I think that serial abdominal exams are important. And if you see worsening distension, worsening, you know, signs of peritoneal irritation, hemodynamic instability with increasing needs for presser support, renal shutdown with no urine production, you know, it starts to build up. And it's like building blocks. And if you have, you know, A, B, and C, it's time to think about surgery.
I think that serial abdominal exams are important. And if you see worsening distension, worsening, you know, signs of peritoneal irritation, hemodynamic instability with increasing needs for presser support, renal shutdown with no urine production, you know, it starts to build up. And it's like building blocks. And if you have, you know, A, B, and C, it's time to think about surgery.
I think that serial abdominal exams are important. And if you see worsening distension, worsening, you know, signs of peritoneal irritation, hemodynamic instability with increasing needs for presser support, renal shutdown with no urine production, you know, it starts to build up. And it's like building blocks. And if you have, you know, A, B, and C, it's time to think about surgery.
I think that serial abdominal exams are important. And if you see worsening distension, worsening, you know, signs of peritoneal irritation, hemodynamic instability with increasing needs for presser support, renal shutdown with no urine production, you know, it starts to build up. And it's like building blocks. And if you have, you know, A, B, and C, it's time to think about surgery.
I have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation, but those things like fixed loops of bowel and serial films, the development of portal venous air, which sometimes can be quite fleeting, those are worrisome signs.
I have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation, but those things like fixed loops of bowel and serial films, the development of portal venous air, which sometimes can be quite fleeting, those are worrisome signs.
Journal of Pediatric Surgery Article Review: January 2022 APSA Issue
▶Ep 26 · 1:41
quoteHistorically, surgeons of all types have been incentivized based on their work or views, and it's certainly important for clinical productivity and clinical program building, but it's really important to take advantage of other strengths that surgeons have.↗
▶Ep 26 · 1:41
opinionHistorically, surgeons have been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have.↗
▶Ep 26 · 2:23
quoteThe Question is, how do we promote academic productivity amongst our partners?↗
▶Ep 26 · 2:55
clinicalThe concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work.↗
▶Ep 26 · 2:55
quoteThe concept of academic RVUs was probably first put out there about 12 or 13 years ago, but it wasn't described how to incentivize people for that.↗
▶Ep 26 · 3:07
clinicalNationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits.↗
▶Ep 26 · 3:27
clinicalThe Nationwide system kept work RVUs as part of the incentivization plan along with other goals that must be achievable.↗
▶Ep 26 · 3:34
quoteAnd I really believe that these types of goals and these types of incentives have to be achievable.↗
quoteDespite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease.↗
▶Ep 9 · 2:11
clinicalDespite 6 decades of research, we don't know exactly what causes NEC and are still quite some ways from finding an absolute cure.↗
▶Ep 9 · 4:14
clinicalIndomethacin predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 9 · 4:44
clinicalPPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; you don't want to neutralize gastric acid.↗
▶Ep 9 · 5:29
clinicalIn premature babies with NEC, intestinal contents can leak into the scrotum through a patent processus vaginalis, causing scrotal swelling and discoloration.↗
▶Ep 9 · 7:17
quoteI get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 9 · 7:17
clinicalNeutropenia (low white blood cell count) is more worrisome than elevated WBC in NEC because it suggests overwhelming sepsis that the patient is not compensating for.↗
▶Ep 9 · 7:33
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and knowledge of platelet count is important for optimizing patient condition prior to surgery.↗
▶Ep 9 · 8:33
clinicalThere is no single test that shows whether you have ischemic or necrotic bowel, but taking all tests in combination gives a sense of how sick the patient is.↗
▶Ep 9 · 8:33
quoteUnfortunately, there's no one test that, you know, shows whether you have an ischemic or necrotic bowel. But if you take all of these tests in combination with each other, you can get a sense as to how sick you think the patient is.↗
▶Ep 9 · 8:50
clinicalFor imaging in suspected NEC, you need plain film plus either cross-table lateral or lateral decubitus film because free air can be quite subtle and you don't want to miss it.↗
▶Ep 9 · 9:08
quoteYou don't want to just get a plain film. You want to get something that will increase your chance of being able to visualize even a small amount of free air.↗
▶Ep 9 · 9:38
clinicalFree air on imaging is an absolute indication for surgical intervention (either drain or laparotomy).↗
▶Ep 9 · 9:54
clinicalClinical deterioration in the face of maximum medical management is an indication for surgery.↗
▶Ep 9 · 10:02
clinicalFixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not going in the right direction.↗
▶Ep 9 · 10:16
clinicalPortal venous air is a concerning and worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.↗
▶Ep 9 · 10:16
quoteI have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation, but those things like fixed loops of bowel and serial films, the development of portal venous air, which sometimes can be quite fleeting, those are worrisome signs.↗
▶Ep 9 · 10:58
clinicalMedical management of NEC includes: withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotics, and performing serial abdominal exams, labs, and X-rays.↗
▶Ep 9 · 12:05
clinicalSmall French feeding tubes are not adequate for gastric decompression in NEC; they should be replaced with an orogastric tube.↗
▶Ep 9 · 12:05
quoteUnfortunately those tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression.↗
▶Ep 9 · 12:43
epidemiologicalThere is tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization of the ICU environment.↗
▶Ep 9 · 12:52
quoteI think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment.↗
▶Ep 9 · 13:37
opinionFor serial X-rays in NEC, obtaining them every 8 hours is reasonable; getting them too frequently makes no sense, but waiting 12-24 hours is too long.↗
▶Ep 9 · 14:15
clinicalPatients with NEC should be kept NPO with NG decompression and antibiotics for at least 1 week to 10 days (preferably a week and a half) before starting feeds.↗
▶Ep 9 · 14:29
clinicalSome babies have repeated episodes of necrotizing enterocolitis.↗
▶Ep 9 · 14:40
clinicalStricture formation is a complication of medical NEC that should be suspected in babies not tolerating feeds post-NEC; strictures typically occur in the colon, usually near the splenic flexure, but can occur anywhere.↗
▶Ep 9 · 15:17
opinionFor suspected stricture post-NEC, starting with contrast enema is preferred over upper GI with small bowel follow-through because strictures are more common in the colon and contrast from above takes long to transit, especially if partially obstructed.↗
▶Ep 9 · 16:23
clinicalSerial abdominal exams are critical for determining when to operate on NEC patients without absolute indications; worsening distention, peritoneal signs, hemodynamic instability with increasing pressor needs, and renal shutdown build up like building blocks to indicate need for surgery.↗
▶Ep 9 · 18:16
clinicalTwo surgical options for NEC are exploratory laparotomy and peritoneal drain placement.↗
▶Ep 9 · 18:22
clinicalThe ongoing NEST trial (necrotizing enterocolitis surgery trial) is concluding and will provide results in the next 1-2 years comparing peritoneal drainage versus laparotomy.↗
▶Ep 9 · 18:22
quoteI wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial.↗
▶Ep 9 · 18:39
clinicalMortality difference between peritoneal drainage and laparotomy for NEC is indecipherable; survival chance is about the same with either procedure.↗
▶Ep 9 · 19:10
quote100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating.↗
▶Ep 9 · 19:10
epidemiologicalAt a NEC conference in London, 100% of surgeons polled do laparotomy and no one puts in a drain in Europe.↗
▶Ep 9 · 19:44
clinicalThe MOSS trial (United States) and PIERO trial (Europe) showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC, but these studies looked at early endpoints rather than delayed neurological outcomes.↗
▶Ep 9 · 20:14
clinicalBabies who have peritoneal drains instead of laparotomy may do worse neurologically if you look at outcomes 1-2 years after recovery from NEC.↗
▶Ep 9 · 20:34
clinicalThe NEST trial will randomize 300 babies to peritoneal drainage versus laparotomy and assess neurological outcomes at 18-22 months after NEC recovery with detailed neurological assessments.↗
▶Ep 9 · 20:53
quoteWe certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road.↗
▶Ep 9 · 21:44
opinionDr. Besner predicts that in the next 1-2 years practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes likely better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.↗
▶Ep 9 · 21:44
quoteI predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies.↗
▶Ep 9 · 22:09
quoteWhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult.↗
▶Ep 9 · 22:09
clinicalWhen peritoneal drains are placed and babies subsequently undergo laparotomy, the degree of dead bowel actually present is often quite striking and it's inconceivable the baby could get over that insult.↗
▶Ep 9 · 22:58
opinionThere are no criteria that help decide between laparotomy or drain for NEC; with current information you can't be faulted for doing either one.↗
▶Ep 9 · 24:15
clinicalYou can get just as sick and hemodynamically unstable from systemic inflammatory response syndrome with an isolated intestinal perforation as from necrotizing enterocolitis.↗
▶Ep 9 · 26:15
clinicalPeritoneal drain placement is a bedside procedure with tiny amount of local anesthesia, using a small transverse incision in the right lower quadrant for a 1/4 inch Penrose drain.↗
▶Ep 9 · 26:34
clinicalIf the incision for peritoneal drain is made too big, it's a problem because the patient can get a hernia once the drain is out.↗
▶Ep 9 · 27:01
clinicalWhen placing peritoneal drain, pass it several times gently without forcing to avoid bleeding; it's hard to achieve the drain curving to all four quadrants as shown in published pictures.↗
▶Ep 9 · 28:43
clinicalAfter peritoneal drain placement, if baby continues producing stool from drain for weeks and you convert to laparotomy, you may be forced to operate at the wrong time when inflammatory process is at its worst, resulting in extensive adhesions and serosal tears.↗
▶Ep 9 · 29:03
opinionOne of the smartest surgical decisions is knowing when to get out and stop; if you're getting serosal tears and making the situation worse during difficult NEC laparotomy, it's time to stop.↗
▶Ep 9 · 29:03
quoteOne of the smartest decisions that a surgeon can make is to know when to get out and to stop.↗
▶Ep 9 · 29:13
clinicalIn difficult NEC laparotomy with extensive adhesions, try to make a proximal diverting stoma to control the area of perforation, but don't keep going if making multiple enterotomies and serosal injuries.↗
▶Ep 9 · 29:24
quoteYou can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run.↗
▶Ep 9 · 29:48
clinicalFor successful peritoneal drain management, advance the drain out over several days starting at 7-10 days post-operation rather than withdrawing it all at once.↗
▶Ep 9 · 30:09
clinicalDon't advance peritoneal drain out if there's continual leakage of stool at the drain site; this suggests ongoing area of leakage.↗
▶Ep 9 · 30:22
opinionThere is difference of opinion about whether to get upper GI small bowel follow-through before removing peritoneal drain; it should be considered if there's ongoing stool leakage.↗
▶Ep 9 · 30:49
clinicalIf baby does well after drain removal without contrast study but doesn't tolerate feeds, then contrast study is compelled to ensure everything is OK.↗
▶Ep 9 · 31:19
clinicalFor NEC laparotomy, if baby is hemodynamically unstable or on very high oscillator settings and can't be safely moved to OR, bring the OR to bedside and operate in the ICU.↗
▶Ep 9 · 31:43
clinicalFor NEC laparotomy, make supraumbilical transverse incision; skin is extraordinarily thin so be careful entering abdomen, especially with underlying dilated bowel loops.↗
▶Ep 9 · 32:08
clinicalFor NEC laparotomy, have blood products available (packed RBCs, platelets, fresh frozen plasma) and partially correct platelet and coagulation abnormalities preoperatively.↗
▶Ep 9 · 32:27
clinicalIn premature babies undergoing NEC laparotomy, it's incredibly important not to hurt the liver or spleen; even looking at or touching the liver wrong can cause subcapsular hematoma that a baby can exsanguinate from.↗
▶Ep 9 · 32:37
quoteIf you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this.↗
▶Ep 9 · 32:46
quoteYou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies.↗
▶Ep 9 · 32:53
clinicalLiver and spleen injuries can occur with peritoneal drain insertion as well.↗
▶Ep 9 · 33:21
clinicalSpontaneous intestinal perforation (SIP) is one small localized area of perforation; NEC is more diffuse disease with pneumatosis involving more than one tiny area. These can be hard to differentiate preoperatively.↗
▶Ep 9 · 34:04
epidemiologicalSome surgeons around the world resect limited NEC and do primary anastomosis; this is less common in the United States where surgeons typically make stomas due to concern about anastomotic healing.↗
▶Ep 9 · 35:07
clinicalFor NEC stomas, bring functional end and mucous fistula out through the laparotomy incision close to each other (facilitating later closure), tack to fascia without maturation.↗
▶Ep 9 · 35:50
clinicalNo matter how carefully NEC stomas are made, sometimes the distal end will slough off, so leave a little distal end sticking out so it doesn't recede under the fascia.↗
▶Ep 9 · 36:19
opinionHigh-quality enterostomal therapists can manage stomas brought out through the incision; the problem gets more complicated if the wound opens.↗
▶Ep 9 · 37:12
clinicalFor indeterminate bowel viability during NEC laparotomy (injured but not necrotic, diffusely the same appearance), it's acceptable to not resect, leave abdomen open to avoid pressure compromising blood flow, and return for second-look operation in 24-48 hours.↗
▶Ep 9 · 38:07
clinicalFor multiple skip lesions in NEC, if very close together and can resect without creating short bowel syndrome, do that rather than multiple anastomoses; otherwise do multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion.↗
▶Ep 9 · 38:46
clinicalClip-and-drop technique (resect dead bowel, clip ends, put back in, return another day) can be life-saving in very unstable NEC patients without time for multiple anastomoses.↗
▶Ep 9 · 39:15
opinionThe 'putting green' approach (bringing out multiple stomas throughout abdomen) can get really confusing and messy; try to avoid if possible.↗
▶Ep 9 · 39:32
clinicalFor stoma reversal timing, typically wait until baby is stable, well, hopefully being fed, and about 2000g (anastomosis is easier when baby is bigger); go in sooner if TPN-induced cholestasis develops or can't nourish baby due to very high stoma.↗
▶Ep 9 · 40:21
opinionStoma reversal timing is more about weight gain, clinical appearance, and TPN sequelae than a mandatory 2-month waiting period.↗
▶Ep 9 · 40:48
clinicalRefeeding mucous fistula is done selectively (not routinely) for very high-output stomas where any nourishment given comes right out the stoma.↗
▶Ep 9 · 41:22
clinicalMucous fistulas often stricture and you lose the opportunity to refeed; if serious about refeeding (e.g., massive resection, very high stoma), consider leaving a small soft catheter in the mucous fistula post-op to maintain access.↗
▶Ep 9 · 42:15
clinicalNEC totalis is one of the most tragic findings on exploratory laparotomy for NEC; the chance of a baby with true NEC totalis living to be old enough for small bowel-liver transplant is very close to zero.↗
▶Ep 9 · 42:15
quoteI think neck totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis.↗
▶Ep 9 · 42:32
quoteThe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero.↗
▶Ep 9 · 42:56
opinionFor very small premature baby with NEC totalis, we don't have the technology to get that baby through this devastating problem; no one would be criticized for explaining severity to parents and closing abdomen with comfort care.↗
▶Ep 9 · 43:42
clinicalFor NEC totalis, the chance of the baby living through months to years of required TPN will irreversibly injure their liver, and even if they live to be big enough, results of small bowel transplant are still suboptimal.↗
▶Ep 9 · 44:28
clinicalThere is a very small subset of premature patients with horrible lung disease who get pneumothorax that dissects through the diaphragm into the abdomen, presenting as free air; make sure the problem is in the abdomen and not in the chest.↗
▶Ep 9 · 45:06
clinicalFor hemodynamically unstable baby with free air and abdominal distention, put an angiocatheter through the abdominal wall to release pneumoperitoneum as a temporizing maneuver while mobilizing for surgery.↗
Necrotizing Enterocolitis with Dr. Gail Besner
▶Ep 27 · 2:11
quoteDespite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease.↗
▶Ep 27 · 2:11
quoteDespite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease.↗
▶Ep 27 · 2:11
clinicalDespite 6 decades of research, the exact cause of necrotizing enterocolitis is unknown and there is no absolute cure for the disease.↗
▶Ep 27 · 2:11
clinicalDespite 6 decades of research, the exact cause of necrotizing enterocolitis is unknown and there is no absolute cure for the disease.↗
▶Ep 27 · 3:53
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 27 · 3:53
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 27 · 4:44
clinicalPPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; gastric acid neutralization should be avoided.↗
▶Ep 27 · 4:44
clinicalPPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; gastric acid neutralization should be avoided.↗
▶Ep 27 · 5:29
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 27 · 5:29
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 27 · 7:17
clinicalNeutropenia and low white blood cell count are more concerning than elevated white count in NEC, suggesting overwhelming sepsis that the patient is not compensating for.↗
▶Ep 27 · 7:17
clinicalNeutropenia and low white blood cell count are more concerning than elevated white count in NEC, suggesting overwhelming sepsis that the patient is not compensating for.↗
▶Ep 27 · 7:17
quoteI get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 27 · 7:17
quoteI get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 27 · 7:33
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC; low platelet count is important to know before surgery to optimize patient condition.↗
▶Ep 27 · 7:33
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC; low platelet count is important to know before surgery to optimize patient condition.↗
▶Ep 27 · 8:50
clinicalCross-table lateral or lateral decubitus X-ray films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 27 · 8:50
clinicalCross-table lateral or lateral decubitus X-ray films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 27 · 8:50
quoteSometimes free air can be quite subtle, and we wouldn't want to miss free air.↗
▶Ep 27 · 8:50
quoteSometimes free air can be quite subtle, and we wouldn't want to miss free air.↗
▶Ep 27 · 9:38
clinicalPneumoperitoneum (free air) is an absolute indication for surgical intervention, either drain placement or laparotomy.↗
▶Ep 27 · 9:38
clinicalPneumoperitoneum (free air) is an absolute indication for surgical intervention, either drain placement or laparotomy.↗
▶Ep 27 · 9:54
clinicalClinical deterioration in the face of maximum medical management is an indication for surgery.↗
▶Ep 27 · 9:54
clinicalClinical deterioration in the face of maximum medical management is an indication for surgery.↗
▶Ep 27 · 10:02
clinicalFixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not improving.↗
▶Ep 27 · 10:02
quoteFixed loops of intestine on serial X-rays are not, in my opinion, an absolute indication for surgery, but it sure is going to start to make bells and whistles go off in your mind that the patient is not going in the direction that you want them to go in.↗
▶Ep 27 · 10:02
clinicalFixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not improving.↗
▶Ep 27 · 10:02
quoteFixed loops of intestine on serial X-rays are not, in my opinion, an absolute indication for surgery, but it sure is going to start to make bells and whistles go off in your mind that the patient is not going in the direction that you want them to go in.↗
▶Ep 27 · 10:16
quoteI have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation.↗
▶Ep 27 · 10:16
clinicalPortal venous air is a concerning and worrisome sign, but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.↗
▶Ep 27 · 10:16
quoteI have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation.↗
▶Ep 27 · 10:16
clinicalPortal venous air is a concerning and worrisome sign, but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.↗
▶Ep 27 · 10:58
clinicalMedical management of NEC includes withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotic therapy, and performing serial abdominal exams, labs, and X-rays.↗
▶Ep 27 · 10:58
clinicalMedical management of NEC includes withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotic therapy, and performing serial abdominal exams, labs, and X-rays.↗
▶Ep 27 · 12:05
quoteThose tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression.↗
▶Ep 27 · 12:05
clinicalSmall French feeding tubes are not adequate for gastric decompression in NEC; feeding tube should be removed and replaced with orogastric tube.↗
▶Ep 27 · 12:05
quoteThose tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression.↗
▶Ep 27 · 12:05
clinicalSmall French feeding tubes are not adequate for gastric decompression in NEC; feeding tube should be removed and replaced with orogastric tube.↗
▶Ep 27 · 12:33
clinicalThere is tremendous diversity in antibiotic regimens for NEC across the United States; broad-spectrum coverage is critical but specific regimen may depend on bacterial colonization of the intensive care unit environment.↗
▶Ep 27 · 12:33
clinicalThere is tremendous diversity in antibiotic regimens for NEC across the United States; broad-spectrum coverage is critical but specific regimen may depend on bacterial colonization of the intensive care unit environment.↗
▶Ep 27 · 12:52
quoteI think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment.↗
▶Ep 27 · 12:52
quoteI think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment.↗
▶Ep 27 · 13:37
clinicalAt Nationwide Children's Hospital, abdominal X-rays are obtained at intervals (approximately every 8 hours) rather than waiting 12-24 hours between films.↗
▶Ep 27 · 13:37
clinicalAt Nationwide Children's Hospital, abdominal X-rays are obtained at intervals (approximately every 8 hours) rather than waiting 12-24 hours between films.↗
▶Ep 27 · 14:15
clinicalMedical management (NPO, decompression, antibiotics) should continue for at least 1 week to 10 days, preferably a week and a half, before starting feeds.↗
▶Ep 27 · 14:15
clinicalMedical management (NPO, decompression, antibiotics) should continue for at least 1 week to 10 days, preferably a week and a half, before starting feeds.↗
▶Ep 27 · 14:29
clinicalSome babies have repeated episodes of necrotizing enterocolitis.↗
▶Ep 27 · 14:29
clinicalSome babies have repeated episodes of necrotizing enterocolitis.↗
▶Ep 27 · 14:40
clinicalPost-NEC stricture formation typically occurs in the colon, usually near the splenic flexure in the left colon, but can occur anywhere.↗
▶Ep 27 · 14:40
quoteYou have to worry about stricture formation in the baby post neck who's not tolerating their feeds well.↗
▶Ep 27 · 14:40
clinicalPost-NEC stricture formation typically occurs in the colon, usually near the splenic flexure in the left colon, but can occur anywhere.↗
▶Ep 27 · 14:40
quoteYou have to worry about stricture formation in the baby post neck who's not tolerating their feeds well.↗
▶Ep 27 · 15:17
clinicalFor suspected post-NEC stricture, contrast enema is preferred as initial study over upper GI with small bowel follow-through because strictures are more common in colon and contrast from below avoids long wait time if patient is partially obstructed.↗
▶Ep 27 · 15:17
clinicalFor suspected post-NEC stricture, contrast enema is preferred as initial study over upper GI with small bowel follow-through because strictures are more common in colon and contrast from below avoids long wait time if patient is partially obstructed.↗
▶Ep 27 · 16:23
clinicalSerial abdominal exams are important for surgical decision-making; worsening distention, signs of peritoneal irritation, hemodynamic instability with increasing pressor support, and renal shutdown with no urine production build up to indicate need for surgery.↗
▶Ep 27 · 16:23
quoteI still believe that it's a matter of serial abdominal exams. I think it's very hard, you know, if you just examine the baby once and think that you know what to do or what the right answer is.↗
▶Ep 27 · 16:23
clinicalSerial abdominal exams are important for surgical decision-making; worsening distention, signs of peritoneal irritation, hemodynamic instability with increasing pressor support, and renal shutdown with no urine production build up to indicate need for surgery.↗
▶Ep 27 · 16:23
quoteI still believe that it's a matter of serial abdominal exams. I think it's very hard, you know, if you just examine the baby once and think that you know what to do or what the right answer is.↗
▶Ep 27 · 18:16
quoteI wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial.↗
▶Ep 27 · 18:16
quoteI wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial.↗
▶Ep 27 · 19:10
quote100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating.↗
▶Ep 27 · 19:10
epidemiologicalAt London NEC conference, 100% of European surgeons polled perform laparotomy for NEC and no one places peritoneal drains.↗
▶Ep 27 · 19:10
epidemiologicalAt London NEC conference, 100% of European surgeons polled perform laparotomy for NEC and no one places peritoneal drains.↗
▶Ep 27 · 19:10
quote100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating.↗
▶Ep 27 · 19:44
clinicalTwo randomized controlled trials (MOSS trial in US and PIERO trial in Europe) of peritoneal drainage versus laparotomy showed no difference in overall mortality.↗
▶Ep 27 · 19:44
clinicalTwo randomized controlled trials (MOSS trial in US and PIERO trial in Europe) of peritoneal drainage versus laparotomy showed no difference in overall mortality.↗
▶Ep 27 · 20:04
clinicalMOSS and PIERO trials looked at early endpoints rather than delayed endpoints of neurological recovery.↗
▶Ep 27 · 20:04
clinicalMOSS and PIERO trials looked at early endpoints rather than delayed endpoints of neurological recovery.↗
▶Ep 27 · 20:14
clinicalBabies who have peritoneal drains instead of laparotomy may do worse from neurological standpoint if neurological outcomes are examined 1-2 years after recovery from NEC.↗
▶Ep 27 · 20:14
quoteIt appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis.↗
▶Ep 27 · 20:14
clinicalBabies who have peritoneal drains instead of laparotomy may do worse from neurological standpoint if neurological outcomes are examined 1-2 years after recovery from NEC.↗
▶Ep 27 · 20:14
quoteIt appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis.↗
▶Ep 27 · 20:34
clinicalThe ongoing NEST trial (necrotizing enterocolitis surgery trial) in the United States has randomized 300 babies to peritoneal drainage versus laparotomy and will examine neurological outcomes at 18-22 months after recovery from NEC with detailed neurological assessments.↗
▶Ep 27 · 20:34
clinicalThe ongoing NEST trial (necrotizing enterocolitis surgery trial) in the United States has randomized 300 babies to peritoneal drainage versus laparotomy and will examine neurological outcomes at 18-22 months after recovery from NEC with detailed neurological assessments.↗
▶Ep 27 · 20:53
quoteWe certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road.↗
▶Ep 27 · 20:53
quoteWe certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road.↗
▶Ep 27 · 21:44
quoteI predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies.↗
▶Ep 27 · 21:44
quoteI predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies.↗
▶Ep 27 · 21:44
opinionDr. Besner predicts that in the next 1-2 years, practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes expected to be better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.↗
▶Ep 27 · 21:44
opinionDr. Besner predicts that in the next 1-2 years, practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes expected to be better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.↗
▶Ep 27 · 22:09
clinicalBabies with peritoneal drains can have striking degree of dead bowel remaining in abdomen, as seen when some drain patients subsequently undergo laparotomy.↗
▶Ep 27 · 22:09
clinicalBabies with peritoneal drains can have striking degree of dead bowel remaining in abdomen, as seen when some drain patients subsequently undergo laparotomy.↗
▶Ep 27 · 22:09
quoteWhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult.↗
▶Ep 27 · 22:09
quoteWhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult.↗
▶Ep 27 · 24:15
quoteYou can get just as sick and just as hemodynamically unstable from the systemic inflammatory response syndrome with an intestinal perforation, an isolated intestinal perforation, as you can from necrotizing enterocolitis.↗
▶Ep 27 · 24:15
clinicalSystemic inflammatory response syndrome can make patients just as sick and hemodynamically unstable from isolated intestinal perforation as from necrotizing enterocolitis.↗
▶Ep 27 · 24:15
quoteYou can get just as sick and just as hemodynamically unstable from the systemic inflammatory response syndrome with an intestinal perforation, an isolated intestinal perforation, as you can from necrotizing enterocolitis.↗
▶Ep 27 · 24:15
clinicalSystemic inflammatory response syndrome can make patients just as sick and hemodynamically unstable from isolated intestinal perforation as from necrotizing enterocolitis.↗
▶Ep 27 · 25:46
clinicalAfter peritoneal drain placement, significant proportion of patients continue to decline and require subsequent laparotomy.↗
▶Ep 27 · 25:46
quoteThere is a significant proportion of patients whereby you can put the drain in and they're going to continue to decline and do badly and they end up needing a laparotomy.↗
▶Ep 27 · 25:46
clinicalAfter peritoneal drain placement, significant proportion of patients continue to decline and require subsequent laparotomy.↗
▶Ep 27 · 25:46
quoteThere is a significant proportion of patients whereby you can put the drain in and they're going to continue to decline and do badly and they end up needing a laparotomy.↗
▶Ep 27 · 26:15
clinicalPeritoneal drain placement is a bedside procedure performed with small amount of local anesthesia using small transverse incision in right lower quadrant; incision must not be too large to prevent subsequent hernia.↗
▶Ep 27 · 26:15
clinicalPeritoneal drain placement is a bedside procedure performed with small amount of local anesthesia using small transverse incision in right lower quadrant; incision must not be too large to prevent subsequent hernia.↗
▶Ep 27 · 26:34
quoteIf you make the incision too big, it's a problem because then you can get a hernia once the drain is out.↗
▶Ep 27 · 26:34
quoteIf you make the incision too big, it's a problem because then you can get a hernia once the drain is out.↗
▶Ep 27 · 26:41
clinicalQuarter-inch Penrose drain is used for peritoneal drainage; drain is passed gently multiple times without forcing to avoid bleeding, then sutured in place.↗
▶Ep 27 · 26:41
clinicalQuarter-inch Penrose drain is used for peritoneal drainage; drain is passed gently multiple times without forcing to avoid bleeding, then sutured in place.↗
▶Ep 27 · 28:43
clinicalOperating during peak inflammatory process (e.g., 2 weeks after drain with ongoing stool output) can result in severe adhesions, serosal tears, and enterotomies; sometimes smartest decision is to stop operation, create proximal diverting stoma if possible, and avoid making situation worse.↗
▶Ep 27 · 28:43
clinicalOperating during peak inflammatory process (e.g., 2 weeks after drain with ongoing stool output) can result in severe adhesions, serosal tears, and enterotomies; sometimes smartest decision is to stop operation, create proximal diverting stoma if possible, and avoid making situation worse.↗
▶Ep 27 · 28:57
quoteI think one of the smartest decisions that a surgeon can make is to know when to get out and to stop.↗
▶Ep 27 · 28:57
quoteI think one of the smartest decisions that a surgeon can make is to know when to get out and to stop.↗
▶Ep 27 · 29:13
quoteYou just can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run.↗
▶Ep 27 · 29:13
quoteYou just can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run.↗
▶Ep 27 · 29:48
clinicalAfter successful drain placement with patient recovery, drain should be advanced out over several days starting at 7-10 days post-operation rather than withdrawing all at once.↗
▶Ep 27 · 29:48
clinicalAfter successful drain placement with patient recovery, drain should be advanced out over several days starting at 7-10 days post-operation rather than withdrawing all at once.↗
▶Ep 27 · 30:09
clinicalContinual leakage of stool at drain site is concerning; upper GI small bowel follow-through should be considered before drain removal if ongoing stool leakage present.↗
▶Ep 27 · 30:09
clinicalContinual leakage of stool at drain site is concerning; upper GI small bowel follow-through should be considered before drain removal if ongoing stool leakage present.↗
▶Ep 27 · 30:49
clinicalIf feeds are started after drain removal without contrast study and patient doesn't tolerate feeds, contrast study becomes mandatory to ensure everything is intact.↗
▶Ep 27 · 30:49
clinicalIf feeds are started after drain removal without contrast study and patient doesn't tolerate feeds, contrast study becomes mandatory to ensure everything is intact.↗
▶Ep 27 · 31:24
clinicalFor laparotomy, if baby is too hemodynamically unstable or on very high oscillator settings to safely transport to OR, operation can be performed at bedside in ICU with surgical team and anesthesiologists.↗
▶Ep 27 · 31:24
clinicalFor laparotomy, if baby is too hemodynamically unstable or on very high oscillator settings to safely transport to OR, operation can be performed at bedside in ICU with surgical team and anesthesiologists.↗
▶Ep 27 · 31:43
clinicalLaparotomy uses supraumbilical transverse incision; extreme care needed due to thin skin and underlying dilated bowel to avoid immediate enterotomy.↗
▶Ep 27 · 31:43
clinicalLaparotomy uses supraumbilical transverse incision; extreme care needed due to thin skin and underlying dilated bowel to avoid immediate enterotomy.↗
▶Ep 27 · 32:05
clinicalPatient should be resuscitated preoperatively with at least partial correction of platelet and coagulation abnormalities; blood products (packed red blood cells, platelets, fresh frozen plasma) must be available for operation.↗
▶Ep 27 · 32:05
clinicalPatient should be resuscitated preoperatively with at least partial correction of platelet and coagulation abnormalities; blood products (packed red blood cells, platelets, fresh frozen plasma) must be available for operation.↗
▶Ep 27 · 32:27
clinicalIt is critically important not to injure liver or spleen in premature babies during laparotomy; even minimal trauma can cause subcapsular hematoma that baby can exsanguinate from.↗
▶Ep 27 · 32:27
quoteIf you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this.↗
▶Ep 27 · 32:27
clinicalIt is critically important not to injure liver or spleen in premature babies during laparotomy; even minimal trauma can cause subcapsular hematoma that baby can exsanguinate from.↗
▶Ep 27 · 32:27
quoteIf you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this.↗
▶Ep 27 · 32:46
quoteYou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies.↗
▶Ep 27 · 32:46
quoteYou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies.↗
▶Ep 27 · 33:21
clinicalSpontaneous intestinal perforation (SIP) presents as one small localized area of perforation, while NEC is more diffuse disease with pneumatosis involving more than one tiny area; differentiation can be difficult preoperatively.↗
▶Ep 27 · 33:21
clinicalSpontaneous intestinal perforation (SIP) presents as one small localized area of perforation, while NEC is more diffuse disease with pneumatosis involving more than one tiny area; differentiation can be difficult preoperatively.↗
▶Ep 27 · 33:26
quoteI sometimes find the too hard to differentiate preoperatively. I've been fooled before thinking it's one and it turns out to be the other.↗
▶Ep 27 · 33:26
quoteI sometimes find the too hard to differentiate preoperatively. I've been fooled before thinking it's one and it turns out to be the other.↗
▶Ep 27 · 34:04
clinicalSome surgeons worldwide perform primary anastomosis after limited NEC resection; in the United States, surgeons are less likely to do primary anastomosis due to concern about anastomotic healing in these patients.↗
▶Ep 27 · 34:04
clinicalSome surgeons worldwide perform primary anastomosis after limited NEC resection; in the United States, surgeons are less likely to do primary anastomosis due to concern about anastomotic healing in these patients.↗
▶Ep 27 · 34:20
clinicalDr. Besner typically performs resection with stoma and mucous fistula rather than primary anastomosis, with stoma closure when patient is bigger (at least 2000g) and stable.↗
▶Ep 27 · 34:20
quoteI err on the side of being a little bit cautious, and I usually make stomas in these patients because I'm just so worried about them not being able to heal their anastomosis.↗
▶Ep 27 · 34:20
clinicalDr. Besner typically performs resection with stoma and mucous fistula rather than primary anastomosis, with stoma closure when patient is bigger (at least 2000g) and stable.↗
▶Ep 27 · 34:20
quoteI err on the side of being a little bit cautious, and I usually make stomas in these patients because I'm just so worried about them not being able to heal their anastomosis.↗
▶Ep 27 · 35:07
clinicalStomas are brought out through laparotomy incision with functional end and mucous fistula positioned close together to facilitate limited reoperation for closure; stomas are tacked to fascia but not matured.↗
▶Ep 27 · 35:07
clinicalStomas are brought out through laparotomy incision with functional end and mucous fistula positioned close together to facilitate limited reoperation for closure; stomas are tacked to fascia but not matured.↗
▶Ep 27 · 35:50
quoteNo matter how careful you make these stomas, sometimes the distal end will slough off.↗
▶Ep 27 · 35:50
clinicalDistal end of stoma must protrude slightly because it can slough off; leaving small distal end prevents recession under fascia.↗
▶Ep 27 · 35:50
clinicalDistal end of stoma must protrude slightly because it can slough off; leaving small distal end prevents recession under fascia.↗
▶Ep 27 · 35:50
quoteNo matter how careful you make these stomas, sometimes the distal end will slough off.↗
▶Ep 27 · 37:12
clinicalWhen bowel appears injured but not clearly necrotic (thin-walled, brownish discoloration, pneumatosis but not dead), acceptable approach is to not resect and perform second-look operation in 24-48 hours.↗
▶Ep 27 · 37:12
clinicalWhen bowel appears injured but not clearly necrotic (thin-walled, brownish discoloration, pneumatosis but not dead), acceptable approach is to not resect and perform second-look operation in 24-48 hours.↗
▶Ep 27 · 37:16
quoteSometimes if we go into the operating room a little too early on these patients, you see just what you described. It kind of looks like, you know, it's injured, but it's not necrotic, and it all kind of looks diffusely the same.↗
▶Ep 27 · 37:16
quoteSometimes if we go into the operating room a little too early on these patients, you see just what you described. It kind of looks like, you know, it's injured, but it's not necrotic, and it all kind of looks diffusely the same.↗
▶Ep 27 · 37:28
quoteI think it's perfectly acceptable to not resect at that point and to simply do nothing.↗
▶Ep 27 · 37:28
quoteI think it's perfectly acceptable to not resect at that point and to simply do nothing.↗
▶Ep 27 · 37:35
clinicalAbdomen may be left open if there are many dilated loops of bowel to avoid adding pressure that may compromise blood flow.↗
▶Ep 27 · 37:35
clinicalAbdomen may be left open if there are many dilated loops of bowel to avoid adding pressure that may compromise blood flow.↗
▶Ep 27 · 38:07
clinicalFor multiple skip lesions that are very close together, can resect all without creating short bowel syndrome rather than having multiple anastomoses.↗
▶Ep 27 · 38:07
clinicalFor multiple skip lesions that are very close together, can resect all without creating short bowel syndrome rather than having multiple anastomoses.↗
▶Ep 27 · 38:19
clinicalFor separated skip lesions, can perform multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion; if anastomotic healing problem occurs, it won't be major issue because of proximal diversion.↗
▶Ep 27 · 38:19
clinicalFor separated skip lesions, can perform multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion; if anastomotic healing problem occurs, it won't be major issue because of proximal diversion.↗
▶Ep 27 · 38:46
clinicalClip and drop technique (resecting dead bowel, clipping ends, replacing in abdomen, returning for anastomosis when baby more stable) can be life-saving maneuver in very unstable patients without time for multiple anastomoses.↗
▶Ep 27 · 38:46
clinicalClip and drop technique (resecting dead bowel, clipping ends, replacing in abdomen, returning for anastomosis when baby more stable) can be life-saving maneuver in very unstable patients without time for multiple anastomoses.↗
▶Ep 27 · 39:32
clinicalStoma reversal typically performed when baby is stable, well, hopefully feeding, and approximately 2000g in size; anastomosis is easier when baby is bigger.↗
▶Ep 27 · 39:32
clinicalStoma reversal typically performed when baby is stable, well, hopefully feeding, and approximately 2000g in size; anastomosis is easier when baby is bigger.↗
▶Ep 27 · 39:56
clinicalEarlier stoma reversal is indicated if baby develops TPN-induced cholestasis or cannot be nourished due to very high stoma output.↗
▶Ep 27 · 39:56
clinicalEarlier stoma reversal is indicated if baby develops TPN-induced cholestasis or cannot be nourished due to very high stoma output.↗
▶Ep 27 · 40:48
clinicalMucous fistula refeeding is done selectively rather than routinely, particularly for very high output stomas where any nourishment given comes directly out the stoma.↗
▶Ep 27 · 40:48
clinicalMucous fistula refeeding is done selectively rather than routinely, particularly for very high output stomas where any nourishment given comes directly out the stoma.↗
▶Ep 27 · 41:22
quoteYou have to be careful when you make that mucous fistula because often it strictures and you lose the opportunity to refeed.↗
▶Ep 27 · 41:22
clinicalMucous fistula often strictures post-operatively, losing opportunity for refeeding; if serious about refeeding (e.g., after massive resection with very high stoma), consider leaving small soft catheter in mucous fistula post-op to maintain access.↗
▶Ep 27 · 41:22
quoteYou have to be careful when you make that mucous fistula because often it strictures and you lose the opportunity to refeed.↗
▶Ep 27 · 41:22
clinicalMucous fistula often strictures post-operatively, losing opportunity for refeeding; if serious about refeeding (e.g., after massive resection with very high stoma), consider leaving small soft catheter in mucous fistula post-op to maintain access.↗
▶Ep 27 · 42:15
quoteNecrotizing enterocolitis totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis.↗
▶Ep 27 · 42:15
clinicalNEC totalis is one of most tragic findings on exploratory laparotomy for NEC; chance of baby living to be old enough for small bowel-liver transplant is very close to zero.↗
▶Ep 27 · 42:15
quoteNecrotizing enterocolitis totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis.↗
▶Ep 27 · 42:15
clinicalNEC totalis is one of most tragic findings on exploratory laparotomy for NEC; chance of baby living to be old enough for small bowel-liver transplant is very close to zero.↗
▶Ep 27 · 42:32
quoteThe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero.↗
▶Ep 27 · 42:32
quoteThe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero.↗
▶Ep 27 · 42:56
quoteI don't think, would be criticized for explaining to the parents the severity of the problem and just closing the abdomen and giving the baby comfort care.↗
▶Ep 27 · 42:56
opinionFor very small premature baby with NEC totalis, current technology cannot get baby through this devastating problem; no one would be criticized for explaining severity to parents and providing comfort care after closing abdomen.↗
▶Ep 27 · 42:56
quoteI don't think, would be criticized for explaining to the parents the severity of the problem and just closing the abdomen and giving the baby comfort care.↗
▶Ep 27 · 42:56
opinionFor very small premature baby with NEC totalis, current technology cannot get baby through this devastating problem; no one would be criticized for explaining severity to parents and providing comfort care after closing abdomen.↗
▶Ep 27 · 43:42
quoteIn my experience, the chance of that baby living through, you know, the months to years of TPN that they're going to require is going to, you know, irreversibly injure their liver.↗
▶Ep 27 · 43:42
opinionIn Dr. Besner's experience, chance of baby with NEC totalis surviving months-to-years of required TPN is very low; TPN will irreversibly injure liver, and even if baby lives to transplant size, small bowel transplant results remain suboptimal.↗
▶Ep 27 · 43:42
quoteIn my experience, the chance of that baby living through, you know, the months to years of TPN that they're going to require is going to, you know, irreversibly injure their liver.↗
▶Ep 27 · 43:42
opinionIn Dr. Besner's experience, chance of baby with NEC totalis surviving months-to-years of required TPN is very low; TPN will irreversibly injure liver, and even if baby lives to transplant size, small bowel transplant results remain suboptimal.↗
▶Ep 27 · 44:01
quoteI just in general think that that's a no-win situation in my experience.↗
▶Ep 27 · 44:01
quoteI just in general think that that's a no-win situation in my experience.↗
▶Ep 27 · 44:28
clinicalSmall subset of premature patients with severe lung disease can develop pneumothorax that dissects through diaphragm into abdomen, causing pneumoperitoneum; must confirm problem is in abdomen rather than chest.↗
▶Ep 27 · 44:28
clinicalSmall subset of premature patients with severe lung disease can develop pneumothorax that dissects through diaphragm into abdomen, causing pneumoperitoneum; must confirm problem is in abdomen rather than chest.↗
▶Ep 27 · 45:06
clinicalFor extremely unstable patient (e.g., 800g on jet ventilation and pressors) with pneumoperitoneum and severe distention, angiocatheter can be inserted through abdominal wall to release pneumoperitoneum as temporizing maneuver while mobilizing for definitive operation.↗
▶Ep 27 · 45:06
clinicalFor extremely unstable patient (e.g., 800g on jet ventilation and pressors) with pneumoperitoneum and severe distention, angiocatheter can be inserted through abdominal wall to release pneumoperitoneum as temporizing maneuver while mobilizing for definitive operation.↗
Journal of Pediatric Surgery Article Review: January 2022 APSA Issue
▶Ep 38 · 1:41
quoteHistorically, surgeons of all types have been incentivized based on their work or views, and it's certainly important for clinical productivity and clinical program building, but it's really important to take advantage of other strengths that surgeons have.↗
▶Ep 38 · 1:41
opinionHistorically, surgeons have been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have.↗
▶Ep 38 · 2:23
quoteThe Question is, how do we promote academic productivity amongst our partners?↗
▶Ep 38 · 2:55
quoteThe concept of academic RVUs was probably first put out there about 12 or 13 years ago, but it wasn't described how to incentivize people for that.↗
▶Ep 38 · 2:55
clinicalThe concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work.↗
▶Ep 38 · 3:07
clinicalNationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits.↗
▶Ep 38 · 3:27
clinicalThe Nationwide system kept work RVUs as part of the incentivization plan along with other goals that must be achievable.↗
▶Ep 38 · 3:34
quoteAnd I really believe that these types of goals and these types of incentives have to be achievable.↗
Stay Current Throwbacks Necrotizing Enterocolitis with Dr. Gail Besner
▶Ep 40 · 1:53
clinicalDespite six decades of research, the exact cause of necrotizing enterocolitis remains unknown and there is no absolute cure.↗
▶Ep 40 · 2:10
quotedespite six decades of research, we really don't know exactly what causes nec, and we still are quite some ways from finding an absolute cure for the disease↗
▶Ep 40 · 3:21
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 40 · 4:46
clinicalAcid suppression medications (PPIs, H2 blockers) should be avoided in at-risk neonates because neutralizing gastric acid may increase NEC risk.↗
▶Ep 40 · 5:10
quoteyou don't want to neutralize the acid that the baby is producing↗
▶Ep 40 · 5:24
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 40 · 7:14
clinicalNeutropenia (low white blood cell count) in a baby with suspected NEC is more concerning than leukocytosis because it may indicate overwhelming sepsis that the baby cannot compensate for.↗
▶Ep 40 · 7:14
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and platelet count is important to know before surgery to optimize the patient's condition.↗
▶Ep 40 · 7:30
quoteI actually get more worried when the patients are neutropenic and they have a low white blood cell count. Because to me, that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 40 · 8:48
clinicalCross-table lateral or lateral decubitus films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 40 · 9:24
clinicalFree air on imaging is an absolute indication for surgical intervention (either drain or laparotomy) in NEC.↗
▶Ep 40 · 9:50
opinionFixed loops of intestine on serial x-rays are not an absolute indication for surgery but are a concerning sign that the patient is not improving.↗
▶Ep 40 · 10:25
clinicalPortal venous air is a worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management.↗
▶Ep 40 · 11:01
guidelineMedical management of NEC includes withholding feeds, orogastric tube decompression, broad-spectrum antibiotics, and serial monitoring (exams, labs, x-rays).↗
▶Ep 40 · 11:46
clinicalSmall French feeding tubes are inadequate for gastric decompression in NEC; they should be replaced with larger orogastric tubes.↗
▶Ep 40 · 12:35
opinionThere is likely tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization patterns in individual ICU environments.↗
▶Ep 40 · 13:39
opinionAbdominal x-rays should be obtained at regular intervals (approximately every 8 hours) during medical NEC management, not waiting 12-24 hours between films.↗
▶Ep 40 · 14:16
opinionBabies should remain NPO for at least 7-10 days (preferably a week and a half) after medical NEC treatment before attempting to restart feeds.↗
▶Ep 40 · 14:45
clinicalStricture formation after medical NEC typically occurs in the colon, usually near the splenic flexure, but can occur anywhere.↗
▶Ep 40 · 15:18
clinicalWhen evaluating for post-NEC stricture, contrast enema should be performed before upper GI with small bowel follow-through because strictures are more common in the colon and waiting for contrast to pass through obstructed small bowel is time-consuming.↗
▶Ep 40 · 16:22
opinionSerial abdominal examinations over time are more valuable than a single examination for determining need for surgery in NEC without absolute indications.↗
▶Ep 40 · 16:40
quoteI think that serial abdominal exams are important. And if you see worsening distension, worsening, you know, signs of peritoneal irritation, hemodynamic instability with increasing needs for presser support, renal shutdown with no urine production, you know, it starts to build up. And it's like building blocks. And if you have, you know, A, B, and C, it's time to think about surgery.↗
▶Ep 40 · 19:29
quote100% of the surgeons do a laparotomy, and no one puts in a drain in Europe, which I thought was just fascinating↗
▶Ep 40 · 19:29
epidemiologicalAt a recent NEC conference in London, 100% of European surgeons reported performing laparotomy for NEC; none use peritoneal drainage.↗
▶Ep 40 · 19:42
epidemiologicalThe MOSS and PIERO randomized controlled trials showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC.↗
▶Ep 40 · 20:20
epidemiologicalBabies who receive peritoneal drains instead of laparotomy may have worse neurological outcomes at 1-2 years post-NEC, though early mortality is similar.↗
▶Ep 40 · 20:30
quoteit appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis↗
▶Ep 40 · 21:00
epidemiologicalThe NEST trial randomized 300 babies to peritoneal drainage versus laparotomy and will assess neurological outcomes at 18-22 months, with results expected in 1-2 years (from 2017).↗
▶Ep 40 · 21:41
quoteI predict that in the next year or two, we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies↗
▶Ep 40 · 22:20
quotewhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult↗
▶Ep 40 · 24:07
clinicalSpontaneous intestinal perforation (SIP) can cause hemodynamic instability similar to NEC through systemic inflammatory response syndrome, making clinical differentiation difficult.↗
▶Ep 40 · 26:17
clinicalPeritoneal drain placement can be performed at bedside with local anesthesia through a small right lower quadrant transverse incision using a quarter-inch Penrose drain.↗
▶Ep 40 · 27:00
clinicalMaking the drain incision too large can lead to hernia formation after drain removal.↗
▶Ep 40 · 28:38
opinionWhen operating on a baby with extensive adhesions after drain placement, surgeons should know when to stop if causing multiple serosal tears and enterotomies, as continuing may worsen the outcome.↗
▶Ep 40 · 29:00
quotesometimes I think that one of the smartest decisions that a surgeon can make is to know when to get out and to stop↗
▶Ep 40 · 29:20
clinicalCreating a proximal diverting stoma is helpful when extensive adhesions prevent safe complete exploration, as it controls the perforation and diverts the fecal stream.↗
▶Ep 40 · 29:50
opinionPeritoneal drains should be advanced out gradually over several days starting at 7-10 days post-placement, rather than removing all at once.↗
▶Ep 40 · 31:18
clinicalFor laparotomy in NEC, a supraumbilical transverse incision is used, with extreme care required to avoid liver and spleen injury in premature infants.↗
▶Ep 40 · 32:00
clinicalEven minimal trauma to the liver in premature babies can cause subcapsular hematomas that can lead to exsanguination.↗
▶Ep 40 · 32:30
quoteyou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies↗
▶Ep 40 · 33:10
clinicalNEC is differentiated from SIP intraoperatively: SIP presents as one small localized perforation, while NEC shows more diffuse disease with pneumatosis involving more than one area.↗
▶Ep 40 · 34:00
clinicalSome surgeons internationally perform primary anastomosis after NEC resection, but many US surgeons create stomas due to concern about anastomotic healing in critically ill premature infants.↗
▶Ep 40 · 35:03
clinicalBringing stoma and mucous fistula out close together through the main incision allows for more limited reoperation at stoma closure compared to separate sites.↗
▶Ep 40 · 35:45
clinicalStomas should be tacked to fascia (not matured) and a small distal end should protrude to prevent recession under the fascia, though sloughing of the distal end can still occur.↗
▶Ep 40 · 37:13
opinionWhen bowel appears injured but not clearly necrotic (thin-walled, brownish, with pneumatosis but diffusely similar), it may be appropriate to not resect, leave the abdomen open to reduce pressure, and return for second-look operation in 24-48 hours.↗
▶Ep 40 · 37:20
quoteI think sometimes if we go into the operating room a little too early on these patients, you see just what you describe. It kind of looks like, you know, it's injured, but it's not necrotic and it all kind of looks diffusely the same.↗
▶Ep 40 · 38:06
opinionFor multiple skip lesions in NEC, if they are close together and can be resected without creating short bowel syndrome, resecting all may be preferable to multiple anastomoses.↗
▶Ep 40 · 38:30
clinicalMultiple anastomoses can be performed with proximal diversion so that if one anastomosis fails to heal, it is distal to the diversion and less problematic.↗
▶Ep 40 · 38:48
clinicalClip-and-drop technique (resecting dead bowel, clipping ends, replacing in abdomen for later definitive surgery) can be lifesaving in very unstable patients when time does not permit multiple anastomoses.↗
▶Ep 40 · 39:28
opinionStoma reversal is typically performed when the baby reaches approximately 2000 grams, though earlier reversal is indicated for TPN-induced cholestasis or inability to nourish due to high stoma output.↗
▶Ep 40 · 40:41
opinionRefeeding through mucous fistula is done selectively (not routinely), primarily for very high-output stomas where most nutrition is lost through the stoma.↗
▶Ep 40 · 41:23
clinicalMucous fistulas often stricture, preventing refeeding access; leaving a small soft catheter in the mucous fistula post-operatively can maintain access for refeeding.↗
▶Ep 40 · 42:06
clinicalThe chance of a premature baby with NEC totalis surviving long enough to receive small bowel-liver transplant is very close to zero.↗
▶Ep 40 · 42:20
quotethe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero↗
▶Ep 40 · 43:39
clinicalBabies with NEC totalis who survive on TPN for months to years will develop irreversible liver injury, and even if they reach transplant size, small bowel transplant outcomes remain suboptimal.↗
▶Ep 40 · 44:22
clinicalPneumothorax can dissect through the diaphragm into the abdomen in premature babies with severe lung disease, mimicking intra-abdominal free air; this must be ruled out before attributing pneumoperitoneum to bowel perforation.↗
▶Ep 40 · 45:00
clinicalIn a hemodynamically unstable baby with pneumoperitoneum, inserting an angiocatheter through the abdominal wall to release pressure is a useful temporizing measure while mobilizing the OR.↗
Journal of Pediatric Surgery Article Review: January 2022 APSA Issue
▶Ep 19 · 1:41
quoteHistorically, surgeons of all types have been incentivized based on their work or views, and it's certainly important for clinical productivity and clinical program building, but it's really important to take advantage of other strengths that surgeons have.↗
▶Ep 19 · 1:41
opinionHistorically, surgeons have been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have.↗
▶Ep 19 · 2:23
quoteThe Question is, how do we promote academic productivity amongst our partners?↗
▶Ep 19 · 2:55
quoteThe concept of academic RVUs was probably first put out there about 12 or 13 years ago, but it wasn't described how to incentivize people for that.↗
▶Ep 19 · 2:55
clinicalThe concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work.↗
▶Ep 19 · 3:07
clinicalNationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits.↗
▶Ep 19 · 3:27
clinicalThe Nationwide system kept work RVUs as part of the incentivization plan along with other goals that must be achievable.↗
▶Ep 19 · 3:34
quoteAnd I really believe that these types of goals and these types of incentives have to be achievable.↗
Journal of Pediatric Surgery Article Review: January 2022 APSA Issue
▶Ep 16 · 1:41
quoteHistorically, surgeons of all types have been incentivized based on their work or views, and it's certainly important for clinical productivity and clinical program building, but it's really important to take advantage of other strengths that surgeons have.↗
▶Ep 16 · 1:41
opinionHistorically, surgeons have been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have.↗
▶Ep 16 · 2:23
quoteThe Question is, how do we promote academic productivity amongst our partners?↗
▶Ep 16 · 2:55
clinicalThe concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work.↗
▶Ep 16 · 2:55
quoteThe concept of academic RVUs was probably first put out there about 12 or 13 years ago, but it wasn't described how to incentivize people for that.↗
▶Ep 16 · 3:07
clinicalNationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits.↗
▶Ep 16 · 3:27
clinicalThe Nationwide system kept work RVUs as part of the incentivization plan along with other goals that must be achievable.↗
▶Ep 16 · 3:34
quoteAnd I really believe that these types of goals and these types of incentives have to be achievable.↗
Journal of Pediatric Surgery Article Review: January 2022 APSA Issue
▶Ep 50 · 1:41
opinionHistorically, surgeons have been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have.↗
▶Ep 50 · 1:41
quoteHistorically, surgeons of all types have been incentivized based on their work or views, and it's certainly important for clinical productivity and clinical program building, but it's really important to take advantage of other strengths that surgeons have.↗
▶Ep 50 · 2:23
quoteThe Question is, how do we promote academic productivity amongst our partners?↗
▶Ep 50 · 2:55
clinicalThe concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work.↗
▶Ep 50 · 2:55
quoteThe concept of academic RVUs was probably first put out there about 12 or 13 years ago, but it wasn't described how to incentivize people for that.↗
▶Ep 50 · 3:07
clinicalNationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits.↗
▶Ep 50 · 3:27
clinicalThe Nationwide system kept work RVUs as part of the incentivization plan along with other goals that must be achievable.↗
▶Ep 50 · 3:34
quoteAnd I really believe that these types of goals and these types of incentives have to be achievable.↗
clinicalDespite 6 decades of research, we don't know exactly what causes NEC and are still quite some ways from finding an absolute cure.↗
▶Ep 16 · 2:11
quoteDespite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease.↗
▶Ep 16 · 4:14
clinicalIndomethacin predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 16 · 4:44
clinicalPPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; you don't want to neutralize gastric acid.↗
▶Ep 16 · 5:29
clinicalIn premature babies with NEC, intestinal contents can leak into the scrotum through a patent processus vaginalis, causing scrotal swelling and discoloration.↗
▶Ep 16 · 7:17
clinicalNeutropenia (low white blood cell count) is more worrisome than elevated WBC in NEC because it suggests overwhelming sepsis that the patient is not compensating for.↗
▶Ep 16 · 7:17
quoteI get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 16 · 7:33
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and knowledge of platelet count is important for optimizing patient condition prior to surgery.↗
▶Ep 16 · 8:33
clinicalThere is no single test that shows whether you have ischemic or necrotic bowel, but taking all tests in combination gives a sense of how sick the patient is.↗
▶Ep 16 · 8:33
quoteUnfortunately, there's no one test that, you know, shows whether you have an ischemic or necrotic bowel. But if you take all of these tests in combination with each other, you can get a sense as to how sick you think the patient is.↗
▶Ep 16 · 8:50
clinicalFor imaging in suspected NEC, you need plain film plus either cross-table lateral or lateral decubitus film because free air can be quite subtle and you don't want to miss it.↗
▶Ep 16 · 9:08
quoteYou don't want to just get a plain film. You want to get something that will increase your chance of being able to visualize even a small amount of free air.↗
▶Ep 16 · 9:38
clinicalFree air on imaging is an absolute indication for surgical intervention (either drain or laparotomy).↗
▶Ep 16 · 9:54
clinicalClinical deterioration in the face of maximum medical management is an indication for surgery.↗
▶Ep 16 · 10:02
clinicalFixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not going in the right direction.↗
▶Ep 16 · 10:16
clinicalPortal venous air is a concerning and worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.↗
▶Ep 16 · 10:16
quoteI have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation, but those things like fixed loops of bowel and serial films, the development of portal venous air, which sometimes can be quite fleeting, those are worrisome signs.↗
▶Ep 16 · 10:58
clinicalMedical management of NEC includes: withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotics, and performing serial abdominal exams, labs, and X-rays.↗
▶Ep 16 · 12:05
clinicalSmall French feeding tubes are not adequate for gastric decompression in NEC; they should be replaced with an orogastric tube.↗
▶Ep 16 · 12:05
quoteUnfortunately those tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression.↗
▶Ep 16 · 12:43
epidemiologicalThere is tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization of the ICU environment.↗
▶Ep 16 · 12:52
quoteI think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment.↗
▶Ep 16 · 13:37
opinionFor serial X-rays in NEC, obtaining them every 8 hours is reasonable; getting them too frequently makes no sense, but waiting 12-24 hours is too long.↗
▶Ep 16 · 14:15
clinicalPatients with NEC should be kept NPO with NG decompression and antibiotics for at least 1 week to 10 days (preferably a week and a half) before starting feeds.↗
▶Ep 16 · 14:29
clinicalSome babies have repeated episodes of necrotizing enterocolitis.↗
▶Ep 16 · 14:40
clinicalStricture formation is a complication of medical NEC that should be suspected in babies not tolerating feeds post-NEC; strictures typically occur in the colon, usually near the splenic flexure, but can occur anywhere.↗
▶Ep 16 · 15:17
opinionFor suspected stricture post-NEC, starting with contrast enema is preferred over upper GI with small bowel follow-through because strictures are more common in the colon and contrast from above takes long to transit, especially if partially obstructed.↗
▶Ep 16 · 16:23
clinicalSerial abdominal exams are critical for determining when to operate on NEC patients without absolute indications; worsening distention, peritoneal signs, hemodynamic instability with increasing pressor needs, and renal shutdown build up like building blocks to indicate need for surgery.↗
▶Ep 16 · 18:16
clinicalTwo surgical options for NEC are exploratory laparotomy and peritoneal drain placement.↗
▶Ep 16 · 18:22
clinicalThe ongoing NEST trial (necrotizing enterocolitis surgery trial) is concluding and will provide results in the next 1-2 years comparing peritoneal drainage versus laparotomy.↗
▶Ep 16 · 18:22
quoteI wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial.↗
▶Ep 16 · 18:39
clinicalMortality difference between peritoneal drainage and laparotomy for NEC is indecipherable; survival chance is about the same with either procedure.↗
▶Ep 16 · 19:10
quote100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating.↗
▶Ep 16 · 19:10
epidemiologicalAt a NEC conference in London, 100% of surgeons polled do laparotomy and no one puts in a drain in Europe.↗
▶Ep 16 · 19:44
clinicalThe MOSS trial (United States) and PIERO trial (Europe) showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC, but these studies looked at early endpoints rather than delayed neurological outcomes.↗
▶Ep 16 · 20:14
clinicalBabies who have peritoneal drains instead of laparotomy may do worse neurologically if you look at outcomes 1-2 years after recovery from NEC.↗
▶Ep 16 · 20:34
clinicalThe NEST trial will randomize 300 babies to peritoneal drainage versus laparotomy and assess neurological outcomes at 18-22 months after NEC recovery with detailed neurological assessments.↗
▶Ep 16 · 20:53
quoteWe certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road.↗
▶Ep 16 · 21:44
quoteI predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies.↗
▶Ep 16 · 21:44
opinionDr. Besner predicts that in the next 1-2 years practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes likely better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.↗
▶Ep 16 · 22:09
clinicalWhen peritoneal drains are placed and babies subsequently undergo laparotomy, the degree of dead bowel actually present is often quite striking and it's inconceivable the baby could get over that insult.↗
▶Ep 16 · 22:09
quoteWhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult.↗
▶Ep 16 · 22:58
opinionThere are no criteria that help decide between laparotomy or drain for NEC; with current information you can't be faulted for doing either one.↗
▶Ep 16 · 24:15
clinicalYou can get just as sick and hemodynamically unstable from systemic inflammatory response syndrome with an isolated intestinal perforation as from necrotizing enterocolitis.↗
▶Ep 16 · 26:15
clinicalPeritoneal drain placement is a bedside procedure with tiny amount of local anesthesia, using a small transverse incision in the right lower quadrant for a 1/4 inch Penrose drain.↗
▶Ep 16 · 26:34
clinicalIf the incision for peritoneal drain is made too big, it's a problem because the patient can get a hernia once the drain is out.↗
▶Ep 16 · 27:01
clinicalWhen placing peritoneal drain, pass it several times gently without forcing to avoid bleeding; it's hard to achieve the drain curving to all four quadrants as shown in published pictures.↗
▶Ep 16 · 28:43
clinicalAfter peritoneal drain placement, if baby continues producing stool from drain for weeks and you convert to laparotomy, you may be forced to operate at the wrong time when inflammatory process is at its worst, resulting in extensive adhesions and serosal tears.↗
▶Ep 16 · 29:03
opinionOne of the smartest surgical decisions is knowing when to get out and stop; if you're getting serosal tears and making the situation worse during difficult NEC laparotomy, it's time to stop.↗
▶Ep 16 · 29:03
quoteOne of the smartest decisions that a surgeon can make is to know when to get out and to stop.↗
▶Ep 16 · 29:13
clinicalIn difficult NEC laparotomy with extensive adhesions, try to make a proximal diverting stoma to control the area of perforation, but don't keep going if making multiple enterotomies and serosal injuries.↗
▶Ep 16 · 29:24
quoteYou can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run.↗
▶Ep 16 · 29:48
clinicalFor successful peritoneal drain management, advance the drain out over several days starting at 7-10 days post-operation rather than withdrawing it all at once.↗
▶Ep 16 · 30:09
clinicalDon't advance peritoneal drain out if there's continual leakage of stool at the drain site; this suggests ongoing area of leakage.↗
▶Ep 16 · 30:22
opinionThere is difference of opinion about whether to get upper GI small bowel follow-through before removing peritoneal drain; it should be considered if there's ongoing stool leakage.↗
▶Ep 16 · 30:49
clinicalIf baby does well after drain removal without contrast study but doesn't tolerate feeds, then contrast study is compelled to ensure everything is OK.↗
▶Ep 16 · 31:19
clinicalFor NEC laparotomy, if baby is hemodynamically unstable or on very high oscillator settings and can't be safely moved to OR, bring the OR to bedside and operate in the ICU.↗
▶Ep 16 · 31:43
clinicalFor NEC laparotomy, make supraumbilical transverse incision; skin is extraordinarily thin so be careful entering abdomen, especially with underlying dilated bowel loops.↗
▶Ep 16 · 32:08
clinicalFor NEC laparotomy, have blood products available (packed RBCs, platelets, fresh frozen plasma) and partially correct platelet and coagulation abnormalities preoperatively.↗
▶Ep 16 · 32:27
clinicalIn premature babies undergoing NEC laparotomy, it's incredibly important not to hurt the liver or spleen; even looking at or touching the liver wrong can cause subcapsular hematoma that a baby can exsanguinate from.↗
▶Ep 16 · 32:37
quoteIf you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this.↗
▶Ep 16 · 32:46
quoteYou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies.↗
▶Ep 16 · 32:53
clinicalLiver and spleen injuries can occur with peritoneal drain insertion as well.↗
▶Ep 16 · 33:21
clinicalSpontaneous intestinal perforation (SIP) is one small localized area of perforation; NEC is more diffuse disease with pneumatosis involving more than one tiny area. These can be hard to differentiate preoperatively.↗
▶Ep 16 · 34:04
epidemiologicalSome surgeons around the world resect limited NEC and do primary anastomosis; this is less common in the United States where surgeons typically make stomas due to concern about anastomotic healing.↗
▶Ep 16 · 35:07
clinicalFor NEC stomas, bring functional end and mucous fistula out through the laparotomy incision close to each other (facilitating later closure), tack to fascia without maturation.↗
▶Ep 16 · 35:50
clinicalNo matter how carefully NEC stomas are made, sometimes the distal end will slough off, so leave a little distal end sticking out so it doesn't recede under the fascia.↗
▶Ep 16 · 36:19
opinionHigh-quality enterostomal therapists can manage stomas brought out through the incision; the problem gets more complicated if the wound opens.↗
▶Ep 16 · 37:12
clinicalFor indeterminate bowel viability during NEC laparotomy (injured but not necrotic, diffusely the same appearance), it's acceptable to not resect, leave abdomen open to avoid pressure compromising blood flow, and return for second-look operation in 24-48 hours.↗
▶Ep 16 · 38:07
clinicalFor multiple skip lesions in NEC, if very close together and can resect without creating short bowel syndrome, do that rather than multiple anastomoses; otherwise do multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion.↗
▶Ep 16 · 38:46
clinicalClip-and-drop technique (resect dead bowel, clip ends, put back in, return another day) can be life-saving in very unstable NEC patients without time for multiple anastomoses.↗
▶Ep 16 · 39:15
opinionThe 'putting green' approach (bringing out multiple stomas throughout abdomen) can get really confusing and messy; try to avoid if possible.↗
▶Ep 16 · 39:32
clinicalFor stoma reversal timing, typically wait until baby is stable, well, hopefully being fed, and about 2000g (anastomosis is easier when baby is bigger); go in sooner if TPN-induced cholestasis develops or can't nourish baby due to very high stoma.↗
▶Ep 16 · 40:21
opinionStoma reversal timing is more about weight gain, clinical appearance, and TPN sequelae than a mandatory 2-month waiting period.↗
▶Ep 16 · 40:48
clinicalRefeeding mucous fistula is done selectively (not routinely) for very high-output stomas where any nourishment given comes right out the stoma.↗
▶Ep 16 · 41:22
clinicalMucous fistulas often stricture and you lose the opportunity to refeed; if serious about refeeding (e.g., massive resection, very high stoma), consider leaving a small soft catheter in the mucous fistula post-op to maintain access.↗
▶Ep 16 · 42:15
clinicalNEC totalis is one of the most tragic findings on exploratory laparotomy for NEC; the chance of a baby with true NEC totalis living to be old enough for small bowel-liver transplant is very close to zero.↗
▶Ep 16 · 42:15
quoteI think neck totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis.↗
▶Ep 16 · 42:32
quoteThe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero.↗
▶Ep 16 · 42:56
opinionFor very small premature baby with NEC totalis, we don't have the technology to get that baby through this devastating problem; no one would be criticized for explaining severity to parents and closing abdomen with comfort care.↗
▶Ep 16 · 43:42
clinicalFor NEC totalis, the chance of the baby living through months to years of required TPN will irreversibly injure their liver, and even if they live to be big enough, results of small bowel transplant are still suboptimal.↗
▶Ep 16 · 44:28
clinicalThere is a very small subset of premature patients with horrible lung disease who get pneumothorax that dissects through the diaphragm into the abdomen, presenting as free air; make sure the problem is in the abdomen and not in the chest.↗
▶Ep 16 · 45:06
clinicalFor hemodynamically unstable baby with free air and abdominal distention, put an angiocatheter through the abdominal wall to release pneumoperitoneum as a temporizing maneuver while mobilizing for surgery.↗
Necrotizing Enterocolitis with Dr. Gail Besner
▶Ep 36 · 2:11
quoteDespite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease.↗
▶Ep 36 · 2:11
quoteDespite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease.↗
▶Ep 36 · 2:11
clinicalDespite 6 decades of research, the exact cause of necrotizing enterocolitis is unknown and there is no absolute cure for the disease.↗
▶Ep 36 · 2:11
clinicalDespite 6 decades of research, the exact cause of necrotizing enterocolitis is unknown and there is no absolute cure for the disease.↗
▶Ep 36 · 3:53
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 36 · 3:53
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 36 · 4:44
clinicalPPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; gastric acid neutralization should be avoided.↗
▶Ep 36 · 4:44
clinicalPPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; gastric acid neutralization should be avoided.↗
▶Ep 36 · 5:29
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 36 · 5:29
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 36 · 7:17
quoteI get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 36 · 7:17
quoteI get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 36 · 7:17
clinicalNeutropenia and low white blood cell count are more concerning than elevated white count in NEC, suggesting overwhelming sepsis that the patient is not compensating for.↗
▶Ep 36 · 7:17
clinicalNeutropenia and low white blood cell count are more concerning than elevated white count in NEC, suggesting overwhelming sepsis that the patient is not compensating for.↗
▶Ep 36 · 7:33
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC; low platelet count is important to know before surgery to optimize patient condition.↗
▶Ep 36 · 7:33
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC; low platelet count is important to know before surgery to optimize patient condition.↗
▶Ep 36 · 8:50
clinicalCross-table lateral or lateral decubitus X-ray films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 36 · 8:50
quoteSometimes free air can be quite subtle, and we wouldn't want to miss free air.↗
▶Ep 36 · 8:50
quoteSometimes free air can be quite subtle, and we wouldn't want to miss free air.↗
▶Ep 36 · 8:50
clinicalCross-table lateral or lateral decubitus X-ray films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 36 · 9:38
clinicalPneumoperitoneum (free air) is an absolute indication for surgical intervention, either drain placement or laparotomy.↗
▶Ep 36 · 9:38
clinicalPneumoperitoneum (free air) is an absolute indication for surgical intervention, either drain placement or laparotomy.↗
▶Ep 36 · 9:54
clinicalClinical deterioration in the face of maximum medical management is an indication for surgery.↗
▶Ep 36 · 9:54
clinicalClinical deterioration in the face of maximum medical management is an indication for surgery.↗
▶Ep 36 · 10:02
quoteFixed loops of intestine on serial X-rays are not, in my opinion, an absolute indication for surgery, but it sure is going to start to make bells and whistles go off in your mind that the patient is not going in the direction that you want them to go in.↗
▶Ep 36 · 10:02
quoteFixed loops of intestine on serial X-rays are not, in my opinion, an absolute indication for surgery, but it sure is going to start to make bells and whistles go off in your mind that the patient is not going in the direction that you want them to go in.↗
▶Ep 36 · 10:02
clinicalFixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not improving.↗
▶Ep 36 · 10:02
clinicalFixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not improving.↗
▶Ep 36 · 10:16
clinicalPortal venous air is a concerning and worrisome sign, but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.↗
▶Ep 36 · 10:16
clinicalPortal venous air is a concerning and worrisome sign, but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.↗
▶Ep 36 · 10:16
quoteI have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation.↗
▶Ep 36 · 10:16
quoteI have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation.↗
▶Ep 36 · 10:58
clinicalMedical management of NEC includes withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotic therapy, and performing serial abdominal exams, labs, and X-rays.↗
▶Ep 36 · 10:58
clinicalMedical management of NEC includes withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotic therapy, and performing serial abdominal exams, labs, and X-rays.↗
▶Ep 36 · 12:05
clinicalSmall French feeding tubes are not adequate for gastric decompression in NEC; feeding tube should be removed and replaced with orogastric tube.↗
▶Ep 36 · 12:05
quoteThose tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression.↗
▶Ep 36 · 12:05
quoteThose tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression.↗
▶Ep 36 · 12:05
clinicalSmall French feeding tubes are not adequate for gastric decompression in NEC; feeding tube should be removed and replaced with orogastric tube.↗
▶Ep 36 · 12:33
clinicalThere is tremendous diversity in antibiotic regimens for NEC across the United States; broad-spectrum coverage is critical but specific regimen may depend on bacterial colonization of the intensive care unit environment.↗
▶Ep 36 · 12:33
clinicalThere is tremendous diversity in antibiotic regimens for NEC across the United States; broad-spectrum coverage is critical but specific regimen may depend on bacterial colonization of the intensive care unit environment.↗
▶Ep 36 · 12:52
quoteI think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment.↗
▶Ep 36 · 12:52
quoteI think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment.↗
▶Ep 36 · 13:37
clinicalAt Nationwide Children's Hospital, abdominal X-rays are obtained at intervals (approximately every 8 hours) rather than waiting 12-24 hours between films.↗
▶Ep 36 · 13:37
clinicalAt Nationwide Children's Hospital, abdominal X-rays are obtained at intervals (approximately every 8 hours) rather than waiting 12-24 hours between films.↗
▶Ep 36 · 14:15
clinicalMedical management (NPO, decompression, antibiotics) should continue for at least 1 week to 10 days, preferably a week and a half, before starting feeds.↗
▶Ep 36 · 14:15
clinicalMedical management (NPO, decompression, antibiotics) should continue for at least 1 week to 10 days, preferably a week and a half, before starting feeds.↗
▶Ep 36 · 14:29
clinicalSome babies have repeated episodes of necrotizing enterocolitis.↗
▶Ep 36 · 14:29
clinicalSome babies have repeated episodes of necrotizing enterocolitis.↗
▶Ep 36 · 14:40
quoteYou have to worry about stricture formation in the baby post neck who's not tolerating their feeds well.↗
▶Ep 36 · 14:40
clinicalPost-NEC stricture formation typically occurs in the colon, usually near the splenic flexure in the left colon, but can occur anywhere.↗
▶Ep 36 · 14:40
quoteYou have to worry about stricture formation in the baby post neck who's not tolerating their feeds well.↗
▶Ep 36 · 14:40
clinicalPost-NEC stricture formation typically occurs in the colon, usually near the splenic flexure in the left colon, but can occur anywhere.↗
▶Ep 36 · 15:17
clinicalFor suspected post-NEC stricture, contrast enema is preferred as initial study over upper GI with small bowel follow-through because strictures are more common in colon and contrast from below avoids long wait time if patient is partially obstructed.↗
▶Ep 36 · 15:17
clinicalFor suspected post-NEC stricture, contrast enema is preferred as initial study over upper GI with small bowel follow-through because strictures are more common in colon and contrast from below avoids long wait time if patient is partially obstructed.↗
▶Ep 36 · 16:23
quoteI still believe that it's a matter of serial abdominal exams. I think it's very hard, you know, if you just examine the baby once and think that you know what to do or what the right answer is.↗
▶Ep 36 · 16:23
quoteI still believe that it's a matter of serial abdominal exams. I think it's very hard, you know, if you just examine the baby once and think that you know what to do or what the right answer is.↗
▶Ep 36 · 16:23
clinicalSerial abdominal exams are important for surgical decision-making; worsening distention, signs of peritoneal irritation, hemodynamic instability with increasing pressor support, and renal shutdown with no urine production build up to indicate need for surgery.↗
▶Ep 36 · 16:23
clinicalSerial abdominal exams are important for surgical decision-making; worsening distention, signs of peritoneal irritation, hemodynamic instability with increasing pressor support, and renal shutdown with no urine production build up to indicate need for surgery.↗
▶Ep 36 · 18:16
quoteI wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial.↗
▶Ep 36 · 18:16
quoteI wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial.↗
▶Ep 36 · 19:10
epidemiologicalAt London NEC conference, 100% of European surgeons polled perform laparotomy for NEC and no one places peritoneal drains.↗
▶Ep 36 · 19:10
quote100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating.↗
▶Ep 36 · 19:10
epidemiologicalAt London NEC conference, 100% of European surgeons polled perform laparotomy for NEC and no one places peritoneal drains.↗
▶Ep 36 · 19:10
quote100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating.↗
▶Ep 36 · 19:44
clinicalTwo randomized controlled trials (MOSS trial in US and PIERO trial in Europe) of peritoneal drainage versus laparotomy showed no difference in overall mortality.↗
▶Ep 36 · 19:44
clinicalTwo randomized controlled trials (MOSS trial in US and PIERO trial in Europe) of peritoneal drainage versus laparotomy showed no difference in overall mortality.↗
▶Ep 36 · 20:04
clinicalMOSS and PIERO trials looked at early endpoints rather than delayed endpoints of neurological recovery.↗
▶Ep 36 · 20:04
clinicalMOSS and PIERO trials looked at early endpoints rather than delayed endpoints of neurological recovery.↗
▶Ep 36 · 20:14
quoteIt appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis.↗
▶Ep 36 · 20:14
quoteIt appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis.↗
▶Ep 36 · 20:14
clinicalBabies who have peritoneal drains instead of laparotomy may do worse from neurological standpoint if neurological outcomes are examined 1-2 years after recovery from NEC.↗
▶Ep 36 · 20:14
clinicalBabies who have peritoneal drains instead of laparotomy may do worse from neurological standpoint if neurological outcomes are examined 1-2 years after recovery from NEC.↗
▶Ep 36 · 20:34
clinicalThe ongoing NEST trial (necrotizing enterocolitis surgery trial) in the United States has randomized 300 babies to peritoneal drainage versus laparotomy and will examine neurological outcomes at 18-22 months after recovery from NEC with detailed neurological assessments.↗
▶Ep 36 · 20:34
clinicalThe ongoing NEST trial (necrotizing enterocolitis surgery trial) in the United States has randomized 300 babies to peritoneal drainage versus laparotomy and will examine neurological outcomes at 18-22 months after recovery from NEC with detailed neurological assessments.↗
▶Ep 36 · 20:53
quoteWe certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road.↗
▶Ep 36 · 20:53
quoteWe certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road.↗
▶Ep 36 · 21:44
quoteI predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies.↗
▶Ep 36 · 21:44
opinionDr. Besner predicts that in the next 1-2 years, practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes expected to be better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.↗
▶Ep 36 · 21:44
quoteI predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies.↗
▶Ep 36 · 21:44
opinionDr. Besner predicts that in the next 1-2 years, practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes expected to be better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.↗
▶Ep 36 · 22:09
clinicalBabies with peritoneal drains can have striking degree of dead bowel remaining in abdomen, as seen when some drain patients subsequently undergo laparotomy.↗
▶Ep 36 · 22:09
quoteWhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult.↗
▶Ep 36 · 22:09
quoteWhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult.↗
▶Ep 36 · 22:09
clinicalBabies with peritoneal drains can have striking degree of dead bowel remaining in abdomen, as seen when some drain patients subsequently undergo laparotomy.↗
▶Ep 36 · 24:15
clinicalSystemic inflammatory response syndrome can make patients just as sick and hemodynamically unstable from isolated intestinal perforation as from necrotizing enterocolitis.↗
▶Ep 36 · 24:15
clinicalSystemic inflammatory response syndrome can make patients just as sick and hemodynamically unstable from isolated intestinal perforation as from necrotizing enterocolitis.↗
▶Ep 36 · 24:15
quoteYou can get just as sick and just as hemodynamically unstable from the systemic inflammatory response syndrome with an intestinal perforation, an isolated intestinal perforation, as you can from necrotizing enterocolitis.↗
▶Ep 36 · 24:15
quoteYou can get just as sick and just as hemodynamically unstable from the systemic inflammatory response syndrome with an intestinal perforation, an isolated intestinal perforation, as you can from necrotizing enterocolitis.↗
▶Ep 36 · 25:46
quoteThere is a significant proportion of patients whereby you can put the drain in and they're going to continue to decline and do badly and they end up needing a laparotomy.↗
▶Ep 36 · 25:46
clinicalAfter peritoneal drain placement, significant proportion of patients continue to decline and require subsequent laparotomy.↗
▶Ep 36 · 25:46
clinicalAfter peritoneal drain placement, significant proportion of patients continue to decline and require subsequent laparotomy.↗
▶Ep 36 · 25:46
quoteThere is a significant proportion of patients whereby you can put the drain in and they're going to continue to decline and do badly and they end up needing a laparotomy.↗
▶Ep 36 · 26:15
clinicalPeritoneal drain placement is a bedside procedure performed with small amount of local anesthesia using small transverse incision in right lower quadrant; incision must not be too large to prevent subsequent hernia.↗
▶Ep 36 · 26:15
clinicalPeritoneal drain placement is a bedside procedure performed with small amount of local anesthesia using small transverse incision in right lower quadrant; incision must not be too large to prevent subsequent hernia.↗
▶Ep 36 · 26:34
quoteIf you make the incision too big, it's a problem because then you can get a hernia once the drain is out.↗
▶Ep 36 · 26:34
quoteIf you make the incision too big, it's a problem because then you can get a hernia once the drain is out.↗
▶Ep 36 · 26:41
clinicalQuarter-inch Penrose drain is used for peritoneal drainage; drain is passed gently multiple times without forcing to avoid bleeding, then sutured in place.↗
▶Ep 36 · 26:41
clinicalQuarter-inch Penrose drain is used for peritoneal drainage; drain is passed gently multiple times without forcing to avoid bleeding, then sutured in place.↗
▶Ep 36 · 28:43
clinicalOperating during peak inflammatory process (e.g., 2 weeks after drain with ongoing stool output) can result in severe adhesions, serosal tears, and enterotomies; sometimes smartest decision is to stop operation, create proximal diverting stoma if possible, and avoid making situation worse.↗
▶Ep 36 · 28:43
clinicalOperating during peak inflammatory process (e.g., 2 weeks after drain with ongoing stool output) can result in severe adhesions, serosal tears, and enterotomies; sometimes smartest decision is to stop operation, create proximal diverting stoma if possible, and avoid making situation worse.↗
▶Ep 36 · 28:57
quoteI think one of the smartest decisions that a surgeon can make is to know when to get out and to stop.↗
▶Ep 36 · 28:57
quoteI think one of the smartest decisions that a surgeon can make is to know when to get out and to stop.↗
▶Ep 36 · 29:13
quoteYou just can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run.↗
▶Ep 36 · 29:13
quoteYou just can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run.↗
▶Ep 36 · 29:48
clinicalAfter successful drain placement with patient recovery, drain should be advanced out over several days starting at 7-10 days post-operation rather than withdrawing all at once.↗
▶Ep 36 · 29:48
clinicalAfter successful drain placement with patient recovery, drain should be advanced out over several days starting at 7-10 days post-operation rather than withdrawing all at once.↗
▶Ep 36 · 30:09
clinicalContinual leakage of stool at drain site is concerning; upper GI small bowel follow-through should be considered before drain removal if ongoing stool leakage present.↗
▶Ep 36 · 30:09
clinicalContinual leakage of stool at drain site is concerning; upper GI small bowel follow-through should be considered before drain removal if ongoing stool leakage present.↗
▶Ep 36 · 30:49
clinicalIf feeds are started after drain removal without contrast study and patient doesn't tolerate feeds, contrast study becomes mandatory to ensure everything is intact.↗
▶Ep 36 · 30:49
clinicalIf feeds are started after drain removal without contrast study and patient doesn't tolerate feeds, contrast study becomes mandatory to ensure everything is intact.↗
▶Ep 36 · 31:24
clinicalFor laparotomy, if baby is too hemodynamically unstable or on very high oscillator settings to safely transport to OR, operation can be performed at bedside in ICU with surgical team and anesthesiologists.↗
▶Ep 36 · 31:24
clinicalFor laparotomy, if baby is too hemodynamically unstable or on very high oscillator settings to safely transport to OR, operation can be performed at bedside in ICU with surgical team and anesthesiologists.↗
▶Ep 36 · 31:43
clinicalLaparotomy uses supraumbilical transverse incision; extreme care needed due to thin skin and underlying dilated bowel to avoid immediate enterotomy.↗
▶Ep 36 · 31:43
clinicalLaparotomy uses supraumbilical transverse incision; extreme care needed due to thin skin and underlying dilated bowel to avoid immediate enterotomy.↗
▶Ep 36 · 32:05
clinicalPatient should be resuscitated preoperatively with at least partial correction of platelet and coagulation abnormalities; blood products (packed red blood cells, platelets, fresh frozen plasma) must be available for operation.↗
▶Ep 36 · 32:05
clinicalPatient should be resuscitated preoperatively with at least partial correction of platelet and coagulation abnormalities; blood products (packed red blood cells, platelets, fresh frozen plasma) must be available for operation.↗
▶Ep 36 · 32:27
clinicalIt is critically important not to injure liver or spleen in premature babies during laparotomy; even minimal trauma can cause subcapsular hematoma that baby can exsanguinate from.↗
▶Ep 36 · 32:27
quoteIf you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this.↗
▶Ep 36 · 32:27
quoteIf you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this.↗
▶Ep 36 · 32:27
clinicalIt is critically important not to injure liver or spleen in premature babies during laparotomy; even minimal trauma can cause subcapsular hematoma that baby can exsanguinate from.↗
▶Ep 36 · 32:46
quoteYou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies.↗
▶Ep 36 · 32:46
quoteYou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies.↗
▶Ep 36 · 33:21
clinicalSpontaneous intestinal perforation (SIP) presents as one small localized area of perforation, while NEC is more diffuse disease with pneumatosis involving more than one tiny area; differentiation can be difficult preoperatively.↗
▶Ep 36 · 33:21
clinicalSpontaneous intestinal perforation (SIP) presents as one small localized area of perforation, while NEC is more diffuse disease with pneumatosis involving more than one tiny area; differentiation can be difficult preoperatively.↗
▶Ep 36 · 33:26
quoteI sometimes find the too hard to differentiate preoperatively. I've been fooled before thinking it's one and it turns out to be the other.↗
▶Ep 36 · 33:26
quoteI sometimes find the too hard to differentiate preoperatively. I've been fooled before thinking it's one and it turns out to be the other.↗
▶Ep 36 · 34:04
clinicalSome surgeons worldwide perform primary anastomosis after limited NEC resection; in the United States, surgeons are less likely to do primary anastomosis due to concern about anastomotic healing in these patients.↗
▶Ep 36 · 34:04
clinicalSome surgeons worldwide perform primary anastomosis after limited NEC resection; in the United States, surgeons are less likely to do primary anastomosis due to concern about anastomotic healing in these patients.↗
▶Ep 36 · 34:20
clinicalDr. Besner typically performs resection with stoma and mucous fistula rather than primary anastomosis, with stoma closure when patient is bigger (at least 2000g) and stable.↗
▶Ep 36 · 34:20
quoteI err on the side of being a little bit cautious, and I usually make stomas in these patients because I'm just so worried about them not being able to heal their anastomosis.↗
▶Ep 36 · 34:20
clinicalDr. Besner typically performs resection with stoma and mucous fistula rather than primary anastomosis, with stoma closure when patient is bigger (at least 2000g) and stable.↗
▶Ep 36 · 34:20
quoteI err on the side of being a little bit cautious, and I usually make stomas in these patients because I'm just so worried about them not being able to heal their anastomosis.↗
▶Ep 36 · 35:07
clinicalStomas are brought out through laparotomy incision with functional end and mucous fistula positioned close together to facilitate limited reoperation for closure; stomas are tacked to fascia but not matured.↗
▶Ep 36 · 35:07
clinicalStomas are brought out through laparotomy incision with functional end and mucous fistula positioned close together to facilitate limited reoperation for closure; stomas are tacked to fascia but not matured.↗
▶Ep 36 · 35:50
clinicalDistal end of stoma must protrude slightly because it can slough off; leaving small distal end prevents recession under fascia.↗
▶Ep 36 · 35:50
clinicalDistal end of stoma must protrude slightly because it can slough off; leaving small distal end prevents recession under fascia.↗
▶Ep 36 · 35:50
quoteNo matter how careful you make these stomas, sometimes the distal end will slough off.↗
▶Ep 36 · 35:50
quoteNo matter how careful you make these stomas, sometimes the distal end will slough off.↗
▶Ep 36 · 37:12
clinicalWhen bowel appears injured but not clearly necrotic (thin-walled, brownish discoloration, pneumatosis but not dead), acceptable approach is to not resect and perform second-look operation in 24-48 hours.↗
▶Ep 36 · 37:12
clinicalWhen bowel appears injured but not clearly necrotic (thin-walled, brownish discoloration, pneumatosis but not dead), acceptable approach is to not resect and perform second-look operation in 24-48 hours.↗
▶Ep 36 · 37:16
quoteSometimes if we go into the operating room a little too early on these patients, you see just what you described. It kind of looks like, you know, it's injured, but it's not necrotic, and it all kind of looks diffusely the same.↗
▶Ep 36 · 37:16
quoteSometimes if we go into the operating room a little too early on these patients, you see just what you described. It kind of looks like, you know, it's injured, but it's not necrotic, and it all kind of looks diffusely the same.↗
▶Ep 36 · 37:28
quoteI think it's perfectly acceptable to not resect at that point and to simply do nothing.↗
▶Ep 36 · 37:28
quoteI think it's perfectly acceptable to not resect at that point and to simply do nothing.↗
▶Ep 36 · 37:35
clinicalAbdomen may be left open if there are many dilated loops of bowel to avoid adding pressure that may compromise blood flow.↗
▶Ep 36 · 37:35
clinicalAbdomen may be left open if there are many dilated loops of bowel to avoid adding pressure that may compromise blood flow.↗
▶Ep 36 · 38:07
clinicalFor multiple skip lesions that are very close together, can resect all without creating short bowel syndrome rather than having multiple anastomoses.↗
▶Ep 36 · 38:07
clinicalFor multiple skip lesions that are very close together, can resect all without creating short bowel syndrome rather than having multiple anastomoses.↗
▶Ep 36 · 38:19
clinicalFor separated skip lesions, can perform multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion; if anastomotic healing problem occurs, it won't be major issue because of proximal diversion.↗
▶Ep 36 · 38:19
clinicalFor separated skip lesions, can perform multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion; if anastomotic healing problem occurs, it won't be major issue because of proximal diversion.↗
▶Ep 36 · 38:46
clinicalClip and drop technique (resecting dead bowel, clipping ends, replacing in abdomen, returning for anastomosis when baby more stable) can be life-saving maneuver in very unstable patients without time for multiple anastomoses.↗
▶Ep 36 · 38:46
clinicalClip and drop technique (resecting dead bowel, clipping ends, replacing in abdomen, returning for anastomosis when baby more stable) can be life-saving maneuver in very unstable patients without time for multiple anastomoses.↗
▶Ep 36 · 39:32
clinicalStoma reversal typically performed when baby is stable, well, hopefully feeding, and approximately 2000g in size; anastomosis is easier when baby is bigger.↗
▶Ep 36 · 39:32
clinicalStoma reversal typically performed when baby is stable, well, hopefully feeding, and approximately 2000g in size; anastomosis is easier when baby is bigger.↗
▶Ep 36 · 39:56
clinicalEarlier stoma reversal is indicated if baby develops TPN-induced cholestasis or cannot be nourished due to very high stoma output.↗
▶Ep 36 · 39:56
clinicalEarlier stoma reversal is indicated if baby develops TPN-induced cholestasis or cannot be nourished due to very high stoma output.↗
▶Ep 36 · 40:48
clinicalMucous fistula refeeding is done selectively rather than routinely, particularly for very high output stomas where any nourishment given comes directly out the stoma.↗
▶Ep 36 · 40:48
clinicalMucous fistula refeeding is done selectively rather than routinely, particularly for very high output stomas where any nourishment given comes directly out the stoma.↗
▶Ep 36 · 41:22
clinicalMucous fistula often strictures post-operatively, losing opportunity for refeeding; if serious about refeeding (e.g., after massive resection with very high stoma), consider leaving small soft catheter in mucous fistula post-op to maintain access.↗
▶Ep 36 · 41:22
quoteYou have to be careful when you make that mucous fistula because often it strictures and you lose the opportunity to refeed.↗
▶Ep 36 · 41:22
quoteYou have to be careful when you make that mucous fistula because often it strictures and you lose the opportunity to refeed.↗
▶Ep 36 · 41:22
clinicalMucous fistula often strictures post-operatively, losing opportunity for refeeding; if serious about refeeding (e.g., after massive resection with very high stoma), consider leaving small soft catheter in mucous fistula post-op to maintain access.↗
▶Ep 36 · 42:15
clinicalNEC totalis is one of most tragic findings on exploratory laparotomy for NEC; chance of baby living to be old enough for small bowel-liver transplant is very close to zero.↗
▶Ep 36 · 42:15
clinicalNEC totalis is one of most tragic findings on exploratory laparotomy for NEC; chance of baby living to be old enough for small bowel-liver transplant is very close to zero.↗
▶Ep 36 · 42:15
quoteNecrotizing enterocolitis totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis.↗
▶Ep 36 · 42:15
quoteNecrotizing enterocolitis totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis.↗
▶Ep 36 · 42:32
quoteThe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero.↗
▶Ep 36 · 42:32
quoteThe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero.↗
▶Ep 36 · 42:56
quoteI don't think, would be criticized for explaining to the parents the severity of the problem and just closing the abdomen and giving the baby comfort care.↗
▶Ep 36 · 42:56
quoteI don't think, would be criticized for explaining to the parents the severity of the problem and just closing the abdomen and giving the baby comfort care.↗
▶Ep 36 · 42:56
opinionFor very small premature baby with NEC totalis, current technology cannot get baby through this devastating problem; no one would be criticized for explaining severity to parents and providing comfort care after closing abdomen.↗
▶Ep 36 · 42:56
opinionFor very small premature baby with NEC totalis, current technology cannot get baby through this devastating problem; no one would be criticized for explaining severity to parents and providing comfort care after closing abdomen.↗
▶Ep 36 · 43:42
opinionIn Dr. Besner's experience, chance of baby with NEC totalis surviving months-to-years of required TPN is very low; TPN will irreversibly injure liver, and even if baby lives to transplant size, small bowel transplant results remain suboptimal.↗
▶Ep 36 · 43:42
quoteIn my experience, the chance of that baby living through, you know, the months to years of TPN that they're going to require is going to, you know, irreversibly injure their liver.↗
▶Ep 36 · 43:42
quoteIn my experience, the chance of that baby living through, you know, the months to years of TPN that they're going to require is going to, you know, irreversibly injure their liver.↗
▶Ep 36 · 43:42
opinionIn Dr. Besner's experience, chance of baby with NEC totalis surviving months-to-years of required TPN is very low; TPN will irreversibly injure liver, and even if baby lives to transplant size, small bowel transplant results remain suboptimal.↗
▶Ep 36 · 44:01
quoteI just in general think that that's a no-win situation in my experience.↗
▶Ep 36 · 44:01
quoteI just in general think that that's a no-win situation in my experience.↗
▶Ep 36 · 44:28
clinicalSmall subset of premature patients with severe lung disease can develop pneumothorax that dissects through diaphragm into abdomen, causing pneumoperitoneum; must confirm problem is in abdomen rather than chest.↗
▶Ep 36 · 44:28
clinicalSmall subset of premature patients with severe lung disease can develop pneumothorax that dissects through diaphragm into abdomen, causing pneumoperitoneum; must confirm problem is in abdomen rather than chest.↗
▶Ep 36 · 45:06
clinicalFor extremely unstable patient (e.g., 800g on jet ventilation and pressors) with pneumoperitoneum and severe distention, angiocatheter can be inserted through abdominal wall to release pneumoperitoneum as temporizing maneuver while mobilizing for definitive operation.↗
▶Ep 36 · 45:06
clinicalFor extremely unstable patient (e.g., 800g on jet ventilation and pressors) with pneumoperitoneum and severe distention, angiocatheter can be inserted through abdominal wall to release pneumoperitoneum as temporizing maneuver while mobilizing for definitive operation.↗
Journal of Pediatric Surgery Article Review: January 2022 APSA Issue
▶Ep 51 · 1:41
opinionHistorically, surgeons have been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have.↗
▶Ep 51 · 1:41
quoteHistorically, surgeons of all types have been incentivized based on their work or views, and it's certainly important for clinical productivity and clinical program building, but it's really important to take advantage of other strengths that surgeons have.↗
▶Ep 51 · 2:23
quoteThe Question is, how do we promote academic productivity amongst our partners?↗
▶Ep 51 · 2:55
quoteThe concept of academic RVUs was probably first put out there about 12 or 13 years ago, but it wasn't described how to incentivize people for that.↗
▶Ep 51 · 2:55
clinicalThe concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work.↗
▶Ep 51 · 3:07
clinicalNationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits.↗
▶Ep 51 · 3:27
clinicalThe Nationwide system kept work RVUs as part of the incentivization plan along with other goals that must be achievable.↗
▶Ep 51 · 3:34
quoteAnd I really believe that these types of goals and these types of incentives have to be achievable.↗
Stay Current Throwbacks Necrotizing Enterocolitis with Dr. Gail Besner
▶Ep 55 · 1:53
clinicalDespite six decades of research, the exact cause of necrotizing enterocolitis remains unknown and there is no absolute cure.↗
▶Ep 55 · 1:53
clinicalDespite six decades of research, the exact cause of necrotizing enterocolitis remains unknown and there is no absolute cure.↗
▶Ep 55 · 2:10
quotedespite six decades of research, we really don't know exactly what causes nec, and we still are quite some ways from finding an absolute cure for the disease↗
▶Ep 55 · 2:10
quotedespite six decades of research, we really don't know exactly what causes nec, and we still are quite some ways from finding an absolute cure for the disease↗
▶Ep 55 · 3:21
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 55 · 3:21
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 55 · 4:46
clinicalAcid suppression medications (PPIs, H2 blockers) should be avoided in at-risk neonates because neutralizing gastric acid may increase NEC risk.↗
▶Ep 55 · 4:46
clinicalAcid suppression medications (PPIs, H2 blockers) should be avoided in at-risk neonates because neutralizing gastric acid may increase NEC risk.↗
▶Ep 55 · 5:10
quoteyou don't want to neutralize the acid that the baby is producing↗
▶Ep 55 · 5:10
quoteyou don't want to neutralize the acid that the baby is producing↗
▶Ep 55 · 5:24
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 55 · 5:24
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 55 · 7:14
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and platelet count is important to know before surgery to optimize the patient's condition.↗
▶Ep 55 · 7:14
clinicalNeutropenia (low white blood cell count) in a baby with suspected NEC is more concerning than leukocytosis because it may indicate overwhelming sepsis that the baby cannot compensate for.↗
▶Ep 55 · 7:14
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and platelet count is important to know before surgery to optimize the patient's condition.↗
▶Ep 55 · 7:14
clinicalNeutropenia (low white blood cell count) in a baby with suspected NEC is more concerning than leukocytosis because it may indicate overwhelming sepsis that the baby cannot compensate for.↗
▶Ep 55 · 7:30
quoteI actually get more worried when the patients are neutropenic and they have a low white blood cell count. Because to me, that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 55 · 7:30
quoteI actually get more worried when the patients are neutropenic and they have a low white blood cell count. Because to me, that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 55 · 8:48
clinicalCross-table lateral or lateral decubitus films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 55 · 8:48
clinicalCross-table lateral or lateral decubitus films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 55 · 9:24
clinicalFree air on imaging is an absolute indication for surgical intervention (either drain or laparotomy) in NEC.↗
▶Ep 55 · 9:24
clinicalFree air on imaging is an absolute indication for surgical intervention (either drain or laparotomy) in NEC.↗
▶Ep 55 · 9:50
opinionFixed loops of intestine on serial x-rays are not an absolute indication for surgery but are a concerning sign that the patient is not improving.↗
▶Ep 55 · 9:50
opinionFixed loops of intestine on serial x-rays are not an absolute indication for surgery but are a concerning sign that the patient is not improving.↗
▶Ep 55 · 10:25
clinicalPortal venous air is a worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management.↗
▶Ep 55 · 10:25
clinicalPortal venous air is a worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management.↗
▶Ep 55 · 11:01
guidelineMedical management of NEC includes withholding feeds, orogastric tube decompression, broad-spectrum antibiotics, and serial monitoring (exams, labs, x-rays).↗
▶Ep 55 · 11:01
guidelineMedical management of NEC includes withholding feeds, orogastric tube decompression, broad-spectrum antibiotics, and serial monitoring (exams, labs, x-rays).↗
▶Ep 55 · 11:46
clinicalSmall French feeding tubes are inadequate for gastric decompression in NEC; they should be replaced with larger orogastric tubes.↗
▶Ep 55 · 11:46
clinicalSmall French feeding tubes are inadequate for gastric decompression in NEC; they should be replaced with larger orogastric tubes.↗
▶Ep 55 · 12:35
opinionThere is likely tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization patterns in individual ICU environments.↗
▶Ep 55 · 12:35
opinionThere is likely tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization patterns in individual ICU environments.↗
▶Ep 55 · 13:39
opinionAbdominal x-rays should be obtained at regular intervals (approximately every 8 hours) during medical NEC management, not waiting 12-24 hours between films.↗
▶Ep 55 · 13:39
opinionAbdominal x-rays should be obtained at regular intervals (approximately every 8 hours) during medical NEC management, not waiting 12-24 hours between films.↗
▶Ep 55 · 14:16
opinionBabies should remain NPO for at least 7-10 days (preferably a week and a half) after medical NEC treatment before attempting to restart feeds.↗
▶Ep 55 · 14:16
opinionBabies should remain NPO for at least 7-10 days (preferably a week and a half) after medical NEC treatment before attempting to restart feeds.↗
▶Ep 55 · 14:45
clinicalStricture formation after medical NEC typically occurs in the colon, usually near the splenic flexure, but can occur anywhere.↗
▶Ep 55 · 14:45
clinicalStricture formation after medical NEC typically occurs in the colon, usually near the splenic flexure, but can occur anywhere.↗
▶Ep 55 · 15:18
clinicalWhen evaluating for post-NEC stricture, contrast enema should be performed before upper GI with small bowel follow-through because strictures are more common in the colon and waiting for contrast to pass through obstructed small bowel is time-consuming.↗
▶Ep 55 · 15:18
clinicalWhen evaluating for post-NEC stricture, contrast enema should be performed before upper GI with small bowel follow-through because strictures are more common in the colon and waiting for contrast to pass through obstructed small bowel is time-consuming.↗
▶Ep 55 · 16:22
opinionSerial abdominal examinations over time are more valuable than a single examination for determining need for surgery in NEC without absolute indications.↗
▶Ep 55 · 16:22
opinionSerial abdominal examinations over time are more valuable than a single examination for determining need for surgery in NEC without absolute indications.↗
▶Ep 55 · 16:40
quoteI think that serial abdominal exams are important. And if you see worsening distension, worsening, you know, signs of peritoneal irritation, hemodynamic instability with increasing needs for presser support, renal shutdown with no urine production, you know, it starts to build up. And it's like building blocks. And if you have, you know, A, B, and C, it's time to think about surgery.↗
▶Ep 55 · 16:40
quoteI think that serial abdominal exams are important. And if you see worsening distension, worsening, you know, signs of peritoneal irritation, hemodynamic instability with increasing needs for presser support, renal shutdown with no urine production, you know, it starts to build up. And it's like building blocks. And if you have, you know, A, B, and C, it's time to think about surgery.↗
▶Ep 55 · 19:29
epidemiologicalAt a recent NEC conference in London, 100% of European surgeons reported performing laparotomy for NEC; none use peritoneal drainage.↗
▶Ep 55 · 19:29
quote100% of the surgeons do a laparotomy, and no one puts in a drain in Europe, which I thought was just fascinating↗
▶Ep 55 · 19:29
epidemiologicalAt a recent NEC conference in London, 100% of European surgeons reported performing laparotomy for NEC; none use peritoneal drainage.↗
▶Ep 55 · 19:29
quote100% of the surgeons do a laparotomy, and no one puts in a drain in Europe, which I thought was just fascinating↗
▶Ep 55 · 19:42
epidemiologicalThe MOSS and PIERO randomized controlled trials showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC.↗
▶Ep 55 · 19:42
epidemiologicalThe MOSS and PIERO randomized controlled trials showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC.↗
▶Ep 55 · 20:20
epidemiologicalBabies who receive peritoneal drains instead of laparotomy may have worse neurological outcomes at 1-2 years post-NEC, though early mortality is similar.↗
▶Ep 55 · 20:20
epidemiologicalBabies who receive peritoneal drains instead of laparotomy may have worse neurological outcomes at 1-2 years post-NEC, though early mortality is similar.↗
▶Ep 55 · 20:30
quoteit appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis↗
▶Ep 55 · 20:30
quoteit appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis↗
▶Ep 55 · 21:00
epidemiologicalThe NEST trial randomized 300 babies to peritoneal drainage versus laparotomy and will assess neurological outcomes at 18-22 months, with results expected in 1-2 years (from 2017).↗
▶Ep 55 · 21:00
epidemiologicalThe NEST trial randomized 300 babies to peritoneal drainage versus laparotomy and will assess neurological outcomes at 18-22 months, with results expected in 1-2 years (from 2017).↗
▶Ep 55 · 21:41
quoteI predict that in the next year or two, we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies↗
▶Ep 55 · 21:41
quoteI predict that in the next year or two, we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies↗
▶Ep 55 · 22:20
quotewhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult↗
▶Ep 55 · 22:20
quotewhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult↗
▶Ep 55 · 24:07
clinicalSpontaneous intestinal perforation (SIP) can cause hemodynamic instability similar to NEC through systemic inflammatory response syndrome, making clinical differentiation difficult.↗
▶Ep 55 · 24:07
clinicalSpontaneous intestinal perforation (SIP) can cause hemodynamic instability similar to NEC through systemic inflammatory response syndrome, making clinical differentiation difficult.↗
▶Ep 55 · 26:17
clinicalPeritoneal drain placement can be performed at bedside with local anesthesia through a small right lower quadrant transverse incision using a quarter-inch Penrose drain.↗
▶Ep 55 · 26:17
clinicalPeritoneal drain placement can be performed at bedside with local anesthesia through a small right lower quadrant transverse incision using a quarter-inch Penrose drain.↗
▶Ep 55 · 27:00
clinicalMaking the drain incision too large can lead to hernia formation after drain removal.↗
▶Ep 55 · 27:00
clinicalMaking the drain incision too large can lead to hernia formation after drain removal.↗
▶Ep 55 · 28:38
opinionWhen operating on a baby with extensive adhesions after drain placement, surgeons should know when to stop if causing multiple serosal tears and enterotomies, as continuing may worsen the outcome.↗
▶Ep 55 · 28:38
opinionWhen operating on a baby with extensive adhesions after drain placement, surgeons should know when to stop if causing multiple serosal tears and enterotomies, as continuing may worsen the outcome.↗
▶Ep 55 · 29:00
quotesometimes I think that one of the smartest decisions that a surgeon can make is to know when to get out and to stop↗
▶Ep 55 · 29:00
quotesometimes I think that one of the smartest decisions that a surgeon can make is to know when to get out and to stop↗
▶Ep 55 · 29:20
clinicalCreating a proximal diverting stoma is helpful when extensive adhesions prevent safe complete exploration, as it controls the perforation and diverts the fecal stream.↗
▶Ep 55 · 29:20
clinicalCreating a proximal diverting stoma is helpful when extensive adhesions prevent safe complete exploration, as it controls the perforation and diverts the fecal stream.↗
▶Ep 55 · 29:50
opinionPeritoneal drains should be advanced out gradually over several days starting at 7-10 days post-placement, rather than removing all at once.↗
▶Ep 55 · 29:50
opinionPeritoneal drains should be advanced out gradually over several days starting at 7-10 days post-placement, rather than removing all at once.↗
▶Ep 55 · 31:18
clinicalFor laparotomy in NEC, a supraumbilical transverse incision is used, with extreme care required to avoid liver and spleen injury in premature infants.↗
▶Ep 55 · 31:18
clinicalFor laparotomy in NEC, a supraumbilical transverse incision is used, with extreme care required to avoid liver and spleen injury in premature infants.↗
▶Ep 55 · 32:00
clinicalEven minimal trauma to the liver in premature babies can cause subcapsular hematomas that can lead to exsanguination.↗
▶Ep 55 · 32:00
clinicalEven minimal trauma to the liver in premature babies can cause subcapsular hematomas that can lead to exsanguination.↗
▶Ep 55 · 32:30
quoteyou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies↗
▶Ep 55 · 32:30
quoteyou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies↗
▶Ep 55 · 33:10
clinicalNEC is differentiated from SIP intraoperatively: SIP presents as one small localized perforation, while NEC shows more diffuse disease with pneumatosis involving more than one area.↗
▶Ep 55 · 33:10
clinicalNEC is differentiated from SIP intraoperatively: SIP presents as one small localized perforation, while NEC shows more diffuse disease with pneumatosis involving more than one area.↗
▶Ep 55 · 34:00
clinicalSome surgeons internationally perform primary anastomosis after NEC resection, but many US surgeons create stomas due to concern about anastomotic healing in critically ill premature infants.↗
▶Ep 55 · 34:00
clinicalSome surgeons internationally perform primary anastomosis after NEC resection, but many US surgeons create stomas due to concern about anastomotic healing in critically ill premature infants.↗
▶Ep 55 · 35:03
clinicalBringing stoma and mucous fistula out close together through the main incision allows for more limited reoperation at stoma closure compared to separate sites.↗
▶Ep 55 · 35:03
clinicalBringing stoma and mucous fistula out close together through the main incision allows for more limited reoperation at stoma closure compared to separate sites.↗
▶Ep 55 · 35:45
clinicalStomas should be tacked to fascia (not matured) and a small distal end should protrude to prevent recession under the fascia, though sloughing of the distal end can still occur.↗
▶Ep 55 · 35:45
clinicalStomas should be tacked to fascia (not matured) and a small distal end should protrude to prevent recession under the fascia, though sloughing of the distal end can still occur.↗
▶Ep 55 · 37:13
opinionWhen bowel appears injured but not clearly necrotic (thin-walled, brownish, with pneumatosis but diffusely similar), it may be appropriate to not resect, leave the abdomen open to reduce pressure, and return for second-look operation in 24-48 hours.↗
▶Ep 55 · 37:13
opinionWhen bowel appears injured but not clearly necrotic (thin-walled, brownish, with pneumatosis but diffusely similar), it may be appropriate to not resect, leave the abdomen open to reduce pressure, and return for second-look operation in 24-48 hours.↗
▶Ep 55 · 37:20
quoteI think sometimes if we go into the operating room a little too early on these patients, you see just what you describe. It kind of looks like, you know, it's injured, but it's not necrotic and it all kind of looks diffusely the same.↗
▶Ep 55 · 37:20
quoteI think sometimes if we go into the operating room a little too early on these patients, you see just what you describe. It kind of looks like, you know, it's injured, but it's not necrotic and it all kind of looks diffusely the same.↗
▶Ep 55 · 38:06
opinionFor multiple skip lesions in NEC, if they are close together and can be resected without creating short bowel syndrome, resecting all may be preferable to multiple anastomoses.↗
▶Ep 55 · 38:06
opinionFor multiple skip lesions in NEC, if they are close together and can be resected without creating short bowel syndrome, resecting all may be preferable to multiple anastomoses.↗
▶Ep 55 · 38:30
clinicalMultiple anastomoses can be performed with proximal diversion so that if one anastomosis fails to heal, it is distal to the diversion and less problematic.↗
▶Ep 55 · 38:30
clinicalMultiple anastomoses can be performed with proximal diversion so that if one anastomosis fails to heal, it is distal to the diversion and less problematic.↗
▶Ep 55 · 38:48
clinicalClip-and-drop technique (resecting dead bowel, clipping ends, replacing in abdomen for later definitive surgery) can be lifesaving in very unstable patients when time does not permit multiple anastomoses.↗
▶Ep 55 · 38:48
clinicalClip-and-drop technique (resecting dead bowel, clipping ends, replacing in abdomen for later definitive surgery) can be lifesaving in very unstable patients when time does not permit multiple anastomoses.↗
▶Ep 55 · 39:28
opinionStoma reversal is typically performed when the baby reaches approximately 2000 grams, though earlier reversal is indicated for TPN-induced cholestasis or inability to nourish due to high stoma output.↗
▶Ep 55 · 39:28
opinionStoma reversal is typically performed when the baby reaches approximately 2000 grams, though earlier reversal is indicated for TPN-induced cholestasis or inability to nourish due to high stoma output.↗
▶Ep 55 · 40:41
opinionRefeeding through mucous fistula is done selectively (not routinely), primarily for very high-output stomas where most nutrition is lost through the stoma.↗
▶Ep 55 · 40:41
opinionRefeeding through mucous fistula is done selectively (not routinely), primarily for very high-output stomas where most nutrition is lost through the stoma.↗
▶Ep 55 · 41:23
clinicalMucous fistulas often stricture, preventing refeeding access; leaving a small soft catheter in the mucous fistula post-operatively can maintain access for refeeding.↗
▶Ep 55 · 41:23
clinicalMucous fistulas often stricture, preventing refeeding access; leaving a small soft catheter in the mucous fistula post-operatively can maintain access for refeeding.↗
▶Ep 55 · 42:06
clinicalThe chance of a premature baby with NEC totalis surviving long enough to receive small bowel-liver transplant is very close to zero.↗
▶Ep 55 · 42:06
clinicalThe chance of a premature baby with NEC totalis surviving long enough to receive small bowel-liver transplant is very close to zero.↗
▶Ep 55 · 42:20
quotethe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero↗
▶Ep 55 · 42:20
quotethe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero↗
▶Ep 55 · 43:39
clinicalBabies with NEC totalis who survive on TPN for months to years will develop irreversible liver injury, and even if they reach transplant size, small bowel transplant outcomes remain suboptimal.↗
▶Ep 55 · 43:39
clinicalBabies with NEC totalis who survive on TPN for months to years will develop irreversible liver injury, and even if they reach transplant size, small bowel transplant outcomes remain suboptimal.↗
▶Ep 55 · 44:22
clinicalPneumothorax can dissect through the diaphragm into the abdomen in premature babies with severe lung disease, mimicking intra-abdominal free air; this must be ruled out before attributing pneumoperitoneum to bowel perforation.↗
▶Ep 55 · 44:22
clinicalPneumothorax can dissect through the diaphragm into the abdomen in premature babies with severe lung disease, mimicking intra-abdominal free air; this must be ruled out before attributing pneumoperitoneum to bowel perforation.↗
▶Ep 55 · 45:00
clinicalIn a hemodynamically unstable baby with pneumoperitoneum, inserting an angiocatheter through the abdominal wall to release pressure is a useful temporizing measure while mobilizing the OR.↗
▶Ep 55 · 45:00
clinicalIn a hemodynamically unstable baby with pneumoperitoneum, inserting an angiocatheter through the abdominal wall to release pressure is a useful temporizing measure while mobilizing the OR.↗
Journal of Pediatric Surgery Article Review: January 2022 APSA Issue
▶Ep 4 · 1:41
quoteHistorically, surgeons of all types have been incentivized based on their work or views, and it's certainly important for clinical productivity and clinical program building, but it's really important to take advantage of other strengths that surgeons have.↗
▶Ep 4 · 1:41
opinionHistorically, surgeons have been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have.↗
▶Ep 4 · 2:23
quoteThe Question is, how do we promote academic productivity amongst our partners?↗
▶Ep 4 · 2:55
quoteThe concept of academic RVUs was probably first put out there about 12 or 13 years ago, but it wasn't described how to incentivize people for that.↗
▶Ep 4 · 2:55
clinicalThe concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work.↗
▶Ep 4 · 3:07
clinicalNationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits.↗
▶Ep 4 · 3:27
clinicalThe Nationwide system kept work RVUs as part of the incentivization plan along with other goals that must be achievable.↗
▶Ep 4 · 3:34
quoteAnd I really believe that these types of goals and these types of incentives have to be achievable.↗
quoteDespite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease.↗
▶Ep 2 · 2:11
clinicalDespite 6 decades of research, we don't know exactly what causes NEC and are still quite some ways from finding an absolute cure.↗
▶Ep 2 · 4:14
clinicalIndomethacin predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 2 · 4:44
clinicalPPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; you don't want to neutralize gastric acid.↗
▶Ep 2 · 5:29
clinicalIn premature babies with NEC, intestinal contents can leak into the scrotum through a patent processus vaginalis, causing scrotal swelling and discoloration.↗
▶Ep 2 · 7:17
clinicalNeutropenia (low white blood cell count) is more worrisome than elevated WBC in NEC because it suggests overwhelming sepsis that the patient is not compensating for.↗
▶Ep 2 · 7:17
quoteI get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 2 · 7:33
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and knowledge of platelet count is important for optimizing patient condition prior to surgery.↗
▶Ep 2 · 8:33
quoteUnfortunately, there's no one test that, you know, shows whether you have an ischemic or necrotic bowel. But if you take all of these tests in combination with each other, you can get a sense as to how sick you think the patient is.↗
▶Ep 2 · 8:33
clinicalThere is no single test that shows whether you have ischemic or necrotic bowel, but taking all tests in combination gives a sense of how sick the patient is.↗
▶Ep 2 · 8:50
clinicalFor imaging in suspected NEC, you need plain film plus either cross-table lateral or lateral decubitus film because free air can be quite subtle and you don't want to miss it.↗
▶Ep 2 · 9:08
quoteYou don't want to just get a plain film. You want to get something that will increase your chance of being able to visualize even a small amount of free air.↗
▶Ep 2 · 9:38
clinicalFree air on imaging is an absolute indication for surgical intervention (either drain or laparotomy).↗
▶Ep 2 · 9:54
clinicalClinical deterioration in the face of maximum medical management is an indication for surgery.↗
▶Ep 2 · 10:02
clinicalFixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not going in the right direction.↗
▶Ep 2 · 10:16
clinicalPortal venous air is a concerning and worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.↗
▶Ep 2 · 10:16
quoteI have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation, but those things like fixed loops of bowel and serial films, the development of portal venous air, which sometimes can be quite fleeting, those are worrisome signs.↗
▶Ep 2 · 10:58
clinicalMedical management of NEC includes: withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotics, and performing serial abdominal exams, labs, and X-rays.↗
▶Ep 2 · 12:05
quoteUnfortunately those tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression.↗
▶Ep 2 · 12:05
clinicalSmall French feeding tubes are not adequate for gastric decompression in NEC; they should be replaced with an orogastric tube.↗
▶Ep 2 · 12:43
epidemiologicalThere is tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization of the ICU environment.↗
▶Ep 2 · 12:52
quoteI think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment.↗
▶Ep 2 · 13:37
opinionFor serial X-rays in NEC, obtaining them every 8 hours is reasonable; getting them too frequently makes no sense, but waiting 12-24 hours is too long.↗
▶Ep 2 · 14:15
clinicalPatients with NEC should be kept NPO with NG decompression and antibiotics for at least 1 week to 10 days (preferably a week and a half) before starting feeds.↗
▶Ep 2 · 14:29
clinicalSome babies have repeated episodes of necrotizing enterocolitis.↗
▶Ep 2 · 14:40
clinicalStricture formation is a complication of medical NEC that should be suspected in babies not tolerating feeds post-NEC; strictures typically occur in the colon, usually near the splenic flexure, but can occur anywhere.↗
▶Ep 2 · 15:17
opinionFor suspected stricture post-NEC, starting with contrast enema is preferred over upper GI with small bowel follow-through because strictures are more common in the colon and contrast from above takes long to transit, especially if partially obstructed.↗
▶Ep 2 · 16:23
clinicalSerial abdominal exams are critical for determining when to operate on NEC patients without absolute indications; worsening distention, peritoneal signs, hemodynamic instability with increasing pressor needs, and renal shutdown build up like building blocks to indicate need for surgery.↗
▶Ep 2 · 18:16
clinicalTwo surgical options for NEC are exploratory laparotomy and peritoneal drain placement.↗
▶Ep 2 · 18:22
clinicalThe ongoing NEST trial (necrotizing enterocolitis surgery trial) is concluding and will provide results in the next 1-2 years comparing peritoneal drainage versus laparotomy.↗
▶Ep 2 · 18:22
quoteI wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial.↗
▶Ep 2 · 18:39
clinicalMortality difference between peritoneal drainage and laparotomy for NEC is indecipherable; survival chance is about the same with either procedure.↗
▶Ep 2 · 19:10
epidemiologicalAt a NEC conference in London, 100% of surgeons polled do laparotomy and no one puts in a drain in Europe.↗
▶Ep 2 · 19:10
quote100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating.↗
▶Ep 2 · 19:44
clinicalThe MOSS trial (United States) and PIERO trial (Europe) showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC, but these studies looked at early endpoints rather than delayed neurological outcomes.↗
▶Ep 2 · 20:14
clinicalBabies who have peritoneal drains instead of laparotomy may do worse neurologically if you look at outcomes 1-2 years after recovery from NEC.↗
▶Ep 2 · 20:34
clinicalThe NEST trial will randomize 300 babies to peritoneal drainage versus laparotomy and assess neurological outcomes at 18-22 months after NEC recovery with detailed neurological assessments.↗
▶Ep 2 · 20:53
quoteWe certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road.↗
▶Ep 2 · 21:44
opinionDr. Besner predicts that in the next 1-2 years practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes likely better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.↗
▶Ep 2 · 21:44
quoteI predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies.↗
▶Ep 2 · 22:09
quoteWhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult.↗
▶Ep 2 · 22:09
clinicalWhen peritoneal drains are placed and babies subsequently undergo laparotomy, the degree of dead bowel actually present is often quite striking and it's inconceivable the baby could get over that insult.↗
▶Ep 2 · 22:58
opinionThere are no criteria that help decide between laparotomy or drain for NEC; with current information you can't be faulted for doing either one.↗
▶Ep 2 · 24:15
clinicalYou can get just as sick and hemodynamically unstable from systemic inflammatory response syndrome with an isolated intestinal perforation as from necrotizing enterocolitis.↗
▶Ep 2 · 26:15
clinicalPeritoneal drain placement is a bedside procedure with tiny amount of local anesthesia, using a small transverse incision in the right lower quadrant for a 1/4 inch Penrose drain.↗
▶Ep 2 · 26:34
clinicalIf the incision for peritoneal drain is made too big, it's a problem because the patient can get a hernia once the drain is out.↗
▶Ep 2 · 27:01
clinicalWhen placing peritoneal drain, pass it several times gently without forcing to avoid bleeding; it's hard to achieve the drain curving to all four quadrants as shown in published pictures.↗
▶Ep 2 · 28:43
clinicalAfter peritoneal drain placement, if baby continues producing stool from drain for weeks and you convert to laparotomy, you may be forced to operate at the wrong time when inflammatory process is at its worst, resulting in extensive adhesions and serosal tears.↗
▶Ep 2 · 29:03
opinionOne of the smartest surgical decisions is knowing when to get out and stop; if you're getting serosal tears and making the situation worse during difficult NEC laparotomy, it's time to stop.↗
▶Ep 2 · 29:03
quoteOne of the smartest decisions that a surgeon can make is to know when to get out and to stop.↗
▶Ep 2 · 29:13
clinicalIn difficult NEC laparotomy with extensive adhesions, try to make a proximal diverting stoma to control the area of perforation, but don't keep going if making multiple enterotomies and serosal injuries.↗
▶Ep 2 · 29:24
quoteYou can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run.↗
▶Ep 2 · 29:48
clinicalFor successful peritoneal drain management, advance the drain out over several days starting at 7-10 days post-operation rather than withdrawing it all at once.↗
▶Ep 2 · 30:09
clinicalDon't advance peritoneal drain out if there's continual leakage of stool at the drain site; this suggests ongoing area of leakage.↗
▶Ep 2 · 30:22
opinionThere is difference of opinion about whether to get upper GI small bowel follow-through before removing peritoneal drain; it should be considered if there's ongoing stool leakage.↗
▶Ep 2 · 30:49
clinicalIf baby does well after drain removal without contrast study but doesn't tolerate feeds, then contrast study is compelled to ensure everything is OK.↗
▶Ep 2 · 31:19
clinicalFor NEC laparotomy, if baby is hemodynamically unstable or on very high oscillator settings and can't be safely moved to OR, bring the OR to bedside and operate in the ICU.↗
▶Ep 2 · 31:43
clinicalFor NEC laparotomy, make supraumbilical transverse incision; skin is extraordinarily thin so be careful entering abdomen, especially with underlying dilated bowel loops.↗
▶Ep 2 · 32:08
clinicalFor NEC laparotomy, have blood products available (packed RBCs, platelets, fresh frozen plasma) and partially correct platelet and coagulation abnormalities preoperatively.↗
▶Ep 2 · 32:27
clinicalIn premature babies undergoing NEC laparotomy, it's incredibly important not to hurt the liver or spleen; even looking at or touching the liver wrong can cause subcapsular hematoma that a baby can exsanguinate from.↗
▶Ep 2 · 32:37
quoteIf you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this.↗
▶Ep 2 · 32:46
quoteYou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies.↗
▶Ep 2 · 32:53
clinicalLiver and spleen injuries can occur with peritoneal drain insertion as well.↗
▶Ep 2 · 33:21
clinicalSpontaneous intestinal perforation (SIP) is one small localized area of perforation; NEC is more diffuse disease with pneumatosis involving more than one tiny area. These can be hard to differentiate preoperatively.↗
▶Ep 2 · 34:04
epidemiologicalSome surgeons around the world resect limited NEC and do primary anastomosis; this is less common in the United States where surgeons typically make stomas due to concern about anastomotic healing.↗
▶Ep 2 · 35:07
clinicalFor NEC stomas, bring functional end and mucous fistula out through the laparotomy incision close to each other (facilitating later closure), tack to fascia without maturation.↗
▶Ep 2 · 35:50
clinicalNo matter how carefully NEC stomas are made, sometimes the distal end will slough off, so leave a little distal end sticking out so it doesn't recede under the fascia.↗
▶Ep 2 · 36:19
opinionHigh-quality enterostomal therapists can manage stomas brought out through the incision; the problem gets more complicated if the wound opens.↗
▶Ep 2 · 37:12
clinicalFor indeterminate bowel viability during NEC laparotomy (injured but not necrotic, diffusely the same appearance), it's acceptable to not resect, leave abdomen open to avoid pressure compromising blood flow, and return for second-look operation in 24-48 hours.↗
▶Ep 2 · 38:07
clinicalFor multiple skip lesions in NEC, if very close together and can resect without creating short bowel syndrome, do that rather than multiple anastomoses; otherwise do multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion.↗
▶Ep 2 · 38:46
clinicalClip-and-drop technique (resect dead bowel, clip ends, put back in, return another day) can be life-saving in very unstable NEC patients without time for multiple anastomoses.↗
▶Ep 2 · 39:15
opinionThe 'putting green' approach (bringing out multiple stomas throughout abdomen) can get really confusing and messy; try to avoid if possible.↗
▶Ep 2 · 39:32
clinicalFor stoma reversal timing, typically wait until baby is stable, well, hopefully being fed, and about 2000g (anastomosis is easier when baby is bigger); go in sooner if TPN-induced cholestasis develops or can't nourish baby due to very high stoma.↗
▶Ep 2 · 40:21
opinionStoma reversal timing is more about weight gain, clinical appearance, and TPN sequelae than a mandatory 2-month waiting period.↗
▶Ep 2 · 40:48
clinicalRefeeding mucous fistula is done selectively (not routinely) for very high-output stomas where any nourishment given comes right out the stoma.↗
▶Ep 2 · 41:22
clinicalMucous fistulas often stricture and you lose the opportunity to refeed; if serious about refeeding (e.g., massive resection, very high stoma), consider leaving a small soft catheter in the mucous fistula post-op to maintain access.↗
▶Ep 2 · 42:15
clinicalNEC totalis is one of the most tragic findings on exploratory laparotomy for NEC; the chance of a baby with true NEC totalis living to be old enough for small bowel-liver transplant is very close to zero.↗
▶Ep 2 · 42:15
quoteI think neck totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis.↗
▶Ep 2 · 42:32
quoteThe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero.↗
▶Ep 2 · 42:56
opinionFor very small premature baby with NEC totalis, we don't have the technology to get that baby through this devastating problem; no one would be criticized for explaining severity to parents and closing abdomen with comfort care.↗
▶Ep 2 · 43:42
clinicalFor NEC totalis, the chance of the baby living through months to years of required TPN will irreversibly injure their liver, and even if they live to be big enough, results of small bowel transplant are still suboptimal.↗
▶Ep 2 · 44:28
clinicalThere is a very small subset of premature patients with horrible lung disease who get pneumothorax that dissects through the diaphragm into the abdomen, presenting as free air; make sure the problem is in the abdomen and not in the chest.↗
▶Ep 2 · 45:06
clinicalFor hemodynamically unstable baby with free air and abdominal distention, put an angiocatheter through the abdominal wall to release pneumoperitoneum as a temporizing maneuver while mobilizing for surgery.↗
Necrotizing Enterocolitis with Dr. Gail Besner
▶Ep 6 · 2:11
clinicalDespite 6 decades of research, the exact cause of necrotizing enterocolitis is unknown and there is no absolute cure for the disease.↗
▶Ep 6 · 2:11
quoteDespite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease.↗
▶Ep 6 · 3:53
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 6 · 4:44
clinicalPPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; gastric acid neutralization should be avoided.↗
▶Ep 6 · 5:29
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 6 · 7:17
clinicalNeutropenia and low white blood cell count are more concerning than elevated white count in NEC, suggesting overwhelming sepsis that the patient is not compensating for.↗
▶Ep 6 · 7:17
quoteI get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 6 · 7:33
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC; low platelet count is important to know before surgery to optimize patient condition.↗
▶Ep 6 · 8:50
quoteSometimes free air can be quite subtle, and we wouldn't want to miss free air.↗
▶Ep 6 · 8:50
clinicalCross-table lateral or lateral decubitus X-ray films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 6 · 9:38
clinicalPneumoperitoneum (free air) is an absolute indication for surgical intervention, either drain placement or laparotomy.↗
▶Ep 6 · 9:54
clinicalClinical deterioration in the face of maximum medical management is an indication for surgery.↗
▶Ep 6 · 10:02
clinicalFixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not improving.↗
▶Ep 6 · 10:02
quoteFixed loops of intestine on serial X-rays are not, in my opinion, an absolute indication for surgery, but it sure is going to start to make bells and whistles go off in your mind that the patient is not going in the direction that you want them to go in.↗
▶Ep 6 · 10:16
quoteI have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation.↗
▶Ep 6 · 10:16
clinicalPortal venous air is a concerning and worrisome sign, but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.↗
▶Ep 6 · 10:58
clinicalMedical management of NEC includes withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotic therapy, and performing serial abdominal exams, labs, and X-rays.↗
▶Ep 6 · 12:05
clinicalSmall French feeding tubes are not adequate for gastric decompression in NEC; feeding tube should be removed and replaced with orogastric tube.↗
▶Ep 6 · 12:05
quoteThose tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression.↗
▶Ep 6 · 12:33
clinicalThere is tremendous diversity in antibiotic regimens for NEC across the United States; broad-spectrum coverage is critical but specific regimen may depend on bacterial colonization of the intensive care unit environment.↗
▶Ep 6 · 12:52
quoteI think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment.↗
▶Ep 6 · 13:37
clinicalAt Nationwide Children's Hospital, abdominal X-rays are obtained at intervals (approximately every 8 hours) rather than waiting 12-24 hours between films.↗
▶Ep 6 · 14:15
clinicalMedical management (NPO, decompression, antibiotics) should continue for at least 1 week to 10 days, preferably a week and a half, before starting feeds.↗
▶Ep 6 · 14:29
clinicalSome babies have repeated episodes of necrotizing enterocolitis.↗
▶Ep 6 · 14:40
clinicalPost-NEC stricture formation typically occurs in the colon, usually near the splenic flexure in the left colon, but can occur anywhere.↗
▶Ep 6 · 14:40
quoteYou have to worry about stricture formation in the baby post neck who's not tolerating their feeds well.↗
▶Ep 6 · 15:17
clinicalFor suspected post-NEC stricture, contrast enema is preferred as initial study over upper GI with small bowel follow-through because strictures are more common in colon and contrast from below avoids long wait time if patient is partially obstructed.↗
▶Ep 6 · 16:23
quoteI still believe that it's a matter of serial abdominal exams. I think it's very hard, you know, if you just examine the baby once and think that you know what to do or what the right answer is.↗
▶Ep 6 · 16:23
clinicalSerial abdominal exams are important for surgical decision-making; worsening distention, signs of peritoneal irritation, hemodynamic instability with increasing pressor support, and renal shutdown with no urine production build up to indicate need for surgery.↗
▶Ep 6 · 18:16
quoteI wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial.↗
▶Ep 6 · 19:10
epidemiologicalAt London NEC conference, 100% of European surgeons polled perform laparotomy for NEC and no one places peritoneal drains.↗
▶Ep 6 · 19:10
quote100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating.↗
▶Ep 6 · 19:44
clinicalTwo randomized controlled trials (MOSS trial in US and PIERO trial in Europe) of peritoneal drainage versus laparotomy showed no difference in overall mortality.↗
▶Ep 6 · 20:04
clinicalMOSS and PIERO trials looked at early endpoints rather than delayed endpoints of neurological recovery.↗
▶Ep 6 · 20:14
quoteIt appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis.↗
▶Ep 6 · 20:14
clinicalBabies who have peritoneal drains instead of laparotomy may do worse from neurological standpoint if neurological outcomes are examined 1-2 years after recovery from NEC.↗
▶Ep 6 · 20:34
clinicalThe ongoing NEST trial (necrotizing enterocolitis surgery trial) in the United States has randomized 300 babies to peritoneal drainage versus laparotomy and will examine neurological outcomes at 18-22 months after recovery from NEC with detailed neurological assessments.↗
▶Ep 6 · 20:53
quoteWe certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road.↗
▶Ep 6 · 21:44
opinionDr. Besner predicts that in the next 1-2 years, practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes expected to be better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.↗
▶Ep 6 · 21:44
quoteI predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies.↗
▶Ep 6 · 22:09
quoteWhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult.↗
▶Ep 6 · 22:09
clinicalBabies with peritoneal drains can have striking degree of dead bowel remaining in abdomen, as seen when some drain patients subsequently undergo laparotomy.↗
▶Ep 6 · 24:15
clinicalSystemic inflammatory response syndrome can make patients just as sick and hemodynamically unstable from isolated intestinal perforation as from necrotizing enterocolitis.↗
▶Ep 6 · 24:15
quoteYou can get just as sick and just as hemodynamically unstable from the systemic inflammatory response syndrome with an intestinal perforation, an isolated intestinal perforation, as you can from necrotizing enterocolitis.↗
▶Ep 6 · 25:46
quoteThere is a significant proportion of patients whereby you can put the drain in and they're going to continue to decline and do badly and they end up needing a laparotomy.↗
▶Ep 6 · 25:46
clinicalAfter peritoneal drain placement, significant proportion of patients continue to decline and require subsequent laparotomy.↗
▶Ep 6 · 26:15
clinicalPeritoneal drain placement is a bedside procedure performed with small amount of local anesthesia using small transverse incision in right lower quadrant; incision must not be too large to prevent subsequent hernia.↗
▶Ep 6 · 26:34
quoteIf you make the incision too big, it's a problem because then you can get a hernia once the drain is out.↗
▶Ep 6 · 26:41
clinicalQuarter-inch Penrose drain is used for peritoneal drainage; drain is passed gently multiple times without forcing to avoid bleeding, then sutured in place.↗
▶Ep 6 · 28:43
clinicalOperating during peak inflammatory process (e.g., 2 weeks after drain with ongoing stool output) can result in severe adhesions, serosal tears, and enterotomies; sometimes smartest decision is to stop operation, create proximal diverting stoma if possible, and avoid making situation worse.↗
▶Ep 6 · 28:57
quoteI think one of the smartest decisions that a surgeon can make is to know when to get out and to stop.↗
▶Ep 6 · 29:13
quoteYou just can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run.↗
▶Ep 6 · 29:48
clinicalAfter successful drain placement with patient recovery, drain should be advanced out over several days starting at 7-10 days post-operation rather than withdrawing all at once.↗
▶Ep 6 · 30:09
clinicalContinual leakage of stool at drain site is concerning; upper GI small bowel follow-through should be considered before drain removal if ongoing stool leakage present.↗
▶Ep 6 · 30:49
clinicalIf feeds are started after drain removal without contrast study and patient doesn't tolerate feeds, contrast study becomes mandatory to ensure everything is intact.↗
▶Ep 6 · 31:24
clinicalFor laparotomy, if baby is too hemodynamically unstable or on very high oscillator settings to safely transport to OR, operation can be performed at bedside in ICU with surgical team and anesthesiologists.↗
▶Ep 6 · 31:43
clinicalLaparotomy uses supraumbilical transverse incision; extreme care needed due to thin skin and underlying dilated bowel to avoid immediate enterotomy.↗
▶Ep 6 · 32:05
clinicalPatient should be resuscitated preoperatively with at least partial correction of platelet and coagulation abnormalities; blood products (packed red blood cells, platelets, fresh frozen plasma) must be available for operation.↗
▶Ep 6 · 32:27
quoteIf you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this.↗
▶Ep 6 · 32:27
clinicalIt is critically important not to injure liver or spleen in premature babies during laparotomy; even minimal trauma can cause subcapsular hematoma that baby can exsanguinate from.↗
▶Ep 6 · 32:46
quoteYou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies.↗
▶Ep 6 · 33:21
clinicalSpontaneous intestinal perforation (SIP) presents as one small localized area of perforation, while NEC is more diffuse disease with pneumatosis involving more than one tiny area; differentiation can be difficult preoperatively.↗
▶Ep 6 · 33:26
quoteI sometimes find the too hard to differentiate preoperatively. I've been fooled before thinking it's one and it turns out to be the other.↗
▶Ep 6 · 34:04
clinicalSome surgeons worldwide perform primary anastomosis after limited NEC resection; in the United States, surgeons are less likely to do primary anastomosis due to concern about anastomotic healing in these patients.↗
▶Ep 6 · 34:20
clinicalDr. Besner typically performs resection with stoma and mucous fistula rather than primary anastomosis, with stoma closure when patient is bigger (at least 2000g) and stable.↗
▶Ep 6 · 34:20
quoteI err on the side of being a little bit cautious, and I usually make stomas in these patients because I'm just so worried about them not being able to heal their anastomosis.↗
▶Ep 6 · 35:07
clinicalStomas are brought out through laparotomy incision with functional end and mucous fistula positioned close together to facilitate limited reoperation for closure; stomas are tacked to fascia but not matured.↗
▶Ep 6 · 35:50
quoteNo matter how careful you make these stomas, sometimes the distal end will slough off.↗
▶Ep 6 · 35:50
clinicalDistal end of stoma must protrude slightly because it can slough off; leaving small distal end prevents recession under fascia.↗
▶Ep 6 · 37:12
clinicalWhen bowel appears injured but not clearly necrotic (thin-walled, brownish discoloration, pneumatosis but not dead), acceptable approach is to not resect and perform second-look operation in 24-48 hours.↗
▶Ep 6 · 37:16
quoteSometimes if we go into the operating room a little too early on these patients, you see just what you described. It kind of looks like, you know, it's injured, but it's not necrotic, and it all kind of looks diffusely the same.↗
▶Ep 6 · 37:28
quoteI think it's perfectly acceptable to not resect at that point and to simply do nothing.↗
▶Ep 6 · 37:35
clinicalAbdomen may be left open if there are many dilated loops of bowel to avoid adding pressure that may compromise blood flow.↗
▶Ep 6 · 38:07
clinicalFor multiple skip lesions that are very close together, can resect all without creating short bowel syndrome rather than having multiple anastomoses.↗
▶Ep 6 · 38:19
clinicalFor separated skip lesions, can perform multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion; if anastomotic healing problem occurs, it won't be major issue because of proximal diversion.↗
▶Ep 6 · 38:46
clinicalClip and drop technique (resecting dead bowel, clipping ends, replacing in abdomen, returning for anastomosis when baby more stable) can be life-saving maneuver in very unstable patients without time for multiple anastomoses.↗
▶Ep 6 · 39:32
clinicalStoma reversal typically performed when baby is stable, well, hopefully feeding, and approximately 2000g in size; anastomosis is easier when baby is bigger.↗
▶Ep 6 · 39:56
clinicalEarlier stoma reversal is indicated if baby develops TPN-induced cholestasis or cannot be nourished due to very high stoma output.↗
▶Ep 6 · 40:48
clinicalMucous fistula refeeding is done selectively rather than routinely, particularly for very high output stomas where any nourishment given comes directly out the stoma.↗
▶Ep 6 · 41:22
clinicalMucous fistula often strictures post-operatively, losing opportunity for refeeding; if serious about refeeding (e.g., after massive resection with very high stoma), consider leaving small soft catheter in mucous fistula post-op to maintain access.↗
▶Ep 6 · 41:22
quoteYou have to be careful when you make that mucous fistula because often it strictures and you lose the opportunity to refeed.↗
▶Ep 6 · 42:15
clinicalNEC totalis is one of most tragic findings on exploratory laparotomy for NEC; chance of baby living to be old enough for small bowel-liver transplant is very close to zero.↗
▶Ep 6 · 42:15
quoteNecrotizing enterocolitis totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis.↗
▶Ep 6 · 42:32
quoteThe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero.↗
▶Ep 6 · 42:56
opinionFor very small premature baby with NEC totalis, current technology cannot get baby through this devastating problem; no one would be criticized for explaining severity to parents and providing comfort care after closing abdomen.↗
▶Ep 6 · 42:56
quoteI don't think, would be criticized for explaining to the parents the severity of the problem and just closing the abdomen and giving the baby comfort care.↗
▶Ep 6 · 43:42
quoteIn my experience, the chance of that baby living through, you know, the months to years of TPN that they're going to require is going to, you know, irreversibly injure their liver.↗
▶Ep 6 · 43:42
opinionIn Dr. Besner's experience, chance of baby with NEC totalis surviving months-to-years of required TPN is very low; TPN will irreversibly injure liver, and even if baby lives to transplant size, small bowel transplant results remain suboptimal.↗
▶Ep 6 · 44:01
quoteI just in general think that that's a no-win situation in my experience.↗
▶Ep 6 · 44:28
clinicalSmall subset of premature patients with severe lung disease can develop pneumothorax that dissects through diaphragm into abdomen, causing pneumoperitoneum; must confirm problem is in abdomen rather than chest.↗
▶Ep 6 · 45:06
clinicalFor extremely unstable patient (e.g., 800g on jet ventilation and pressors) with pneumoperitoneum and severe distention, angiocatheter can be inserted through abdominal wall to release pneumoperitoneum as temporizing maneuver while mobilizing for definitive operation.↗
Stay Current Throwbacks Necrotizing Enterocolitis with Dr. Gail Besner
▶Ep 10 · 1:53
clinicalDespite six decades of research, the exact cause of necrotizing enterocolitis remains unknown and there is no absolute cure.↗
▶Ep 10 · 2:10
quotedespite six decades of research, we really don't know exactly what causes nec, and we still are quite some ways from finding an absolute cure for the disease↗
▶Ep 10 · 3:21
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 10 · 4:46
clinicalAcid suppression medications (PPIs, H2 blockers) should be avoided in at-risk neonates because neutralizing gastric acid may increase NEC risk.↗
▶Ep 10 · 5:10
quoteyou don't want to neutralize the acid that the baby is producing↗
▶Ep 10 · 5:24
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 10 · 7:14
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and platelet count is important to know before surgery to optimize the patient's condition.↗
▶Ep 10 · 7:14
clinicalNeutropenia (low white blood cell count) in a baby with suspected NEC is more concerning than leukocytosis because it may indicate overwhelming sepsis that the baby cannot compensate for.↗
▶Ep 10 · 7:30
quoteI actually get more worried when the patients are neutropenic and they have a low white blood cell count. Because to me, that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 10 · 8:48
clinicalCross-table lateral or lateral decubitus films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 10 · 9:24
clinicalFree air on imaging is an absolute indication for surgical intervention (either drain or laparotomy) in NEC.↗
▶Ep 10 · 9:50
opinionFixed loops of intestine on serial x-rays are not an absolute indication for surgery but are a concerning sign that the patient is not improving.↗
▶Ep 10 · 10:25
clinicalPortal venous air is a worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management.↗
▶Ep 10 · 11:01
guidelineMedical management of NEC includes withholding feeds, orogastric tube decompression, broad-spectrum antibiotics, and serial monitoring (exams, labs, x-rays).↗
▶Ep 10 · 11:46
clinicalSmall French feeding tubes are inadequate for gastric decompression in NEC; they should be replaced with larger orogastric tubes.↗
▶Ep 10 · 12:35
opinionThere is likely tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization patterns in individual ICU environments.↗
▶Ep 10 · 13:39
opinionAbdominal x-rays should be obtained at regular intervals (approximately every 8 hours) during medical NEC management, not waiting 12-24 hours between films.↗
▶Ep 10 · 14:16
opinionBabies should remain NPO for at least 7-10 days (preferably a week and a half) after medical NEC treatment before attempting to restart feeds.↗
▶Ep 10 · 14:45
clinicalStricture formation after medical NEC typically occurs in the colon, usually near the splenic flexure, but can occur anywhere.↗
▶Ep 10 · 15:18
clinicalWhen evaluating for post-NEC stricture, contrast enema should be performed before upper GI with small bowel follow-through because strictures are more common in the colon and waiting for contrast to pass through obstructed small bowel is time-consuming.↗
▶Ep 10 · 16:22
opinionSerial abdominal examinations over time are more valuable than a single examination for determining need for surgery in NEC without absolute indications.↗
▶Ep 10 · 16:40
quoteI think that serial abdominal exams are important. And if you see worsening distension, worsening, you know, signs of peritoneal irritation, hemodynamic instability with increasing needs for presser support, renal shutdown with no urine production, you know, it starts to build up. And it's like building blocks. And if you have, you know, A, B, and C, it's time to think about surgery.↗
▶Ep 10 · 19:29
quote100% of the surgeons do a laparotomy, and no one puts in a drain in Europe, which I thought was just fascinating↗
▶Ep 10 · 19:29
epidemiologicalAt a recent NEC conference in London, 100% of European surgeons reported performing laparotomy for NEC; none use peritoneal drainage.↗
▶Ep 10 · 19:42
epidemiologicalThe MOSS and PIERO randomized controlled trials showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC.↗
▶Ep 10 · 20:20
epidemiologicalBabies who receive peritoneal drains instead of laparotomy may have worse neurological outcomes at 1-2 years post-NEC, though early mortality is similar.↗
▶Ep 10 · 20:30
quoteit appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis↗
▶Ep 10 · 21:00
epidemiologicalThe NEST trial randomized 300 babies to peritoneal drainage versus laparotomy and will assess neurological outcomes at 18-22 months, with results expected in 1-2 years (from 2017).↗
▶Ep 10 · 21:41
quoteI predict that in the next year or two, we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies↗
▶Ep 10 · 22:20
quotewhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult↗
▶Ep 10 · 24:07
clinicalSpontaneous intestinal perforation (SIP) can cause hemodynamic instability similar to NEC through systemic inflammatory response syndrome, making clinical differentiation difficult.↗
▶Ep 10 · 26:17
clinicalPeritoneal drain placement can be performed at bedside with local anesthesia through a small right lower quadrant transverse incision using a quarter-inch Penrose drain.↗
▶Ep 10 · 27:00
clinicalMaking the drain incision too large can lead to hernia formation after drain removal.↗
▶Ep 10 · 28:38
opinionWhen operating on a baby with extensive adhesions after drain placement, surgeons should know when to stop if causing multiple serosal tears and enterotomies, as continuing may worsen the outcome.↗
▶Ep 10 · 29:00
quotesometimes I think that one of the smartest decisions that a surgeon can make is to know when to get out and to stop↗
▶Ep 10 · 29:20
clinicalCreating a proximal diverting stoma is helpful when extensive adhesions prevent safe complete exploration, as it controls the perforation and diverts the fecal stream.↗
▶Ep 10 · 29:50
opinionPeritoneal drains should be advanced out gradually over several days starting at 7-10 days post-placement, rather than removing all at once.↗
▶Ep 10 · 31:18
clinicalFor laparotomy in NEC, a supraumbilical transverse incision is used, with extreme care required to avoid liver and spleen injury in premature infants.↗
▶Ep 10 · 32:00
clinicalEven minimal trauma to the liver in premature babies can cause subcapsular hematomas that can lead to exsanguination.↗
▶Ep 10 · 32:30
quoteyou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies↗
▶Ep 10 · 33:10
clinicalNEC is differentiated from SIP intraoperatively: SIP presents as one small localized perforation, while NEC shows more diffuse disease with pneumatosis involving more than one area.↗
▶Ep 10 · 34:00
clinicalSome surgeons internationally perform primary anastomosis after NEC resection, but many US surgeons create stomas due to concern about anastomotic healing in critically ill premature infants.↗
▶Ep 10 · 35:03
clinicalBringing stoma and mucous fistula out close together through the main incision allows for more limited reoperation at stoma closure compared to separate sites.↗
▶Ep 10 · 35:45
clinicalStomas should be tacked to fascia (not matured) and a small distal end should protrude to prevent recession under the fascia, though sloughing of the distal end can still occur.↗
▶Ep 10 · 37:13
opinionWhen bowel appears injured but not clearly necrotic (thin-walled, brownish, with pneumatosis but diffusely similar), it may be appropriate to not resect, leave the abdomen open to reduce pressure, and return for second-look operation in 24-48 hours.↗
▶Ep 10 · 37:20
quoteI think sometimes if we go into the operating room a little too early on these patients, you see just what you describe. It kind of looks like, you know, it's injured, but it's not necrotic and it all kind of looks diffusely the same.↗
▶Ep 10 · 38:06
opinionFor multiple skip lesions in NEC, if they are close together and can be resected without creating short bowel syndrome, resecting all may be preferable to multiple anastomoses.↗
▶Ep 10 · 38:30
clinicalMultiple anastomoses can be performed with proximal diversion so that if one anastomosis fails to heal, it is distal to the diversion and less problematic.↗
▶Ep 10 · 38:48
clinicalClip-and-drop technique (resecting dead bowel, clipping ends, replacing in abdomen for later definitive surgery) can be lifesaving in very unstable patients when time does not permit multiple anastomoses.↗
▶Ep 10 · 39:28
opinionStoma reversal is typically performed when the baby reaches approximately 2000 grams, though earlier reversal is indicated for TPN-induced cholestasis or inability to nourish due to high stoma output.↗
▶Ep 10 · 40:41
opinionRefeeding through mucous fistula is done selectively (not routinely), primarily for very high-output stomas where most nutrition is lost through the stoma.↗
▶Ep 10 · 41:23
clinicalMucous fistulas often stricture, preventing refeeding access; leaving a small soft catheter in the mucous fistula post-operatively can maintain access for refeeding.↗
▶Ep 10 · 42:06
clinicalThe chance of a premature baby with NEC totalis surviving long enough to receive small bowel-liver transplant is very close to zero.↗
▶Ep 10 · 42:20
quotethe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero↗
▶Ep 10 · 43:39
clinicalBabies with NEC totalis who survive on TPN for months to years will develop irreversible liver injury, and even if they reach transplant size, small bowel transplant outcomes remain suboptimal.↗
▶Ep 10 · 44:22
clinicalPneumothorax can dissect through the diaphragm into the abdomen in premature babies with severe lung disease, mimicking intra-abdominal free air; this must be ruled out before attributing pneumoperitoneum to bowel perforation.↗
▶Ep 10 · 45:00
clinicalIn a hemodynamically unstable baby with pneumoperitoneum, inserting an angiocatheter through the abdominal wall to release pressure is a useful temporizing measure while mobilizing the OR.↗
clinicalDespite 6 decades of research, the exact cause of necrotizing enterocolitis is unknown and there is no absolute cure for the disease.↗
▶Ep 2 · 2:11
quoteDespite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease.↗
▶Ep 2 · 2:11
quoteDespite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease.↗
▶Ep 2 · 2:11
clinicalDespite 6 decades of research, the exact cause of necrotizing enterocolitis is unknown and there is no absolute cure for the disease.↗
▶Ep 2 · 3:53
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 2 · 3:53
clinicalIndomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.↗
▶Ep 2 · 4:44
clinicalPPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; gastric acid neutralization should be avoided.↗
▶Ep 2 · 4:44
clinicalPPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; gastric acid neutralization should be avoided.↗
▶Ep 2 · 5:29
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 2 · 5:29
clinicalIn premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.↗
▶Ep 2 · 7:17
clinicalNeutropenia and low white blood cell count are more concerning than elevated white count in NEC, suggesting overwhelming sepsis that the patient is not compensating for.↗
▶Ep 2 · 7:17
quoteI get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 2 · 7:17
quoteI get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for.↗
▶Ep 2 · 7:17
clinicalNeutropenia and low white blood cell count are more concerning than elevated white count in NEC, suggesting overwhelming sepsis that the patient is not compensating for.↗
▶Ep 2 · 7:33
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC; low platelet count is important to know before surgery to optimize patient condition.↗
▶Ep 2 · 7:33
clinicalThrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC; low platelet count is important to know before surgery to optimize patient condition.↗
▶Ep 2 · 8:50
clinicalCross-table lateral or lateral decubitus X-ray films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 2 · 8:50
quoteSometimes free air can be quite subtle, and we wouldn't want to miss free air.↗
▶Ep 2 · 8:50
quoteSometimes free air can be quite subtle, and we wouldn't want to miss free air.↗
▶Ep 2 · 8:50
clinicalCross-table lateral or lateral decubitus X-ray films are essential in addition to plain films because free air can be quite subtle and easily missed.↗
▶Ep 2 · 9:38
clinicalPneumoperitoneum (free air) is an absolute indication for surgical intervention, either drain placement or laparotomy.↗
▶Ep 2 · 9:38
clinicalPneumoperitoneum (free air) is an absolute indication for surgical intervention, either drain placement or laparotomy.↗
▶Ep 2 · 9:54
clinicalClinical deterioration in the face of maximum medical management is an indication for surgery.↗
▶Ep 2 · 9:54
clinicalClinical deterioration in the face of maximum medical management is an indication for surgery.↗
▶Ep 2 · 10:02
clinicalFixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not improving.↗
▶Ep 2 · 10:02
quoteFixed loops of intestine on serial X-rays are not, in my opinion, an absolute indication for surgery, but it sure is going to start to make bells and whistles go off in your mind that the patient is not going in the direction that you want them to go in.↗
▶Ep 2 · 10:02
clinicalFixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not improving.↗
▶Ep 2 · 10:02
quoteFixed loops of intestine on serial X-rays are not, in my opinion, an absolute indication for surgery, but it sure is going to start to make bells and whistles go off in your mind that the patient is not going in the direction that you want them to go in.↗
▶Ep 2 · 10:16
quoteI have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation.↗
▶Ep 2 · 10:16
clinicalPortal venous air is a concerning and worrisome sign, but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.↗
▶Ep 2 · 10:16
clinicalPortal venous air is a concerning and worrisome sign, but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.↗
▶Ep 2 · 10:16
quoteI have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation.↗
▶Ep 2 · 10:58
clinicalMedical management of NEC includes withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotic therapy, and performing serial abdominal exams, labs, and X-rays.↗
▶Ep 2 · 10:58
clinicalMedical management of NEC includes withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotic therapy, and performing serial abdominal exams, labs, and X-rays.↗
▶Ep 2 · 12:05
clinicalSmall French feeding tubes are not adequate for gastric decompression in NEC; feeding tube should be removed and replaced with orogastric tube.↗
▶Ep 2 · 12:05
quoteThose tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression.↗
▶Ep 2 · 12:05
quoteThose tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression.↗
▶Ep 2 · 12:05
clinicalSmall French feeding tubes are not adequate for gastric decompression in NEC; feeding tube should be removed and replaced with orogastric tube.↗
▶Ep 2 · 12:33
clinicalThere is tremendous diversity in antibiotic regimens for NEC across the United States; broad-spectrum coverage is critical but specific regimen may depend on bacterial colonization of the intensive care unit environment.↗
▶Ep 2 · 12:33
clinicalThere is tremendous diversity in antibiotic regimens for NEC across the United States; broad-spectrum coverage is critical but specific regimen may depend on bacterial colonization of the intensive care unit environment.↗
▶Ep 2 · 12:52
quoteI think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment.↗
▶Ep 2 · 12:52
quoteI think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment.↗
▶Ep 2 · 13:37
clinicalAt Nationwide Children's Hospital, abdominal X-rays are obtained at intervals (approximately every 8 hours) rather than waiting 12-24 hours between films.↗
▶Ep 2 · 13:37
clinicalAt Nationwide Children's Hospital, abdominal X-rays are obtained at intervals (approximately every 8 hours) rather than waiting 12-24 hours between films.↗
▶Ep 2 · 14:15
clinicalMedical management (NPO, decompression, antibiotics) should continue for at least 1 week to 10 days, preferably a week and a half, before starting feeds.↗
▶Ep 2 · 14:15
clinicalMedical management (NPO, decompression, antibiotics) should continue for at least 1 week to 10 days, preferably a week and a half, before starting feeds.↗
▶Ep 2 · 14:29
clinicalSome babies have repeated episodes of necrotizing enterocolitis.↗
▶Ep 2 · 14:29
clinicalSome babies have repeated episodes of necrotizing enterocolitis.↗
▶Ep 2 · 14:40
clinicalPost-NEC stricture formation typically occurs in the colon, usually near the splenic flexure in the left colon, but can occur anywhere.↗
▶Ep 2 · 14:40
quoteYou have to worry about stricture formation in the baby post neck who's not tolerating their feeds well.↗
▶Ep 2 · 14:40
clinicalPost-NEC stricture formation typically occurs in the colon, usually near the splenic flexure in the left colon, but can occur anywhere.↗
▶Ep 2 · 14:40
quoteYou have to worry about stricture formation in the baby post neck who's not tolerating their feeds well.↗
▶Ep 2 · 15:17
clinicalFor suspected post-NEC stricture, contrast enema is preferred as initial study over upper GI with small bowel follow-through because strictures are more common in colon and contrast from below avoids long wait time if patient is partially obstructed.↗
▶Ep 2 · 15:17
clinicalFor suspected post-NEC stricture, contrast enema is preferred as initial study over upper GI with small bowel follow-through because strictures are more common in colon and contrast from below avoids long wait time if patient is partially obstructed.↗
▶Ep 2 · 16:23
quoteI still believe that it's a matter of serial abdominal exams. I think it's very hard, you know, if you just examine the baby once and think that you know what to do or what the right answer is.↗
▶Ep 2 · 16:23
clinicalSerial abdominal exams are important for surgical decision-making; worsening distention, signs of peritoneal irritation, hemodynamic instability with increasing pressor support, and renal shutdown with no urine production build up to indicate need for surgery.↗
▶Ep 2 · 16:23
clinicalSerial abdominal exams are important for surgical decision-making; worsening distention, signs of peritoneal irritation, hemodynamic instability with increasing pressor support, and renal shutdown with no urine production build up to indicate need for surgery.↗
▶Ep 2 · 16:23
quoteI still believe that it's a matter of serial abdominal exams. I think it's very hard, you know, if you just examine the baby once and think that you know what to do or what the right answer is.↗
▶Ep 2 · 18:16
quoteI wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial.↗
▶Ep 2 · 18:16
quoteI wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial.↗
▶Ep 2 · 19:10
quote100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating.↗
▶Ep 2 · 19:10
epidemiologicalAt London NEC conference, 100% of European surgeons polled perform laparotomy for NEC and no one places peritoneal drains.↗
▶Ep 2 · 19:10
epidemiologicalAt London NEC conference, 100% of European surgeons polled perform laparotomy for NEC and no one places peritoneal drains.↗
▶Ep 2 · 19:10
quote100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating.↗
▶Ep 2 · 19:44
clinicalTwo randomized controlled trials (MOSS trial in US and PIERO trial in Europe) of peritoneal drainage versus laparotomy showed no difference in overall mortality.↗
▶Ep 2 · 19:44
clinicalTwo randomized controlled trials (MOSS trial in US and PIERO trial in Europe) of peritoneal drainage versus laparotomy showed no difference in overall mortality.↗
▶Ep 2 · 20:04
clinicalMOSS and PIERO trials looked at early endpoints rather than delayed endpoints of neurological recovery.↗
▶Ep 2 · 20:04
clinicalMOSS and PIERO trials looked at early endpoints rather than delayed endpoints of neurological recovery.↗
▶Ep 2 · 20:14
quoteIt appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis.↗
▶Ep 2 · 20:14
clinicalBabies who have peritoneal drains instead of laparotomy may do worse from neurological standpoint if neurological outcomes are examined 1-2 years after recovery from NEC.↗
▶Ep 2 · 20:14
quoteIt appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis.↗
▶Ep 2 · 20:14
clinicalBabies who have peritoneal drains instead of laparotomy may do worse from neurological standpoint if neurological outcomes are examined 1-2 years after recovery from NEC.↗
▶Ep 2 · 20:34
clinicalThe ongoing NEST trial (necrotizing enterocolitis surgery trial) in the United States has randomized 300 babies to peritoneal drainage versus laparotomy and will examine neurological outcomes at 18-22 months after recovery from NEC with detailed neurological assessments.↗
▶Ep 2 · 20:34
clinicalThe ongoing NEST trial (necrotizing enterocolitis surgery trial) in the United States has randomized 300 babies to peritoneal drainage versus laparotomy and will examine neurological outcomes at 18-22 months after recovery from NEC with detailed neurological assessments.↗
▶Ep 2 · 20:53
quoteWe certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road.↗
▶Ep 2 · 20:53
quoteWe certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road.↗
▶Ep 2 · 21:44
quoteI predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies.↗
▶Ep 2 · 21:44
quoteI predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies.↗
▶Ep 2 · 21:44
opinionDr. Besner predicts that in the next 1-2 years, practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes expected to be better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.↗
▶Ep 2 · 21:44
opinionDr. Besner predicts that in the next 1-2 years, practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes expected to be better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.↗
▶Ep 2 · 22:09
quoteWhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult.↗
▶Ep 2 · 22:09
clinicalBabies with peritoneal drains can have striking degree of dead bowel remaining in abdomen, as seen when some drain patients subsequently undergo laparotomy.↗
▶Ep 2 · 22:09
clinicalBabies with peritoneal drains can have striking degree of dead bowel remaining in abdomen, as seen when some drain patients subsequently undergo laparotomy.↗
▶Ep 2 · 22:09
quoteWhen you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult.↗
▶Ep 2 · 24:15
quoteYou can get just as sick and just as hemodynamically unstable from the systemic inflammatory response syndrome with an intestinal perforation, an isolated intestinal perforation, as you can from necrotizing enterocolitis.↗
▶Ep 2 · 24:15
clinicalSystemic inflammatory response syndrome can make patients just as sick and hemodynamically unstable from isolated intestinal perforation as from necrotizing enterocolitis.↗
▶Ep 2 · 24:15
quoteYou can get just as sick and just as hemodynamically unstable from the systemic inflammatory response syndrome with an intestinal perforation, an isolated intestinal perforation, as you can from necrotizing enterocolitis.↗
▶Ep 2 · 24:15
clinicalSystemic inflammatory response syndrome can make patients just as sick and hemodynamically unstable from isolated intestinal perforation as from necrotizing enterocolitis.↗
▶Ep 2 · 25:46
quoteThere is a significant proportion of patients whereby you can put the drain in and they're going to continue to decline and do badly and they end up needing a laparotomy.↗
▶Ep 2 · 25:46
quoteThere is a significant proportion of patients whereby you can put the drain in and they're going to continue to decline and do badly and they end up needing a laparotomy.↗
▶Ep 2 · 25:46
clinicalAfter peritoneal drain placement, significant proportion of patients continue to decline and require subsequent laparotomy.↗
▶Ep 2 · 25:46
clinicalAfter peritoneal drain placement, significant proportion of patients continue to decline and require subsequent laparotomy.↗
▶Ep 2 · 26:15
clinicalPeritoneal drain placement is a bedside procedure performed with small amount of local anesthesia using small transverse incision in right lower quadrant; incision must not be too large to prevent subsequent hernia.↗
▶Ep 2 · 26:15
clinicalPeritoneal drain placement is a bedside procedure performed with small amount of local anesthesia using small transverse incision in right lower quadrant; incision must not be too large to prevent subsequent hernia.↗
▶Ep 2 · 26:34
quoteIf you make the incision too big, it's a problem because then you can get a hernia once the drain is out.↗
▶Ep 2 · 26:34
quoteIf you make the incision too big, it's a problem because then you can get a hernia once the drain is out.↗
▶Ep 2 · 26:41
clinicalQuarter-inch Penrose drain is used for peritoneal drainage; drain is passed gently multiple times without forcing to avoid bleeding, then sutured in place.↗
▶Ep 2 · 26:41
clinicalQuarter-inch Penrose drain is used for peritoneal drainage; drain is passed gently multiple times without forcing to avoid bleeding, then sutured in place.↗
▶Ep 2 · 28:43
clinicalOperating during peak inflammatory process (e.g., 2 weeks after drain with ongoing stool output) can result in severe adhesions, serosal tears, and enterotomies; sometimes smartest decision is to stop operation, create proximal diverting stoma if possible, and avoid making situation worse.↗
▶Ep 2 · 28:43
clinicalOperating during peak inflammatory process (e.g., 2 weeks after drain with ongoing stool output) can result in severe adhesions, serosal tears, and enterotomies; sometimes smartest decision is to stop operation, create proximal diverting stoma if possible, and avoid making situation worse.↗
▶Ep 2 · 28:57
quoteI think one of the smartest decisions that a surgeon can make is to know when to get out and to stop.↗
▶Ep 2 · 28:57
quoteI think one of the smartest decisions that a surgeon can make is to know when to get out and to stop.↗
▶Ep 2 · 29:13
quoteYou just can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run.↗
▶Ep 2 · 29:13
quoteYou just can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run.↗
▶Ep 2 · 29:48
clinicalAfter successful drain placement with patient recovery, drain should be advanced out over several days starting at 7-10 days post-operation rather than withdrawing all at once.↗
▶Ep 2 · 29:48
clinicalAfter successful drain placement with patient recovery, drain should be advanced out over several days starting at 7-10 days post-operation rather than withdrawing all at once.↗
▶Ep 2 · 30:09
clinicalContinual leakage of stool at drain site is concerning; upper GI small bowel follow-through should be considered before drain removal if ongoing stool leakage present.↗
▶Ep 2 · 30:09
clinicalContinual leakage of stool at drain site is concerning; upper GI small bowel follow-through should be considered before drain removal if ongoing stool leakage present.↗
▶Ep 2 · 30:49
clinicalIf feeds are started after drain removal without contrast study and patient doesn't tolerate feeds, contrast study becomes mandatory to ensure everything is intact.↗
▶Ep 2 · 30:49
clinicalIf feeds are started after drain removal without contrast study and patient doesn't tolerate feeds, contrast study becomes mandatory to ensure everything is intact.↗
▶Ep 2 · 31:24
clinicalFor laparotomy, if baby is too hemodynamically unstable or on very high oscillator settings to safely transport to OR, operation can be performed at bedside in ICU with surgical team and anesthesiologists.↗
▶Ep 2 · 31:24
clinicalFor laparotomy, if baby is too hemodynamically unstable or on very high oscillator settings to safely transport to OR, operation can be performed at bedside in ICU with surgical team and anesthesiologists.↗
▶Ep 2 · 31:43
clinicalLaparotomy uses supraumbilical transverse incision; extreme care needed due to thin skin and underlying dilated bowel to avoid immediate enterotomy.↗
▶Ep 2 · 31:43
clinicalLaparotomy uses supraumbilical transverse incision; extreme care needed due to thin skin and underlying dilated bowel to avoid immediate enterotomy.↗
▶Ep 2 · 32:05
clinicalPatient should be resuscitated preoperatively with at least partial correction of platelet and coagulation abnormalities; blood products (packed red blood cells, platelets, fresh frozen plasma) must be available for operation.↗
▶Ep 2 · 32:05
clinicalPatient should be resuscitated preoperatively with at least partial correction of platelet and coagulation abnormalities; blood products (packed red blood cells, platelets, fresh frozen plasma) must be available for operation.↗
▶Ep 2 · 32:27
clinicalIt is critically important not to injure liver or spleen in premature babies during laparotomy; even minimal trauma can cause subcapsular hematoma that baby can exsanguinate from.↗
▶Ep 2 · 32:27
clinicalIt is critically important not to injure liver or spleen in premature babies during laparotomy; even minimal trauma can cause subcapsular hematoma that baby can exsanguinate from.↗
▶Ep 2 · 32:27
quoteIf you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this.↗
▶Ep 2 · 32:27
quoteIf you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this.↗
▶Ep 2 · 32:46
quoteYou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies.↗
▶Ep 2 · 32:46
quoteYou can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies.↗
▶Ep 2 · 33:21
clinicalSpontaneous intestinal perforation (SIP) presents as one small localized area of perforation, while NEC is more diffuse disease with pneumatosis involving more than one tiny area; differentiation can be difficult preoperatively.↗
▶Ep 2 · 33:21
clinicalSpontaneous intestinal perforation (SIP) presents as one small localized area of perforation, while NEC is more diffuse disease with pneumatosis involving more than one tiny area; differentiation can be difficult preoperatively.↗
▶Ep 2 · 33:26
quoteI sometimes find the too hard to differentiate preoperatively. I've been fooled before thinking it's one and it turns out to be the other.↗
▶Ep 2 · 33:26
quoteI sometimes find the too hard to differentiate preoperatively. I've been fooled before thinking it's one and it turns out to be the other.↗
▶Ep 2 · 34:04
clinicalSome surgeons worldwide perform primary anastomosis after limited NEC resection; in the United States, surgeons are less likely to do primary anastomosis due to concern about anastomotic healing in these patients.↗
▶Ep 2 · 34:04
clinicalSome surgeons worldwide perform primary anastomosis after limited NEC resection; in the United States, surgeons are less likely to do primary anastomosis due to concern about anastomotic healing in these patients.↗
▶Ep 2 · 34:20
clinicalDr. Besner typically performs resection with stoma and mucous fistula rather than primary anastomosis, with stoma closure when patient is bigger (at least 2000g) and stable.↗
▶Ep 2 · 34:20
clinicalDr. Besner typically performs resection with stoma and mucous fistula rather than primary anastomosis, with stoma closure when patient is bigger (at least 2000g) and stable.↗
▶Ep 2 · 34:20
quoteI err on the side of being a little bit cautious, and I usually make stomas in these patients because I'm just so worried about them not being able to heal their anastomosis.↗
▶Ep 2 · 34:20
quoteI err on the side of being a little bit cautious, and I usually make stomas in these patients because I'm just so worried about them not being able to heal their anastomosis.↗
▶Ep 2 · 35:07
clinicalStomas are brought out through laparotomy incision with functional end and mucous fistula positioned close together to facilitate limited reoperation for closure; stomas are tacked to fascia but not matured.↗
▶Ep 2 · 35:07
clinicalStomas are brought out through laparotomy incision with functional end and mucous fistula positioned close together to facilitate limited reoperation for closure; stomas are tacked to fascia but not matured.↗
▶Ep 2 · 35:50
clinicalDistal end of stoma must protrude slightly because it can slough off; leaving small distal end prevents recession under fascia.↗
▶Ep 2 · 35:50
clinicalDistal end of stoma must protrude slightly because it can slough off; leaving small distal end prevents recession under fascia.↗
▶Ep 2 · 35:50
quoteNo matter how careful you make these stomas, sometimes the distal end will slough off.↗
▶Ep 2 · 35:50
quoteNo matter how careful you make these stomas, sometimes the distal end will slough off.↗
▶Ep 2 · 37:12
clinicalWhen bowel appears injured but not clearly necrotic (thin-walled, brownish discoloration, pneumatosis but not dead), acceptable approach is to not resect and perform second-look operation in 24-48 hours.↗
▶Ep 2 · 37:12
clinicalWhen bowel appears injured but not clearly necrotic (thin-walled, brownish discoloration, pneumatosis but not dead), acceptable approach is to not resect and perform second-look operation in 24-48 hours.↗
▶Ep 2 · 37:16
quoteSometimes if we go into the operating room a little too early on these patients, you see just what you described. It kind of looks like, you know, it's injured, but it's not necrotic, and it all kind of looks diffusely the same.↗
▶Ep 2 · 37:16
quoteSometimes if we go into the operating room a little too early on these patients, you see just what you described. It kind of looks like, you know, it's injured, but it's not necrotic, and it all kind of looks diffusely the same.↗
▶Ep 2 · 37:28
quoteI think it's perfectly acceptable to not resect at that point and to simply do nothing.↗
▶Ep 2 · 37:28
quoteI think it's perfectly acceptable to not resect at that point and to simply do nothing.↗
▶Ep 2 · 37:35
clinicalAbdomen may be left open if there are many dilated loops of bowel to avoid adding pressure that may compromise blood flow.↗
▶Ep 2 · 37:35
clinicalAbdomen may be left open if there are many dilated loops of bowel to avoid adding pressure that may compromise blood flow.↗
▶Ep 2 · 38:07
clinicalFor multiple skip lesions that are very close together, can resect all without creating short bowel syndrome rather than having multiple anastomoses.↗
▶Ep 2 · 38:07
clinicalFor multiple skip lesions that are very close together, can resect all without creating short bowel syndrome rather than having multiple anastomoses.↗
▶Ep 2 · 38:19
clinicalFor separated skip lesions, can perform multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion; if anastomotic healing problem occurs, it won't be major issue because of proximal diversion.↗
▶Ep 2 · 38:19
clinicalFor separated skip lesions, can perform multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion; if anastomotic healing problem occurs, it won't be major issue because of proximal diversion.↗
▶Ep 2 · 38:46
clinicalClip and drop technique (resecting dead bowel, clipping ends, replacing in abdomen, returning for anastomosis when baby more stable) can be life-saving maneuver in very unstable patients without time for multiple anastomoses.↗
▶Ep 2 · 38:46
clinicalClip and drop technique (resecting dead bowel, clipping ends, replacing in abdomen, returning for anastomosis when baby more stable) can be life-saving maneuver in very unstable patients without time for multiple anastomoses.↗
▶Ep 2 · 39:32
clinicalStoma reversal typically performed when baby is stable, well, hopefully feeding, and approximately 2000g in size; anastomosis is easier when baby is bigger.↗
▶Ep 2 · 39:32
clinicalStoma reversal typically performed when baby is stable, well, hopefully feeding, and approximately 2000g in size; anastomosis is easier when baby is bigger.↗
▶Ep 2 · 39:56
clinicalEarlier stoma reversal is indicated if baby develops TPN-induced cholestasis or cannot be nourished due to very high stoma output.↗
▶Ep 2 · 39:56
clinicalEarlier stoma reversal is indicated if baby develops TPN-induced cholestasis or cannot be nourished due to very high stoma output.↗
▶Ep 2 · 40:48
clinicalMucous fistula refeeding is done selectively rather than routinely, particularly for very high output stomas where any nourishment given comes directly out the stoma.↗
▶Ep 2 · 40:48
clinicalMucous fistula refeeding is done selectively rather than routinely, particularly for very high output stomas where any nourishment given comes directly out the stoma.↗
▶Ep 2 · 41:22
clinicalMucous fistula often strictures post-operatively, losing opportunity for refeeding; if serious about refeeding (e.g., after massive resection with very high stoma), consider leaving small soft catheter in mucous fistula post-op to maintain access.↗
▶Ep 2 · 41:22
quoteYou have to be careful when you make that mucous fistula because often it strictures and you lose the opportunity to refeed.↗
▶Ep 2 · 41:22
clinicalMucous fistula often strictures post-operatively, losing opportunity for refeeding; if serious about refeeding (e.g., after massive resection with very high stoma), consider leaving small soft catheter in mucous fistula post-op to maintain access.↗
▶Ep 2 · 41:22
quoteYou have to be careful when you make that mucous fistula because often it strictures and you lose the opportunity to refeed.↗
▶Ep 2 · 42:15
clinicalNEC totalis is one of most tragic findings on exploratory laparotomy for NEC; chance of baby living to be old enough for small bowel-liver transplant is very close to zero.↗
▶Ep 2 · 42:15
quoteNecrotizing enterocolitis totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis.↗
▶Ep 2 · 42:15
quoteNecrotizing enterocolitis totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis.↗
▶Ep 2 · 42:15
clinicalNEC totalis is one of most tragic findings on exploratory laparotomy for NEC; chance of baby living to be old enough for small bowel-liver transplant is very close to zero.↗
▶Ep 2 · 42:32
quoteThe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero.↗
▶Ep 2 · 42:32
quoteThe chance of a baby who has true necrotizing enterocolitis totalis and who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero.↗
▶Ep 2 · 42:56
quoteI don't think, would be criticized for explaining to the parents the severity of the problem and just closing the abdomen and giving the baby comfort care.↗
▶Ep 2 · 42:56
opinionFor very small premature baby with NEC totalis, current technology cannot get baby through this devastating problem; no one would be criticized for explaining severity to parents and providing comfort care after closing abdomen.↗
▶Ep 2 · 42:56
quoteI don't think, would be criticized for explaining to the parents the severity of the problem and just closing the abdomen and giving the baby comfort care.↗
▶Ep 2 · 42:56
opinionFor very small premature baby with NEC totalis, current technology cannot get baby through this devastating problem; no one would be criticized for explaining severity to parents and providing comfort care after closing abdomen.↗
▶Ep 2 · 43:42
opinionIn Dr. Besner's experience, chance of baby with NEC totalis surviving months-to-years of required TPN is very low; TPN will irreversibly injure liver, and even if baby lives to transplant size, small bowel transplant results remain suboptimal.↗
▶Ep 2 · 43:42
quoteIn my experience, the chance of that baby living through, you know, the months to years of TPN that they're going to require is going to, you know, irreversibly injure their liver.↗
▶Ep 2 · 43:42
quoteIn my experience, the chance of that baby living through, you know, the months to years of TPN that they're going to require is going to, you know, irreversibly injure their liver.↗
▶Ep 2 · 43:42
opinionIn Dr. Besner's experience, chance of baby with NEC totalis surviving months-to-years of required TPN is very low; TPN will irreversibly injure liver, and even if baby lives to transplant size, small bowel transplant results remain suboptimal.↗
▶Ep 2 · 44:01
quoteI just in general think that that's a no-win situation in my experience.↗
▶Ep 2 · 44:01
quoteI just in general think that that's a no-win situation in my experience.↗
▶Ep 2 · 44:28
clinicalSmall subset of premature patients with severe lung disease can develop pneumothorax that dissects through diaphragm into abdomen, causing pneumoperitoneum; must confirm problem is in abdomen rather than chest.↗
▶Ep 2 · 44:28
clinicalSmall subset of premature patients with severe lung disease can develop pneumothorax that dissects through diaphragm into abdomen, causing pneumoperitoneum; must confirm problem is in abdomen rather than chest.↗
▶Ep 2 · 45:06
clinicalFor extremely unstable patient (e.g., 800g on jet ventilation and pressors) with pneumoperitoneum and severe distention, angiocatheter can be inserted through abdominal wall to release pneumoperitoneum as temporizing maneuver while mobilizing for definitive operation.↗
▶Ep 2 · 45:06
clinicalFor extremely unstable patient (e.g., 800g on jet ventilation and pressors) with pneumoperitoneum and severe distention, angiocatheter can be inserted through abdominal wall to release pneumoperitoneum as temporizing maneuver while mobilizing for definitive operation.↗
