I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.
You need to break the cycle of the physiologic obstruction. They are obstructed both at the sphincter level and in the aganglionic segment. And you have to break that cycle by getting a tube across it and then a lumen of that tube then to allow for egress of that stool because it's the stasis that's the problem. It's the stasis, the bacterial overgrowth. That overgrowth leads to translocation and that's where the sepsis comes in.
if you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit
if you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit
if you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit
They describe a line that's drawn on this diagram between the GE junction and the pylorus, and it's spinning around that axis. The greater curvature then sort of flips up and over and becomes more superior than the lesser curvature.
Gastroschisis and sutureless abdominal wall closure
▶Ep 22 · 7:20
opinionPatients with more favorable bowel theoretically would have less hospital stay and feed faster↗
▶Ep 22 · 7:20
opinionPatients able to undergo primary repair probably had more favorable bowel↗
▶Ep 22 · 7:20
opinionMany sutureless repair patients were done in more recent cohorts and tended towards less interventions↗
▶Ep 22 · 8:05
clinicalIn sutured repair, mobilizing flaps from skin and fascia causes redness and bruising around the incision↗
▶Ep 22 · 8:05
opinionThe finding of increased antibiotics needed after sutured repair was expected↗
▶Ep 22 · 8:05
clinicalTissue manipulation in sutured repair puts patients at higher risk for potential infection or erythema↗
▶Ep 22 · 8:50
epidemiologicalSeveral small studies show that some sutureless patients had a high umbilical hernia repair rate or at least a high umbilical hernia rate↗
▶Ep 22 · 8:50
clinicalLong-term follow-up data on the same patients examining growth and umbilical hernia repair rates has been completed and will be analyzed soon↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 29 · 3:10
clinicalOne institution does not intubate gastroschisis babies at all for dressing placement↗
▶Ep 29 · 3:10
clinicalSome protocols say to start feeding when you clamp the NG and there is no output↗
▶Ep 29 · 3:10
clinicalSome published protocols say to start feeding when the baby has had a bowel movement↗
▶Ep 29 · 3:10
quotewe don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it↗
▶Ep 29 · 3:10
clinicalSome protocols say to start feeding when NG output is clear↗
▶Ep 29 · 5:13
quoteif you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit↗
▶Ep 29 · 5:13
clinicalIf you empty the stomach, squish out the colon, go slow, give the baby sweeties, and have nurses help relax the baby, you can reduce gastroschisis without sedation↗
▶Ep 29 · 6:19
clinicalIn parts of the world without TPN access, they must feed gastroschisis babies immediately↗
▶Ep 29 · 6:19
quotein the us we were such privileged that we have pic lines we have tpn and things like that↗
▶Ep 29 · 10:30
epidemiologicalAfter instituting a feeding protocol, Cincinnati dropped gastroschisis length of stay by 10 days over two years↗
▶Ep 29 · 10:30
clinicalCincinnati is starting to see a decrease in time from first feed to full feeds↗
▶Ep 29 · 10:30
epidemiologicalCincinnati has not seen a change in days from admission to first feed, although 2020 showed improvement before bouncing back↗
▶Ep 29 · 10:30
opinionThe SSI reduction was probably because protocol-fed patients had less variability and fewer changes in care↗
▶Ep 29 · 10:30
epidemiologicalThe study was inconclusive due to lots of different feeding protocols used across member institutions↗
▶Ep 29 · 10:30
quoteover two years we dropped the length of stay by 10 days and the mix of patients is not different↗
▶Ep 29 · 10:30
quoteour average length of stay was 49 days and it was comparing to other nicu's like kansas city and and other places that are taking care of very similar babies↗
▶Ep 29 · 10:30
epidemiologicalCincinnati's average length of stay for gastroschisis was 49 days, astronomically higher than other NICUs in their cooperative network↗
▶Ep 29 · 15:05
clinicalIf a patient has significant issues and complete intolerance, one approach is to stop feeds for six hours↗
▶Ep 29 · 15:05
clinicalSome people will ignore bilious emesis completely in gastroschisis patients↗
▶Ep 29 · 15:05
clinicalSome people check residuals which will be bilious and some will completely ignore that↗
▶Ep 29 · 15:05
clinicalA study from New Zealand discusses attitudes towards feeding in gastroschisis↗
▶Ep 29 · 15:05
quotewe really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go↗
▶Ep 29 · 15:05
quotesome people will ignore bilious emesis completely you know some people check residuals and that's going to be bilious a lot of the time too and some people will just completely ignore that↗
▶Ep 29 · 15:05
opinionInstitutions need to define their own tolerance thresholds and stay on protocol while continually evaluating patient condition↗
▶Ep 29 · 17:15
clinicalThe institution tries to push oral feeds quickly to avoid oral aversion↗
▶Ep 29 · 17:15
epidemiologicalCurrent gastroschisis length of stay is about 30 to 34 days at one institution↗
▶Ep 29 · 17:15
clinicalOne recent patient who was primarily reduced on day of life zero was out of hospital in about two weeks↗
▶Ep 29 · 18:00
clinicalOne institution has not seen any aspirations with early aggressive feeding yet↗
▶Ep 29 · 18:56
epidemiologicalAt least two-thirds of gastroschisis cases at one institution cannot be reduced right away and are placed in a silo↗
Bowel Management Updates & Innovations with Live Q&A: April 2018
▶Ep 2 · 0:32
quoteWe see patients from all over the world and all 50 states.↗
▶Ep 2 · 7:27
clinicalPatients with deformed sacrums have lower likelihood of being successful with bowel management using medication alone, not on an enema program↗
▶Ep 2 · 8:17
clinicalMalone procedure typically performed starting at around age 5 years and older, most commonly between ages 5 and 10 or 12↗
▶Ep 2 · 8:53
clinicalVomiting from enemas can be caused by high volume enemas with irritants stretching the colon and causing discomfort↗
▶Ep 2 · 10:42
guidelineSacral nerve stimulators are not FDA approved for children under 18 in the United States but are performed off-label↗
▶Ep 2 · 10:59
guidelineManufacturer indication for sacral nerve stimulator requires 50% improvement on symptoms↗
▶Ep 2 · 17:28
clinicalThe large intestine or colon can absorb up to 1 liter of water per day in adults↗
▶Ep 2 · 17:33
clinicalWhen portion of colon is removed, stool becomes softer or less water is absorbed; as more colon removed, stool becomes softer and looser↗
▶Ep 2 · 19:53
clinicalNo proven surgery absolutely works for constipation; surgery may lessen the amount of treatment needed but is not definitively curative↗
▶Ep 2 · 22:31
clinicalColon resection is a big surgery requiring anastomosis with associated risks and is used as last-resort option↗
▶Ep 2 · 23:54
quoteI think we get asked that question every day.↗
▶Ep 2 · 25:04
clinicalPatients on long-term Senna use may show melanosis coli (freckling of colon) on colonoscopy but no other long-term side effects↗
▶Ep 2 · 25:29
quoteI sort of say it's like insulin for a diabetic. A diabetic needs insulin to lower their blood blood glucose levels. A patient who has severe constipation needs a laxative stimulant to help move their bowels.↗
▶Ep 2 · 26:59
clinicalStimulant laxatives (Senna, Dulcolax) make the colon squeeze and push stool forward, and stool moves quicker through colon with less time to absorb water↗
▶Ep 2 · 27:41
clinicalMiraLax allows colon to absorb water so water stays in colon and is not absorbed, making stool softer↗
▶Ep 2 · 37:10
clinicalSacral nerve stimulator initially designed for urinary incontinence; during testing in postpartum women, found to also help with fecal constipation and incontinence↗
▶Ep 2 · 38:03
clinicalSacral nerve stimulator works well in patients with urinary and stool issues in combination↗
▶Ep 2 · 38:30
clinicalNo published pediatric literature details which patients sacral nerve stimulator works in and which it does not due to many variables in patient population↗
▶Ep 2 · 40:57
clinicalConstipation or fecal impaction puts pressure on urinary tract and can cause urinary infections, improper emptying, urgency, and other symptoms↗
▶Ep 2 · 41:58
guidelineAll patients with anorectal malformations should be followed by urologist long-term to ensure kidney function and proper urinary tract emptying↗
▶Ep 2 · 46:28
clinicalLong-term use of fleet phosphate enemas can make colon irritated and stiff like a lead pipe, losing mobility and pliability↗
▶Ep 2 · 47:27
clinicalCelesta is hyaluronic acid polymer used as filler in patulous anus to help with fecal incontinence by making anal canal smaller↗
▶Ep 2 · 48:21
clinicalCelesta has little side effect with small risk of infection↗
▶Ep 2 · 49:18
clinicalSacral nerve stimulator results in spina bifida patients are mixed; some respond positively, others do not↗
▶Ep 2 · 50:25
clinicalSacral nerve stimulator requires 3rd sacral foramina or opening where 3rd sacral nerve exits sacrum and innervates pelvis↗
▶Ep 2 · 51:57
clinicalBotox is muscle relaxant that relaxes anal sphincter, typically used in Hirschsprung disease patients with higher resting anal pressures↗
▶Ep 2 · 56:58
clinicalAnorectal malformation is abnormal development of where colon or rectum ends up during development, with wide spectrum in male and female patients↗
▶Ep 2 · 59:04
quoteThis is my favorite. We do Globalcast to help and educate surgeons and doctors around the country and around the world. This is the first one we've done here for patients, by far my most favorite.↗
clinicalThree 3-mm laparoscopic ports allow mobilization in approximately 45 minutes for standard rectosigmoid Hirschsprung disease↗
▶Ep 14 · 6:12
clinicalPatients with complications after Hirschsprung surgery fall into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) or soiling issues (true incontinence vs. pseudo-incontinence from constipation)↗
▶Ep 14 · 7:25
clinicalWorkup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; biopsy performed if no anatomic cause found↗
▶Ep 14 · 9:04
clinicalAnastomosis is placed approximately 1 cm above the dentate line (defined as transition from squamous to columnar epithelium, at the bottom of the anal columns)↗
▶Ep 14 · 9:04
clinicalGoing 1 cm above the dentate line in a newborn may become 2.5–3 cm in a 7-year-old, potentially leaving a segment resembling short-segment or ultra-short-segment Hirschsprung disease↗
▶Ep 14 · 9:43
clinicalInjury to the dentate line can render patients fecally incontinent, which is a devastating complication↗
▶Ep 14 · 10:39
clinicalFor J-pouch procedures in ulcerative colitis or FAP, anastomosis is placed right at the top of the anal columns or slightly lower if polyps are present in that region↗
▶Ep 14 · 18:07
clinicalPrimary repair of anorectal malformations in the newborn period is technically difficult because it is harder to identify the center of the sphincter complex in a 2-kg baby than in an 8–9-kg baby↗
▶Ep 14 · 18:54
clinicalIn the setting of vestibular fistula with absent vagina, if the patient has good prognosis for bowel control, a graft (colon or small bowel) can be used to replace the vagina while bringing the rectum down as a pull-through↗
▶Ep 14 · 19:21
clinicalIn vestibular fistula with absent vagina, if the patient has poor prognosis for bowel control (sacral agenesis, tethered cord), the rectum/fistula can be used as the vagina and a more proximal piece of colon brought down as the pull-through↗
▶Ep 14 · 22:45
clinicalRe-operating on patients who have had sclerosing agent injection for rectal prolapse is not more difficult↗
▶Ep 14 · 22:45
opinionSclerosing agent injection for rectal prolapse has high failure rate; most patients ultimately require rectopexy↗
▶Ep 14 · 23:02
clinicalTransabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate↗
▶Ep 14 · 23:02
clinicalTransanal approaches for rectal prolapse (transanal pull-through or Altmeier procedure) have 15–20% recurrence rate↗
▶Ep 14 · 23:36
clinicalResection and rectopexy may be better for patients with constipation problems but has higher complication rate than rectopexy alone↗
▶Ep 14 · 23:56
clinicalPatients can be discharged the next day or even same day after laparoscopic rectopexy for rectal prolapse↗
▶Ep 14 · 24:33
clinicalVentral mesh rectopexy involves placing mesh on the anterior surface of the rectum without posterior dissection, then tacking the mesh to the sacral promontory; can be done open or laparoscopically↗
▶Ep 14 · 24:55
clinicalThe pathophysiology of rectal prolapse in younger patients involves a straighter angle between rectum and anal canal that becomes more acute with age; ventral mesh rectopexy attempts to change this angulation↗
Hirschsprung Disease: Update Course 2015
▶Ep 35 · 0:22
quoteI recall having a full day of uh Hirschprung's webcast, and now I get 5 minutes.↗
▶Ep 35 · 0:39
clinicalThe case involves a newborn with increased abdominal distention, not tolerating feeds, and hasn't passed meconium↗
▶Ep 35 · 0:56
clinicalSuction rectal biopsy demonstrated no ganglion cells, hypertrophic nerves, and abnormal ACE staining, confirming Hirschsprung's disease↗
▶Ep 35 · 1:48
clinicalThe contrast enema shows a transition zone at almost the descending colon level, higher than standard rectosigmoid↗
▶Ep 35 · 3:06
quoteI, every time that I do a primary trans anal, I get. I tighten up a little bit to make sure that I'm confident that I can do, and I have an exit strategy in mind if I get in trouble↗
▶Ep 35 · 3:06
opinionThe safe way to proceed is some sort of biopsy, whether laparoscopically or through the umbilicus for full thickness biopsy↗
▶Ep 35 · 3:11
quoteThe safe way to do this is some sort of biopsy, whether you do it laparoscopically or laparoscopic mobilization, maybe do the biopsy through the umbilicus if you want to get a nice full thickness biopsy, whatever your technique or trick is, that's certainly the safest way to go.↗
▶Ep 35 · 3:46
clinicalLeveling colostomy may be appropriate if pathology support is limited or pathologist is not comfortable reading for Hirschsprung's disease↗
quoteIt depends on what pathologists, your pathology at your home institution, if you have concern about your pathologist, if you don't have someone comfortable reading, um, for Hirschberg's disease, uh, that might be the safest thing to do.↗
▶Ep 35 · 4:03
clinicalLeveling colostomy is used on mission trips where pathologists are not available, making it almost a three-stage procedure↗
▶Ep 35 · 4:03
quoteI know people who go on mission trips and trips where you don't have pathologists.↗
▶Ep 35 · 4:08
quoteIt's a almost a three stage type procedure to do that.↗
▶Ep 35 · 5:03
quoteI think if it's beyond that, then you're going to do laparoscopy or laparotomy if you're not Belinda and I talk about this a lot, and it's about a comfort level and how fit, I take, I watch the clock how long I'm doing a trans anal dissection because I do not want to be stretching on those sphincters for 4 hours trying to dig up in a dark hole when I could put a scope in.↗
▶Ep 35 · 5:07
opinionProlonged transanal dissection (4 hours) stretching sphincters should be avoided when laparoscopic mobilization could be done in 45 minutes↗
▶Ep 35 · 5:30
quoteI easily put 3. 3 millimeter ports in and mobilize laparoscopically in 45 minutes or so and get the same I mean what's so because I could do it from the bottom in the same time frame if it's a nice standard rectosigmoid↗
▶Ep 35 · 5:46
quoteI mean if you know where your level is and if you have a good contrast study, I think the image on the screen I would do with laparoscopy without question, but a standard rectosigmoid 68, 10 centimeters up, I could do transanally in the same time frame.↗
▶Ep 35 · 5:46
clinicalStandard rectosigmoid Hirschsprung (6, 8, 10 centimeters up) can be done transanally in a couple hours if the level is known from good contrast study↗
▶Ep 35 · 5:46
quoteit's rectosigmoid you can get it done in a couple hours.↗
▶Ep 35 · 6:08
quoteSo that was not controversial at all, and I'm gonna, that was the simple question.↗
▶Ep 35 · 6:12
quotethis is the, the patient population I really enjoy taking care of, and I think that pediatric surgeons need to be aggressive at caring for these patients because they are our patients, and I think we know what's How to help them best↗
▶Ep 35 · 6:12
clinicalPatients with complications after Hirschsprung disease are divided into two categories: obstructive symptoms (enterocolitis, failure to thrive, abdominal distention) or soiling issues↗
▶Ep 35 · 6:31
quotepatients who have complications after Hirschberg's disease, we sort of put into two piles. They either have obstructive symptoms and things like enterocolitis, failure to thrive, abdominal distention, or they have soiling issues and then divide them into true incontinence and pseudo incontinence.↗
▶Ep 35 · 6:31
clinicalSoiling issues are divided into true incontinence and pseudo-incontinence↗
▶Ep 35 · 6:45
clinicalFor obstructive symptoms, must discern whether the problem is anatomic or pathologic↗
▶Ep 35 · 6:45
quoteAnd then the patients with obstructive symptoms, you have to discern whether it's an anatomic problem or a pathologic problem.↗
▶Ep 35 · 6:52
clinicalTrue fecal incontinence can be due to injury to the sphincter or injury to the dentate line↗
▶Ep 35 · 6:52
quoteAnd Soiling, like I said, you have to discern whether it's true fecal incontinence, and that could be due to injury to the sphincter, injury to the dentate line, or pseudo incontinence.↗
▶Ep 35 · 7:04
clinicalPseudo-incontinence can be caused by constipation issues↗
▶Ep 35 · 7:04
quoteIs there a constipation issue causing the incontinence?↗
▶Ep 35 · 7:08
guidelineJack Langer published an algorithm describing workup for patients with problems after Hirschsprung disease↗
▶Ep 35 · 7:11
quoteI think Jack Langer published this in a paper, um, a few years ago, this algorithm, which really does a nice job of describing how to work up patients with, um, With problems after Hirschrung's disease.↗
▶Ep 35 · 7:25
clinicalWorkup includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists↗
▶Ep 35 · 7:25
quoteThe workup I, I include, includes a contrast enema, water soluble, and then an exam under anesthesia, looking for the listed items below which dentate lines, stricture, stretched sphincter, um, looking for twists↗
Hirschsprung Disease: Update Course 2013
▶Ep 53 · 33:42
clinicalColonoscopic biopsies can miss Hirschsprung disease; rectal biopsy is more reliable↗
Hirschsprung's Disease
▶Ep 73 · 0:35
clinicalSome infants with Hirschsprung's disease do pass meconium↗
▶Ep 73 · 0:35
clinicalMore than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease↗
▶Ep 73 · 0:35
quoteMore than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 73 · 1:57
clinicalA rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease↗
▶Ep 73 · 1:57
clinicalApproximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema↗
▶Ep 73 · 1:57
clinicalRectal biopsy is the true definitive diagnosis for Hirschsprung disease↗
▶Ep 73 · 1:57
guidelineAn adequate biopsy must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers↗
▶Ep 73 · 1:57
clinicalTypical biopsy features include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining↗
▶Ep 73 · 1:57
clinicalThe classic finding on contrast enema is a transition zone in the rectosigmoid↗
▶Ep 73 · 4:23
guidelineAny patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis↗
▶Ep 73 · 4:23
clinicalIn Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR)↗
▶Ep 73 · 6:42
guidelineThere are three goals to the surgical management of Hirschsprung's disease: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity↗
▶Ep 73 · 6:42
quoteThere are three goals to the surgical management of Hirschsprung's disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity.↗
▶Ep 73 · 7:36
clinicalThe Swenson procedure involves pulling down the aganglionic bowel and performing a full thickness anastomosis one to two centimeters above the dentate line↗
▶Ep 73 · 7:36
clinicalIn the Suave procedure, the aganglionic cuff can become stiff enough to cause an obstruction or an outlet obstruction↗
▶Ep 73 · 7:36
clinicalThe Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel↗
▶Ep 73 · 12:34
clinicalHirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth↗
▶Ep 73 · 12:34
quoteThe key tenants to treating enterocolitis are fluid resuscitation, digital rectal exam, and colonic irrigations.↗
▶Ep 73 · 12:34
guidelineTreatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations↗
▶Ep 73 · 12:34
clinicalA child with enterocolitis presents with abdominal distension, vomiting, fever, and change in bowel habits that could be either diarrhea or not passing stool at all↗
▶Ep 73 · 18:35
guidelineAll patients should be able to perform irrigations before they get their pull-through and go home↗
The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula
▶Ep 84 · 5:08
guidelineCross-table lateral radiograph is obtained at approximately 24 hours of life to visualize the rectal gas column position↗
▶Ep 84 · 6:10
clinicalCross-table lateral is performed with the baby prone and a bump under the buttocks to position the buttock as the highest point where air will rise↗
▶Ep 84 · 6:28
clinicalA marker should be placed at the expected anal location on cross-table lateral to enable distance measurements↗
▶Ep 84 · 7:47
clinicalWell-formed buttocks and visible sphincter mechanism location on physical exam contribute to good prognosis↗
quoteWe both agree that probably in real life, we would have done a primary posterior sagittal approach on this patient, and we would have found the rectum, and we could have made that rectum reach the perineum and done our anoplasty. How do we handle this? Because I didn't know that there was a fistula there. This is troublesome.↗
▶Ep 84 · 12:34
clinicalLow bulbar fistulas are located very close to the rectum, requiring careful plane dissection↗
▶Ep 84 · 13:00
clinicalBulbar fistula nomenclature refers to anatomic location at the elbow of the urethra↗
quotePreviously, we used to do this transanally, it would take a few hours. Now, the transanal dissection should be usually way under 1 hour, especially in a primary pull-through point.↗
▶Ep 88 · 6:37
clinicalTransanal dissection in primary pull-through should take well under 1 hour when preceded by adequate laparoscopic dissection↗
▶Ep 88 · 12:26
clinicalFor distal disease, only distal IMA branches need division; for left colon involvement, IMA itself may require division to achieve adequate reach↗
The Colorectal Quiz Episode 8: Motility Disorders Part 1
▶Ep 91 · 6:29
quoteIt's saying that this is not a Monet, that is for certain.↗
▶Ep 91 · 6:53
opinionThere are probably many people with redundant colons that stool perfectly normally without imaging documentation↗
▶Ep 91 · 8:06
clinicalWater-soluble contrast is used instead of barium because it helps empty the colon and acts as a cleanout for patients starting new medical therapy↗
▶Ep 91 · 10:51
clinicalIn the past, the sphincter and its major role in constipation patients was not well understood↗
The Colorectal Quiz Episode 9: Motility Disorders Part 2
▶Ep 93 · 8:02
epidemiologicalMany patients get colonic manometry but the results come back normal↗
The Colorectal Quiz Episode 10: Total Colonic Hirschsprung Disease Part 1
▶Ep 94 · 7:26
quoteMy cutoff is around 6 months when I switch from suction rectal biopsy to full thickness biopsy.↗
▶Ep 94 · 7:26
opinionAge cutoff for switching from suction rectal biopsy to full-thickness biopsy is around 6 months↗
▶Ep 94 · 8:38
guidelineIf a patient is doing well and can be managed with irrigations, final diagnosis of Hirschsprung disease should be obtained through rectal biopsy before entering the abdomen↗
▶Ep 94 · 9:13
guidelineStandard intraoperative biopsy sites include rectosigmoid, proximal sigmoid, left colon, splenic flexure area, transverse colon, right colon, and hepatic flexure area↗
The Colorectal Quiz Episode 11: Total Colonic Hirschsprung's Part 2
▶Ep 95 · 3:30
clinicalTiming of pull-through should wait until child has good growth and more solid stool consistency from solid diet↗
▶Ep 95 · 4:12
clinicalSkin training technique involves taking stool from ostomy bag and placing in diaper for 15-20 minutes to expose virgin buttock skin to stool before pull-through↗
▶Ep 95 · 5:19
clinicalUrine sodium (total body sodium) is a key component for growth in patients with long-standing ileostomies, not just blood sodium↗
▶Ep 95 · 5:30
quoteI often check a urine sodium. Near a few weeks after the, the, the um creation of an ileostomy, prior to discharge, um, a month or two later, and making sure that the patient has the right total body sodium, not just blood sodium↗
▶Ep 95 · 5:34
clinicalUrine sodium should be checked a few weeks after ileostomy creation, prior to discharge, and a month or two later↗
▶Ep 95 · 5:49
clinicalLow total body sodium can be treated with salt tablets or salt addition↗
▶Ep 95 · 8:00
clinicalFor total colonic Hirschsprung, typical approach is ileoanal anastomosis (straight pull-through)↗
▶Ep 95 · 9:57
clinicalDecision to redivert after ileoanal pull-through is made intraoperatively based on anastomosis quality, blood supply, tension, and nutritional optimization↗
▶Ep 95 · 10:57
clinicalFamily comfort with rectal irrigations is an important consideration in surgical planning↗
▶Ep 95 · 11:26
clinicalFirst-line medication treatment is loperamide↗
▶Ep 95 · 11:30
clinicalLiquid loperamide contains glucose and sugar which can cause hypermotility; crushing pills in applesauce is preferred↗
▶Ep 95 · 12:07
clinicalLomotil (atropine-diphenoxylate) is a controlled substance in the United States↗
▶Ep 95 · 12:24
clinicalBotox is given immediately when intestinal continuity is established↗
▶Ep 95 · 12:34
clinicalFirst post-operative visit is at 2 weeks for routine check of eating, growth, and rash assessment↗
▶Ep 95 · 12:38
clinicalAnastomosis check is performed at 4 weeks post-operatively in clinic using Hagar dilators sized appropriately for child's age↗
▶Ep 95 · 13:05
clinicalAnastomotic sizing starts with 7 or 8 Hagar dilator and gently sizes up to resistance, not to stretch but to check size↗
▶Ep 95 · 13:15
clinicalFor a child undergoing pull-through at around 10 months of age, proper anastomotic size should be 13 or 14 Hagar dilator↗
Colorectal Quiz Episode 13: Newborn ARM Part 2
▶Ep 98 · 4:45
clinicalPerineal groove typically does not require surgical intervention and will keratinize to look like a normal perineal body over time↗
▶Ep 98 · 5:00
clinicalSurgical indication for perineal groove exists only if it is secreting mucus, causing irritation, or developing ulcers, where mucosal lining could be excised↗
▶Ep 98 · 8:22
quoteAnd that's not even a joke. That's a true statement.↗
▶Ep 98 · 9:35
clinicalVestibular fistula is very common in females and needs a formal repair with the hole transposed to the center of the sphincter↗
▶Ep 98 · 10:22
clinicalDiversion in vestibular fistula repair is to try to avoid perineal body dehiscence↗
▶Ep 98 · 10:22
clinicalFor vestibular fistula diagnosed in the newborn period, primary repair can be done if the baby is well, or the baby can stool through the fistula for a couple of months followed by elective operation without a stoma after bowel prep↗
▶Ep 98 · 10:22
clinicalPatients diagnosed with vestibular fistula at 6, 8, or 12 months of life who have dilated their rectosigmoid need diversion as the first step, then repair↗
▶Ep 98 · 12:43
clinicalGood lighting and good visualization are needed for perineal exam in newborn females, with magnification tools like loops helpful for seeing small holes↗
▶Ep 98 · 14:11
clinicalTo evaluate for vestibular fistula, use both hands on the right and left labia, pulling the labia toward you and opening them to visualize the vaginal opening and look for the urethra↗
Colorectal Quiz Episode 15: Bowel Management in Spinal Patients - Need for a UrologistPart 1
▶Ep 100 · 5:30
quoteI think it's almost like a chemical burn. The cause they're blistered usually. We treat it with silver sulfadiazine, and they've all gotten better with time.↗
▶Ep 100 · 5:30
clinicalSenna rash is thought to be a chemical burn rather than a true allergy, presenting as blistering.↗
▶Ep 100 · 5:38
clinicalSenna rash is treated with silver sulfadiazine and resolves with time; some patients tolerate Senna upon reintroduction.↗
▶Ep 100 · 5:53
clinicalTiming Senna dose in the early morning so stool passes during the day (when diapers are changed frequently) reduces the risk of Senna rash from prolonged overnight stool contact.↗
▶Ep 100 · 10:08
clinicalCare coordination with urology from the beginning is essential in spina bifida patients to avoid committing the appendix to colorectal use when it may be needed for urologic reconstruction.↗
▶Ep 100 · 10:11
quoteIf there's one take-home message from this podcast, you just said it.↗
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
▶Ep 101 · 1:55
clinicalThe colorectal team benefits from using the portion of appendix closer to the cecum because it has a stronger blood supply↗
▶Ep 101 · 2:11
clinicalA 1-2 centimeter appendiceal stump can be extended 2-3 more centimeters by suturing or using a non-cutting laparoscopic stapler along the cecal wall↗
▶Ep 101 · 2:34
clinicalOne of the main problems with Malone appendicostomy is leakage↗
▶Ep 101 · 2:47
clinicalThe longer the Malone channel, the less likely it is to leak↗
▶Ep 101 · 2:52
quoteThe longer the channel, the less likely that Malone's going to leak.↗
▶Ep 101 · 2:55
clinicalExtending the channel 2-3 centimeters by suturing or stapling can be extremely helpful in preventing leakage↗
▶Ep 101 · 4:00
clinicalRectal irrigation devices made by companies like Coloplast can be used by patients with hand difficulties to self-administer enemas↗
▶Ep 101 · 8:45
clinicalFecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux↗
▶Ep 101 · 9:44
clinicalAt Cincinnati, 99% of Malones are placed in the umbilicus and almost all Mitrofanoffs are in the right lower quadrant with a tunnel channel through the rectus to prevent leakage↗
▶Ep 101 · 10:21
clinicalBlood supply is the ultimate driving factor for orifice placement; Malones not in the umbilicus are typically due to blood supply issues↗
▶Ep 101 · 10:51
clinicalThe last steps of combined procedures should be: mature the Mitrofanoff, mature the Malone, then close the abdomen↗
▶Ep 101 · 11:09
clinicalThe laxity of pelvic floor and anal canal in spinal patients makes them different, especially when doing retrograde enemas↗
guidelineManagement at Cincinnati Children's prioritizes maximizing medical therapy and understanding anatomic and functional issues before resorting to surgical resection.↗
▶Ep 104 · 11:04
opinionResection should not be performed immediately based on one abnormal finding; multiple factors must be considered.↗
▶Ep 104 · 11:04
quoteI want to stress that we shouldn't resort to resection right away just because we have one abnormal finding.↗
▶Ep 104 · 12:13
guidelineThe first step in evaluating a patient with suspected motility disorder is to ensure normal anatomy, which can be assessed with contrast studies.↗
Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1
▶Ep 105 · 4:51
clinicalWhen performing initial rectal exam on a distended Hirschsprung patient, the examiner should step to the side to avoid an explosive release of stool↗
▶Ep 105 · 12:06
clinicalIf a patient with past Hirschsprung diagnosis comes in sick, one must assume Hirschsprung-associated enterocolitis; treatment with rectal irrigations, IV fluids, and antibiotics will not cause harm even if the diagnosis turns out to be different↗
▶Ep 105 · 12:06
quoteif you have a patient that comes in with a diagnosis of Hirschprung's in the past and comes with, comes in sick, you have to assume it's Hirschprung's associated enterocolitis↗
▶Ep 105 · 14:58
opinionFamilies should not undergo Hirschsprung pull-through surgery until they can demonstrate ability to perform irrigations↗
▶Ep 105 · 14:58
quoteyou do not do an operation on a Hirschprung's patient until the family can demonstrate that they are able to do irrigations↗
▶Ep 105 · 15:24
quotea simple thing of a Foley catheter, some saline, and a syringe, and a, and a bucket could be life-saving↗
▶Ep 105 · 15:24
clinicalFamilies should be discharged with supplies (Foley catheter, saline, syringe, bucket) to perform irrigations at home, as this could be life-saving↗
▶Ep 105 · 19:46
clinicalA lateral view of the rectum on contrast study provides important information and should be obtained↗
▶Ep 105 · 21:40
clinicalWidened presacral space on contrast study suggests a Soave pull-through↗
▶Ep 105 · 21:57
clinicalA dilated colon narrowing over the distal 6 cm with widened presacral space suggests either retained aganglionosis or a long Soave cuff constricting the distal neorectum↗
The Colorectal Quiz Episode 20: Hirschsprung Disease Obstruction Part 2
▶Ep 107 · 4:26
clinicalBotox is being investigated to prevent enterocolitis through chemical denervation of nerves in the area, as an alternative to permanent stretch or anatomic destruction from surgery↗
▶Ep 107 · 5:27
clinicalMany institutions use pre-made operative reports as a checklist model to ensure all examination components are documented↗
▶Ep 107 · 10:27
opinionRectal cuff left at initial pull-through (0.5-1.5 cm in neonate) may grow proportionally as child grows, potentially causing delayed obstruction from lengthened aganglionic segment↗
▶Ep 107 · 11:11
quoteIs now, let's say 3 centimeters, or 4, or 5. Well, is that the problem that this kid did well until that cuff got to a length, that's a ganglionic, and now it's causing obstructive problems.↗
▶Ep 107 · 12:01
clinicalSwenson dissection starts 0.5-1 cm above the dentate line↗
▶Ep 107 · 17:28
clinicalInitial treatment for obstructed Hirschsprung's patient includes IV antibiotics and colonic irrigation↗
▶Ep 107 · 17:28
guidelineRectal irrigation should be done early and every institution should have a protocol for rapid, efficient response↗
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
▶Ep 108 · 10:08
clinicalDoctor Martin developed the Martin procedure, an expansion of the Duhamel leaving a longer aganglionic segment of rectum for long segment Hirschsprung disease↗
▶Ep 108 · 10:40
clinicalDoctor Martin published in 1977 the application of endorectal pull-through technique from Hirschsprung disease to the surgical treatment of ulcerative colitis↗
▶Ep 108 · 11:03
clinicalMartin performed total proctocolectomy using endorectal techniques from Hirschsprung surgery and did an ileoanal anastomosis for ulcerative colitis, before the J pouch was developed↗
The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1
▶Ep 109 · 5:07
clinicalPathology can change over time; cases exist where ganglion cells were present at pull-through but absent with hypertrophic nerves 7 years later when problems developed↗
▶Ep 109 · 16:07
clinicalDuring normal bowel movements, sphincters relax and some mucosa comes down, but as soon as sphincters tighten back up, mucosa is retracted back in; prolapse at rest indicates damaged sphincters↗
clinicalIf terminal ileum cannot be intubated, the approach is to assume Crohn's disease, treat, and re-scope after a few months of treatment when inflammation has likely gone down↗
▶Ep 115 · 6:52
clinicalThe highest risk factors for lymphoma with biologics are males, teenagers, and combination with methotrexate↗
▶Ep 115 · 9:17
epidemiologicalMales over age 10 with perianal fistulas have a much higher incidence of Crohn's disease diagnosis↗
▶Ep 115 · 9:29
clinicalIn pediatric patients, the first presenting factor for Crohn's disease can often be perianal disease↗
▶Ep 115 · 9:40
clinicalPatients often present with perianal disease because that's what really hurts, then deeper history reveals GI symptoms like diarrhea and abdominal pain↗
▶Ep 115 · 12:25
quoteI don't like to make holes when there aren't holes there.↗
▶Ep 115 · 12:31
clinicalMucosa heals first, so if you treat with a biologic and heal the mucosa while an abscess persists, you will get a recurrent abscess↗
▶Ep 115 · 12:31
quoteThe thing that's going to heal first is the mucosa.↗
▶Ep 115 · 13:12
quoteI don't like when we get a kid in the ER, a 10 year old boy with a perianal abscess, and we go and make a big cruciate incision and pack it with tons of gauze, and that thing doesn't heal, you're in trouble. You may have bought that kid a colostomy or ileostomy.↗
▶Ep 115 · 13:12
clinicalMaking a big cruciate incision and packing a perianal abscess with gauze in a patient who may have Crohn's can result in non-healing and may require colostomy or ileostomy↗
▶Ep 115 · 14:13
opinionHydrogen peroxide is preferred over methylene blue for identifying fistula tracts because it is neater↗
▶Ep 115 · 14:18
clinicalTechnique for hydrogen peroxide injection: use 3% hydrogen peroxide in a syringe with 16-20 gauge angiocath depending on skin lesion size, place speculum in anus to visualize where fistula would be, then inject to identify the tract↗
▶Ep 115 · 17:26
clinicalIf an abscess is not adequately drained, re-imaging should be done before giving biologics or steroids↗
▶Ep 115 · 19:23
clinicalCriteria for seton removal include: bottom looks better, drainage is better, patient is symptom-free, steady state of biologic achieved (loading dose plus at least 3 more doses, typically 2-3 months), and inflammatory markers (fecal calprotectin, ESR, CRP) show systemic disease is under control↗
▶Ep 115 · 20:55
guidelineThe initial Remicade paper from 1998 or 1999 in New England Journal of Medicine was on perianal disease and demonstrated improved healing time and improved length of time between recurrence when combination of seton and infliximab is used versus either separately↗
Hirschsprung Disease in Brief
▶Ep 116 · 0:33
clinicalHirschsprung disease is a congenital anomaly of the GI tract that results in a functional bowel obstruction↗
▶Ep 116 · 1:11
quoteMore than 95% of neonates pass meconium within the first 48 hours of life. And failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 116 · 1:11
clinicalMore than 95% of neonates pass meconium within the first 48 hours of life↗
▶Ep 116 · 1:11
clinicalFailure to pass meconium is typical of Hirschsprung's disease↗
▶Ep 116 · 1:11
guidelineIf an infant who has not passed meconium in the first 48 hours of life presents to your clinic, the possibility of Hirschsprung's disease should be entertained↗
▶Ep 116 · 1:43
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung's disease↗
▶Ep 116 · 1:43
clinicalHirschsprung's disease is associated with Wordenberg syndrome, congenital central hyperventilation (Andine's curse), and some other syndromes↗
▶Ep 116 · 1:43
clinicalThere are predisposing genetic conditions such as the RET gene↗
▶Ep 116 · 1:43
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21↗
▶Ep 116 · 1:43
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history↗
▶Ep 116 · 2:25
guidelineThe three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry↗
▶Ep 116 · 2:25
clinicalWater-soluble contrast enema is typically used for evaluation↗
▶Ep 116 · 2:42
clinicalThe classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel↗
▶Ep 116 · 2:42
quoteThe classic finding is a transition zone in the rectosigmoid, but that transition zone really can be located anywhere within the bowel.↗
▶Ep 116 · 3:14
clinicalA rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease↗
▶Ep 116 · 3:49
quoteThe second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.↗
▶Ep 116 · 3:49
guidelineRectal biopsy is the most important part of diagnostic workup and is the true definitive diagnosis↗
▶Ep 116 · 4:04
clinicalTypical features on biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of colon esterase staining, and an absence of calretinine staining↗
▶Ep 116 · 4:04
guidelineTo be considered an adequate biopsy, it must be taken from the rectum at least 1 cm above the dentate line and must include both mucosa and submucosal layers↗
▶Ep 116 · 4:29
guidelineOne should consider using a full thickness technique for patients older than 6 months or when a suction biopsy is inadequate↗
▶Ep 116 · 4:29
clinicalA rectal biopsy can be obtained through suction technique or open full thickness technique↗
▶Ep 116 · 4:29
guidelineThe suction technique is typically used for patients less than 6 months of age↗
▶Ep 116 · 5:42
guidelineAny patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis↗
▶Ep 116 · 5:42
quoteAny patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.↗
▶Ep 116 · 7:29
quoteThere are three goals to the surgical management of Hirschsprung disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity.↗
▶Ep 116 · 7:29
guidelineThere are three goals to surgical management: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity↗
▶Ep 116 · 7:59
clinicalThe Duamel procedure involves performing a pouch with an anastomosis of aganglionic and ganglionated bowel↗
▶Ep 116 · 7:59
clinicalThe Swensen technique is a full thickness dissection and anastomosis↗
▶Ep 116 · 7:59
clinicalThe three procedures for Hirschsprung disease all involve a transanal approach of removing the aganglionic colon and pulling down healthy colon and sewing it to the anus↗
▶Ep 116 · 7:59
clinicalThe Suave procedure is a mucosectomy where you leave a cuff of aganglionic bowel and bring the ganglionated bowel through that cuff of rectum and perform the anastomosis↗
▶Ep 116 · 9:15
guidelineTreatment for enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations↗
▶Ep 116 · 9:15
guidelineDepending on the severity of enterocolitis, broad-spectrum antibiotics are sometimes added and patients are usually started on metronidazole↗
▶Ep 116 · 9:15
quoteThis must be recognized as potential enterocolitis and treated urgently.↗
▶Ep 116 · 9:15
quoteHirschsprung's associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 116 · 9:15
clinicalA child with enterocolitis presents with abdominal distention, vomiting, fever, and change in bowel habits↗
▶Ep 116 · 9:15
guidelineEnterocolitis must be recognized as potential enterocolitis and treated urgently↗
▶Ep 116 · 9:15
clinicalHirschsprung's associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth↗
The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...
▶Ep 118 · 3:12
clinicalThe dentate line represents the transition from squamous epithelium to columnar epithelium, occurring about 2/3 of the way up the anal canal↗
▶Ep 118 · 3:54
clinicalThe dentate line region contains nerves that provide sensation to distinguish gas, liquid, and solid stool and determine how hard and how long to squeeze↗
▶Ep 118 · 6:27
clinicalThe ability to sense stool in the rectum or neorectum region is critical for success in children with anorectal malformation, Hirschsprung disease, or spinal conditions↗
▶Ep 118 · 6:45
clinicalMaking stool too soft or loose puts patients on the edge of control over the edge into incontinence↗
▶Ep 118 · 11:16
clinicalA missing dentate line scenario is similar to an anorectal malformation anastomosis (rectum or colon mucosa to skin)↗
▶Ep 118 · 18:25
quoteIt sounds counterintuitive, but at least the way I treat these patients, I constipate them, and then I empty them.↗
▶Ep 118 · 22:42
clinicalSome Hirschsprung patients with good operations have super strong sphincters that need relaxation to allow stool passage until they learn proper coordination↗
▶Ep 118 · 23:10
clinicalAnorectal manometry can provide objective data showing resting pressures are usually on the higher end of normal in these patients↗
▶Ep 118 · 23:43
clinicalPatients with Hirschsprung disease are very sensitive to some foods, particularly lactose↗
▶Ep 118 · 24:26
quoteNone. We have to get it right the first time.↗
Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula
▶Ep 119 · 15:22
clinicalWhen neurologic anomalies are found, there is increased likelihood of gynecological anomalies, especially on the same side.↗
Colorectal Quiz Episode 29: Female ARM-Post Op Management
▶Ep 120 · 14:20
clinicalIn the dilation study, 4 patients required redo operations for stricture: 2 in dilation arm and 2 in non-dilation arm↗
▶Ep 120 · 14:58
clinicalApproximately 20% of patients in the study required redo operations, either local or total↗
Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease
▶Ep 136 · 12:26
epidemiologicalDr. Newman brought Dr. Yancey's story to the Hirschsprung interest group at APSA, leading to efforts to change nomenclature and references↗
▶Ep 136 · 15:06
quoteI was reading the operative note from one of my fellows who provided the history of the patient. I had to do a reoperation on the patient. And the history read that this five-year-old child is status post a Yancey Suave procedure in such and such date and had an asthmatic stricture.↗
Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery
▶Ep 158 · 4:02
clinicalMRI with specific protocols can show whether anoplasty is within muscle complex↗
▶Ep 158 · 4:10
clinicalEndorectal ultrasound can help assess anoplasty position within sphincter↗
▶Ep 158 · 14:05
opinionCollaborative operating during transition is a key component↗
▶Ep 158 · 14:05
quoteI love the idea of that transition where you have a couple of clinic visits together↗
▶Ep 158 · 15:04
opinionFreestanding children's hospitals face more challenges than integrated adult-pediatric systems due to physical and financial separation↗
▶Ep 158 · 15:14
quotemost of us have like a hybrid system in place↗
▶Ep 158 · 15:21
clinicalIn Cincinnati, ARM patients continue to come to colorectal center at children's hospital regardless of age, partnering with adult colorectal surgeon↗
▶Ep 158 · 18:58
quoteHaving a pulmonary embolism in a children's hospital or a myocardial infarction in a children's hospital, that talking about a lot of meetings after that event↗
▶Ep 158 · 18:58
clinicalPulmonary embolism or myocardial infarction in children's hospital creates safety concerns and potential for poor outcomes↗
▶Ep 158 · 19:10
opinionAdult hospitals are more skilled at managing perioperative complications like PE and MI↗
▶Ep 158 · 19:33
opinionSurgeons are making progress on transition, but struggle remains with intensive bowel management training for adult patients↗
▶Ep 158 · 19:40
quoteWhere I think we struggle a little more is that 35 year old patient who needs some intensive bowel management training↗
▶Ep 158 · 19:57
clinicalPediatric centers are adept at bowel management for patients of all ages, but adult patients requiring intensive outpatient bowel management are still being seen at children's hospitals↗
Colorectal Quiz: Episode 42 - HD Constipation
▶Ep 169 · 3:47
clinicalIn younger children age less than 3 or so, hypertrophic nerves are defined as greater than 40 microns in diameter↗
▶Ep 169 · 4:01
clinicalThe definition of hypertrophic nerve is more gray in older patients and in patients who have chronic constipation issues↗
▶Ep 169 · 10:27
clinicalOnce distal obstruction is ruled out or fixed and the colon is still not working, then you have a problem warranting colonic manometry↗
▶Ep 169 · 11:01
clinicalIf there's a segment less than 30 centimeters of inadequate high amplitude propagating contractions, the approach is not super aggressive; over 30 centimeters is definitely more of a red flag↗
Colorectal Quiz: Episode 47
▶Ep 223 · 1:51
quoteevery patient with a cloacoal history, we have to remember to think about three systems↗
▶Ep 223 · 1:51
clinicalEvery patient with cloaca history requires evaluation of three systems: urologic, gynecologic, and colorectal↗
▶Ep 223 · 3:11
clinicalSpina bifida bladders and cloaca bladders need to stay empty to prevent kidney damage↗
▶Ep 223 · 3:11
quotespina bifida bladders need to stay empty. Cholaica bladders need to stay empty↗
▶Ep 223 · 3:11
epidemiologicalA 13-year-old cloaca patient historically would often show up with kidney damage, and many unfortunately ended up with renal transplant↗
▶Ep 223 · 3:11
clinicalCystatin C is helpful to check GFR and renal function in cloaca patients↗
▶Ep 223 · 5:09
quotethe most incredibly frustrating thing about anorectal malformation patients. You've done an excellent anatomical repair, and they still have soiling↗
▶Ep 223 · 5:09
clinicalAnorectal malformation patients can have excellent anatomical repair and still have soiling↗
▶Ep 223 · 7:14
guidelineAll anorectal malformation patients get an exam under anesthesia (EUA)↗
▶Ep 223 · 11:53
clinicalDistention of the rectum (proprioception) provides the cue to squeeze the external sphincter and hold in stool↗
▶Ep 223 · 11:53
clinicalThe rectum is vitally important for bowel control in anorectal malformation patients↗
▶Ep 223 · 11:53
clinicalARM patients don't really have anal canal sensation or an internal sphincter unless the very distal aspect of the rectum was saved↗
▶Ep 223 · 11:53
clinicalIf you remove the rectum in ARM patients, you lose the capacity for proprioception↗
▶Ep 223 · 11:53
quotethe rectum is vitally important in anorectal malformation patients. In general, you want to keep the rectum because the rectum is vital for bowel control↗
▶Ep 223 · 13:29
clinicalOlder ARM patients who had abdominal perineal pull-through can be recognized on contrast study by haustral markings at the anus and in the pelvis↗
▶Ep 223 · 13:29
clinicalPrior to 1980 and the PSARP, an abdominal perineal pull-through was done for ARM, throwing the rectum away and pulling sigmoid down, which was wrong↗
▶Ep 223 · 16:49
clinicalA sacral ratio of 0.45 indicates the sacrum and perineal musculature are not great↗
▶Ep 223 · 16:49
clinicalMany ARM kids still have trouble with incontinence even with the best operative plans due to their anatomy and musculature↗
clinicalColons can empty surprisingly well with antegrade enemas only, potentially avoiding resection↗
▶Ep 223 · 19:24
clinicalVery often ARM patients with mega-rectosigmoid have an analplasty that is not good—either strictured, mislocated, or prolapsed↗
▶Ep 223 · 20:14
clinicalIf the anus is just strictured, making it bigger might allow the colon to decompress and improve↗
Colorectal Quiz: Episode 47
▶Ep 224 · 6:29
guidelineAnorectal manometry is not part of standard initial workup for anorectal malformation patients↗
▶Ep 224 · 16:49
quoteI think this patient is going to be a bowel management candidate. And I doubt they will ever achieve successful bowel control anyway, given the quality of their pelvis↗
▶Ep 224 · 16:49
clinicalA sacral ratio of 0.45 indicates the sacrum and perineal musculature are not great, making the patient likely a bowel management candidate↗
▶Ep 224 · 16:49
clinicalPatients with poor sacral ratios will likely never achieve successful bowel control given the quality of their pelvis and amount of sacral regression↗
Colorectal Quiz: Episode 46
▶Ep 225 · 6:27
clinicalIn anorectal malformation patients with perforation, the sigmoid colon typically perforates with a linear longitudinal tear along the taenia↗
▶Ep 225 · 6:53
clinicalFinding a perforation in the cecum should prompt rectal biopsy for Hirschsprung disease, and most patients would receive an ileostomy↗
▶Ep 225 · 7:34
clinicalStasis leads to bacterial overgrowth, which leads to translocation and sepsis in Hirschsprung disease↗
▶Ep 225 · 7:34
clinicalIrrigation breaks the cycle of physiologic obstruction at both the sphincter level and in the aganglionic segment↗
▶Ep 225 · 8:41
clinicalCold saline can change the temperature of a small child during irrigations, so warm saline should be used↗
▶Ep 225 · 10:55
clinicalSawtoothing in the rectum on contrast enema represents hyperperistalsis and is classic for Hirschsprung disease↗
▶Ep 225 · 22:52
opinionIleostomy is preferred in resource-rich settings where patients can be kept hydrated and have easy access to healthcare↗
▶Ep 225 · 23:41
clinicalFrozen section should be performed on the ileostomy to ensure it will function↗
▶Ep 225 · 26:54
clinicalBotox injection at the anal sphincter at time of restoring intestinal continuity is being studied prospectively but is not 100% effective↗
▶Ep 225 · 28:04
clinicalFamilies should be taught irrigation technique and practice before pull-through so they know how to do it if enterocolitis occurs↗
▶Ep 225 · 28:04
quoteEducation is so key and preparing the families for this is life-saving.↗
Colorectal Quiz: Episode 46
▶Ep 226 · 5:49
clinicalIn Hirschsprung patients with free air, perforation typically occurs in the cecum↗
▶Ep 226 · 6:27
clinicalIn anorectal malformation patients with perforation, the perforation typically occurs in the sigmoid colon as a longitudinal tear along the tinea↗
▶Ep 226 · 7:34
quoteYou need to break the cycle of the physiologic obstruction. They are obstructed both at the sphincter level and in the aganglionic segment. And you have to break that cycle by getting a tube across it and then a lumen of that tube then to allow for egress of that stool because it's the stasis that's the problem. It's the stasis, the bacterial overgrowth. That overgrowth leads to translocation and that's where the sepsis comes in.↗
▶Ep 226 · 8:41
clinicalCold saline can change the temperature of a small child during irrigations, so warm saline should be used↗
▶Ep 226 · 10:55
clinicalSawtoothing in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease↗
▶Ep 226 · 14:25
guidelineMinimum wait time of four weeks from treating enterocolitis before doing definitive surgery is recommended↗
▶Ep 226 · 14:29
clinicalLiterature from PCPLC shows similar outcomes for Hirschsprung surgery delayed to about three months↗
▶Ep 226 · 17:23
clinicalWithout frozen section available, mapping should include left colon, transverse colon, and hepatic flexure/right colon↗
▶Ep 226 · 23:41
guidelineFrozen section should be performed on the ileostomy to ensure it will function↗
▶Ep 226 · 28:04
guidelineFamilies should be taught irrigation technique and practice it before the pull-through surgery↗
▶Ep 226 · 28:04
quoteEducation is so key and preparing the families for this is life-saving.↗
Colorectal Quiz: Episode 43
▶Ep 227 · 5:37
clinicalAbout 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work↗
▶Ep 227 · 7:37
clinicalPoiseuille's law governs flow of fluid through a tube based on radius to the fourth power and length; longer appendix less likely to leak↗
▶Ep 227 · 8:35
clinicalIn a study of 10 Malones in a row without plicating, five leaked, leading to decision to plicate all appendicostomies↗
▶Ep 227 · 9:03
clinicalIf short and stumpy appendix, best for Malone and Mitrofanoff should be made from small bowel↗
▶Ep 227 · 9:03
clinicalIf appendix is seven centimeters or greater it can be split, requiring two centimeters minimum for Malone and five centimeters minimum for Mitrofanoff↗
▶Ep 227 · 9:03
clinicalIf appendix is five to seven centimeters, not enough to share and should go for Mitrofanoff, requiring neo-Malone↗
▶Ep 227 · 16:13
clinicalStenosis rate can be minimized by using 10 French tube not 8, leaving it in for a month, and catheterizing twice a day↗
▶Ep 227 · 16:54
quoteYou can't get a stenosis if you leave a tube in. That's physically impossible. But you're stenting that tract open. So there's a chance of leakage, right? Your valve no longer is as pertinent because you have a stent across the valve.↗
▶Ep 227 · 16:54
clinicalLeaving indwelling tubes increases prolapse rate due to pressure on appendiceal base pushing up mucosa↗
▶Ep 227 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanoff because they catheterize every four hours; catheterizing Malone twice daily has reduced stenosis rate↗
Colorectal Quiz: Episode 43
▶Ep 228 · 5:37
epidemiologicalAbout 60% of the time there is success with using a split appendix for both channels↗
▶Ep 228 · 5:37
epidemiologicalAbout 40% of the time a split appendix cannot be made to work for both channels↗
▶Ep 228 · 7:37
clinicalFlow of fluid through a tube is based on Poiseuille's law: radius to the fourth power and length↗
▶Ep 228 · 8:35
clinicalA longer appendix is less likely to leak and may not need plication↗
▶Ep 228 · 8:35
clinicalIn a study of 10 Malones without plication, five leaked, leading to universal plication policy↗
▶Ep 228 · 8:35
clinicalUniversal plication has resulted in no leakage for several years↗
▶Ep 228 · 9:03
clinicalShort and stumpy appendix is best for Malone; Mitrofanoff should be made from small bowel in this case↗
▶Ep 228 · 9:03
clinicalFive to seven centimeter appendix is not enough to share and should go to Mitrofanoff because long-term Mitrofanovs do much better; requires neo-Malone creation↗
▶Ep 228 · 9:03
clinicalAppendix seven centimeters or greater can be split, requiring minimum two centimeters for Malone and five centimeters for Mitrofanoff↗
▶Ep 228 · 16:11
clinicalUsing a G-tube device in 10-French and stenting the channel for many months reduces stenosis incidence↗
▶Ep 228 · 16:11
clinicalStenosis rate can be minimized by using 10-French tube (not 8), leaving it in for a month, and catheterizing twice daily↗
▶Ep 228 · 16:54
clinicalLeaving indwelling tubes increases prolapse rate by creating pressure on appendiceal base pushing up mucosa↗
▶Ep 228 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanoff because they catheterize every four hours↗
▶Ep 228 · 17:45
clinicalCatheterizing Malone tract twice daily has reduced stenosis rate↗
Colorectal Quiz: Episode 40
▶Ep 229 · 5:32
quoteWait, is this Meyer-Rotakansky-Kuster-Hauser syndrome?↗
▶Ep 229 · 11:35
clinicalOptions for vaginal reconstruction include dilation of the existing introitus, buccal graft placement, or future tissue engineering solutions.↗
▶Ep 229 · 12:14
quoteI think it's going to be, there are people right now taking a few vaginal cells and growing them and hopeful, just like you said, Mark, we're going to have some great tissue engineering that will assist us and make this a easier and better procedure for our patients.↗
▶Ep 229 · 13:09
opinionIf a neovagina functions well without problems, there may be no need to remove it even if it was intended as temporary.↗
▶Ep 229 · 13:09
quoteI think you need it when there's a problem. If there's no problem, why go in and remove tissue, whether it be bowel or whatever you have as your graft?↗
▶Ep 229 · 14:50
quoteI applaud you, Chris, and your partners for going in thinking you're going to do this big reconstruction, encounter something that you weren't expecting and doing the safe thing.↗
▶Ep 229 · 15:57
opinionSurgeons should be willing to stop an operation when encountering uncertain anatomy, gather more information, and return to complete the procedure rather than proceeding blindly.↗
▶Ep 229 · 15:57
quoteFred Reichman used to say, you are judged by what you are willing to stop for. And as surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through.↗
Colorectal Quiz: Episode 40
▶Ep 230 · 5:32
quoteIs this Meyer-Rotakansky-Kuster-Hauser syndrome?↗
▶Ep 230 · 11:35
clinicalA dilatable introitus can potentially be dilated in the future to create a functional vagina↗
▶Ep 230 · 13:09
opinionIf there is no problem with a neovagina bridge, there is no need to go in and remove tissue later↗
▶Ep 230 · 14:50
quoteI applaud you, Chris, and your partners for going in thinking you're going to do this big reconstruction, encounter something that you weren't expecting and doing the safe thing.↗
▶Ep 230 · 15:57
opinionSurgeons are judged by what they are willing to stop for; it is wise to stop an operation when uncertain about anatomy, gather more information, and return another day↗
▶Ep 230 · 15:57
quoteFred Reichman used to say, you are judged by what you are willing to stop for. And as surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through.↗
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
quoteDo you automatically get an echo on every one of your anorectal malformation babies?↗
▶Ep 231 · 7:24
clinicalIn cardiac patients with external ARM opening, dilation is typically performed as long as evacuation is adequate↗
▶Ep 231 · 7:48
opinionConcern exists about healing of ARM repair in blue babies with significant cardiac lesions requiring early surgery↗
▶Ep 231 · 7:55
quoteMy concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair.↗
▶Ep 231 · 14:23
clinicalWhen fistula opening is 50-50 (half within, half anterior to sphincter complex), leave the anterior wall and mobilize posteriorly to achieve 80-20 reconstruction↗
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
▶Ep 232 · 7:24
clinicalIn a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they are evacuating okay↗
▶Ep 232 · 7:48
clinicalThe concern with significant cardiac lesions requiring early surgery in a blue baby is worry about healing of the repair↗
▶Ep 232 · 7:55
quoteMy concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair.↗
▶Ep 232 · 11:21
clinicalIt is important to irrigate the distal bowel as much as possible during colostomy creation↗
Colorectal Quiz Episode 29: Female ARM
▶Ep 233 · 7:58
quotejust because it's published. Doesn't mean it works.↗
▶Ep 233 · 14:04
clinicalIn the dilation study, approximately 20% required a redo operation (either local or total), with four patients requiring total redo anoplasties for stricture (two in dilation arm who chose not to dilate, two in non-dilation arm)↗
▶Ep 233 · 14:04
quoteMy only concern is what's the continence rate of your patients?↗
▶Ep 233 · 15:02
quoteall the parents want is their kid pooping in the potty. And we don't know that answer.↗
Colorectal Quiz Episode 29: Female ARM
▶Ep 234 · 7:58
quotejust because it's published. Doesn't mean it works.↗
▶Ep 234 · 15:02
clinicalApproximately 20% of patients in the dilation study required either local or total redo operations, mostly local procedures↗
clinicalDr. Martin developed the Martin procedure, an expansion of the Duhamel leaving a longer aganglionated segment of rectum and pulling through ganglionated bowel for long segment Hirschsprung disease↗
▶Ep 236 · 9:40
clinicalDr. Martin was the first surgeon in chief and pediatric surgeon at Cincinnati Children's Hospital↗
Colorectal Quiz Episode 18: Cloaca Part 2
▶Ep 237 · 1:45
clinicalDefinitive diagnostic workup for cloacal malformation is typically performed at 5-6 months of age↗
▶Ep 237 · 1:45
quoteYeah, so we usually do it at about five to six months.↗
▶Ep 237 · 4:34
clinicalDuring cystoscopy it is important to identify cervices to understand Müllerian development and to look for ureteral orifices which may have anomalous attachments to the bladder or bladder neck↗
▶Ep 237 · 4:45
quoteI think it's also important to look for cervices and see if you have one vagina, two vaginas. Do you have a cervix, which will sort of be the front door? Is there a uterus behind there?↗
▶Ep 237 · 7:41
opinionRoutine endoscopy allows general pediatric surgeons to differentiate straightforward from complex cloacas and identify cases that should be referred to specialized centers↗
▶Ep 237 · 8:30
quoteI can tell you, as recently as 10 or 15 years ago, there was a lot more redoing of cloacas that was required because I think surgeons attempted a repair and then realized that it was much more complicated than they had imagined.↗
▶Ep 237 · 8:30
epidemiologicalAs recently as 10-15 years ago, many cloacal repairs required revision because surgeons attempted repairs that were more complicated than anticipated↗
▶Ep 237 · 9:00
quoteThe lower confluence, if you know how to do it, is a beautiful, elegant operation.↗
▶Ep 237 · 9:00
opinionLower confluence cloacas can be elegantly repaired by appropriately trained surgeons, while higher confluence cases with vaginal replacements and ectopic ureters should be done at specialized centers↗
▶Ep 237 · 18:50
quoteThat is not the length of the common channel to the bladder neck.↗
Colorectal Quiz: Episode 2
▶Ep 240 · 10:30
clinicalIn higher malformations like bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated↗
The Colorectal Quiz Episode 4
▶Ep 241 · 6:33
quoteI previously used to do this transanal and it would take a few hours. Now the transanal dissection should be usually way under an hour, especially in a primary pull-through point↗
▶Ep 241 · 6:33
clinicalTransanal dissection in primary pull-through should take under one hour when adequate laparoscopic dissection is performed↗
▶Ep 241 · 12:43
clinicalFor distal disease only distal IMA branches need division; for left colon disease IMA itself may require division↗
Colorectal Quiz: Episode 2
▶Ep 242 · 10:30
clinicalIn higher malformations like bladder neck fistula, the sphincter complex is sometimes more anterior than anticipated↗
The Colorectal Quiz: Episode 1
▶Ep 243 · 4:15
clinicalPatients with pre-sacral mass in the setting of anorectal malformation will end up getting an MRI↗
▶Ep 243 · 4:15
epidemiologicalPre-sacral mass is found almost half the time in anal stenosis or rectal atresia defects↗
▶Ep 243 · 5:05
quoteWe typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up?↗
▶Ep 243 · 5:05
clinicalCross-table lateral radiograph is typically obtained at about the 24-hour mark to visualize the gas column location↗
▶Ep 243 · 6:51
quoteThe air column has really risen very nicely, and boy, is that thing close to the perineal skin. It's right there, isn't it?↗
▶Ep 243 · 7:36
clinicalWell-formed buttock, good muscle, and true area where sphincter mechanism can be located, combined with well-developed sacrum, indicate likely good prognosis↗
▶Ep 243 · 12:34
clinicalBulbar fistula nomenclature refers to anatomic location at the elbow of the urethra↗
▶Ep 243 · 12:34
quoteYou can see this fistula is very close to the rectum. And if you're going to dissect that free and along the urethra, it's important to make sure that you know that those two structures are not very far apart.↗
The Colorectal Quiz: Episode 1
▶Ep 244 · 4:15
epidemiologicalPre-sacral masses are rare in typical imperforate anus cases↗
▶Ep 244 · 4:15
epidemiologicalIn anal stenosis or rectal atresia defects, pre-sacral mass is found almost half the time↗
▶Ep 244 · 4:15
clinicalPatients with pre-sacral mass will need MRI↗
▶Ep 244 · 5:05
clinicalCross-table lateral radiograph should be obtained at about 24 hours of life, give or take a few hours↗
▶Ep 244 · 7:36
clinicalWell-formed buttock, good muscle, and true area where sphincter mechanism can be located indicate likely good prognosis↗
▶Ep 244 · 8:25
quoteI think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.↗
▶Ep 244 · 9:57
quoteIt goes without saying, and one of our, I think one of our big teaching points is you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum.↗
▶Ep 244 · 12:34
clinicalBulbar fistula nomenclature refers to anatomic location at the elbow of the urethra↗
Gastroschisis and sutureless abdominal wall closure
▶Ep 31 · 7:20
opinionMany sutureless repair patients were done in more recent cohorts and tended towards less interventions↗
▶Ep 31 · 7:20
opinionPatients with more favorable bowel theoretically would have less hospital stay and feed faster↗
▶Ep 31 · 7:20
opinionPatients able to undergo primary repair probably had more favorable bowel↗
▶Ep 31 · 8:05
clinicalTissue manipulation in sutured repair puts patients at higher risk for potential infection or erythema↗
▶Ep 31 · 8:05
clinicalIn sutured repair, mobilizing flaps from skin and fascia causes redness and bruising around the incision↗
▶Ep 31 · 8:05
opinionThe finding of increased antibiotics needed after sutured repair was expected↗
▶Ep 31 · 8:50
clinicalLong-term follow-up data on the same patients examining growth and umbilical hernia repair rates has been completed and will be analyzed soon↗
▶Ep 31 · 8:50
epidemiologicalSeveral small studies show that some sutureless patients had a high umbilical hernia repair rate or at least a high umbilical hernia rate↗
Neonatal Gastric Volvulus with Dr. Jason Frischer
▶Ep 43 · 1:10
quoteI've seen it associated with congenital diaphragmatic hernias a few times, and I think that's when we have a high suspicion for it.↗
▶Ep 43 · 1:33
epidemiological60% of gastric volvulus cases happen in the first year of life in the pediatric population↗
▶Ep 43 · 1:33
epidemiologicalAbout 21% of pediatric gastric volvulus cases occur in the first month of life↗
▶Ep 43 · 1:33
quote60% happen in the first year of life in the pediatric population, and so about 21% in the first month and over a third in the first year of life.↗
▶Ep 43 · 1:58
clinicalAcute gastric volvulus in young infants (around 4 months old) is more likely than chronic presentation↗
▶Ep 43 · 2:47
quoteI think a little bit of bloody aspirate from the. Logo can't advance it. Funny looking stomach bubble on the X-ray.↗
▶Ep 43 · 3:10
clinicalChronic gastric volvulus is related to laxity of the gastric ligaments↗
▶Ep 43 · 3:10
clinicalThe stomach has ligamentous attachments including gastrophrenic, gastrosplenic, gastrocolic, and gastropatic ligaments↗
▶Ep 43 · 3:10
quoteThose are more to do with the laxity of the gastric ligaments, and the stomach has ligamentous attachments basically surrounding the entire stomach from gastrophrenic, gastrosplenic, gastrocolic.↗
▶Ep 43 · 3:43
clinicalOrganoaxial volvulus is the first and most common type of gastric volvulus↗
▶Ep 43 · 3:43
quoteThe first one, the first and most common is organoaxial volvulus.↗
▶Ep 43 · 3:55
clinicalIn organoaxial volvulus, the stomach rotates around an axis between the GE junction and pylorus, with the greater curvature flipping superior to the lesser curvature↗
▶Ep 43 · 3:55
quoteThey describe a line that's drawn on this diagram between the GE junction and the pylorus, and it's spinning around that axis. The greater curvature then sort of flips up and over and becomes more superior than the lesser curvature.↗
▶Ep 43 · 4:18
clinicalIn mesenteroaxial volvulus, rotation occurs around a line through the middle of the stomach from lesser to greater curvature↗
▶Ep 43 · 4:46
clinicalIn mesenteroaxial volvulus with contrast, the pylorus appears next to or near the GE junction and above the body of the stomach↗
▶Ep 43 · 4:46
quoteWhen the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach.↗
▶Ep 43 · 8:40
quoteAlso, you always want to check the viability of the stomach. So, right, if this is chronically volvulized or been volvulized for a couple of days, uh, at least looking at the cirrhosa and looking at the blood flow.↗
▶Ep 43 · 8:40
clinicalViability of the stomach must always be assessed intraoperatively, especially if chronically volvulized↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 46 · 3:10
quotewe don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it↗
▶Ep 46 · 3:10
clinicalSome published protocols say to start feeding when the baby has had a bowel movement↗
▶Ep 46 · 3:10
clinicalSome protocols say to start feeding when NG output is clear↗
▶Ep 46 · 3:10
clinicalSome protocols say to start feeding when you clamp the NG and there is no output↗
▶Ep 46 · 3:10
clinicalOne institution does not intubate gastroschisis babies at all for dressing placement↗
▶Ep 46 · 5:13
clinicalIf you empty the stomach, squish out the colon, go slow, give the baby sweeties, and have nurses help relax the baby, you can reduce gastroschisis without sedation↗
▶Ep 46 · 5:13
quoteif you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit↗
▶Ep 46 · 6:19
clinicalIn parts of the world without TPN access, they must feed gastroschisis babies immediately↗
▶Ep 46 · 6:19
quotein the us we were such privileged that we have pic lines we have tpn and things like that↗
▶Ep 46 · 10:30
epidemiologicalAfter instituting a feeding protocol, Cincinnati dropped gastroschisis length of stay by 10 days over two years↗
▶Ep 46 · 10:30
quoteover two years we dropped the length of stay by 10 days and the mix of patients is not different↗
▶Ep 46 · 10:30
quoteour average length of stay was 49 days and it was comparing to other nicu's like kansas city and and other places that are taking care of very similar babies↗
▶Ep 46 · 10:30
epidemiologicalCincinnati has not seen a change in days from admission to first feed, although 2020 showed improvement before bouncing back↗
▶Ep 46 · 10:30
clinicalCincinnati is starting to see a decrease in time from first feed to full feeds↗
▶Ep 46 · 10:30
epidemiologicalCincinnati's average length of stay for gastroschisis was 49 days, astronomically higher than other NICUs in their cooperative network↗
▶Ep 46 · 10:30
opinionThe SSI reduction was probably because protocol-fed patients had less variability and fewer changes in care↗
▶Ep 46 · 10:30
epidemiologicalThe study was inconclusive due to lots of different feeding protocols used across member institutions↗
▶Ep 46 · 15:05
quotewe really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go↗
▶Ep 46 · 15:05
clinicalSome people will ignore bilious emesis completely in gastroschisis patients↗
▶Ep 46 · 15:05
clinicalSome people check residuals which will be bilious and some will completely ignore that↗
▶Ep 46 · 15:05
clinicalA study from New Zealand discusses attitudes towards feeding in gastroschisis↗
▶Ep 46 · 15:05
opinionInstitutions need to define their own tolerance thresholds and stay on protocol while continually evaluating patient condition↗
▶Ep 46 · 15:05
clinicalIf a patient has significant issues and complete intolerance, one approach is to stop feeds for six hours↗
▶Ep 46 · 15:05
quotesome people will ignore bilious emesis completely you know some people check residuals and that's going to be bilious a lot of the time too and some people will just completely ignore that↗
▶Ep 46 · 17:15
clinicalThe institution tries to push oral feeds quickly to avoid oral aversion↗
▶Ep 46 · 17:15
epidemiologicalCurrent gastroschisis length of stay is about 30 to 34 days at one institution↗
▶Ep 46 · 17:15
clinicalOne recent patient who was primarily reduced on day of life zero was out of hospital in about two weeks↗
▶Ep 46 · 18:00
clinicalOne institution has not seen any aspirations with early aggressive feeding yet↗
▶Ep 46 · 18:56
epidemiologicalAt least two-thirds of gastroschisis cases at one institution cannot be reduced right away and are placed in a silo↗
Gastroschisis and sutureless abdominal wall closure
▶Ep 40 · 7:20
opinionPatients with more favorable bowel theoretically would have less hospital stay and feed faster↗
▶Ep 40 · 7:20
opinionPatients able to undergo primary repair probably had more favorable bowel↗
▶Ep 40 · 7:20
opinionMany sutureless repair patients were done in more recent cohorts and tended towards less interventions↗
▶Ep 40 · 8:05
clinicalTissue manipulation in sutured repair puts patients at higher risk for potential infection or erythema↗
▶Ep 40 · 8:05
clinicalIn sutured repair, mobilizing flaps from skin and fascia causes redness and bruising around the incision↗
▶Ep 40 · 8:05
opinionThe finding of increased antibiotics needed after sutured repair was expected↗
▶Ep 40 · 8:50
clinicalLong-term follow-up data on the same patients examining growth and umbilical hernia repair rates has been completed and will be analyzed soon↗
▶Ep 40 · 8:50
epidemiologicalSeveral small studies show that some sutureless patients had a high umbilical hernia repair rate or at least a high umbilical hernia rate↗
The Colorectal Quiz Episode 8: Motility Disorders Part 1
▶Ep 41 · 6:29
quoteIt's saying that this is not a Monet, that is for certain.↗
▶Ep 41 · 6:53
opinionThere are probably many people with redundant colons that stool perfectly normally without imaging documentation↗
▶Ep 41 · 8:06
clinicalWater-soluble contrast is used instead of barium because it helps empty the colon and acts as a cleanout for patients starting new medical therapy↗
▶Ep 41 · 10:51
clinicalIn the past, the sphincter and its major role in constipation patients was not well understood↗
The Colorectal Quiz Episode 9: Motility Disorders Part 2
▶Ep 42 · 8:02
epidemiologicalMany patients get colonic manometry but the results come back normal↗
guidelineManagement at Cincinnati Children's prioritizes maximizing medical therapy and understanding anatomic and functional issues before resorting to surgical resection.↗
▶Ep 44 · 11:04
opinionResection should not be performed immediately based on one abnormal finding; multiple factors must be considered.↗
▶Ep 44 · 11:04
quoteI want to stress that we shouldn't resort to resection right away just because we have one abnormal finding.↗
▶Ep 44 · 12:13
guidelineThe first step in evaluating a patient with suspected motility disorder is to ensure normal anatomy, which can be assessed with contrast studies.↗
Neonatal Gastric Volvulus with Dr. Jason Frischer
▶Ep 59 · 1:10
quoteI've seen it associated with congenital diaphragmatic hernias a few times, and I think that's when we have a high suspicion for it.↗
▶Ep 59 · 1:33
quote60% happen in the first year of life in the pediatric population, and so about 21% in the first month and over a third in the first year of life.↗
▶Ep 59 · 1:33
epidemiologicalAbout 21% of pediatric gastric volvulus cases occur in the first month of life↗
▶Ep 59 · 1:33
epidemiological60% of gastric volvulus cases happen in the first year of life in the pediatric population↗
▶Ep 59 · 1:58
clinicalAcute gastric volvulus in young infants (around 4 months old) is more likely than chronic presentation↗
▶Ep 59 · 2:47
quoteI think a little bit of bloody aspirate from the. Logo can't advance it. Funny looking stomach bubble on the X-ray.↗
▶Ep 59 · 3:10
clinicalThe stomach has ligamentous attachments including gastrophrenic, gastrosplenic, gastrocolic, and gastropatic ligaments↗
▶Ep 59 · 3:10
quoteThose are more to do with the laxity of the gastric ligaments, and the stomach has ligamentous attachments basically surrounding the entire stomach from gastrophrenic, gastrosplenic, gastrocolic.↗
▶Ep 59 · 3:10
clinicalChronic gastric volvulus is related to laxity of the gastric ligaments↗
▶Ep 59 · 3:43
quoteThe first one, the first and most common is organoaxial volvulus.↗
▶Ep 59 · 3:43
clinicalOrganoaxial volvulus is the first and most common type of gastric volvulus↗
▶Ep 59 · 3:55
clinicalIn organoaxial volvulus, the stomach rotates around an axis between the GE junction and pylorus, with the greater curvature flipping superior to the lesser curvature↗
▶Ep 59 · 3:55
quoteThey describe a line that's drawn on this diagram between the GE junction and the pylorus, and it's spinning around that axis. The greater curvature then sort of flips up and over and becomes more superior than the lesser curvature.↗
▶Ep 59 · 4:18
clinicalIn mesenteroaxial volvulus, rotation occurs around a line through the middle of the stomach from lesser to greater curvature↗
▶Ep 59 · 4:46
clinicalIn mesenteroaxial volvulus with contrast, the pylorus appears next to or near the GE junction and above the body of the stomach↗
▶Ep 59 · 4:46
quoteWhen the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach.↗
▶Ep 59 · 8:40
quoteAlso, you always want to check the viability of the stomach. So, right, if this is chronically volvulized or been volvulized for a couple of days, uh, at least looking at the cirrhosa and looking at the blood flow.↗
▶Ep 59 · 8:40
clinicalViability of the stomach must always be assessed intraoperatively, especially if chronically volvulized↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 62 · 3:10
clinicalSome published protocols say to start feeding when the baby has had a bowel movement↗
▶Ep 62 · 3:10
clinicalOne institution does not intubate gastroschisis babies at all for dressing placement↗
▶Ep 62 · 3:10
clinicalSome protocols say to start feeding when you clamp the NG and there is no output↗
▶Ep 62 · 3:10
clinicalSome protocols say to start feeding when NG output is clear↗
▶Ep 62 · 3:10
quotewe don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it↗
▶Ep 62 · 5:13
clinicalIf you empty the stomach, squish out the colon, go slow, give the baby sweeties, and have nurses help relax the baby, you can reduce gastroschisis without sedation↗
▶Ep 62 · 5:13
quoteif you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit↗
▶Ep 62 · 6:19
quotein the us we were such privileged that we have pic lines we have tpn and things like that↗
▶Ep 62 · 6:19
clinicalIn parts of the world without TPN access, they must feed gastroschisis babies immediately↗
▶Ep 62 · 10:30
quoteover two years we dropped the length of stay by 10 days and the mix of patients is not different↗
▶Ep 62 · 10:30
quoteour average length of stay was 49 days and it was comparing to other nicu's like kansas city and and other places that are taking care of very similar babies↗
▶Ep 62 · 10:30
opinionThe SSI reduction was probably because protocol-fed patients had less variability and fewer changes in care↗
▶Ep 62 · 10:30
clinicalCincinnati is starting to see a decrease in time from first feed to full feeds↗
▶Ep 62 · 10:30
epidemiologicalCincinnati has not seen a change in days from admission to first feed, although 2020 showed improvement before bouncing back↗
▶Ep 62 · 10:30
epidemiologicalCincinnati's average length of stay for gastroschisis was 49 days, astronomically higher than other NICUs in their cooperative network↗
▶Ep 62 · 10:30
epidemiologicalAfter instituting a feeding protocol, Cincinnati dropped gastroschisis length of stay by 10 days over two years↗
▶Ep 62 · 10:30
epidemiologicalThe study was inconclusive due to lots of different feeding protocols used across member institutions↗
▶Ep 62 · 15:05
opinionInstitutions need to define their own tolerance thresholds and stay on protocol while continually evaluating patient condition↗
▶Ep 62 · 15:05
clinicalIf a patient has significant issues and complete intolerance, one approach is to stop feeds for six hours↗
▶Ep 62 · 15:05
quotesome people will ignore bilious emesis completely you know some people check residuals and that's going to be bilious a lot of the time too and some people will just completely ignore that↗
▶Ep 62 · 15:05
quotewe really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go↗
▶Ep 62 · 15:05
clinicalSome people will ignore bilious emesis completely in gastroschisis patients↗
▶Ep 62 · 15:05
clinicalSome people check residuals which will be bilious and some will completely ignore that↗
▶Ep 62 · 15:05
clinicalA study from New Zealand discusses attitudes towards feeding in gastroschisis↗
▶Ep 62 · 17:15
epidemiologicalCurrent gastroschisis length of stay is about 30 to 34 days at one institution↗
▶Ep 62 · 17:15
clinicalOne recent patient who was primarily reduced on day of life zero was out of hospital in about two weeks↗
▶Ep 62 · 17:15
clinicalThe institution tries to push oral feeds quickly to avoid oral aversion↗
▶Ep 62 · 18:00
clinicalOne institution has not seen any aspirations with early aggressive feeding yet↗
▶Ep 62 · 18:56
epidemiologicalAt least two-thirds of gastroschisis cases at one institution cannot be reduced right away and are placed in a silo↗
Colorectal Quiz: Episode 42 - HD Constipation
▶Ep 88 · 3:47
clinicalIn younger children age less than 3 or so, hypertrophic nerves are defined as greater than 40 microns in diameter↗
▶Ep 88 · 4:01
clinicalThe definition of hypertrophic nerve is more gray in older patients and in patients who have chronic constipation issues↗
▶Ep 88 · 10:27
clinicalOnce distal obstruction is ruled out or fixed and the colon is still not working, then you have a problem warranting colonic manometry↗
▶Ep 88 · 11:01
clinicalIf there's a segment less than 30 centimeters of inadequate high amplitude propagating contractions, the approach is not super aggressive; over 30 centimeters is definitely more of a red flag↗
The Colorectal Quiz Episode 8: Motility Disorders Part 1
▶Ep 2 · 6:29
quoteIt's saying that this is not a Monet, that is for certain.↗
▶Ep 2 · 6:53
opinionThere are probably many people with redundant colons that stool perfectly normally without imaging documentation↗
▶Ep 2 · 8:06
clinicalWater-soluble contrast is used instead of barium because it helps empty the colon and acts as a cleanout for patients starting new medical therapy↗
▶Ep 2 · 10:51
clinicalIn the past, the sphincter and its major role in constipation patients was not well understood↗
The Colorectal Quiz Episode 9: Motility Disorders Part 2
▶Ep 3 · 8:02
epidemiologicalMany patients get colonic manometry but the results come back normal↗
guidelineManagement at Cincinnati Children's prioritizes maximizing medical therapy and understanding anatomic and functional issues before resorting to surgical resection.↗
▶Ep 4 · 11:04
opinionResection should not be performed immediately based on one abnormal finding; multiple factors must be considered.↗
▶Ep 4 · 11:04
quoteI want to stress that we shouldn't resort to resection right away just because we have one abnormal finding.↗
▶Ep 4 · 12:13
guidelineThe first step in evaluating a patient with suspected motility disorder is to ensure normal anatomy, which can be assessed with contrast studies.↗
Colorectal Quiz: Episode 42 - HD Constipation
▶Ep 7 · 3:47
clinicalIn younger children age less than 3 or so, hypertrophic nerves are defined as greater than 40 microns in diameter↗
▶Ep 7 · 4:01
clinicalThe definition of hypertrophic nerve is more gray in older patients and in patients who have chronic constipation issues↗
▶Ep 7 · 10:27
clinicalOnce distal obstruction is ruled out or fixed and the colon is still not working, then you have a problem warranting colonic manometry↗
▶Ep 7 · 11:01
clinicalIf there's a segment less than 30 centimeters of inadequate high amplitude propagating contractions, the approach is not super aggressive; over 30 centimeters is definitely more of a red flag↗
