic neuroblastoma typically receive four or five cycles of neoadjuvant chemotherapy and then are reassessed.↗
▶Ep 5 · 7:55
clinicalIf the metastatic disease is progressing on neoadjuvant chemotherapy, then surgery is not indicated.↗
▶Ep 5 · 7:55
clinicalMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow (specifically not bone, not cortical bone) and is less than 18 months of age.↗
▶Ep 5 · 7:55
quoteMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow, specifically not bone, not cortical bone, and is less than 18 months of age.↗
▶Ep 5 · 8:55
clinicalYou can biopsy the skin lesions in MS disease and that will give you the diagnosis.↗
▶Ep 5 · 8:55
clinicalYou can biopsy the skin lesions in MS disease and that will give you the diagnosis.↗
Neuroblastoma
▶Ep 6 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 6 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 6 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 6 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 6 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 6 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 6 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 6 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 6 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 6 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 6 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 6 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 6 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 6 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 6 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 6 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 6 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 6 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 6 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
▶Ep 6 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
▶Ep 6 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
▶Ep 6 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
Update Course Rewind: Highlighting Collaboration from Surgery & Interventional Radiology in the OR 2024
▶Ep 20 · 1:02
quoteThis session. It is really about combining the expertise of surgeons with the expertise of our interventional radiologists and ultimately impacting the patient, so you keep the focus on what's right for the patient and put the egos aside, and you can do really great things.↗
clinicalIn younger patients, neuroblastoma is often picked up either prenatally on ultrasound, or in younger kids (two-year-old or three-year-old) as a solid abdominal mass.↗
▶Ep 3 · 0:41
clinicalWhen neuroblastoma patients have metastatic disease, they may present with either bony pain or potentially neurologic symptoms from cord compression.↗
▶Ep 3 · 0:41
clinicalIn younger patients, neuroblastoma is often picked up either prenatally on ultrasound, or in younger kids (two-year-old or three-year-old) as a solid abdominal mass.↗
▶Ep 3 · 0:41
clinicalWhen neuroblastoma patients have metastatic disease, they may present with either bony pain or potentially neurologic symptoms from cord compression.↗
▶Ep 3 · 0:41
quoteSo in the younger patients, they're oftentimes picked up either prenatally on ultrasound, or in younger kids, say two-year-old or three-year-old, it might be picked up as a solid abdominal mass.↗
▶Ep 3 · 0:41
quoteSo in the younger patients, they're oftentimes picked up either prenatally on ultrasound, or in younger kids, say two-year-old or three-year-old, it might be picked up as a solid abdominal mass.↗
▶Ep 3 · 1:07
clinicalWhen considering neuroblastoma as part of the differential diagnosis, it is important to get catecholamines (either urine or serum) as one of the most diagnostic laboratory tests for this tumor.↗
▶Ep 3 · 1:07
clinicalWhen considering neuroblastoma as part of the differential diagnosis, it is important to get catecholamines (either urine or serum) as one of the most diagnostic laboratory tests for this tumor.↗
▶Ep 3 · 1:39
clinicalThe MIBG study is helpful for confirming the diagnosis of neuroblastoma and can also demonstrate metastatic disease.↗
▶Ep 3 · 1:39
clinicalIf imaging suggests neuroblastoma (central abdominal mass or adrenal mass rather than kidney mass), the next test would be a nuclear medicine study, typically an MIBG study.↗
▶Ep 3 · 1:39
clinicalMost children with suspected neuroblastoma would get a cross-sectional imaging study, either a CT scan or an MRI.↗
▶Ep 3 · 1:39
clinicalMost children with suspected neuroblastoma would get a cross-sectional imaging study, either a CT scan or an MRI.↗
▶Ep 3 · 1:39
clinicalIf imaging suggests neuroblastoma (central abdominal mass or adrenal mass rather than kidney mass), the next test would be a nuclear medicine study, typically an MIBG study.↗
▶Ep 3 · 1:39
clinicalThe MIBG study is helpful for confirming the diagnosis of neuroblastoma and can also demonstrate metastatic disease.↗
▶Ep 3 · 2:20
quoteAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 3 · 2:20
clinicalSome centers, including Cincinnati Children's Hospital, would get a PET scan looking for tumor uptake as well as potential metastatic disease.↗
▶Ep 3 · 2:20
clinicalSome centers, including Cincinnati Children's Hospital, would get a PET scan looking for tumor uptake as well as potential metastatic disease.↗
▶Ep 3 · 2:20
quoteAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 3 · 2:20
clinicalAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 3 · 2:20
clinicalAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 3 · 2:45
guidelineIn the INRGSS system, tumors that are localized are categorized as L1; if localized but have image-defined risk factors (encasing nerves or vessels), they are L2; if they have metastatic disease, they are M.↗
▶Ep 3 · 2:45
guidelineThere is a special category MS for children less than 18 months of age who have metastases to either the bone marrow or the skin.↗
▶Ep 3 · 2:45
guidelineBased on the most recent iteration of the neuroblastoma staging system (INRGSS), it is possible to assign a stage before any invasive procedure is performed.↗
▶Ep 3 · 2:45
guidelineBased on the most recent iteration of the neuroblastoma staging system (INRGSS), it is possible to assign a stage before any invasive procedure is performed.↗
▶Ep 3 · 2:45
guidelineIn the INRGSS system, tumors that are localized are categorized as L1; if localized but have image-defined risk factors (encasing nerves or vessels), they are L2; if they have metastatic disease, they are M.↗
▶Ep 3 · 2:45
guidelineThere is a special category MS for children less than 18 months of age who have metastases to either the bone marrow or the skin.↗
▶Ep 3 · 3:36
guidelineThe prior neuroblastoma staging system required tissue diagnosis before assigning a stage.↗
▶Ep 3 · 3:36
guidelineThe prior neuroblastoma staging system required tissue diagnosis before assigning a stage.↗
▶Ep 3 · 3:36
guidelineThe INRGSS pre-biopsy staging system was specifically created to allow studies from different centers in different countries to be compared based on the pre-surgical staging of the patient.↗
▶Ep 3 · 3:36
guidelineThe INRGSS pre-biopsy staging system was specifically created to allow studies from different centers in different countries to be compared based on the pre-surgical staging of the patient.↗
▶Ep 3 · 4:06
opinionSome surgeons would approach resection of a localized neuroblastoma with laparoscopy depending on the size of the tumor.↗
▶Ep 3 · 4:06
clinicalA child with an adrenal mass on the right side and a positive MIBG scan but no evidence of metastases could potentially be treated with a primary resection of the mass via laparotomy.↗
▶Ep 3 · 4:06
clinicalA child with an adrenal mass on the right side and a positive MIBG scan but no evidence of metastases could potentially be treated with a primary resection of the mass via laparotomy.↗
▶Ep 3 · 4:06
opinionSome surgeons would approach resection of a localized neuroblastoma with laparoscopy depending on the size of the tumor.↗
▶Ep 3 · 4:44
clinicalFor very large masses that encase the aorta, cava, or other major vasculature, all you really want is tissue for diagnosis, which can be obtained through open biopsy, laparoscopic biopsy, or core needle biopsies done by an interventional radiologist.↗
▶Ep 3 · 4:44
clinicalFor very large masses that encase the aorta, cava, or other major vasculature, all you really want is tissue for diagnosis, which can be obtained through open biopsy, laparoscopic biopsy, or core needle biopsies done by an interventional radiologist.↗
▶Ep 3 · 5:14
clinicalIn addition to NMIC status, you want to look for 1P and 11Q deletions and Shimada histology in neuroblastoma biopsy tissue.↗
▶Ep 3 · 5:14
clinicalThe most important biologic risk determinant to obtain from neuroblastoma biopsy tissue is the NMIC status.↗
▶Ep 3 · 5:14
clinicalThe most important biologic risk determinant to obtain from neuroblastoma biopsy tissue is the NMIC status.↗
▶Ep 3 · 5:14
clinicalIn addition to NMIC status, you want to look for 1P and 11Q deletions and Shimada histology in neuroblastoma biopsy tissue.↗
▶Ep 3 · 5:45
epidemiologicalNeuroblastoma risk is divided about 50-50 between the low risk categories and the high risk category, with a smaller percentage being intermediate risk.↗
▶Ep 3 · 5:45
clinicalBiologic risk determinants from biopsy will tell you what risk category the patient falls into: very low risk, low risk, intermediate risk, or high risk.↗
▶Ep 3 · 5:45
epidemiologicalNeuroblastoma risk is divided about 50-50 between the low risk categories and the high risk category, with a smaller percentage being intermediate risk.↗
▶Ep 3 · 5:45
clinicalBiologic risk determinants from biopsy will tell you what risk category the patient falls into: very low risk, low risk, intermediate risk, or high risk.↗
▶Ep 3 · 6:11
clinicalNMIC amplification and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 3 · 6:11
clinicalPatients with high risk neuroblastoma receive aggressive chemotherapy including peripheral stem cell transplant times 2, aggressive surgery with the goal of greater than 90% resection of the tumor, followed by radiation, immunotherapy after chemotherapy, and potentially retinoic acid therapy.↗
▶Ep 3 · 6:11
quoteNMIC and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 3 · 6:11
quoteNMIC and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 3 · 6:11
clinicalPatients with high risk neuroblastoma receive aggressive chemotherapy including peripheral stem cell transplant times 2, aggressive surgery with the goal of greater than 90% resection of the tumor, followed by radiation, immunotherapy after chemotherapy, and potentially retinoic acid therapy.↗
▶Ep 3 · 6:11
clinicalNMIC amplification and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 3 · 6:51
clinicalFor intermediate risk neuroblastoma, the goal at the time of debulking or resecting the primary tumor is to achieve at least a 50% response from the initial volume of the primary tumor through the combination of neoadjuvant chemotherapy and surgical resection.↗
▶Ep 3 · 6:51
clinicalIntermediate risk neuroblastoma tumors get varying cycles of chemotherapy based on the biologic risk factors they have.↗
▶Ep 3 · 6:51
clinicalIntermediate risk neuroblastoma tumors get varying cycles of chemotherapy based on the biologic risk factors they have.↗
▶Ep 3 · 6:51
clinicalFor intermediate risk neuroblastoma, the goal at the time of debulking or resecting the primary tumor is to achieve at least a 50% response from the initial volume of the primary tumor through the combination of neoadjuvant chemotherapy and surgical resection.↗
▶Ep 3 · 7:22
clinicalThe low risk neuroblastoma group, depending on the actual age of the patient and how it is diagnosed, could potentially be followed simply with observation.↗
▶Ep 3 · 7:22
clinicalThe low risk neuroblastoma group, depending on the actual age of the patient and how it is diagnosed, could potentially be followed simply with observation.↗
▶Ep 3 · 7:22
clinicalJed Nocturne led a study through the Children's Oncology Group looking at patients less than six months of age with either a prenatally diagnosed or shortly postnatally diagnosed localized mass, showing these patients can be observed with the expectation that the vast majority will avoid any type of surgical procedure.↗
▶Ep 3 · 7:22
clinicalJed Nocturne led a study through the Children's Oncology Group looking at patients less than six months of age with either a prenatally diagnosed or shortly postnatally diagnosed localized mass, showing these patients can be observed with the expectation that the vast majority will avoid any type of surgical procedure.↗
▶Ep 3 · 7:55
clinicalPatients with metastatic neuroblastoma typically receive four or five cycles of neoadjuvant chemotherapy and then are reassessed.↗
▶Ep 3 · 7:55
clinicalPatients with metastatic neuroblastoma typically receive four or five cycles of neoadjuvant chemotherapy and then are reassessed.↗
▶Ep 3 · 7:55
clinicalIf the metastatic disease is progressing on neoadjuvant chemotherapy, then surgery is not indicated.↗
▶Ep 3 · 7:55
clinicalMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow (specifically not bone, not cortical bone) and is less than 18 months of age.↗
▶Ep 3 · 7:55
clinicalIn patients with MS disease, simple observation can be the treatment path.↗
▶Ep 3 · 7:55
clinicalIf MS disease patients progress or develop respiratory issues because of an enlarging liver mass, treatment might be elected because of the complication of the size of the tumor, but the tumor itself usually does not have to be treated.↗
▶Ep 3 · 7:55
quoteMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow, specifically not bone, not cortical bone, and is less than 18 months of age.↗
▶Ep 3 · 7:55
clinicalIf the tumor and metastatic disease are responding to neoadjuvant chemotherapy, one would attack the primary tumor site with a resection, with many advocating for attempting a greater than 90% resection.↗
▶Ep 3 · 7:55
clinicalIf the metastatic disease is progressing on neoadjuvant chemotherapy, then surgery is not indicated.↗
▶Ep 3 · 7:55
clinicalMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow (specifically not bone, not cortical bone) and is less than 18 months of age.↗
▶Ep 3 · 7:55
clinicalIn patients with MS disease, simple observation can be the treatment path.↗
▶Ep 3 · 7:55
clinicalIf MS disease patients progress or develop respiratory issues because of an enlarging liver mass, treatment might be elected because of the complication of the size of the tumor, but the tumor itself usually does not have to be treated.↗
▶Ep 3 · 7:55
quoteMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow, specifically not bone, not cortical bone, and is less than 18 months of age.↗
▶Ep 3 · 7:55
clinicalIf the tumor and metastatic disease are responding to neoadjuvant chemotherapy, one would attack the primary tumor site with a resection, with many advocating for attempting a greater than 90% resection.↗
▶Ep 3 · 8:55
clinicalYou can biopsy the skin lesions in MS disease and that will give you the diagnosis.↗
▶Ep 3 · 8:55
clinicalYou can biopsy the skin lesions in MS disease and that will give you the diagnosis.↗
Neuroblastoma
▶Ep 5 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 5 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 5 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 5 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 5 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 5 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 5 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 5 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 5 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 5 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 5 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 5 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 5 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 5 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 5 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 5 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 5 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 5 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 5 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
▶Ep 5 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
▶Ep 5 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
▶Ep 5 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
Update Course Rewind: Highlighting Collaboration from Surgery & Interventional Radiology in the OR 2024
▶Ep 12 · 1:02
quoteThis session. It is really about combining the expertise of surgeons with the expertise of our interventional radiologists and ultimately impacting the patient, so you keep the focus on what's right for the patient and put the egos aside, and you can do really great things.↗
Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula
▶Ep 1 · 9:58
clinicalIf a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse.↗
▶Ep 1 · 14:02
clinicalRoutine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues.↗
▶Ep 1 · 19:37
clinicalDual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings.↗
quoteThe tissue damage extends beyond what you can appreciate with the naked eye, and the progression of it probably extends beyond what you would think is the normal time frame.↗
▶Ep 1 · 1:52:36
clinicalIn a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured.↗
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
▶Ep 2 · 0:46
quoteOur method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap.↗
▶Ep 2 · 0:46
clinicalAt Cincinnati Children's, if a child has no gas in the abdomen, they place a G-tube and may put something up the distal esophagus for a fluoro shot, then wait a couple of weeks for a protocol gap measurement in interventional radiology.↗
▶Ep 2 · 2:10
quoteThe physiology, which I believe in intensely, is that stretch is a very strong promoter of growth. And then if you put things on tension, they will actually grow over time. That's how the cardiovascular system develops in utero.↗
▶Ep 2 · 2:10
clinicalStretch is a very strong promoter of growth, and if you put things on tension they will actually grow over time, which is how the cardiovascular system develops in utero.↗
▶Ep 2 · 2:10
quoteBut the philosophy here is that with traction, you can get the two ends of the esophagus to grow. And if you can get them to grow far enough, you can put them together.↗
▶Ep 2 · 2:10
clinicalThe philosophy of traction-based elongation is that with traction, you can get the two ends of the esophagus to grow, and if you can get them to grow far enough, you can put them together.↗
▶Ep 2 · 3:15
epidemiologicalIn the Boston Group 2015 study, the primary group had a median ICU stay of 70 days with a couple of weeks being paralyzed, and the secondary group had a median ICU stay of 110 days with a month of being paralyzed.↗
▶Ep 2 · 3:15
epidemiologicalIn the Boston Group 2015 study, the primary group (de novo cases) achieved an intact esophagus in 96% of patients, while the secondary group (patients with previous operations) achieved this in about two thirds of patients.↗
▶Ep 2 · 3:15
epidemiologicalIn the Boston Group 2015 study, about two thirds of patients with primary repair were able to get full oral nutrition and about 10% of patients who had secondary repair achieved full oral nutrition.↗
▶Ep 2 · 3:15
quoteThere was a great article published by the Boston Group 2015. Divides the cases into two groups, a primary group and a secondary group. Secondary being patients who had had operations previously in the primary group, being cases that they saw de novo.↗
▶Ep 2 · 3:15
quoteObviously, you look at the result of getting the esophagus together and intact esophagus in 96% of patients in the primary group, about two thirds of patients in the secondary group.↗
▶Ep 2 · 3:15
quoteBut these procedures are not without some morbidity. And you look at the ICU stay is a median of 70 days with a couple of weeks being paralyzed for the primary group and 110 days for the secondary group with a month of being paralyzed.↗
▶Ep 2 · 3:15
quoteAbout two thirds of patients with the primary repair were able to get the full oral nutrition and about 10% of the patients who had the secondary repair.↗
▶Ep 2 · 4:36
clinicalThe colon can be used as an interposition for esophageal replacement.↗
▶Ep 2 · 4:36
quoteYou can actually use the colon as an interposition as well. I personally was trained to do colon interpositions.↗
▶Ep 2 · 4:36
guidelineThe surgical group from INOEA recommends gastric pull up as the first option for esophageal replacement, dividing the esophageal stump at the esophageal hiatus and mobilizing the fundus to pull it up in either the anterior or posterior mediastinum.↗
▶Ep 2 · 4:36
quoteYou could use the stomach. That would be called a gastric transposition. The surgical group from the INOEA, their recommendation, the recommendation for the first option is a gastric pull up.↗
▶Ep 2 · 4:36
quoteYou divide the esophageal stump at the esophageal hiatus and mobilize the fundus and pull the fundus up and you can pull it up either in the anterior or posterior mediastinum.↗
▶Ep 2 · 8:00
clinicalCommon problems with colonic interposition are that the colon can dilate and become tortuous, and it's not uncommon to get a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 2 · 8:00
quoteCommon problems with this are that they dilate and they can become tortuous. It's not uncommon to get kind of a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 2 · 8:17
clinicalVon Allman passes the colonic interposition posterior to the stomach, which leaves the vascular pedicle along the spine, allowing mobilization of the colon by dividing the gastric duodenotomy and colon attachment to the stomach, then mobilizing the sigmoid redundancy transhiatally and reanastomosing the colon to the stomach.↗
▶Ep 2 · 8:17
quoteSo I wouldn't pretend to say that these don't need to be revised sometimes, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 2 · 8:17
quoteI pass the interposition posterior to the stomach, which leaves the vascular pedicle along the spine. And you can mobilize the colon. You can divide the gastric dual aporotomy, divide the colon attachment to the stomach, and then mobilize that sigmoid redundancy transhiatally, and then reinestimose the colon to the stomach.↗
▶Ep 2 · 8:17
quoteI was taught initially that you can't fix that and that it's too dangerous and that you'll risk the blood supply to the colon interposition. But I found that actually that's not really true.↗
▶Ep 2 · 8:17
opinionVon Allman was initially taught that sigmoid redundancy in colonic interposition can't be fixed and that it's too dangerous because it will risk the blood supply, but he found that this is not really true.↗
▶Ep 2 · 8:17
opinionColonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 2 · 9:03
quoteYou can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.↗
▶Ep 2 · 9:03
clinicalYou can get extraordinary length with colonic interposition, allowing treatment of cases with caustic injuries extending to the pharynx by sewing the colon to the pharynx and down to the stomach, which is tough to do with a gastric pull-up.↗
▶Ep 2 · 9:56
quoteI don't think we know we should do the studies to understand that. But I would say that this gets back to David van der Zee's comment about, go have a cup of coffee and come back and it'll be fine. Clearly, that's not growth, that's stretch.↗
▶Ep 2 · 9:56
quoteAnd yet there's very good physiologic data that tension is a growth promoter, not necessarily in the esophagus, but in other organs. So I think that it's an area ripe for a little more basic science.↗
▶Ep 2 · 9:56
opinionVon Allman states we don't know whether esophageal elongation is growth or stretch and should do studies to understand that, but notes that tension is a very good physiologic growth promoter in other organs, making this an area ripe for more basic science.↗
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 9 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 9 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 9 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 9 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 9 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 9 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 9 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 9 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 9 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 9 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 9 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 9 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 9 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 9 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 9 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 9 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 9 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 9 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
▶Ep 9 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
▶Ep 9 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
▶Ep 9 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
