Marc Levitt

1500 timestamped statements across 1 collection — auto-found in recorded discussions, each timestamp jumps to the exact moment.

Colorectal / ARM & Hirschsprung · guest expert Etiologies (Gastroschisis/NEC/Atresia/Volvulus) · guest expert Intestinal Rehab · guest expert Motility / Pseudo-obstruction · guest expert Pediatric Robotic Surgery · episode host Single Ventricle / HLHS · guest expert

Featured diaries

▶ Ep 109 · 1:41
I actually like to talk about the problematic post- pull through Hirschprung's patient in two versions. The obstructed patient, they are not emptying, they're having distention, they're having enterocolitis episodes, multiple, they're having failure to thrive. That's what we talked about last podcast. Then there's a group of patients. That don't have any of those obstructive symptoms, or if they do, they're fairly minimal, they're basically some constipation. But they are soiling, they're pooping all the time, never distended. That's the patient that we're gonna talk about today.
quote · Colorectal / ARM & Hirschsprung
▶ Ep 79 · 6:24
I've yet to meet a patient with Hirschberg's disease that is anatomically perfect. Meaning no stricture, no cuff, no duhamel pouch that's causing trouble, no twist with normal ganglion cells and nerves less than 40 microns. I've never met such a patient that does not spontaneously empty, except the rare patient under a year of age who simply has not learned how to relax their anal canal and allow their poop to exit.
quote · Colorectal / ARM & Hirschsprung

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Colorectal / ARM & Hirschsprung 1500 entries

How I Do It Levitt PSARP

▶ Ep 8 · 0:20
clinical A no fistula defect is very similar to a bulbar fistula in terms of surgical approach ↗
▶ Ep 8 · 0:45
quote Obviously the key to starting any such case is a good imaging study. ↗
▶ Ep 8 · 0:45
clinical The key to starting any anorectal malformation case is a good imaging study ↗
▶ Ep 8 · 1:05
clinical A bladder neck fistula is at the deltoid level, rectoprostatic fistula at the triceps level, and rectobulbar fistula at the elbow of the urethral curve or distal ↗
▶ Ep 8 · 1:31
clinical Patient positioning requires prone position with buttocks elevated, good axillary support, and feet supported so toes don't touch the bed ↗
▶ Ep 8 · 1:50
clinical The sphincter ellipse should be marked before the posterior sagittal incision because it becomes hard to identify afterward ↗
▶ Ep 8 · 2:28
clinical The sphincters must be cut perfectly in the midline so they can be easily reconstructed ↗
▶ Ep 8 · 2:42
clinical Without a good distal colostogram, the midline whitish structure could be urinary tract rather than rectum ↗
▶ Ep 8 · 2:46
quote If you don't have a good distal colostogram, this midline whitish structure could very easily be the urinary tract. ↗
▶ Ep 8 · 3:09
clinical The anterior dissection should continue until running out of rectum, which is the point where a fistula would normally be ↗
▶ Ep 8 · 3:21
clinical Lateral dissection should be performed before turning attention anteriorly ↗
▶ Ep 8 · 3:29
quote You want to separate the rectum from the urinary tract below without injuring the urinary tract. ↗
▶ Ep 8 · 3:35
clinical The initial anterior dissection for the first few millimeters is a submucosal dissection ↗
▶ Ep 8 · 4:07
quote The lateral defines the anterior. If you're not sure, go lateral. ↗
▶ Ep 8 · 4:07
clinical The lateral dissection defines the anterior dissection; when unsure, go lateral ↗
▶ Ep 8 · 4:14
clinical When lateral, any fat seen means you can get closer to the rectum ↗
▶ Ep 8 · 4:23
clinical The lower the rectum, the longer the common wall between rectum and urinary tract ↗
▶ Ep 8 · 4:29
clinical Lower rectum is easier in that it is lower, but harder because there is a longer dissection adjacent to the urethra ↗
▶ Ep 8 · 4:38
opinion A rectobulbar fistula is too low to approach laparoscopically and is much safer to approach posterior sagittally ↗
▶ Ep 8 · 4:41
quote That is way too low in my opinion to approach laparoscopically, much safer to approach such an operation posterior sagittally. ↗
▶ Ep 8 · 4:51
quote If you approach such a rectum laparoscopically, you are going to very likely risk leaving behind the distal rectum a remnant of the urethral fistula, a roof. ↗
▶ Ep 8 · 4:51
clinical Laparoscopic approach to low rectum risks leaving behind distal rectum, a remnant of the urethral fistula, or a roof ↗
▶ Ep 8 · 5:13
clinical If you see fat during dissection, you can get closer to the rectum ↗
▶ Ep 8 · 5:13
quote If you see fat, you can get closer. You must be in the correct plane, otherwise the rectum does not mobilize. ↗
▶ Ep 8 · 5:16
clinical You must be in the correct plane for the rectum to mobilize ↗
▶ Ep 8 · 5:44
clinical For muscle complex bites, taking a bite of the rectum helps to avoid prolapse ↗
▶ Ep 8 · 5:54
clinical The rectum should lie adjacent to, not constricted by, the muscle complex ↗
▶ Ep 8 · 6:15
clinical Very little rectum should be trimmed; preserve as much rectum as possible ↗
▶ Ep 8 · 6:32
clinical The anoplasty uses 16 sutures ↗
▶ Ep 8 · 6:36
clinical The anoplasty should be under slight tension so that when stitches are cut, the rectum will gently retract in ↗
▶ Ep 8 · 6:52
clinical Dilations will begin at 2 weeks postoperatively ↗
▶ Ep 8 · 6:52
clinical Colostomy closure can take place 2 to 3 months after surgery once the anus has reached its desired size ↗

Hirschsprung Disease Part I with Marc Levitt

▶ Ep 28 · 8:50
clinical Irrigations are probably the best treatment for Hirschsprung disease and it is very rare that Hirschsprung disease is a surgical emergency, but without irrigation it will become an emergency ↗
▶ Ep 28 · 8:50
quote It is very rare that Hirschsprung's disease is a surgical emergency. But if you don't irrigate and overcome the distal obstruction, it will become an emergency. ↗
▶ Ep 28 · 9:13
clinical Proper irrigation technique requires a large bore tube (20 French Foley), instilling 10-20 cc aliquots of warm saline at a time, moving the tube to and fro, and allowing fluid mixed with stool to drip back ↗
▶ Ep 28 · 10:51
clinical The biggest mistake with irrigations is using too small of a tube and just putting fluid in and letting it sit (an enema), when babies with Hirschsprung disease have no ability to expel enema fluid ↗
▶ Ep 28 · 11:02
quote Babies with Hirschsprung's disease have no ability to expel the enema fluid. ↗
▶ Ep 28 · 12:38
clinical Rectal biopsies must be taken at least 1 centimeter in from the dentate line because everyone has an aganglionic segment at the dentate line and biopsying too close can give a false positive diagnosis ↗
▶ Ep 28 · 13:23
clinical The pathologist must confirm both the absence of ganglion cells AND the presence of hypertrophic nerves; absence of ganglion cells alone is not Hirschsprung disease as that could be a biopsy taken too low ↗
▶ Ep 28 · 13:23
quote You as the surgeon cannot accept a pathologist's report unless there is the absence of ganglion cells and the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung's disease. ↗
▶ Ep 28 · 14:35
clinical Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia due to an immune component that makes the bowel mucosa more susceptible to translocation ↗
▶ Ep 28 · 15:01
quote Stasis in a Hirschsprung's patient leads to bacterial translocation and a very sick baby from bacteremia. ↗
▶ Ep 28 · 15:42
clinical When irrigations fail and the baby is ill, diversion should be done at the ileum rather than a leveling colostomy, especially without reliable frozen section pathology ↗
▶ Ep 28 · 16:40
clinical Frozen section results can be inaccurate, particularly for transition zones higher in the colon, making permanent section more reliable for determining resection level ↗
▶ Ep 28 · 18:17
clinical The Swenson operation was done incorrectly historically with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence ↗
▶ Ep 28 · 19:19
clinical The Soave procedure involves a mucosal dissection inside the outer rectal wall to avoid injuring pelvic nerves, which was quite brilliant ↗
▶ Ep 28 · 21:18
quote It's fascinating actually that of those four procedures, the only one that actually leaves behind virtually no Hirschsprung's is the Swenson. ↗
▶ Ep 28 · 21:18
clinical Of the four classic procedures (Swenson, Soave, Duhamel, Rebein), only the Swenson actually leaves behind virtually no Hirschsprung tissue ↗
▶ Ep 28 · 21:43
quote The ganglionic bowel, if it's good, can overcome a lot. ↗
▶ Ep 28 · 21:43
clinical Many patients with residual aganglionic bowel (from Soave, Duhamel, or Rebein) did perfectly well because ganglionic bowel, if it's good, can overcome a lot ↗
▶ Ep 28 · 25:34
opinion The transanal Swenson is the preferred approach because it is the purest operation, leaving behind no Hirschsprung except at the very bottom just above the dentate line ↗
▶ Ep 28 · 26:10
clinical If you find the right plane for transanal Swenson it's elegant and bloodless, but if you find the wrong plane you can really injure the patient by dissecting too wide ↗
▶ Ep 28 · 28:50
clinical Overly aggressive transanal-only approach trying to reach the transition zone without laparoscopy has resulted in significant morbidity ↗
▶ Ep 28 · 28:50
quote I've seen a lot of morbidity that has resulted from an overly aggressive transanal-only approach. ↗
▶ Ep 28 · 29:18
clinical Transanal-only approach is appropriate when there is a very reachable transition zone comfortably at mid-sigmoid and the transition zone is obvious ↗
▶ Ep 28 · 29:52
opinion Prone positioning for transanal approach is preferred because the tough anterior dissection becomes easier when looking down on it rather than up at it ↗
▶ Ep 28 · 29:54
quote Anyone who tries a transanal approach prone will never go back to supine because the tough part of the dissection is the anterior part, and it's nice to be looking down on the harder part of the dissection. ↗
▶ Ep 28 · 31:18
clinical Total colonic Hirschsprung patients present differently: diagnosis isn't made right away, contrast study is not typical, and irrigations don't go well ↗
▶ Ep 28 · 33:55
clinical The biggest problem in technique is surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or they overstretch the sphincters with aggressive exposure ↗
▶ Ep 28 · 33:55
quote The biggest problem is people don't give themselves good exposure and then they start the dissection too low and they injure the dentate line or resect the dentate line. ↗
▶ Ep 28 · 35:42
clinical The dissection must start 1 centimeter proximal to the dentate line, which by definition leaves behind 1 centimeter of aganglionic columnar epithelium and the internal sphincter, but ganglionic bowel can overcome this ↗
▶ Ep 28 · 36:28
quote By definition, you're leaving behind 1 centimeter of columnar epithelium, that of course is Hirschsprung's disease, but the ganglionic bowel is able to overcome that. ↗
▶ Ep 28 · 40:48
clinical Seromuscular laparoscopic biopsies can show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa, potentially leading to a transition zone pull-through ↗
▶ Ep 28 · 44:05
clinical Normal nerve size is 40 microns or less; anything bigger than 40 microns indicates transition zone bowel requiring higher resection ↗
▶ Ep 28 · 44:09
quote Anything bigger than 40 microns is transition zone bowel, and I go a little bit higher. ↗
▶ Ep 28 · 44:14
clinical The concept of going 5 centimeters above the transition zone is inaccurate because transition zone is a spectrum ranging from 3 to 10 centimeters ↗
▶ Ep 28 · 44:20
quote Transition zone is a spectrum. I've seen 10 centimeter transition zone. I've seen 3 centimeter transition zones. ↗
▶ Ep 28 · 45:51
clinical Taking the IMA and preserving the marginal arcade makes the left colon and sigmoid straight down into the perineum, creating an easy-to-irrigate configuration ↗
▶ Ep 28 · 46:05
clinical Many patients have not had enough of a pull-through when the entire sigmoid loop is still present, requiring redo surgery to remove more bowel ↗
▶ Ep 28 · 46:46
clinical For transition zones proximal to the splenic flexure, colonic biopsies and ileostomy should be performed rather than relying on frozen section, which is notoriously fraught with errors in these cases ↗
▶ Ep 28 · 48:34
clinical Sequential stitches placed at the 6 o'clock position (in prone) as the bowel is pulled out helps maintain alignment and prevents twisting of the pull-through ↗
▶ Ep 28 · 53:06
clinical Postoperative feeding should be delayed until the abdomen is absolutely soft and flat with bowel function, usually 3-4 days, to prevent enterocolitis readmission ↗
▶ Ep 28 · 53:12
quote I am passionately committed to not have a baby come back and readmitted with enterocolitis. ↗
▶ Ep 28 · 53:23
clinical Abdominal distention can be subclinical, so an X-ray should be obtained before feeding to confirm the bowel is decompressed ↗
▶ Ep 28 · 53:54
quote I don't want to take one step forward and two steps back. ↗
▶ Ep 28 · 54:02
clinical Families must be taught irrigation technique preoperatively and made paranoid about distention so they will seek care immediately if it develops ↗
▶ Ep 28 · 54:28
clinical Anal calibration (not true dilation) should be performed at one month using Hegar dilators, as the stimulation helps the baby more successfully empty ↗
▶ Ep 28 · 57:05
clinical For hepatic flexure transition zones, the entire right colon must be taken down, the ileocolic vessel preserved, and the colon de-rotated so the cecum is at the hepatic liver bed to achieve adequate length ↗
▶ Ep 28 · 57:57
clinical When bringing de-rotated colon down the left side of the abdomen, the ligament of Treitz must be mobilized to prevent the mesenteric vessel from draping across the third portion of the duodenum and causing obstruction ↗

Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison

▶ Ep 31 · 2:38
clinical The most common prenatal ultrasound finding in cloaca is a pelvic mass, often initially thought to be the bladder but actually representing a dilated vagina (hydrocolpos) ↗
▶ Ep 31 · 3:56
clinical Fetal intervention for cloaca is unlikely to be necessary; there is almost never a situation requiring fetal intervention ↗
▶ Ep 31 · 6:35
clinical In cloaca, there is one perineal hole in the area just below the clitoris and no anus ↗
▶ Ep 31 · 6:57
clinical A single hole underneath the clitoris with a completely normal anus is not a cloaca but a urogenital sinus ↗
▶ Ep 31 · 7:25
clinical Cloaca is not ambiguous genitalia, not adrenal hyperplasia, and the baby is a normal female with two normal ovaries who will be hormonally normal ↗
▶ Ep 31 · 9:03
clinical Many patients considered cloacas actually have three holes (vestibular fistula) when examined properly with good lighting and labial retraction ↗
▶ Ep 31 · 15:15
clinical The hydronephrosis in cloaca is usually caused by the hydrocolpos pressing forward on the trigone and compressing the distal ureters, not by bladder obstruction ↗
▶ Ep 31 · 15:40
clinical Draining the hydrocolpos relieves pressure on the ureteral orifices, allowing them to drain into the bladder; vesicostomy does not resolve the hydronephrosis ↗
▶ Ep 31 · 16:15
clinical Vesicostomy is only indicated if the bladder still does not drain after successful hydrocolpos drainage, which is exceedingly rare ↗
▶ Ep 31 · 17:54
clinical The exception for vesicostomy is massive bilateral ureteral reflux, where vesicostomy is a safe way to decompress the system ↗
▶ Ep 31 · 18:24
clinical Hydrocolpos forms because the bladder preferentially fills the vagina through the fistula rather than exiting the common channel, combined with vaginal mucus and maternal estrogen effect ↗
▶ Ep 31 · 20:29
opinion Cystoscopy in the newborn period is not advantageous; the scope is tiny, visualization is poor, and the perineum is swollen ↗
▶ Ep 31 · 21:22
clinical For massive hydrocolpos above the umbilicus, a tubeless vaginostomy can be created by suturing the vagina to the abdominal wall like a G-tube ↗
▶ Ep 31 · 22:28
clinical Urogenital sinus patients need workup for adrenal problems and electrolyte abnormalities if there is virilization ↗
▶ Ep 31 · 23:57
guideline Cloaca repair timing: colostomy at birth, endoscopy and cloacagram at 2-3 months, definitive repair within one year, ideally by 6 months ↗
▶ Ep 31 · 25:41
clinical The length of the urethra (from urethral takeoff to bladder neck) is a critical measurement not mentioned in traditional papers but determines which operation to perform ↗
▶ Ep 31 · 26:21
clinical Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with the healthy rectum in the abdomen; contrast study is needed ↗
▶ Ep 31 · 28:34
clinical 3D cloacagram reconstruction is better than 2D, and printed 3D models where you can hold the anatomy in your hand may be even more valuable ↗
▶ Ep 31 · 30:29
opinion Cloaca patients benefit from collaborative approach with urology and gynecology; the days of a single surgeon handling this complexity are over ↗
▶ Ep 31 · 30:29
quote We like to joke that it's a Cloaca by committee. ↗
▶ Ep 31 · 30:44
quote I think the days of a single surgeon being able to handle a case of this complexity are over. ↗
▶ Ep 31 · 32:33
quote I still remember that I was a trainee standing behind Alberto Pena as he explained to Hardy Hendren this concept, this new concept he had. Oh, you're a general scientist and immobilization. He was drawing pictures. I remember like it was yesterday. It was a moment of history. ↗
▶ Ep 31 · 33:39
clinical Urogenital mobilization is appropriate when common channel is ≤3 cm and urethra above the takeoff is at least 1.5-2 cm ↗
▶ Ep 31 · 34:34
clinical If urethral length is inadequate, the common channel should be left alone to become the urethra, and the vagina must be separated from it ↗
▶ Ep 31 · 35:17
clinical If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery, which often fails and can result in urethral loss from devascularization ↗
▶ Ep 31 · 35:52
clinical Leaving a patient with inadequate urethral length after urogenital mobilization results in leakage that cannot be controlled without tightening or closing the bladder neck ↗
▶ Ep 31 · 36:33
clinical For type 1 cloaca (1 cm common channel with adequate urethral length), only vaginal mobilization is needed and a slightly hypospadiac urethra is acceptable if the patient will void ↗
▶ Ep 31 · 38:00
clinical When native vagina does not reach after full mobilization, options include vaginal switch or vaginal replacement with colon (preferred), rectum, or small bowel ↗
▶ Ep 31 · 39:17
opinion Tissue engineering of vaginas using patient stem cells is on the horizon and would revolutionize cloaca care by eliminating the need for vaginal replacement ↗
▶ Ep 31 · 40:27
clinical The most common problem in redo cloaca is that the surgeon never realized they were dealing with a cloaca and only fixed the rectum, leaving the urogenital sinus untouched ↗
▶ Ep 31 · 40:56
clinical The second most common redo problem is inadequate mobilization of structures leaving the patient with a stenosed or lost vagina ↗

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 32 · 2:57
clinical Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period ↗
▶ Ep 32 · 3:06
clinical Males with perineal fistula may pass meconium and the malformation goes unnoticed, typically presenting in the first year of life with severe constipation ↗
▶ Ep 32 · 4:25
opinion The standard of not checking rectal temperature in newborns makes it easier to miss anorectal malformations ↗
▶ Ep 32 · 4:54
clinical Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation ↗
▶ Ep 32 · 5:40
clinical Patients with uncorrected perineal fistula will soil with loose stool or athletic activity because they cannot completely close the hole when squeezing sphincters ↗
▶ Ep 32 · 6:16
clinical A newborn anus should accept a size 12 Hagar dilator and a one-year-old should accept size 15 ↗
▶ Ep 32 · 6:42
clinical A bucket handle skin tag is consistent with a perineal fistula even if the fistula itself is not visible ↗
▶ Ep 32 · 7:33
opinion Perineal fistula in females is probably the most confounding diagnostic challenge in pediatric colorectal surgery, with both missed diagnoses and overdiagnosis occurring ↗
▶ Ep 32 · 8:47
clinical If the anal opening in a female is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed as the perineal body will lengthen with growth ↗
▶ Ep 32 · 9:08
quote It's very hard to improve on an asymptomatic patient. ↗
▶ Ep 32 · 10:52
clinical Commercial muscle stimulators costing $15,000 can be replaced by anesthesia nerve stimulators costing $150 with appropriate needle attachments ↗
▶ Ep 32 · 12:45
clinical In rectourethral fistula, the rectum could be at bladder neck, prostatic, or bulbar level, and attempting to find it without knowing the level risks finding urinary tract structures instead ↗
▶ Ep 32 · 13:20
guideline Rectourethral fistulas should be managed with colostomy and distal colostogram rather than primary repair, except in exceedingly rare cases where cross-table lateral at 20 hours shows very low rectum ↗
▶ Ep 32 · 14:42
quote I think their lost art of examining the anus and ensuring that someone's putting a rectal thermometer in is an unfortunate change into modern medicine because I think it's harder to miss an anal malformation if someone's put a probe through. ↗
▶ Ep 32 · 15:49
clinical Cloaca is distinguished from urogenital sinus with virilization by the absence of a normal anus; cloaca patients have no anus while urogenital sinus patients have completely normal anus ↗
▶ Ep 32 · 17:18
clinical The most common colostomy error is opening too distal in the sigmoid, which restricts the ultimate pull-through ↗
▶ Ep 32 · 17:45
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections ↗
▶ Ep 32 · 17:58
quote I prefer a separate, separated stomas so that there can't be a chance of any stool going across. ↗
▶ Ep 32 · 18:38
clinical Transverse colostomies can cause acidosis when large rectourethral fistulas allow the left colon to absorb urine ↗
▶ Ep 32 · 19:58
clinical Prolapse risk depends on colostomy location: mid-transverse can prolapse both sides, hepatic flexure only distal, proximal sigmoid only distal because left colon is fixed to retroperitoneum ↗
▶ Ep 32 · 21:30
clinical Marking the anoplasty location on the skin surface before making the incision prevents getting lost when looking at stimulated jumping muscles ↗
▶ Ep 32 · 24:11
clinical A properly done distal colostogram requires enough contrast and pressure to overcome the PC line (puborectalis compression), otherwise it gives false impression of high rectum or absent fistula ↗
▶ Ep 32 · 25:23
clinical The urethra can be visualized as a reverse C or elbow; fistula at or below the elbow is bulbar, above the elbow is prostatic, at bladder neck is bladder neck fistula ↗
▶ Ep 32 · 25:55
clinical Bulbous rectums are more easily approached posterior sagittally while tapered rectums are better suited for laparoscopy ↗
▶ Ep 32 · 27:00
clinical Opening posterior sagittally without knowing rectum location risks finding and potentially mobilizing bladder neck instead of rectum ↗
▶ Ep 32 · 27:36
clinical Bulbar and low prostatic fistulas are found right under or distal to the coccyx; bladder neck fistulas are not reachable through posterior sagittal approach ↗
▶ Ep 32 · 29:28
quote You should never go to the operating room without knowing exactly what anatomy you're going to expect to find. ↗
▶ Ep 32 · 31:48
quote I never look at it that way. I think that laparoscopy replaces laparotomy. It's an elegant dissection from above, but don't give away the advantages of the PSARP. ↗
▶ Ep 32 · 31:48
opinion Laparoscopy replaces laparotomy, not PSARP; a mini-PSARP should still be done with laparoscopy for safe entry and prolapse prevention ↗
▶ Ep 32 · 32:44
quote I like to call mine a laparoscopic assisted PSAP. I think that's a better terminology. ↗
▶ Ep 32 · 33:33
epidemiological Rectal prolapse occurs in about 3% of cases, particularly in patients without great muscles ↗
▶ Ep 32 · 34:14
clinical Rectal prolapse greater than 3 millimeters should be treated because it causes bleeding, mucus, and can inhibit bowel control even in patients with good muscles ↗
▶ Ep 32 · 34:48
clinical Circumferential prolapse can be repaired in two stages (half circumference each) in ambulatory settings, avoiding hospitalization and eliminating need for dilation since half remains untouched ↗
▶ Ep 32 · 35:41
clinical Proper anterior rectal wall mobilization to the areolar plane between rectum and vagina is essential to prevent tension and subsequent perineal body dehiscence ↗
▶ Ep 32 · 36:03
epidemiological Perineal body dehiscence is the most common cause of reoperation in female ARM repairs ↗
▶ Ep 32 · 36:45
clinical Clear liquids only for one week postoperatively prevents hard stool formation while allowing more stool volume, showing good perineal body healing results ↗
▶ Ep 32 · 37:48
clinical Early perineal body dehiscence detected on days 5-8 can be salvaged by taking patient back to OR for re-suturing ↗
▶ Ep 32 · 38:36
clinical Attempting laparoscopic dissection of rectum that is too low risks leaving behind remnant of original fistula (distal rectum) or getting too close to urinary tract ↗
▶ Ep 32 · 39:33
clinical For high rectums, especially bladder neck fistulas, the IMA must be preserved because prior colostomy may have disrupted collaterals down the left colic, making rectum completely dependent on IMA ↗
▶ Ep 32 · 42:23
clinical The ARM continence index uses three factors to predict continence potential: original malformation type, sacral ratio, and spine quality ↗
▶ Ep 32 · 43:19
clinical A bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control ↗
▶ Ep 32 · 43:29
clinical A bladder neck fistula with sacral ratio of 0.4 and tethered cord or myelomeningocele has no real chance of good bowel control ↗
▶ Ep 32 · 46:25
opinion The unique challenge of ARM surgery is that technical errors may not become apparent for several years, unlike most surgical procedures where problems are immediately evident ↗
▶ Ep 32 · 46:34
quote Most things in surgery, if you don't do it right, you know right away. Like if you don't sew a hepatic artery together properly during a liver transplant, the next day, you have a thrombosed artery. If you don't put an anus in the right place, You think you did a perfectly fine operation. The patient goes home. Everyone's happy, and only 4 years later do they come soiling. ↗

Posterior Sagittal Anorectaplasty-Female Part III: Pediatric Colorectal...

▶ Ep 62 · 0:58
quote So this is like a hymen, see. ↗
▶ Ep 62 · 1:52
quote I prefer colon, and I'm curious to know what everyone else in the room who does this. ↗
▶ Ep 62 · 2:07
clinical Small bowel does not produce less mucus than colon for vaginoplasty ↗
▶ Ep 62 · 2:12
quote I don't think that's the case. I find the small bowel mesentery a bit tenuous. ↗
▶ Ep 62 · 2:12
clinical Colon is preferred over small bowel for neovagina due to more robust blood supply; small bowel mesentery is tenuous ↗
▶ Ep 62 · 2:20
quote I think the colon is a little bit more robust. From a blood supply point of view. ↗
▶ Ep 62 · 7:56
clinical 7-8 centimeters is used for bowel segment length because that approximates normal vaginal length in a baby ↗
▶ Ep 62 · 7:56
quote I just normally in a baby do about 78 centimeters because that's what a normal vaginal length looks like in a. ↗
▶ Ep 62 · 8:06
opinion There is no science behind the 7-8 cm vaginal length measurement ↗
▶ Ep 62 · 8:06
quote I think there's no science behind that at all. ↗
▶ Ep 62 · 9:52
quote I think they, you know, obviously. Very new information from them. I would never have a conversation of this type. Every perineal vestibular fistula. ↗
▶ Ep 62 · 10:09
clinical Family agreed to leave structures that did not need to be removed, given uncertainty about future reproductive potential ↗
▶ Ep 62 · 10:09
quote But uh yeah, they were cool and they agreed that they wanted to leave structures that did not need to be removed today. ↗
▶ Ep 62 · 10:37
quote I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation. The successful. ↗
▶ Ep 62 · 10:37
clinical Uterine transplantation is now a successful procedure (referenced as recent development) ↗
▶ Ep 62 · 11:06
quote Yes, that's a very good question and the answer is yes. I would either tack it to the uh pelvic fascia or to the posterior uh bladder. So that it grows with her lengthens into her pelvis. ↗
▶ Ep 62 · 11:06
clinical Neovagina should be tacked to pelvic fascia or posterior bladder to allow it to grow and lengthen into pelvis ↗
▶ Ep 62 · 11:58
clinical Vaginal dilation is not performed post-operatively; some patients will need introitoplasty later ↗
▶ Ep 62 · 11:58
quote Well, I, I don't dilate the, I don't dilate these vaginas. And I anticipate that a certain percentage of them will need a little bit of an internalplasty later, but I think it's a lot of torture to make them go through vaginal dilations. ↗
▶ Ep 62 · 12:24
guideline Pelvic ultrasound and examination under anesthesia with vaginoscopy should be performed 6 months after breast budding ↗
▶ Ep 62 · 13:55
quote And if There's no cervix, then we have a tough decision to make. Whether to empirically remove it ↗
▶ Ep 62 · 13:55
clinical If no cervix is found, decision must be made whether to empirically remove uterus or wait for trouble ↗
▶ Ep 62 · 14:17
clinical Surgeon has patients without cervix: one had two episodes of pelvic inflammatory disease requiring removal, another has been asymptomatic ↗
▶ Ep 62 · 14:17
quote I have, I have a couple of these patients that I follow that don't have a cervix at all. I think this patient has a bit of a cervix and, uh, in one of them, she had two TID episodes and we removed. And the other one, she's been perfectly fine with no episodes. ↗
▶ Ep 62 · 22:33
quote This is, this is good. I'm really happy you're here. ↗
▶ Ep 62 · 24:51
quote Um, you know, the validity of a pelvic MRI to look at gynecologic structures in a baby like this, um, I, I'd say every time, regardless of what the truth is, I struggle with whether or not there's a vaginal lumen, um, unless there is clearly a, uh, hematoculpos or a hydroculpos ↗
▶ Ep 62 · 24:51
clinical Pelvic MRI in infants has limited utility for identifying vaginal lumen unless there is hematocolpos or hydrocolpos ↗
▶ Ep 62 · 25:32
clinical MRI can frequently identify fallopian tubes, ovaries, and uterine anatomy but has low confidence for vaginal lumen assessment in young patients ↗
▶ Ep 62 · 27:31
opinion Preoperative workup would not have been changed; imaging did not hint at Müllerian anomaly and office exam appeared gynecologically normal ↗
▶ Ep 62 · 27:31
quote So I don't think I would have changed a thing. I don't think we would have changed the preoperative workup. I wouldn't do an independent EUA. I would examine the patient at the time of the PSA. ↗
▶ Ep 62 · 27:39
guideline Independent examination under anesthesia would not be performed; patient should be examined at time of PSARP ↗
▶ Ep 62 · 28:15
quote None of the imaging hinted at this, and even the office exam looked amazingly normal from a, a gynecologic point of view. ↗
▶ Ep 62 · 29:20
clinical Neovagina is already tethered to patient's proximal vagina, eliminating need for separate tacking to bladder ↗

Posterior Sagittal Anorectaplasty in a Female: Pediatric Colorectal...

▶ Ep 63 · 1:17
quote There's no vagina here. Isn't that incredible? It looks very, very normal. ↗
▶ Ep 63 · 1:17
quote I think this is a very good representation. I just have a very good question. ↗
▶ Ep 63 · 3:21
quote What should we do? What should we do? ↗
▶ Ep 63 · 4:25
clinical Neonatal pelvic ultrasound did not show hydrocolpos in this case ↗
▶ Ep 63 · 5:49
quote Now we have a difficult decision on our hands of whether to use the rectum as rectum or make a neovagina here. Any suggestions? ↗
▶ Ep 63 · 5:49
clinical Urethra is typically enlarged in anorectal malformations with absent vagina ↗
▶ Ep 63 · 7:47
clinical Electrical nerve stimulator from anesthesia (train-of-four) is cost-effective alternative to dedicated perineal stimulator ↗
▶ Ep 63 · 9:40
quote You don't want me to continue? Well... What do you want me to do? ↗
▶ Ep 63 · 11:45
quote Hey, what are people saying? They don't want me to do this? They left. ↗
▶ Ep 63 · 12:11
clinical Renal and urologic workup was normal preoperatively ↗
▶ Ep 63 · 13:53
clinical Parasympathetic nerve fibers are at risk during dissection in female patients without vagina ↗
▶ Ep 63 · 15:16
clinical Lateral dissection plane defines anterior plane in posterior sagittal approach ↗
▶ Ep 63 · 20:28
clinical In absent vagina cases, thick wall typically exists between rectum and urethra ↗
▶ Ep 63 · 25:36
clinical This patient has good potential for bowel control based on sacral anatomy ↗
▶ Ep 63 · 26:53
opinion Separate examination under anesthesia would not be performed for straightforward primary perineal fistula repair in newborn ↗
▶ Ep 63 · 33:24
quote It would be such a nice vagina, don't you think? What do you think, guys? What should we do? ↗
▶ Ep 63 · 35:07
clinical Presence of fat in dissection plane indicates surgeon can dissect closer to rectal wall ↗
▶ Ep 63 · 35:26
quote 98% of people surveyed want this to be a rectum. I suppose we have to make it a rectum, right? That's what God made it into. ↗
▶ Ep 63 · 44:03
epidemiological Vaginal agenesis in perineal fistula occurs approximately once per 500 cases ↗
▶ Ep 63 · 48:12
opinion Optimal timing for neovagina creation is during initial rectal mobilization to avoid operating through scarred perineum later ↗
▶ Ep 63 · 49:17
clinical Staple line should be removed from neovagina segment to avoid leaving foreign material ↗
▶ Ep 63 · 59:42
opinion Sigmoid colon is preferred over small bowel for neovagina due to more robust blood supply ↗
▶ Ep 63 · 1:05:08
clinical Normal vaginal length in infant is approximately 7-8 centimeters ↗
▶ Ep 63 · 1:07:53
quote I don't know what's going to happen with our technology and our ability to think with uteruses. I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation? ↗
▶ Ep 63 · 1:08:53
clinical Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse ↗
▶ Ep 63 · 1:09:37
clinical Vaginal dilation is not routinely performed postoperatively; some patients require minor revision for introital stenosis ↗
▶ Ep 63 · 1:10:40
guideline Pelvic ultrasound and examination under anesthesia with vaginoscopy should be performed after breast budding to assess Müllerian structures ↗
▶ Ep 63 · 1:20:11
quote I don't think I would have changed a thing. I don't think we would have changed the preoperative workup. ↗
▶ Ep 63 · 1:22:15
clinical MRI has limited utility for visualizing vaginal lumen in infants unless hydrocolpos or hematocolpos present ↗
▶ Ep 63 · 1:26:40
clinical Patient-controlled analgesia is planned postoperative pain management ↗

Urologic and Gynecologic Aspects in Anorectal Malformations: Pediatric...

▶ Ep 61 · 21:00
guideline In ARM patients with absent sacrum and malrotation requiring Ladd's procedure, the appendix should be preserved (not removed) for potential future use in Mitrofanoff or Malone procedures. ↗
▶ Ep 61 · 34:52
clinical Total urogenital mobilization patients are likely to void and be easily catheterized, but complex urethral reconstructions may not be easily catheterizable, warranting prolonged urethral stenting or vesicostomy. ↗
▶ Ep 61 · 35:33
clinical A vesicostomy with refluxing ureters provides safety and allows waiting until ultimate urologic reconstruction at age 4. ↗
▶ Ep 61 · 36:20
quote The fundamental principle is to keep the kidneys at low pressure, and there are many, many different ways to do that. ↗
▶ Ep 61 · 36:20
guideline The fundamental principle is to keep the kidneys at low pressure—there are many different ways to accomplish this. ↗
▶ Ep 61 · 38:30
guideline A febrile urinary tract infection should prompt immediate assumption that the bladder is not successfully emptying—pre- and post-void residuals and assessment for scarring are essential. ↗

ARMs in Female Patients: Pediatric Colorectal Controversies 2014

▶ Ep 64 · 0:23
clinical Perineal fistula is diagnosed when the fistula opening is at or anterior to the fourchette, with normal urethra and vagina visible ↗
▶ Ep 64 · 1:53
clinical Vestibular fistula is diagnosed when the fistula opens posterior to the fourchette within the vestibule ↗
▶ Ep 64 · 2:50
quote I'd like to have it completely separated from the vagina because you'll find there's a... It's always very attached to it. It's like the common wall. If you finally get it loose, you can place the tension free. ↗
▶ Ep 64 · 2:50
opinion Complete separation from vagina is preferred because incomplete mobilization may lead to retraction and wound problems ↗
▶ Ep 64 · 5:40
clinical In every redo of a female ARM, areolar tissue is found that had never been dissected by the original surgeon ↗
▶ Ep 64 · 5:40
quote In every single redo of a female, I find that perineal, I'm sorry, that areolar tissue that had never been dissected by the original surgeon. We know it. We say, see, no one, no one was ever here. ↗
▶ Ep 64 · 6:10
clinical Inadequate anterior rectal wall mobilization can lead to perineal body disruption as the anterior wall pulls back ↗
▶ Ep 64 · 13:09
clinical The rectal blood supply is intramural, so injuring the rectal wall hurts its blood supply ↗
▶ Ep 64 · 13:35
clinical Starting laterally before attempting anterior separation is key to avoiding injury when separating rectum from vagina ↗
▶ Ep 64 · 15:00
opinion Primary vestibular repair without colostomy can be done in newborn or within 3-4 months depending on child's condition ↗
▶ Ep 64 · 16:28
opinion Waiting until perineal body is healed (day 6-7) before feeding allows intervention if dehiscence is developing ↗
▶ Ep 64 · 17:18
clinical 10% dextrose can be used for NPO periods up to 7 days in well-nourished children, avoiding need for hyperalimentation ↗
▶ Ep 64 · 18:48
epidemiological Systematic review shows early enteral nutrition appears better than later nutrition in ARM patients, but all studies are retrospective and poor quality ↗
▶ Ep 64 · 20:53
quote The plural of anecdote is not data. ↗
▶ Ep 64 · 26:39
epidemiological About 2-5% of vestibular fistulas have a vaginal septum ↗
▶ Ep 64 · 26:58
opinion The ideal time to remove a vaginal septum is when the rectum is being mobilized and the perineal body is open ↗
▶ Ep 64 · 29:17
clinical Women with longitudinal vaginal septum often learn to work around it for intercourse but have problems with tampon use ↗
▶ Ep 64 · 30:30
clinical Vaginal septum resection in adolescents is not a difficult operation and can be done with electrocautery ↗
▶ Ep 64 · 32:28
clinical True vaginal fistula (within introitus) is rare and requires slightly more rectal mobilization than vestibular fistula ↗
▶ Ep 64 · 35:33
opinion Using rectum as vagina and mobilizing proximal bowel as neo-rectum should only be done if patient unlikely to be continent (spinal anomaly, absent sacrum) ↗
▶ Ep 64 · 37:18
clinical Rectum separates from urethra more easily than from vagina in absent vagina cases, with thick fibrous tissue rather than adherent common wall ↗
▶ Ep 64 · 38:42
clinical Neovagina is technically easier in younger children because the pedicle reaches more easily in a shorter pelvis ↗
▶ Ep 64 · 44:12
clinical There are two types of cloacas: lower ones (common channel ≤3 cm) and complicated ones (>3 cm) ↗
▶ Ep 64 · 44:40
clinical Hydrocolpos in cloaca may obstruct distal ureters and cause bilateral hydronephrosis ↗
▶ Ep 64 · 44:51
epidemiological About 50% of cloacas have a duplicated gynecologic system ↗
▶ Ep 64 · 45:10
opinion For newborn cloaca with hydrocolpos, open divided colostomy with pigtail catheter decompression of vagina is preferred over formal vaginostomy ↗
▶ Ep 64 · 45:49
clinical Attempting cystoscopy at time of colostomy creation in cloaca makes the colostomy very difficult ↗
▶ Ep 64 · 47:53
clinical Laparoscopic approach for cloaca colostomy allows visualization of pelvic structures and percutaneous vaginostomy tube placement ↗
▶ Ep 64 · 48:50
clinical Curled tube is preferred over straight tube for vaginostomy because straight tubes fall out at 2 months when inflammation resolves ↗
▶ Ep 64 · 50:11
clinical Intermittent catheterization of cloaca 2-3 times daily can drain urine and avoid need for vaginostomy tube in many cases ↗
▶ Ep 64 · 51:00
clinical Catheterization teaching should be done under ultrasound guidance because tube can go into right vagina, left vagina, bladder, or rectum ↗
▶ Ep 64 · 52:45
clinical Once hydrocolpos is drained, the bladder can fill, demonstrating that hydrocolpos compresses ureters and prevents bladder filling ↗

Hirschsprung Disease Part I with Marc Levitt

▶ Ep 77 · 8:50
quote It is very rare that Hirschsprung's disease is a surgical emergency. But if you don't irrigate and overcome the distal obstruction, it will become an emergency. ↗
▶ Ep 77 · 8:50
clinical Irrigations are probably the best treatment for Hirschsprung disease and it is very rare that Hirschsprung disease is a surgical emergency, but without irrigation it will become an emergency ↗
▶ Ep 77 · 9:13
clinical Proper irrigation technique requires a large bore tube (20 French Foley), instilling 10-20 cc aliquots of warm saline at a time, moving the tube to and fro, and allowing fluid mixed with stool to drip back ↗
▶ Ep 77 · 10:51
clinical The biggest mistake with irrigations is using too small of a tube and just putting fluid in and letting it sit (an enema), when babies with Hirschsprung disease have no ability to expel enema fluid ↗
▶ Ep 77 · 11:02
quote Babies with Hirschsprung's disease have no ability to expel the enema fluid. ↗
▶ Ep 77 · 12:38
clinical Rectal biopsies must be taken at least 1 centimeter in from the dentate line because everyone has an aganglionic segment at the dentate line and biopsying too close can give a false positive diagnosis ↗
▶ Ep 77 · 13:23
quote You as the surgeon cannot accept a pathologist's report unless there is the absence of ganglion cells and the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung's disease. ↗
▶ Ep 77 · 13:23
clinical The pathologist must confirm both the absence of ganglion cells AND the presence of hypertrophic nerves; absence of ganglion cells alone is not Hirschsprung disease as that could be a biopsy taken too low ↗
▶ Ep 77 · 14:35
clinical Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia due to an immune component that makes the bowel mucosa more susceptible to translocation ↗
▶ Ep 77 · 15:01
quote Stasis in a Hirschsprung's patient leads to bacterial translocation and a very sick baby from bacteremia. ↗
▶ Ep 77 · 15:42
clinical When irrigations fail and the baby is ill, diversion should be done at the ileum rather than a leveling colostomy, especially without reliable frozen section pathology ↗
▶ Ep 77 · 16:40
clinical Frozen section results can be inaccurate, particularly for transition zones higher in the colon, making permanent section more reliable for determining resection level ↗
▶ Ep 77 · 18:17
clinical The Swenson operation was done incorrectly historically with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence ↗
▶ Ep 77 · 19:19
clinical The Soave procedure involves a mucosal dissection inside the outer rectal wall to avoid injuring pelvic nerves, which was quite brilliant ↗
▶ Ep 77 · 21:18
quote It's fascinating actually that of those four procedures, the only one that actually leaves behind virtually no Hirschsprung's is the Swenson. ↗
▶ Ep 77 · 21:18
clinical Of the four classic procedures (Swenson, Soave, Duhamel, Rebein), only the Swenson actually leaves behind virtually no Hirschsprung tissue ↗
▶ Ep 77 · 21:43
clinical Many patients with residual aganglionic bowel (from Soave, Duhamel, or Rebein) did perfectly well because ganglionic bowel, if it's good, can overcome a lot ↗
▶ Ep 77 · 21:43
quote The ganglionic bowel, if it's good, can overcome a lot. ↗
▶ Ep 77 · 25:34
opinion The transanal Swenson is the preferred approach because it is the purest operation, leaving behind no Hirschsprung except at the very bottom just above the dentate line ↗
▶ Ep 77 · 26:10
clinical If you find the right plane for transanal Swenson it's elegant and bloodless, but if you find the wrong plane you can really injure the patient by dissecting too wide ↗
▶ Ep 77 · 28:50
clinical Overly aggressive transanal-only approach trying to reach the transition zone without laparoscopy has resulted in significant morbidity ↗
▶ Ep 77 · 28:50
quote I've seen a lot of morbidity that has resulted from an overly aggressive transanal-only approach. ↗
▶ Ep 77 · 29:18
clinical Transanal-only approach is appropriate when there is a very reachable transition zone comfortably at mid-sigmoid and the transition zone is obvious ↗
▶ Ep 77 · 29:52
opinion Prone positioning for transanal approach is preferred because the tough anterior dissection becomes easier when looking down on it rather than up at it ↗
▶ Ep 77 · 29:54
quote Anyone who tries a transanal approach prone will never go back to supine because the tough part of the dissection is the anterior part, and it's nice to be looking down on the harder part of the dissection. ↗
▶ Ep 77 · 31:18
clinical Total colonic Hirschsprung patients present differently: diagnosis isn't made right away, contrast study is not typical, and irrigations don't go well ↗
▶ Ep 77 · 33:55
clinical The biggest problem in technique is surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or they overstretch the sphincters with aggressive exposure ↗
▶ Ep 77 · 33:55
quote The biggest problem is people don't give themselves good exposure and then they start the dissection too low and they injure the dentate line or resect the dentate line. ↗
▶ Ep 77 · 35:42
clinical The dissection must start 1 centimeter proximal to the dentate line, which by definition leaves behind 1 centimeter of aganglionic columnar epithelium and the internal sphincter, but ganglionic bowel can overcome this ↗
▶ Ep 77 · 36:28
quote By definition, you're leaving behind 1 centimeter of columnar epithelium, that of course is Hirschsprung's disease, but the ganglionic bowel is able to overcome that. ↗
▶ Ep 77 · 40:48
clinical Seromuscular laparoscopic biopsies can show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa, potentially leading to a transition zone pull-through ↗
▶ Ep 77 · 44:05
clinical Normal nerve size is 40 microns or less; anything bigger than 40 microns indicates transition zone bowel requiring higher resection ↗
▶ Ep 77 · 44:09
quote Anything bigger than 40 microns is transition zone bowel, and I go a little bit higher. ↗
▶ Ep 77 · 44:14
clinical The concept of going 5 centimeters above the transition zone is inaccurate because transition zone is a spectrum ranging from 3 to 10 centimeters ↗
▶ Ep 77 · 44:20
quote Transition zone is a spectrum. I've seen 10 centimeter transition zone. I've seen 3 centimeter transition zones. ↗
▶ Ep 77 · 45:51
clinical Taking the IMA and preserving the marginal arcade makes the left colon and sigmoid straight down into the perineum, creating an easy-to-irrigate configuration ↗
▶ Ep 77 · 46:05
clinical Many patients have not had enough of a pull-through when the entire sigmoid loop is still present, requiring redo surgery to remove more bowel ↗
▶ Ep 77 · 46:46
clinical For transition zones proximal to the splenic flexure, colonic biopsies and ileostomy should be performed rather than relying on frozen section, which is notoriously fraught with errors in these cases ↗
▶ Ep 77 · 48:34
clinical Sequential stitches placed at the 6 o'clock position (in prone) as the bowel is pulled out helps maintain alignment and prevents twisting of the pull-through ↗
▶ Ep 77 · 53:06
clinical Postoperative feeding should be delayed until the abdomen is absolutely soft and flat with bowel function, usually 3-4 days, to prevent enterocolitis readmission ↗
▶ Ep 77 · 53:12
quote I am passionately committed to not have a baby come back and readmitted with enterocolitis. ↗
▶ Ep 77 · 53:23
clinical Abdominal distention can be subclinical, so an X-ray should be obtained before feeding to confirm the bowel is decompressed ↗
▶ Ep 77 · 53:54
quote I don't want to take one step forward and two steps back. ↗
▶ Ep 77 · 54:02
clinical Families must be taught irrigation technique preoperatively and made paranoid about distention so they will seek care immediately if it develops ↗
▶ Ep 77 · 54:28
clinical Anal calibration (not true dilation) should be performed at one month using Hegar dilators, as the stimulation helps the baby more successfully empty ↗
▶ Ep 77 · 57:05
clinical For hepatic flexure transition zones, the entire right colon must be taken down, the ileocolic vessel preserved, and the colon de-rotated so the cecum is at the hepatic liver bed to achieve adequate length ↗
▶ Ep 77 · 57:57
clinical When bringing de-rotated colon down the left side of the abdomen, the ligament of Treitz must be mobilized to prevent the mesenteric vessel from draping across the third portion of the duodenum and causing obstruction ↗

Hirschsprung Disease Audience Q&A with Dr. Marc Levitt

▶ Ep 79 · 1:57
clinical Botox paralyzes skeletal muscle theoretically but clearly has some impact on smooth muscle ↗
▶ Ep 79 · 2:06
clinical Babies have very tight anal sphincter with or without Hirschsprung's disease ↗
▶ Ep 79 · 2:14
clinical In normal babies who hold stool in successfully they get constipated, in Hirschsprung babies they get enterocolitis ↗
▶ Ep 79 · 2:26
clinical After a perfectly done operation preserving 1 centimeter of anal canal, you can have high tone in a baby that doesn't know how to relax ↗
▶ Ep 79 · 3:15
clinical Botox is valuable if a baby is coming back with enterocolitis episodes after ruling out anatomic or pathologic problems ↗
▶ Ep 79 · 3:27
clinical In the early period up to one year of age, you can have bad behavior by the patient even with a perfectly done pull-through ↗
▶ Ep 79 · 3:36
clinical After a year or so of age, there may be an anatomic or pathologic problem and Botox is not very valuable because you have to figure out what the problem is ↗
▶ Ep 79 · 4:47
clinical A retained cuff that is too big, not split completely, or rolled up is particularly offensive to the ability of the pull-through to empty ↗
▶ Ep 79 · 5:09
clinical Patients with retained cuff will get better temporarily with Botox but will continue to fall off the wagon every 2 or 3 months ↗
▶ Ep 79 · 5:35
clinical Nerves greater than 40 microns indicate a transition zone pull-through ↗
▶ Ep 79 · 5:43
opinion Many pathologists are not measuring the nerves, and pediatric surgeons should demand that their pathologists do that ↗
▶ Ep 79 · 5:43
quote Many pathologists are not measuring the nerves, and I want to encourage that all the pediatric surgeons demand that their pathologists do that so that they don't put themselves in a situation where they're doing a beautiful pull-through, but it's the transition zone valve. ↗
▶ Ep 79 · 5:58
clinical If anatomic and pathologic issues are completely ruled out, Botox maybe gets done once, maybe a second time, and then you're done ↗
▶ Ep 79 · 6:14
opinion If a patient over 1 year of age keeps misbehaving, there is likely an anatomic or pathologic problem ↗
▶ Ep 79 · 6:24
quote I've yet to meet a patient with Hirschberg's disease that is anatomically perfect. Meaning no stricture, no cuff, no duhamel pouch that's causing trouble, no twist with normal ganglion cells and nerves less than 40 microns. I've never met such a patient that does not spontaneously empty, except the rare patient under a year of age who simply has not learned how to relax their anal canal and allow their poop to exit. ↗
▶ Ep 79 · 6:24
opinion Dr. Levitt has never met a patient with Hirschsprung disease that is anatomically perfect (no stricture, no cuff, no duhamel pouch causing trouble, no twist) with normal ganglion cells and nerves less than 40 microns that does not spontaneously empty, except rare patients under a year of age who have not learned to relax their anal canal ↗
▶ Ep 79 · 7:00
opinion If an older child is not emptying spontaneously, there is an anatomic or pathologic problem that has not yet been identified ↗
▶ Ep 79 · 7:07
clinical Botox injection technique: 100 units in 10cc saline, 2.5cc submucosal into each quadrant right into the muscle surrounding the anal canal ↗
▶ Ep 79 · 7:30
quote I will never do, ever do. I've never done and will never do an internal sphincterotomy because I'm essentially that's permanent Botox, and my worry is that it could cause permanent incontinence because you shouldn't have to keep Botoxing. ↗
▶ Ep 79 · 7:30
opinion Dr. Levitt will never do an internal sphincterotomy because it is permanent Botox and could cause permanent incontinence ↗
▶ Ep 79 · 7:45
opinion Patients will eventually figure out how to relax, so there is no need to make sphincterotomy a permanent anatomic solution ↗
▶ Ep 79 · 9:35
clinical A dilated pull-through segment may be secondary to noncompliance with dilations or bowel regimen, or the surgeon may not have taken out enough bowel at the original surgery ↗
▶ Ep 79 · 10:01
clinical For patients with a dilated segment and no other anatomic abnormality who continue to misbehave, redo surgery to remove the dilated segment can be offered ↗
▶ Ep 79 · 10:12
clinical Almost always there is something causing the dilation, either a cuff or a transition zone segment of bowel ↗
▶ Ep 79 · 11:24
clinical If a tapered segment is created during redo, it will be a fairly dysmotile segment of bowel for many, many months ↗
▶ Ep 79 · 11:31
clinical If tapering or redo is necessary, the patient should always be diverted with an ileostomy ↗
▶ Ep 79 · 11:40
clinical Most likely you can remove the dilated segment and bring the healthy segment down without tapering ↗
▶ Ep 79 · 11:46
clinical You must make sure any distal obstruction is removed during redo surgery ↗

Hirschsprung Disease Part II with Dr. Marc Levitt

▶ Ep 78 · 3:29
quote The vast majority of patients with Hirschprung's disease do extremely well, and they have no problem with emptying, and they stool normally and have normal bowel control. ↗
▶ Ep 78 · 3:29
clinical The vast majority of patients with Hirschsprung's disease do extremely well after pull-through with no emptying problems and normal bowel control ↗
▶ Ep 78 · 3:37
clinical Problem patients divide into two types: obstruction patients who do not empty, and soiling patients ↗
▶ Ep 78 · 4:21
quote I like to know the timing. ↗
▶ Ep 78 · 4:25
clinical Babies have very tight sphincters capable of keeping sphincters tight for many hours, leading to enterocolitis even after perfectly done pull-through ↗
▶ Ep 78 · 4:59
clinical After about age one, patients should learn to empty and relax sphincters with more normal bowel movement pattern ↗
▶ Ep 78 · 5:20
clinical Evaluation of obstructed post-pull-through patient involves contrast study of colon and examination under anesthesia ↗
▶ Ep 78 · 5:38
clinical Anatomic causes of obstruction include distal stricture, obstructing cuff, atonic Duhamel pouch, twisted pull-through, and dilated segment ↗
▶ Ep 78 · 5:56
epidemiological Soave cuff has been getting shorter as most surgeons do Soave pull-throughs ↗
▶ Ep 78 · 6:08
clinical Aganglionic outer rectal wall (cuff) that is not properly split, fused, or scarred can cause obstruction ↗
▶ Ep 78 · 6:41
clinical Pull-through can be twisted up to 360 degrees leading to obstruction ↗
▶ Ep 78 · 7:14
clinical Pathologic cause of obstruction is pull-through not done to ganglionated bowel with normal sized nerves ↗
▶ Ep 78 · 7:52
clinical Nerve roots should be no bigger than 40 microns; anything larger is transition zone bowel that might not function ↗
▶ Ep 78 · 8:45
clinical Treatment for enterocolitis includes hydration, intravenous metronidazole (Flagyl), and aggressive irrigations 2-3 times daily ↗
▶ Ep 78 · 9:23
clinical Irrigation volume is 10-20 ccs per cycle using size 20-22 Foley catheter, moving tube to wash inside of colon ↗
▶ Ep 78 · 10:51
quote Flagyl is pretty nauseating. ↗
▶ Ep 78 · 11:21
clinical Metronidazole has same efficacy IV or PO because in both cases it is excreted in bile ↗
▶ Ep 78 · 11:32
clinical In diverted colon with ileostomy, Flagyl will not work for C. difficile colitis because drug does not reach colon; vancomycin enemas needed instead ↗
▶ Ep 78 · 12:13
epidemiological Approximately 15-20% of patients can have enterocolitis episode within first year after pull-through ↗
▶ Ep 78 · 12:26
clinical After one year post-pull-through, patients should not be having enterocolitis; if they are, seek anatomic or pathologic explanation ↗
▶ Ep 78 · 13:09
quote I particularly focus on the presacral space. The pull through ought to hug the sacrum. ↗
▶ Ep 78 · 13:09
clinical On contrast study, pull-through should hug the sacrum; diversion forward suggests space-occupying mass which may be a cuff ↗
▶ Ep 78 · 16:34
clinical Obstructing cuff can be felt on digital rectal exam as rubbery thick rubber band structure around pull-through outside the lumen, along hollow of sacrum ↗
▶ Ep 78 · 17:02
quote You've got to put in your mind's eye what is outside of the pull through, and this is really important, particularly for gastroenterologists who are used to visualizing colons intraluminally with scopes. This is not something you'd ever detect intraluminally. It's outside of the pull through. ↗
▶ Ep 78 · 17:02
clinical Cuff is outside the pull-through and cannot be detected intraluminally with scopes ↗
▶ Ep 78 · 17:22
clinical Biopsy should be taken 1 cm above dentate line and sent for permanent section to assess ganglion cell quality and nerve size ↗
▶ Ep 78 · 18:17
clinical Transition zone pull-through with hypertrophic nerves requires redo pull-through ↗
▶ Ep 78 · 18:27
clinical Redo pull-through approach is prone and supine transanal dissection with preservation of anal canal and dentate line, full thickness dissection of pull-through, and removal of cuff ↗
▶ Ep 78 · 20:31
clinical For obstructing cuff, dissect between bowel and cuff, then make second plane outside cuff in Swenson plane to remove muscular tissue ↗
▶ Ep 78 · 21:22
clinical Do not need to remove entire cuff circumferentially; breaking the ring posteriorly and laterally solves the problem while avoiding anterior structures ↗
▶ Ep 78 · 21:51
quote I actually think that the myectomies that have been traditionally successful may very well have been myectomies that were done for wave cuff situations, but the surgeons didn't necessarily know that that's what they were cutting. ↗
▶ Ep 78 · 21:51
opinion Successful myectomies may have been cutting Soave cuff rather than internal sphincter, though surgeons thought they were cutting sphincter ↗
▶ Ep 78 · 22:09
opinion Myectomies performed by 10 different surgeons would all look different because of varying concepts of what is being cut ↗
▶ Ep 78 · 22:43
clinical Myectomies can hurt skeletal muscle and leave patient incontinent ↗
▶ Ep 78 · 24:16
clinical Number of Hirschsprung patients have tight sphincters with powerful internal sphincter that fails to relax, confirmed by anorectal manometry ↗
▶ Ep 78 · 24:34
opinion Post pull-through sphincter problems are relatively rare compared to anatomic problems ↗
▶ Ep 78 · 25:22
clinical Sphincter-mediated obstruction is relatively rare in children over one year of age ↗
▶ Ep 78 · 25:35
clinical Botox acts as temporary myectomy and is preferred over permanent myectomy because it wears off as child learns sphincter coordination ↗
▶ Ep 78 · 25:40
quote I much prefer that strategy because then it wears off, and by the time the kid gets a little older and learns how to coordinate their stooling with their sphincter relaxation, they no longer need it, whereas a myectomy is permanent and can lead to permanent harm and incontinence. ↗
▶ Ep 78 · 26:19
clinical Botox at 4-8 weeks combined with aggressive laxatives helps children learn appropriate bowel movement pattern ↗
▶ Ep 78 · 26:45
clinical Botox provides temporary improvement for cuff problems but patients will recur because cuff must be removed for long-term fix ↗
▶ Ep 78 · 27:17
quote We actually gotten so, so neat about the study that they will actually tell me the length of high tone. ↗
▶ Ep 78 · 27:17
clinical Anorectal manometry can distinguish sphincter dysfunction (1 cm high tone) from sphincter plus cuff obstruction (3-4 cm high tone) ↗
▶ Ep 78 · 28:01
clinical Twisted pull-through requires dissection in Swenson plane around pull-through up to peritoneal reflection, often requiring laparotomy for mobilization ↗
▶ Ep 78 · 28:21
quote I usually end up making an incision and not doing this laparoscopically because it's very hard to figure out the twist and the blood supply and to make sure you're pulling through a new healthy segment. ↗
▶ Ep 78 · 30:18
opinion Redo Duhamel is probably the hardest operation in Hirschsprung disease due to pelvic fibrosis from stapled connection ↗
▶ Ep 78 · 30:31
quote We wrote a paper about redos for Duhamel, and I really wanted to call the paper the Duhamel Pouch Why I Why I Have Learned to Hate You, because it's really an operation that I start to cry during sometimes because it's so stuck. ↗
▶ Ep 78 · 31:00
clinical Redo Duhamel requires combined transanal and deep pelvic dissection using St. Mark's lighted retractor, removing pouch and doing Swenson-format redo ↗
▶ Ep 78 · 33:15
quote I'd like to say that all patients with Hirschspring's disease should be able to empty spontaneously and should be clean. ↗
▶ Ep 78 · 33:15
opinion All patients with Hirschsprung disease should be able to empty spontaneously and should be clean ↗
▶ Ep 78 · 33:23
opinion Concept that Hirschsprung patients will eventually get better as teenagers is wrong; must address emptying and cleanliness issues earlier ↗
▶ Ep 78 · 33:23
quote The concept that many of these folks will get better over many, many years and eventually when they're teenagers they'll get better, I think is wrong. ↗
▶ Ep 78 · 33:48
clinical Patients with Hirschsprung disease are born with normal anal canal and normal sphincters; if anything, sphincters are too good ↗
▶ Ep 78 · 33:48
quote By definition, patients with Hirschman's disease are born with a normal anal canal and a normal set of sphincters. If anything, their sphincters are too good. ↗
▶ Ep 78 · 33:59
quote No Hirschprung's patient is born with a missing anal canal. No Hirschprung's patient is born with a weak sphincter. ↗
▶ Ep 78 · 33:59
clinical No Hirschsprung patient is born with missing anal canal or weak sphincter ↗
▶ Ep 78 · 34:08
clinical Soiling Hirschsprung patients with destroyed anal canal or weak sphincter have iatrogenic injury from transanal dissection started too low, invading dentate line ↗
▶ Ep 78 · 34:08
quote Unfortunately the only possible conclusion is that those are iatrogenic. ↗
▶ Ep 78 · 34:57
clinical Overstretching during surgery can destroy sphincter, causing patient to sit with open anus even when awake ↗
▶ Ep 78 · 35:04
opinion Laparoscopy avoids deep transanal work and reduces risk of sphincter injury compared to aggressive transanal dissection ↗
▶ Ep 78 · 41:35
clinical Capacity for bowel control in Hirschsprung patients is determined by whether sphincters and anal canal are intact ↗
▶ Ep 78 · 41:42
clinical Patients with intact sphincters and anal canal have every reason to expect normal bowel control ↗
▶ Ep 78 · 41:51
clinical Soiling patients with capacity for bowel control can usually be treated with medicines; those without capacity need enema programs ↗
▶ Ep 78 · 42:03
clinical Enema volume (low vs high) is based on caliber of colon on contrast study ↗
▶ Ep 78 · 42:30
clinical Surgical management for patients without bowel control capacity is Malone appendicostomy or cecostomy ↗

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 82 · 2:57
clinical Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period ↗
▶ Ep 82 · 3:06
clinical Male babies with perineal fistula may pass meconium and no one notices anything wrong with their anorectal anatomy, typically presenting in the first year of life with severe constipation ↗
▶ Ep 82 · 4:25
clinical The standard now is to not check rectal temperature but check temperature on forehead or ear, making it easier to miss anorectal malformations ↗
▶ Ep 82 · 4:35
quote If you don't look, you might not know. ↗
▶ Ep 82 · 4:54
clinical Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation ↗
▶ Ep 82 · 5:38
clinical Patients with uncorrected perineal fistula will soil with loose stool or athletic activity because they cannot completely close the hole when squeezing sphincters ↗
▶ Ep 82 · 6:16
clinical A newborn should accept a size 12 Hagar dilator and a 1 year old should accept a size 15 ↗
▶ Ep 82 · 8:02
clinical Female perineal fistula diagnosis requires assessment of three criteria: hole size, adequate perineal body, and hole centered in sphincter ↗
▶ Ep 82 · 8:47
clinical If the hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, the patient does not need surgery and the perineal body will lengthen with growth ↗
▶ Ep 82 · 9:08
quote It's very hard to improve on an asymptomatic patient. ↗
▶ Ep 82 · 12:45
clinical Rectourethral fistula patients should not be approached primarily because you cannot know where the rectum is (bladder neck, prostatic, or bulbar level) ↗
▶ Ep 82 · 13:20
clinical All rectourethral fistula patients should be managed with colostomy and distal colostogram, except exceedingly rare cases with very low rectum on cross table lateral at 20 hours ↗
▶ Ep 82 · 17:18
clinical Colostomy opened too distal in the sigmoid restricts the ultimate pull-through by location of colostomy or mucous fistula ↗
▶ Ep 82 · 17:45
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate distal segment, leading to urinary tract infections ↗
▶ Ep 82 · 18:38
clinical Transverse colostomies can prolapse and if there is a large rectourethral fistula, the left colon absorbs all the urine causing acidosis ↗
▶ Ep 82 · 19:14
clinical Proximal sigmoid colostomy leaves entire sigmoid loop for pull-through and only the distal segment can prolapse because left colon is fixed to retroperitoneum ↗
▶ Ep 82 · 20:04
clinical Prolapse is related to mobility of colon proximal or distal to the stoma; ileostomies prolapse frequently because they are free floating unless tacked to anterior abdominal wall ↗
▶ Ep 82 · 21:30
clinical Mark the anoplasty location on skin surface before making incision to avoid getting lost when looking at jumping muscles from stimulator ↗
▶ Ep 82 · 23:04
clinical Really good surgeons have put anuses in wrong places because they do not have sense of center once everything is disrupted and open ↗
▶ Ep 82 · 24:11
clinical Common distal colostogram mistake is not giving enough contrast or pressure, creating false impression that rectum is high with no fistula ↗
▶ Ep 82 · 24:26
clinical If you see flattening of rectum corresponding to pubococcygeal line, the radiologist did not give enough contrast or pressure to overcome the sphincters ↗
▶ Ep 82 · 25:23
clinical Fistula location can be determined by viewing urethra as reverse C or elbow: at or below elbow is bulbar, above elbow is prostatic, at bladder neck is bladder neck fistula ↗
▶ Ep 82 · 25:58
clinical Bulbous rectum might be reachable posterior sagittally and hard laparoscopically; tapered rectum is better approached laparoscopically ↗
▶ Ep 82 · 27:00
clinical Opening posterior sagittally without knowing where rectum is will lead to finding whitish shiny structures that are urinary tract (bladder neck) rather than rectum ↗
▶ Ep 82 · 30:09
clinical Bulbar and low prostatic rectums with bulge are more easily approached posterior sagittally; high prostatic tapered rectums and bladder neck fistulas are best served by laparoscopy ↗
▶ Ep 82 · 30:43
clinical Attempting laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level risks leaving behind remnant of original fistula (roof) ↗
▶ Ep 82 · 31:48
clinical Laparoscopy replaces laparotomy, not PSARP; should do mini-PSARP with laparoscopy to safely enter pelvis and tack rectum to posterior muscle complex to avoid prolapse ↗
▶ Ep 82 · 33:35
epidemiological Prolapse occurs in about 3% of cases, particularly in those without great muscles ↗
▶ Ep 82 · 33:58
clinical Rectal prolapse causes bleeding, mucus, and can inhibit bowel control in patients with good potential because they cannot close opening with prolapsed tissue through it ↗
▶ Ep 82 · 34:25
clinical Prolapse more than 3 millimeters should be treated; ideal time is when patient still has colostomy ↗
▶ Ep 82 · 34:48
clinical Circumferential prolapse can be trimmed in two stages (half circumference each) in ambulatory settings, avoiding hospitalization and not requiring dilation because half circumference is untouched ↗
▶ Ep 82 · 35:41
clinical Key to preventing perineal body dehiscence is mobilizing rectum well to get anterior rectal wall completely separated from posterior vaginal wall to areolar plane, avoiding tension on anoplasty ↗
▶ Ep 82 · 36:03
epidemiological Perineal body dehiscence is the most common cause of reoperation in female ARM repairs ↗
▶ Ep 82 · 36:35
clinical Traditional management is NPO for 7 days on 10% dextrose; recently trialing clear liquids only for a week because major problem is hard stool, not stool volume ↗
▶ Ep 82 · 37:48
clinical If perineal body dehiscence is detected on days 5-8, can salvage by taking patient back to OR to re-suture; by 3-4 weeks later, entire perineal body is dehisced and nothing can be done ↗
▶ Ep 82 · 39:20
clinical High rectums, particularly bladder neck fistulas, require preservation of IMA because colostomy may have disrupted collaterals down left colic, making rectum completely dependent on IMA ↗
▶ Ep 82 · 39:47
clinical Rectum has excellent intramural blood supply from IMA; taking IMA or branches too close to aorta will cause rectal necrosis without left colic collateralization ↗
▶ Ep 82 · 42:14
clinical ARM continence potential is determined by three factors: original malformation type, quality of sacrum with calculated sacral ratio, and quality of spine ↗
▶ Ep 82 · 43:19
clinical Bulbar fistula with good sacrum (sacral ratio of 1) and normal spine should absolutely have bowel control ↗
▶ Ep 82 · 43:29
clinical Bladder neck fistula with poor sacrum (sacral ratio 0.4) and tethered cord or myelomeningocele has no chance of good bowel control ↗
▶ Ep 82 · 43:54
clinical First step for soiling 4-year-old is to get them clean mechanically with bowel management using enemas; for those with continence potential, try switching to laxatives when older and more mature ↗
▶ Ep 82 · 44:39
clinical Indications for redo procedure include improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum) in patients with any continence potential ↗
▶ Ep 82 · 46:25
quote I think one of the biggest problems with anorectal malformations is that if you don't get it right, you don't really know for a few years. Most things in surgery, if you don't do it right, you know right away. ↗
▶ Ep 82 · 46:59
quote How are you supposed to as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? ↗

Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison

▶ Ep 83 · 2:38
clinical The most common prenatal ultrasound finding in cloaca is a pelvic mass, often initially thought to be the bladder but actually representing a dilated vagina (hydrocolpos) ↗
▶ Ep 83 · 3:35
clinical Associated anomalies that increase suspicion for cloaca include missing radius, absent sacrum, single kidney, or hydronephrosis, particularly in a female fetus ↗
▶ Ep 83 · 3:56
clinical Fetal intervention for cloaca is unlikely to be necessary, with the only indication being massive hydronephrosis with impending renal loss ↗
▶ Ep 83 · 5:17
epidemiological At least one case report from Japan describes prenatal drainage of hydrocolpos for severe hydronephrosis, similar to bladder drainage for urethral valves ↗
▶ Ep 83 · 6:35
clinical In cloaca, there is one perineal hole below the clitoris with no anus; if there is a normal anus present with one hole, it is a urogenital sinus, not a cloaca ↗
▶ Ep 83 · 7:02
clinical Urogenital sinus with virilizing component (hypertrophied clitoris) requires evaluation for adrenal hyperplasia to rule out urgent electrolyte abnormality ↗
▶ Ep 83 · 7:27
clinical Cloaca is not ambiguous genitalia; the patient is a normal female with two normal ovaries and will be hormonally normal with no adrenal problem ↗
▶ Ep 83 · 8:06
epidemiological The most common anorectal malformation in females is three holes (normal urethra, normal vagina, and third hole in wrong place - vestibular or perineal fistula) ↗
▶ Ep 83 · 8:36
clinical Proper perineal examination requires very good lighting and lifting the labia up and out to accentuate visualization of the single hole in cloaca ↗
▶ Ep 83 · 9:03
clinical Many patients have been misdiagnosed as cloaca when better examination would reveal three distinct holes indicating vestibular fistula ↗
▶ Ep 83 · 9:59
guideline Initial workup for cloaca includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, cardiac auscultation, and spine X-ray to assess sacrum quality ↗
▶ Ep 83 · 11:14
clinical Intermittent catheterization of the common channel may decompress hydrocolpos but is unreliable because the catheter may enter urethra, right vagina, left vagina, or rectum ↗
▶ Ep 83 · 12:09
clinical If intermittent catheterization of common channel is attempted, ultrasound confirmation is needed to verify actual decompression of the hydrocolpos ↗
▶ Ep 83 · 12:33
guideline Hydrocolpos should be drained at the time of colostomy creation if intermittent catheterization is not successful ↗
▶ Ep 83 · 13:28
clinical For bilateral hydrocolpos, the septum between vaginas must be removed so one tube can drain both sides ↗
▶ Ep 83 · 14:21
clinical An 8 French or 10 French pigtail catheter from interventional radiology is preferred for vaginostomy because curled catheters do not fall out as hydrocolpos recedes, unlike straight catheters ↗
▶ Ep 83 · 15:15
clinical Vesicostomy does not relieve hydronephrosis in cloaca because the problem is hydrocolpos compressing the distal ureters at the trigone, not bladder outlet obstruction ↗
▶ Ep 83 · 15:46
clinical Draining the hydrocolpos relieves pressure on the ureteral orifices, allowing ureters to drain into the bladder, which then drains through the common channel or vaginostomy tube ↗
▶ Ep 83 · 16:15
clinical Vesicostomy or suprapubic tube is only needed in the rare circumstance when hydrocolpos is drained but bladder still does not decompress, typically with very long narrow common channel or absent urethra ↗
▶ Ep 83 · 16:56
clinical Hydronephrosis in cloaca is often a prenatal finding and will not resolve immediately; it should be monitored to ensure it is stable and not worsening, with resolution expected over several days to two weeks ↗
▶ Ep 83 · 17:54
clinical Massive bilateral ureteral reflux is an exception where vesicostomy may be needed to decompress the system until later in life ↗
▶ Ep 83 · 18:24
clinical Hydrocolpos develops because urine preferentially fills the vagina through the fistula rather than exiting the common channel, combined with vaginal mucus and maternal estrogen effect ↗
▶ Ep 83 · 18:48
clinical Some centers report hydrocolpos resolution with intermittent catheterization after maternal estrogen effect wanes at a couple weeks of age ↗
▶ Ep 83 · 19:03
clinical Hydrocolpos fluid is typically clear turbid fluid (combination of mucus and urine), though blood has been seen related to estrogen effect ↗
▶ Ep 83 · 19:31
clinical Urine does not drain easily from hydrocolpos because the urethra is far from the perineum and requires a steep turn upward into the bladder, while the vaginal fistula acts as a pop-off valve ↗
▶ Ep 83 · 20:29
opinion Cystoscopy is not performed in the newborn period because the required scope is tiny with poor visualization, the perineum is swollen, and minimizing OR time in newborns is important ↗
▶ Ep 83 · 20:49
clinical Laparoscopic approach for colostomy and hydrocolpos drainage, as described by the Michigan group, provides excellent visualization ↗
▶ Ep 83 · 21:17
clinical For massive hydrocolpos extending above the umbilicus, a lower midline incision is preferred over left lower quadrant oblique incision to access the dome of the hydrocolpos ↗
▶ Ep 83 · 21:47
clinical For very large hydrocolpos, a tubeless vaginostomy can be created by suturing the vagina to the abdominal wall like a G-tube, avoiding need for indwelling tube ↗
▶ Ep 83 · 22:27
clinical Urogenital sinus without anorectal malformation requires workup for adrenal problems causing virilization and may need hydrocolpos drainage if present ↗
▶ Ep 83 · 23:08
clinical Most urogenital sinus cases can be managed with perineal urogenital mobilization without touching the rectum; high UG sinus may require transrectal (Astra) approach ↗
▶ Ep 83 · 23:57
guideline Endoscopy with cystoscopy and vaginoscopy is performed at 2-3 months of age, with definitive cloaca repair typically within one year, ideally before 6 months if managing from birth ↗
▶ Ep 83 · 25:10
clinical Common channel length (traditionally 3cm cutoff) has been the standard measure for cloaca complexity, but urethral length from urethral takeoff to bladder neck is equally important for surgical planning ↗
▶ Ep 83 · 26:21
clinical Endoscopy alone can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum high in the abdomen; contrast study is needed to determine this ↗
▶ Ep 83 · 26:44
clinical Cloacogram is performed by injecting distal colostomy, vaginostomy (if present), and common channel, with catheters left in place during fluoroscopy or 3D reconstruction in interventional radiology ↗
▶ Ep 83 · 27:55
clinical Lateral fluoroscopic image is the most important view to assess rectal position, vaginal reachability, and urethral location ↗
▶ Ep 83 · 28:34
epidemiological A study comparing 2D cloacogram, 3D reconstruction, 3D printed model, and virtual reality found that more complex modalities yielded more correct anatomic descriptions by experienced surgeons ↗
▶ Ep 83 · 29:03
opinion 3D imaging is definitively better than 2D for cloacogram interpretation, and 3D printed models may be better than 3D reconstruction alone ↗
▶ Ep 83 · 30:29
quote We like to joke that it's a Cloaca by committee. ↗
▶ Ep 83 · 30:29
opinion Cloaca patients benefit from collaborative multidisciplinary approach including pediatric surgery, urology, and gynecology ↗
▶ Ep 83 · 30:44
quote I think the days of a single surgeon being able to handle a case of this complexity are over. ↗
▶ Ep 83 · 30:44
opinion The days of a single surgeon handling cloaca complexity are over ↗
▶ Ep 83 · 30:44
quote I am so thankful that I have urologists to help me and gynecologists to help me through these coal repairs. ↗
▶ Ep 83 · 32:15
clinical Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate of prior techniques ↗
▶ Ep 83 · 32:33
quote I still remember that I was a trainee standing behind Alberto Pena as he explained to Hardy Hendren this concept, this new concept he had. Oh, you're a general scientist and immobilization. He was drawing pictures. I remember like it was yesterday. It was a moment of history. ↗
▶ Ep 83 · 33:39
clinical Urogenital mobilization is appropriate when common channel is 3cm or less AND urethral length above the takeoff is at least 1.5-2cm ↗
▶ Ep 83 · 34:06
opinion Well-trained general pediatric surgeons can perform urogenital mobilization for appropriate cases (adequate urethral length), though it is more technically demanding for those who do it infrequently ↗
▶ Ep 83 · 34:34
clinical When urethral length is inadequate, the common channel must be preserved as the urethra by separating the vagina from it, which is technically demanding ↗
▶ Ep 83 · 34:56
clinical After vaginal separation, the common channel repair should be reinforced with anorectal fat pad and possibly SIS to ensure healing and avoid urethral-vaginal fistula ↗
▶ Ep 83 · 35:09
clinical If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery of the urogenital complex, which often fails and can result in devascularized urethral loss requiring Mitrofanoff ↗
▶ Ep 83 · 35:52
clinical Performing urogenital mobilization with inadequate urethral length leaves the patient with urinary leakage that cannot be controlled without tightening or closing the bladder neck ↗
▶ Ep 83 · 36:05
clinical Preserving the common channel as the entire urethra provides approximately 4cm urethral length, allowing intermittent catheterization and continence ↗
▶ Ep 83 · 36:40
clinical Type 1 cloaca has common channel of 1cm with adequate urethral length; only vaginal mobilization is needed, and a slightly hypospadiac urethra is acceptable if the patient will void and not require catheterization ↗
▶ Ep 83 · 37:11
clinical Patients with neurogenic bladder component (whether from tethered cord or not) require a visible urethral orifice that is easily catheterized ↗
▶ Ep 83 · 37:42
clinical When native vagina does not reach after full mobilization including abdominal approach, options include vaginal switch (disconnecting one side while preserving ovarian blood supply) or vaginal replacement ↗
▶ Ep 83 · 38:46
opinion For vaginal replacement, colon (particularly left colon or sigmoid depending on arcade) is the preferred conduit over rectum or small bowel ↗
▶ Ep 83 · 39:10
clinical Tissue engineering of vaginas using patient stem cells is on the horizon, with work already done at Wake Forest and in Mexico, which could revolutionize cloaca care by eliminating need for vaginal replacement ↗
▶ Ep 83 · 39:48
clinical Complex cloaca cases requiring expertise include common channel greater than 3cm or urethral length less than 1.5cm from takeoff to bladder neck ↗
▶ Ep 83 · 40:27
epidemiological The most common problem in redo cloaca cases is that the surgeon never realized they were dealing with a cloaca and only repaired the rectum, leaving the urogenital sinus untouched ↗
▶ Ep 83 · 40:56
epidemiological The second most common redo scenario is inadequate mobilization of structures resulting in stenosed or lost vagina ↗

The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula

▶ Ep 84 · 3:12
guideline VACTERL association screening includes plain abdominal X-ray for vertebral abnormalities including hemivertebrae ↗
▶ Ep 84 · 3:34
guideline Cardiac evaluation for anorectal malformation includes both physical exam and echocardiogram ↗
▶ Ep 84 · 3:40
guideline Esophageal atresia screening requires NG tube passage ↗
▶ Ep 84 · 3:47
guideline Renal evaluation requires kidney ultrasound ↗
▶ Ep 84 · 3:57
clinical True sacral ratio measurements should wait until the child is 3 months of age ↗
▶ Ep 84 · 4:22
guideline Radiologists evaluating anorectal malformation patients should examine the presacral space with spinal ultrasound ↗
▶ Ep 84 · 4:33
clinical Patients with anal stenosis or rectal atresia and presacral mass will require MRI ↗
▶ Ep 84 · 4:33
epidemiological Presacral masses are rare in typical imperforate anus but found almost half the time in anal stenosis or rectal atresia defects ↗
▶ Ep 84 · 5:44
clinical The 24-hour waiting period allows the baby to declare whether they need colostomy or might benefit from primary repair ↗
▶ Ep 84 · 7:20
clinical A sacral ratio greater than 0.7 connotes very good prognosis for bowel control ↗
▶ Ep 84 · 9:25
quote the danger is that you go in posterior sagita, you don't know where the rectum is, and you find something midline and white, like the urethra, the bladder neck or the bladder itself. ↗
▶ Ep 84 · 9:25
clinical The danger of primary posterior sagittal approach without knowing rectal location is finding midline white structures like urethra, bladder neck, or bladder instead of rectum ↗
▶ Ep 84 · 9:42
clinical Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically ↗
▶ Ep 84 · 10:34
clinical Colostomy carries its own complications both from the initial procedure and from subsequent closure ↗
▶ Ep 84 · 11:20
quote I have seen this done by some very good surgeons where they went in, did a beautiful anoplasty, but ignored the fistula, and the child down the road started peeing out their anus. ↗
▶ Ep 84 · 11:20
clinical Performing anoplasty without identifying and addressing a fistula can result in the child urinating through the anus postoperatively ↗
▶ Ep 84 · 12:09
clinical During primary posterior sagittal anorectoplasty, the posterior rectal wall should be opened and the anterior wall inspected to rule out fistula ↗
▶ Ep 84 · 12:17
clinical In low rectal lesions, inspecting and dissecting a small portion of the anterior rectal wall will usually rule out fistula ↗
▶ Ep 84 · 13:44
epidemiological 95% of Down syndrome patients with anorectal malformation have no fistula, but 5% do have fistulas ↗
▶ Ep 84 · 13:44
guideline Distal colostogram should still be performed in Down syndrome patients with imperforate anus despite the low fistula rate ↗

Colorectal Quiz Episode 2: When to redo a PSARP

▶ Ep 85 · 4:30
clinical The original malformation was a prostatic fistula and the patient has a tethered cord and a sacral ratio of 0.66 ↗
▶ Ep 85 · 8:40
clinical The patient was born with a vestibular fistula, the spine is normal and has an excellent sacrum, so this is a much better prognosis bowel control patient ↗
▶ Ep 85 · 9:50
clinical The stimulator is the same electrical stimulator that anesthesia uses for their train of four ↗
▶ Ep 85 · 9:50
quote The stimulator is the same electrical stimulator that anesthesia uses for their train of four. ↗
▶ Ep 85 · 10:05
clinical You have to tell your anesthesiologist not to give skeletal muscle relaxant because the stimulator is a little bit weaker than the traditional stimulator ↗
▶ Ep 85 · 12:00
clinical The vast majority of redo operations were for mislocation, then came stricture, and less common reasons included remnant of original fistula (roof), rectal prolapse, and others ↗
▶ Ep 85 · 12:30
clinical Quality of life improved with a redo operation ↗
▶ Ep 85 · 12:40
clinical Patients had an improved ability to achieve continence after redo ↗
▶ Ep 85 · 12:50
clinical 20% of patients with a poor sacrum or poor spine actually developed bowel control after their redo ↗
▶ Ep 85 · 13:05
clinical Patients with good potential—a good sacrum and good spine—did extremely well after redo ↗
▶ Ep 85 · 13:15
clinical Patients who did not develop voluntary bowel movements were still able to be clean with a bowel management program with enemas or antegrade using a Malone ↗
▶ Ep 85 · 13:21
epidemiological The average age of patients in the study is about three and a half years ↗
▶ Ep 85 · 13:28
opinion If you know the anatomy is off, you should do the redo ↗
▶ Ep 85 · 13:40
opinion There's an advantage to getting the anatomy right the younger the child is ↗
▶ Ep 85 · 14:10
clinical Many patients present after the age of potty training because they're incontinent, and evaluation reveals the reason is they don't have the best operation ↗
▶ Ep 85 · 14:30
clinical When doing redo at older age, usually add a Malone at the same time so patients can learn how to get control with their new anatomy before trying voluntary bowel movements ↗
▶ Ep 85 · 14:43
clinical The process of learning control with new anatomy after redo may take 6 to 12 months ↗

The Colorectal Quiz Episode 4: Classic Hirschsprung disease - Surgical Technique

▶ Ep 88 · 6:01
clinical Deep laparoscopic dissection into the pelvis minimizes transanal work and prevents overstretching of sphincters, a significant source of morbidity in Hirschsprung surgery ↗
▶ Ep 88 · 6:01
quote Probably the most important thing I think though, is a good deep Uh, laparoscopic dissection into the pelvis so that you have very minimal transatal work to do. ↗
▶ Ep 88 · 7:37
clinical Full-thickness biopsy should be cut as a cube with seromuscular side matching mucosal side dimensions ↗
▶ Ep 88 · 10:20
clinical Biopsy specimen must include submucosa because ganglion cells may be present in seromuscular layer while hypertrophic nerves persist in submucosal layer ↗
▶ Ep 88 · 11:52
clinical Too wide dissection of distal rectum in old Swenson technique caused urinary retention and incontinence, likely from injury to nervi erigentes ↗
▶ Ep 88 · 11:52
quote You need to be right on the bow, because in the old days, the old Swenson. Done through the abdomen. Patients were um incontinent, non-infrequently, and they had urinary retention non-frequently. ↗
▶ Ep 88 · 14:12
quote My preference is a Swenson full thickness, looking for the areolar plane. It's basically a bloodless plane. ↗
▶ Ep 88 · 14:12
clinical Swenson full-thickness dissection in the areolar plane is essentially bloodless ↗
▶ Ep 88 · 14:24
clinical If performing Soave technique with muscular cuff, the cuff should be very short (approximately 1 cm) and must be split ↗

The Colorectal Quiz Episode 8: Motility Disorders Part 1

▶ Ep 91 · 2:08
quote nowadays, it's sort of funny because sometimes Anil says to me, I think the kid needs surgery, and I say to Anil, no, I think the kid needs more medical treatment, and that's the collaboration you're shooting for. ↗
▶ Ep 91 · 7:36
clinical Colons used to be resected based on appearance, but patients with motility disorders did not need resection ↗
▶ Ep 91 · 7:54
clinical Many dilated colons will respond to treatment ↗
▶ Ep 91 · 10:47
quote I don't know how I survive without this test. ↗

The Colorectal Quiz Episode 9: Motility Disorders Part 2

▶ Ep 93 · 1:29
quote I hear crickets waiting for. ↗
▶ Ep 93 · 4:38
epidemiological Colonic manometry is not available everywhere, but Sitz marker study should be available pretty much anywhere ↗
▶ Ep 93 · 4:45
quote I can tell you that colonic manometry is absolutely not available everywhere. ↗
▶ Ep 93 · 5:32
epidemiological Nuclear scintigraphy is available in most centers that have nuclear medicine capacity ↗
▶ Ep 93 · 5:40
clinical Three colonic motility scenarios: diffusely slow but functional, normal motility with segmental obstruction, and entire colon severely slow and amodal ↗
▶ Ep 93 · 8:10
opinion No one normal or typical gets a colonic motility test ↗
▶ Ep 93 · 8:22
clinical If the colon moves uniformly with HAPCs throughout, antegrade flush will work well and reliably ↗
▶ Ep 93 · 9:55
quote Jason, what do you think about maybe us trading our gastroenterologist because I, I like, I like to believe a lot. Maybe we could flip them. ↗
▶ Ep 93 · 10:11
clinical The case was concluded to not be Hirschsprung's disease; the absent RAIR was a sampling error ↗
▶ Ep 93 · 10:20
clinical The surgeon did not re-biopsy because of calretinin positivity ↗
▶ Ep 93 · 10:20
quote I was so convinced that I actually didn't re-biopsy because of the calretinin positivity. ↗
▶ Ep 93 · 11:00
opinion A perfectly good endpoint is to have a mechanically emptying colon, not necessarily weaning to laxatives alone ↗
▶ Ep 93 · 11:03
quote I used to be someone that if you can't get them on laxatives, it's a failure, they need surgery. I don't think that's true. ↗
▶ Ep 93 · 11:11
opinion Enemas from below or from above (through a Malone or cecostomy) are acceptable long-term management; resection is reserved for failures of conservative therapy ↗
▶ Ep 93 · 11:32
clinical The vast majority of patients with segmental disease respond to antegrade enema only and never need resection ↗

The Colorectal Quiz Episode 10: Total Colonic Hirschsprung Disease Part 1

▶ Ep 94 · 3:13
epidemiological 10% of patients with meconium plug have Hirschsprung disease ↗
▶ Ep 94 · 3:13
quote 10% of those patients have Hirschprung's, and you do not want to have that kid limp along for the next few months, constipated, not eating well, distended, and in fact you missed the diagnosis of Hirschprung's. ↗
▶ Ep 94 · 5:37
quote Seeing this image, I can see how it might have been read as normal or just meconium plug. But this does not look right to me. ↗
▶ Ep 94 · 6:44
quote there's no narrowing at the um rectum compared to the sigmoid, so I could see how this would be called um normal, to be honest. ↗
▶ Ep 94 · 7:46
quote suction biopsies are great except when you don't have a definitive diagnosis and then you have to do something more definitive and then you need to go to the OR and do a formal biopsy. ↗
▶ Ep 94 · 7:46
clinical Suction biopsies are problematic when they do not provide a definitive diagnosis, requiring subsequent formal biopsy in the operating room ↗

The Colorectal Quiz Episode 11: Total Colonic Hirschsprung's Part 2

▶ Ep 95 · 2:23
clinical Five to ten years ago, the recommendation for total colonic Hirschsprung was to wait until the child was potty trained for urine and could sit on a potty before performing pull-through ↗
▶ Ep 95 · 2:23
quote 5, even 5, 10 years ago, my recommendation in these cases was to wait until the child was potty trained for urine and could sit on a potty. ↗
▶ Ep 95 · 2:58
quote I've had two patients with, that I waited until they were older, and then we did their pull through, and they held in the stool so efficiently, that they got proctalgia. ↗
▶ Ep 95 · 2:58
clinical Two patients who waited until older age for pull-through developed proctalgia (anal sphincter spasm unresponsive to Botox) requiring ileostomy recreation ↗
▶ Ep 95 · 3:23
clinical Current routine is to perform pull-through somewhere between 6 and 18 months of age ↗
▶ Ep 95 · 3:23
quote So now my routine is to do this case somewhere between 6 and 18 months. ↗
▶ Ep 95 · 4:57
clinical These ileostomies can remain in place for 6, 12, or 24 months ↗
▶ Ep 95 · 6:49
quote If you have salt in your GI tract that you've taken in orally. You're much better at absorbing glucose, so you have a better absorption of glucose and better nutrition. ↗
▶ Ep 95 · 6:49
clinical Oral salt intake improves glucose absorption in the GI tract, leading to better nutrition ↗
▶ Ep 95 · 7:37
clinical Urine sodium should be greater than 20 millimoles per liter; if less, the baby is retaining sodium and likely sodium-depleted despite normal serum sodium ↗
▶ Ep 95 · 8:17
quote Do you remember the, uh, The education policy No Child Left Behind. Well, I am a big fan of No Hirschprung's Left Behind. ↗
▶ Ep 95 · 8:26
opinion Duhamel procedure leads to stasis, which is problematic ↗
▶ Ep 95 · 8:26
clinical The Martin procedure (ultimate Duhamel using entire sigmoid and left colon) has been abandoned due to excessive stasis ↗
▶ Ep 95 · 8:50
clinical The Kamura procedure involves right colon connected to ileum in form of ileostomy ↗
▶ Ep 95 · 9:01
opinion An ileoduhamel with a very short pouch is a very nice operation for total colonic Hirschsprung and many patients do well ↗
▶ Ep 95 · 9:26
quote I think the issue is not the Duhamel itself, I think the issue is the ganglionic bowel, and not all ganglionated bowel is created equally. ↗
▶ Ep 95 · 9:26
opinion The issue with Duhamel failures is not the Duhamel itself but the ganglionic bowel, as not all ganglionated bowel is created equally ↗
▶ Ep 95 · 10:26
opinion In theory, an ileoanal anastomosis should not require diversion ↗
▶ Ep 95 · 10:26
quote In theory though, an ileoanal should not require diversion. ↗
▶ Ep 95 · 10:30
clinical Diverting more proximally may make the patient short gut with inadequate intestinal length for absorption, resulting in higher output ileostomy ↗
▶ Ep 95 · 11:42
clinical Dietary recommendations include avoiding sugar (berries particularly offensive), avoiding fats and oily foods, and bulking the stool ↗
▶ Ep 95 · 11:56
clinical Levsin is used successfully as an added medicine to slow down stool ↗

Colorectal Quiz Episode 13: Newborn ARM Part 2

▶ Ep 98 · 2:34
clinical Perineal fistula requires surgery when the hole is too small, not in the center of the sphincter, and there is an inadequate perineal body ↗
▶ Ep 98 · 7:14
clinical An adequately sized hole that appears surrounded by sphincter with a peroneal body, albeit short, requires no surgery ↗
▶ Ep 98 · 8:01
clinical The peroneal body will grow over time and there is nothing to do about a short peroneal body when other anatomical features are correct ↗
▶ Ep 98 · 8:01
quote It's very hard to improve on an asymptomatic patient. ↗
▶ Ep 98 · 8:39
clinical If half the fistula is within the sphincter complex and half is outside, the patient will leak stool because they cannot close the hole, making surgery worthy to relocate the hole ↗
▶ Ep 98 · 11:25
clinical Cloaca patients have no endocrine problem, do not need steroids, and do not need an endocrinologic workup ↗
▶ Ep 98 · 11:25
clinical A baby with no anal opening and a single perineal orifice has a cloaca ↗
▶ Ep 98 · 11:25
clinical The hypertrophied area around the clitoral hood in cloaca is fairly typical and is not ambiguous genitalia ↗
▶ Ep 98 · 11:25
clinical There is no question of gender assignment in cloaca - it is a female ↗
▶ Ep 98 · 11:25
clinical Cloaca patients are still being misdiagnosed as ambiguous genitalia, with some babies not having proper gender assignment for a week or two ↗
▶ Ep 98 · 13:10
quote Nowadays, I use my loops to tie my sneakers. ↗
▶ Ep 98 · 13:26
clinical The key to perineal examination is to push down and flatten the perineal body to see if it is normal or not ↗

Colorectal Quiz Episode 15: Bowel Management in Spinal Patients - Need for a UrologistPart 1

▶ Ep 100 · 6:59
clinical Bisacodyl and Senna are the two medications that provide a motility 'kick'; everything else is a stool softener. ↗
▶ Ep 100 · 7:15
clinical MiraLax is problematic for patients with anorectal malformations who need fullness to detect stool, because it makes soft stool that 'mushes out'. ↗
▶ Ep 100 · 7:36
quote MiraLax is their enemy because it makes a soft stool that just sort of mushes out. ↗
▶ Ep 100 · 12:22
clinical A non-plicated, non-trimmed Malone (tip of appendix sewn to right lower quadrant with a tube, without plication) preserves the appendix for future urologic use or splitting. ↗
▶ Ep 100 · 13:36
quote Our urologists insists on a 5 centimeter appendix if they're gonna use it for a metrofenov. Anything shorter. They don't want, that, that's for us. ↗
▶ Ep 100 · 13:36
clinical Urologists require an appendix of at least 5 cm length for a Mitrofanoff; shorter appendices are not useful for urology and may be used for Malone. ↗
▶ Ep 100 · 13:59
clinical An appendix of 7 cm or longer may be splittable (e.g., 2 cm for Malone + 5 cm for Mitrofanoff). ↗
▶ Ep 100 · 14:07
clinical Urologists prefer the appendix for Mitrofanoff over a Monti channel made from small bowel because it has better long-term outcomes. ↗
▶ Ep 100 · 14:18
clinical A neo-Malone can be created from a flap of colon if the appendix is used for urologic reconstruction. ↗
▶ Ep 100 · 15:10
clinical The scenario requiring a temporizing conduit (cecostomy or non-plicated Malone) is rare: a child not tolerating rectal enemas, needing antegrade access, whose bladder reconstruction plan (augment, bladder neck sling) is not yet defined. ↗
▶ Ep 100 · 15:38
clinical Taking down a cecostomy tube is relatively easy and leaves the appendix free for future use. ↗

Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2

▶ Ep 101 · 1:30
quote urologists are not very good shares ↗
▶ Ep 101 · 1:38
quote when you have two kids, two kids on a playground, and they're splitting a cookie, usually you split it, and the person who split it isn't the one who uses it. But when it comes to urology, a split is about 70/30. ↗
▶ Ep 101 · 1:38
opinion When urologists and colorectal surgeons split an appendix, the division is typically 70/30 in favor of urology, not equal sharing ↗
▶ Ep 101 · 5:53
opinion Most spinal patients prefer not to have a bag and would prefer transferring to a commode and doing an antegrade flush ↗
▶ Ep 101 · 6:48
clinical If a colon is very difficult to empty (requiring voluminous or concentrated enemas) and the urologist needs to do an augment, the sigmoid can be removed from colonic transit to make bowel management easier and used for bladder augmentation ↗
▶ Ep 101 · 7:24
clinical If a patient has an easy-to-empty colon and needs bladder augmentation, the urologist can use small bowel instead ↗
▶ Ep 101 · 7:52
clinical A good bowel management plan can influence the urologic plan; patients who are empty regularly for stool may have improved bladder function ↗
▶ Ep 101 · 8:07
clinical Vesicoureteral reflux might resolve with successful bowel management, potentially saving a patient from ureteral reimplantation ↗
▶ Ep 101 · 9:29
clinical Anatomically, the bladder is a midline structure and access through the umbilicus makes sense; the cecum is right lower quadrant and placement there makes sense ↗
▶ Ep 101 · 10:42
clinical Orifices should not be matured until everyone has a plan in the OR to avoid one team pulling on the other's mesentery ↗
▶ Ep 101 · 13:11
quote did you guys hear that there were, um, 22 red blood cells that fell in love. It's true. Sadly, though. Their love was in vain. ↗

Colorectal Quiz Episode 17: Cloaca Part 1

▶ Ep 102 · 5:41
epidemiological In a large majority of patients with cloaca, the diagnosis is made at birth. ↗
▶ Ep 102 · 10:06
quote I really want to emphasize, Richard, what you just said, because I really think that that dogma is no longer valid. ↗
▶ Ep 102 · 11:08
clinical A lot of hydrocolpos cases can be drained perineally; you are more likely to get into the vagina than the bladder when catheterizing, given the anatomy of the urethral takeoff. ↗
▶ Ep 102 · 13:01
clinical When you drain the hydrocolpos with a catheter, the bladder fills immediately, demonstrating the physiology: the hydrocolpos obstructs the ureters. ↗
▶ Ep 102 · 13:40
opinion A vesicostomy is the wrong move in almost every cloaca; the hydrocolpos needs to be drained, not the bladder. ↗
▶ Ep 102 · 13:40
quote A vesicostomy is the wrong move here. In almost every cloaca, a vesicostomy is not necessary, but the hydrocolpos needs to be drained. ↗
▶ Ep 102 · 13:59
clinical Once the hydrocolpos is drained, the ureters are no longer compressed at the trigone and can empty into the bladder, which then empties out the common channel or back into the hydrocolpos for sequential perineal catheterization. ↗
▶ Ep 102 · 21:37
clinical If a massive hydrocolpos is present and you are doing an open technique, use a lower midline incision to get above the hydrocolpos, which is very adherent to the anterior abdominal wall and inflamed. ↗
▶ Ep 102 · 22:20
clinical For a large hydrocolpos, open into the dome, take out a bit of the septum, close it, put in a tube to drain both sides, or suture it to the abdominal wall like a vesicostomy or gastrostomy to avoid an indwelling tube as a nidus for infection. ↗
▶ Ep 102 · 23:08
guideline A single perineal orifice with no anal opening is a cloaca and does not need an endocrine workup, whereas a perineal opening with a normal anus is a urogenital sinus and does need an endocrine workup. ↗
▶ Ep 102 · 23:40
quote If there is no anus, it is a cloaca. It is not ambiguous genitalia. It is a cloaca. It is a female. ↗
▶ Ep 102 · 23:40
clinical Urogenital sinus patients can also have hydrocolpos and hydronephrosis, requiring similar management but no colostomy. ↗

Colorectal Quiz Episode 18: Cloaca Part 2

▶ Ep 103 · 7:41
opinion Endoscopy has value in helping general pediatric surgeons differentiate straightforward from complex cloacas and determine whether referral to a specialized center is needed ↗
▶ Ep 103 · 8:52
opinion Lower confluence cloacas, if the surgeon knows the technique, represent a beautiful, elegant operation ↗
▶ Ep 103 · 8:57
opinion Higher confluence cloacas requiring vaginal replacement, high vaginas, and management of ectopic ureters should be done by specialized centers ↗
▶ Ep 103 · 14:11
clinical Hardy Hendren was the father of cloacal management in the late 1960s and 1970s, with specific focus on urology and urethral reconstruction ↗
▶ Ep 103 · 14:36
clinical Alberto Pena made a major advance in 1996 with development of total urogenital mobilization (TUM); prior to that, all patients had urogenital separation ↗
▶ Ep 103 · 15:05
clinical The next major change in cloaca protocol came 21 years after TUM, in 2017, with the algorithm incorporating urethral length measurement ↗
▶ Ep 103 · 16:32
quote I have no question. I just have a statement. I agree with everything that's been said. ↗
▶ Ep 103 · 18:24
clinical The major change in the 2017 algorithm was ensuring measurement of urethral length, whereas previously the decision was based only on common channel length (less than or greater than 3 cm) ↗
▶ Ep 103 · 22:06
quote kill the gnat? That was a circumcision. ↗

Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1

▶ Ep 105 · 3:19
clinical The anatomy of the original pull-through could explain the patient's obstructive symptoms and whether there is a fixable problem ↗
▶ Ep 105 · 7:48
clinical A contrast study is helpful for inferring the original surgery type based on findings when the operative note is unavailable ↗
▶ Ep 105 · 10:10
clinical In Hirschsprung enterocolitis, the colon fills with liquid stool with severe bacterial overgrowth, causing fluid loss into the bowel lumen, hypovolemia, and bacterial translocation leading to bacteremia, all with no passage of stool ↗
▶ Ep 105 · 11:06
clinical Hirschsprung enterocolitis can occur before surgery, after surgery, and even after successful surgery when patients do not relax their sphincters and hold stool efficiently ↗
▶ Ep 105 · 14:08
epidemiological Post-pull-through enterocolitis within the first 3 months occurs in about 20% of cases ↗
▶ Ep 105 · 14:47
quote there's nothing worse than having a patient in an ER with mild symptoms that could have gotten the patient better very quickly ↗
▶ Ep 105 · 16:40
clinical If sedation in the ER does not work for a severely ill patient, one should go to the OR under general anesthesia to irrigate until the child feels better ↗
▶ Ep 105 · 16:50
clinical In rare circumstances, an ileostomy may be needed to get the child out of trouble, with workup of the pull-through problem deferred ↗
▶ Ep 105 · 19:14
clinical The presacral space (space between the hollow of the sacrum and the pull-through) is an important observation on contrast studies ↗

The Colorectal Quiz Episode 20: Hirschsprung Disease Obstruction Part 2

▶ Ep 107 · 2:57
clinical In Duhamel pull-through, rectal exam should assess for two lumens and a spur between them ↗
▶ Ep 107 · 3:12
clinical In Duhamel procedure, stool can flow into the Duhamel pouch, fill it, and compress the ganglionic pull-through causing obstruction ↗
▶ Ep 107 · 3:12
quote The stool flows down, does not exit the anus, flows up into the Duomel pouch. The Duomel pouch fills with stool and compresses the ganglionated pull-through. ↗
▶ Ep 107 · 3:25
clinical Treatment for obstructing Duhamel spur is excision of the common wall; occasionally the entire Duhamel pouch requires excision ↗
▶ Ep 107 · 3:36
clinical Before anesthesia induction, the anus should be inspected for sphincteric contraction versus patulous appearance ↗
▶ Ep 107 · 3:48
quote Obviously, a pattuus patient, patulus anus is not gonna get enterocolitis ↗
▶ Ep 107 · 3:48
clinical A patulous anus will not develop enterocolitis ↗
▶ Ep 107 · 4:02
clinical During EUA, the dentate line must be examined to ensure it was preserved at the original pull-through ↗
▶ Ep 107 · 4:12
clinical If the dentate line was lost or sphincters overstretched at original pull-through, the patient will not have enterocolitis but will have fecal incontinence ↗
▶ Ep 107 · 4:12
quote if the dentate line has been lost at the original pull-through, or the sphincters have been overstretched, the one thing you're not gonna have in this patient is enterocolitis, which is quite sad. You will have fecal incontinence ↗
▶ Ep 107 · 8:08
quote I think if you rebiopsy a patient who's doing poorly, and you find no ganglion cells, It's very likely that that is an a ganglionic or a transition zone pull-through. ↗
▶ Ep 107 · 8:08
clinical If repeat biopsy after pull-through shows no ganglion cells, it is very likely an aganglionic or transition zone pull-through, though sampling error must be considered ↗
▶ Ep 107 · 8:33
opinion Ganglion cells with hypertrophic nerves on repeat biopsy is more controversial; may represent original pathology error or decompensation over time ↗
▶ Ep 107 · 8:52
clinical Hypertrophic nerves in the presence of ganglion cells can occur in functional constipation patients ↗
▶ Ep 107 · 8:52
quote hypertrophic nerves in the presence of ganglion cells can occur in functional constipation patients ↗
▶ Ep 107 · 8:52
opinion Patients with significant obstructive symptoms and biopsy showing ganglion cells with hypertrophic nerves may benefit from redo pull-through ↗
▶ Ep 107 · 9:54
quote until you compare the two pathologies, you don't know. The pathology originally might be perfect, and the pathology today might be problematic, and something evolved ↗
▶ Ep 107 · 11:41
quote I don't leave cuffs, because I think cuffs are problems ↗
▶ Ep 107 · 12:18
opinion A good pull-through can overcome the small amount of aganglionosis intentionally left behind to avoid coming too close to the dentate line ↗
▶ Ep 107 · 12:18
quote I think a good pull-through can overcome that little bit of a ganglionosis, and you're leaving that gangliosis behind intentionally, so you don't come too close to the dentate line. ↗
▶ Ep 107 · 12:30
quote the suave is approaching a Swenson in most of those people's hands, and many of them have actually gone to a Swenson too ↗
▶ Ep 107 · 12:30
clinical Many surgeons performing Swabé have moved toward a mini-cuff approach (approximately 1 cm) that is essentially a Swenson, sometimes called a 'Swabson' ↗
▶ Ep 107 · 12:40
quote Dan von Almen, who used to call it a swabson ↗
▶ Ep 107 · 13:05
opinion The original laparoscopic Swabé technique recommended a 5 cm cuff, which is considered too long ↗
▶ Ep 107 · 13:15
quote the Swenson was the first operation, and it is the purest of the operations, it leaves the least amount of Hirschprung's behind ↗
▶ Ep 107 · 13:15
clinical The Swenson was the first Hirschsprung's operation and leaves the least amount of Hirschsprung's tissue behind ↗
▶ Ep 107 · 13:24
clinical Staying directly on the bowel wall during Swenson dissection avoids nerve injury ↗
▶ Ep 107 · 13:24
quote if you stay right on the bowel wall, you don't get into this trouble ↗
▶ Ep 107 · 13:24
clinical Swabé and Duhamel procedures were developed because surgeons performing Swenson were dissecting in too wide a plane and injuring the nervi erigentes in the mesorectum ↗
▶ Ep 107 · 13:45
quote sometimes the cuff fuses back together, or you don't cut it all the way, so it rolls up a little bit and makes a, a ganglionic obstructive ring around, around the pull-through ↗
▶ Ep 107 · 13:45
clinical In Swabé procedure, if the cuff is not completely divided or fuses back together, it can create an aganglionic obstructive ring around the pull-through ↗
▶ Ep 107 · 14:08
clinical To palpate for Swabé cuff, place finger against the sacrum and pull down to feel rubbery tissue outside the pull-through ↗
▶ Ep 107 · 14:12
quote It's very important to put your finger against the sacrum and pull down. And you feel this rubbery tissue that's, that's outside of the pull-through, that is the cuff. ↗
▶ Ep 107 · 15:54
quote I would do a total body prep, and then I would go transanal in prone position first. I think the redos are really easier prone ↗
▶ Ep 107 · 15:54
clinical For redo pull-through in transition zone cases, the approach is total body prep, transanal dissection in prone position as far as possible, with readiness to proceed to laparoscopy or laparotomy if healthy bowel cannot reach ↗
▶ Ep 107 · 16:07
opinion Redo pull-throughs are easier to perform in prone position ↗
▶ Ep 107 · 18:32
clinical Knowing the anatomy of the original pull-through (Swabé, Swenson, or Duhamel) is essential for gastroenterologists and surgeons managing complications ↗
▶ Ep 107 · 18:44
clinical If anatomic causes are excluded, sphincter dysfunction should be considered and may be treated with Botox ↗

The Colorectal Quiz Episode 21: The History of Hirschsprung Disease

▶ Ep 108 · 1:03
clinical Harold Hirschsprung identified that a baby could be sick due to this problem but did not understand the pathology ↗
▶ Ep 108 · 1:15
guideline The correct nomenclature is Hirschsprung disease, not with apostrophe S ↗
▶ Ep 108 · 1:27
clinical Orvar Swenson defined the pathology by identifying the absence of ganglion cells ↗
▶ Ep 108 · 1:35
clinical Prior to Swenson's discovery, removal of the dilated colon was the treatment, which was a mistake because the distal narrow colon was the actual problem ↗
▶ Ep 108 · 1:46
clinical Swenson developed the first operation for Hirschsprung disease, which is a full thickness rectal dissection ↗
▶ Ep 108 · 2:00
opinion Modern Suave procedures are becoming more Swenson-like, making maybe a 1 centimeter cuff, which are basically Swensons with a 1 centimeter cuff according to Dan von Almen ↗
▶ Ep 108 · 2:07
quote those are basically swabsons with a. 1 centimeter cuff ↗
▶ Ep 108 · 2:13
clinical Doctor Yancey was the first surgeon to describe a submucosal dissection for Hirschsprung disease, but published in a journal that not many people read ↗
▶ Ep 108 · 2:34
clinical Doctor Suave published his article on submucosal dissection years later in a more widely read journal, which is why the procedure bears his name rather than Yancey's ↗
▶ Ep 108 · 2:40
clinical The Suave procedure was developed because people believed the Swenson caused fecal and urinary incontinence or voiding dysfunction ↗
▶ Ep 108 · 2:56
quote you guys are wrong, it's a good operation, you're doing it wrong, you're dissecting too wide ↗
▶ Ep 108 · 2:56
opinion Swenson wrote that the incontinence complications were due to surgeons doing the operation wrong by dissecting too wide, not due to the technique itself ↗
▶ Ep 108 · 3:10
clinical The Yancey, Suave, and Duhamel techniques were all designed to avoid full thickness rectal dissection and stay out of the rectal plane to avoid injury to the nerve erigens ↗
▶ Ep 108 · 3:30
clinical A proper Swenson dissection should be done right on the bowel wall like a PSARP; if you see fat you can get closer, and the nerves are in the fatty layer ↗
▶ Ep 108 · 3:46
quote thank you very much for promoting the Swenson ↗
▶ Ep 108 · 3:56
clinical Swenson was 105 when he died ↗
▶ Ep 108 · 3:58
quote Please tell everybody that it's a good operation ↗
▶ Ep 108 · 4:06
clinical Duhamel's technique involved leaving the original rectum behind, doing a pull-through next to it, and then mating the two lumens ↗
▶ Ep 108 · 4:22
opinion The Duhamel procedure is now only appropriate for an ileoduhamel, though some surgeons would still do an ileoanal ↗
▶ Ep 108 · 4:35
clinical Rabine performed a low anterior resection for Hirschsprung disease, leaving about 6 centimeters of aganglionic bowel behind ↗
▶ Ep 108 · 4:42
clinical Some patients who had Rabine's procedure with 6 centimeters of aganglionic bowel left behind did perfectly fine, with ganglionated bowel functioning through the aganglionic segment ↗
▶ Ep 108 · 6:15
clinical Doctor Boley was the first to do primary coloanal anastomosis of a Suave, eliminating the need to leave bowel hanging out and return at day 7 ↗
▶ Ep 108 · 6:36
guideline The proper description of the modified technique is the Suave technique with the Boley modification, or Suave-Boley ↗
▶ Ep 108 · 7:11
quote you know, Mark, there is a field called pediatric surgery, you could do both ↗
▶ Ep 108 · 7:57
quote Some guy named Pena ↗
▶ Ep 108 · 8:38
clinical Henry So was the first surgeon to do a primary pull-through for Hirschsprung disease, performing the entire operation without a preceding stoma ↗
▶ Ep 108 · 8:58
clinical Henry So performed primary pull-throughs because patients with stomas in the Philippines faced severe social stigma and babies were basically left to die by their families ↗
▶ Ep 108 · 11:28
clinical The transanal dissection and Suave plane dissection is the same concept as the mucosectomy in ulcerative colitis ↗
▶ Ep 108 · 12:32
clinical Helen Noblett figured out the suction rectal biopsy technique and is from Melbourne, Australia ↗
▶ Ep 108 · 12:40
clinical Keith Jorgeson performed the laparoscopic version of the Suave procedure ↗
▶ Ep 108 · 12:57
opinion In Jorgeson's original description of laparoscopic Suave, they discussed leaving a 5 centimeter cuff, which nowadays would be way too much ↗
▶ Ep 108 · 13:17
clinical Jack Langer and Luis de la Torre developed transanal resection of the rectosigmoid around the same time ↗
▶ Ep 108 · 13:35
clinical Some places around the world are doing transanal-only approaches for Hirschsprung disease ↗
▶ Ep 108 · 13:47
clinical Dan Teitelbaum did significant research work in Hirschsprung disease, particularly in enterocolitis ↗

The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1

▶ Ep 109 · 1:41
quote I actually like to talk about the problematic post- pull through Hirschprung's patient in two versions. The obstructed patient, they are not emptying, they're having distention, they're having enterocolitis episodes, multiple, they're having failure to thrive. That's what we talked about last podcast. Then there's a group of patients. That don't have any of those obstructive symptoms, or if they do, they're fairly minimal, they're basically some constipation. But they are soiling, they're pooping all the time, never distended. That's the patient that we're gonna talk about today. ↗
▶ Ep 109 · 1:41
clinical Post-pull-through Hirschsprung's patients present in two distinct patterns: obstructed patients with distention, enterocolitis, and failure to thrive versus soiling patients who poop constantly and are never distended ↗
▶ Ep 109 · 4:09
clinical If the pull-through is done correctly with no anatomic problems and preservation of the sphincter mechanism, most Hirschsprung's patients do extremely well ↗
▶ Ep 109 · 4:09
quote I believe that in Hirschprung's disease, if you get the pull through right, with no anatomic problems, and a preservation of the sphincter mechanism. Most of those patients do extremely well. ↗
▶ Ep 109 · 4:34
quote there is no reason why any Hirschprung patient should be obstructed, and there's no reason why any Hirschprung patients should be soiling, and if they are, We need to investigate why, and we can fix them ↗
▶ Ep 109 · 4:34
opinion There is no reason why any Hirschsprung patient should be obstructed or soiling if properly managed and investigated ↗
▶ Ep 109 · 5:47
clinical Pull-throughs can decompensate if patients do not have adequate medical management or sphincter management, potentially leading to nerve hypertrophy ↗
▶ Ep 109 · 6:47
clinical The most important question for any soiling patient is: what is the patient's potential for bowel control ↗
▶ Ep 109 · 6:47
quote I'm gonna really emphasize this, to always ask the question, and by the way, this is true for any soiling patient. What is the patient's potential for bowel control? This is a question that is often neglected. ↗
▶ Ep 109 · 7:09
clinical All Hirschsprung's patients have the best possible potential for bowel control because they were born with normal sphincters and intact dentate line with anal canal sensation ↗
▶ Ep 109 · 7:38
quote when you take care of a Hirschrung's patient, and their dentate line is intact, and their sphincters are intact, they have all the potential to have voluntary bowel movements and to have bowel control. ↗
▶ Ep 109 · 7:38
clinical Hirschsprung's patients with intact dentate line and intact sphincters have all the potential to have voluntary bowel movements and bowel control ↗
▶ Ep 109 · 7:52
clinical If the dentate line is lost because dissection was started too low, or sphincters were overstretched and don't contract well, patients may have lost their potential for bowel control ↗
▶ Ep 109 · 9:15
clinical 3D anorectal manometry can visualize whether the sphincter squeeze is concentric; one patient had good squeeze but no squeeze on the anterior side ↗
▶ Ep 109 · 10:48
clinical Sphincters become overstretched through transanal approach with deep dissection in the wrong plane and retractors placed in the anus ↗
▶ Ep 109 · 12:20
clinical Patients with poor potential for bowel control due to overstretched sphincters need mechanical emptying programs with enemas or antegrade options ↗
▶ Ep 109 · 12:39
clinical Mechanical bowel programs can get borderline patients to a point where they are clean and psychologically want to be clean, making them more likely to successfully potty train ↗
▶ Ep 109 · 13:11
clinical Routine practice now includes 3D anorectal manometry in all soiling Hirschsprung's patients to assess sphincter squeeze and determine potential for bowel control ↗
▶ Ep 109 · 14:02
clinical A new sphincter tightening technique has been developed and published in JPS with great results in multiple patients with disrupted or patulous sphincters ↗
▶ Ep 109 · 15:02
clinical Rectal prolapse after Hirschsprung's pull-through is iatrogenic and should never occur if sphincters are preserved ↗
▶ Ep 109 · 15:05
quote There is no, there is no patient, you have never seen. And all those wonderful colorectal people that you have gotten the opportunity to train with, none of those people have ever had a rectal prolapse after Hirschsprung's pull-through, ever. Jason Fisher, never. Me, never. Why? Because the sphincters are preserved. ↗
▶ Ep 109 · 15:26
clinical Overstretched sphincters become patulous to the point of prolapse, resembling a spina bifida anus ↗
▶ Ep 109 · 17:13
clinical For patients with patulous sphincters, sphincter reconstruction should be offered and can be done at the same time as Malone procedure ↗
▶ Ep 109 · 17:53
clinical Malone can serve as a bridge to continence by allowing patients to practice holding in the flush and releasing on command, potentially improving sphincter function to achieve bowel control ↗

Colorectal Quiz 25: Perineal Groove

▶ Ep 114 · 5:58
clinical Perineal groove is characterized by a mucosal-lined tract between the anterior anus and the vestibule ↗
▶ Ep 114 · 9:16
clinical The anus needs to be supple without narrowing or stenosis; passing an adequately sized Hagar through a stenotic ringed anus does not guarantee functional adequacy ↗
▶ Ep 114 · 10:46
clinical Examination under anesthesia with electrical stimulation can definitively confirm whether the sphincter maps properly and closes around the anal opening ↗
▶ Ep 114 · 17:03
clinical An anterior anus (normal anus that is anteriorly positioned) does not need surgical correction ↗
▶ Ep 114 · 17:36
quote it's very hard to improve on an asymptomatic patient ↗
▶ Ep 114 · 17:58
clinical A perineal fistula is defined as fistulous tissue that is too small, not distensible, lacks a dentate line, and is anterior to the center of the sphincter ↗
▶ Ep 114 · 19:41
clinical Over time, the mucosal-lined perineal groove becomes squamous epithelium and is of no consequence ↗
▶ Ep 114 · 25:11
clinical If a patient has no anus, it is a cloaca with a single perineal opening ↗
▶ Ep 114 · 25:23
clinical If a patient has a patent normal anus and a urogenital sinus, this suggests an endocrine problem rather than cloaca ↗
▶ Ep 114 · 26:09
clinical Perineal fistulas can be associated with tethered cord ↗

Colorectal Quiz Episode 24: Cloaca Part 3

▶ Ep 117 · 2:41
clinical Surgeons who do not specialize in cloaca often repair the rectum but leave the urogenital sinus for later, creating a reoperative field ↗
▶ Ep 117 · 2:57
quote The ideal time is to understand the entire cloacal anatomy and fix it all at once. And the urogenital complex is the complicated part. The rectum is usually the easier part, and it ought to all be done together. ↗
▶ Ep 117 · 4:57
quote I actually have noticed a significant reduction in the need for redos because surgeons are following the protocol, understanding the measurements and saying, OK, this is a cloaca that I think I can handle, or this is a cloaca that I think needs to be referred. ↗
▶ Ep 117 · 4:57
opinion The protocol has led to a significant reduction in need for redo operations ↗
▶ Ep 117 · 8:02
quote Common channel less than 3 centimeters sets you up for a possible TUM. But, you need to have an adequate urethral length, and that's 1.5 centimeters or greater. Common channel greater than 3 centimeters almost always means a urogenital separation. Period. ↗
▶ Ep 117 · 8:02
clinical Common channel less than 3 cm with urethral length 1.5 cm or greater allows total urogenital mobilization ↗
▶ Ep 117 · 8:14
clinical Common channel greater than 3 cm almost always requires urogenital separation ↗
▶ Ep 117 · 9:35
clinical High rectum in cloaca may be reachable posterior sagittally when doing TUM, unlike in males ↗
▶ Ep 117 · 16:17
clinical The two sides of the split common channel in TUM become the labia minora ↗
▶ Ep 117 · 19:47
clinical Suspensory ligaments should be released until retropubic fat is visible, gaining approximately 2 to 2.5 cm of length ↗
▶ Ep 117 · 19:51
quote I really wanna go until I see the retropubic fat. You see a little fatty layer, which you know is covered by a little whitish fascia, and when you incise into the whitish fascia, the TUM releases, it gets nice and free. You gain about 2, 2.5 centimeters at that point. ↗
▶ Ep 117 · 26:08
quote Do not open the common channel. Make the meatoplasty just enough to slip a catheter in, maybe 1 or 2 millimeters, but do not touch the common channel. ↗
▶ Ep 117 · 26:32
clinical In separation, ureters approach from lateral, requiring strict midline dissection initially ↗
▶ Ep 117 · 26:36
quote The ureters are coming in from the side, so be careful, stay very midline. ↗
▶ Ep 117 · 26:59
clinical Leaving adequate vaginal cuff tissue allows tension-free urethral closure and is critical for fistula prevention ↗
▶ Ep 117 · 35:37
quote We had a problem. We put about 6 brains on the problem, sat down at a devoted meeting, and came up with a list of things that we were gonna do to try to avoid urethral vaginal fistula. We implemented, everyone on the team agreed, haven't had a fistula since. ↗
▶ Ep 117 · 41:06
quote If you go for a TUM, and it doesn't reach, now you are in some serious trouble, because now you have to do the separation. And guess what? You've already dissected the anterior urethra. And therefore, you may have a reconstructed urethra now dissected on both sides that unfortunately, in a number of cases became ischemic and left the patient with essentially no urethra. ↗
▶ Ep 117 · 41:26
clinical Attempting TUM that fails and then converting to separation can devascularize the urethra, leaving patient with no functional urethra ↗
▶ Ep 117 · 42:13
quote Since we started doing these measurements, we never got into a Cloaca and said, oh my gosh, this is not what we thought. Every single time we implemented the plan for the case, and that's thanks to good measurement. ↗
▶ Ep 117 · 42:13
opinion Since implementing measurement protocol, surgical plans have matched intraoperative findings in every case ↗

Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula

▶ Ep 119 · 2:25
quote the conversations that go around a female, the perineal fistula are more time-consuming than the conversations that need to happen about a cloaca. ↗
▶ Ep 119 · 2:39
quote it's amazing to me that there still remains a lot of uh mystery about what to do and whether this is an anorectal malformation at all. ↗
▶ Ep 119 · 3:12
quote If the hole is in the center of the sphincter or it's in somewhat of the sphincter, and if the hole is enough of a lumen, and if there's a perineal body, that patient does not need to be touched. ↗
▶ Ep 119 · 3:12
clinical If the hole is in the center of the sphincter with adequate lumen and a perineal body, the patient does not need to be touched. ↗
▶ Ep 119 · 3:24
clinical If the hole is too small or outside of the sphincter, the patient needs surgery. ↗
▶ Ep 119 · 4:20
clinical There are five management options for perineal fistula: colostomy then repair, primary repair, dilation then repair, colostomy with simultaneous repair, and dilation only. ↗
▶ Ep 119 · 5:23
clinical Diverting with a colostomy does not necessarily prevent wound complications and carries morbidity from both the colostomy and its closure. ↗
▶ Ep 119 · 5:23
quote diverting with a colostomy doesn't necessarily stop that from happening and You have the morbidity of a colostomy and of the colostomy closure, which is nothing to sneeze at. ↗
▶ Ep 119 · 5:46
quote this is not an emergency. They are passing stool, so the diversion of stool is not the reason for the colostomy, unless it's a very, very tiny fistula, and they can't pass stool ↗
▶ Ep 119 · 5:54
clinical Diversion of stool is not the reason for colostomy unless the fistula is very tiny and the patient cannot pass stool, which can be managed by dilation. ↗
▶ Ep 119 · 6:07
clinical Dilation alone could be problematic if the distal end is fistulous and will not grow, causing proximal distension. ↗
▶ Ep 119 · 6:32
quote everyone's definition of a perineal fistula and where that fistula is may differ. ↗
▶ Ep 119 · 7:38
clinical Anal stenosis with a tiny hole in the middle of the sphincteric ellipse requires screening for Currarino syndrome. ↗
▶ Ep 119 · 9:14
quote This is not, none of these, this vestibular fistula is not a vaginal fistula because the vaginal wall, the posterior vaginal wall is intact. There's no fistula to it. ↗
▶ Ep 119 · 9:14
clinical A vestibular fistula is not a vaginal fistula because the posterior vaginal wall is intact with no fistula to it. ↗
▶ Ep 119 · 9:34
epidemiological True vaginal fistulas are exceedingly rare. ↗
▶ Ep 119 · 10:52
clinical Some perineal fistulas can be managed with posterior wall mobilization without touching the anterior wall. ↗
▶ Ep 119 · 14:28
epidemiological The incidence of vaginal atresia is quite rare, and vaginal septums are more common at around 3 to 5% of vestibular fistulas. ↗
▶ Ep 119 · 14:36
clinical Perineal fistulas can also be associated with distal vaginal atresia. ↗
▶ Ep 119 · 16:36
clinical Differential renal function is relevant when considering whether to reimplant an ectopic ureter or remove a non-functional kidney. ↗
▶ Ep 119 · 17:20
clinical Absent kidneys are usually not truly absent but rather non-functional, often multicystic and dysplastic. ↗
▶ Ep 119 · 17:44
guideline Every surgeon caring for an anorectal malformation should know the malformation type, spine status (tethered cord or myelomeningocele, or normal), and sacral status including sacral ratio. ↗
▶ Ep 119 · 18:15
clinical A patient with a low-type malformation but associated spinal problem has a different prognosis for bowel control than a perineal fistula patient with a normal spine. ↗

Colorectal Quiz Episode 29: Female ARM-Post Op Management

▶ Ep 120 · 1:37
clinical Alberto Pena's original protocol mandated 7 days NPO with central line and hyperalimentation, feeding only on day 7 if healed ↗
▶ Ep 120 · 3:10
clinical A study comparing NPO for 7 days versus clear liquids for 7 days found the same amount of stool output in both groups ↗
▶ Ep 120 · 3:30
clinical Hard stool passage, not stool passage itself, is the problem that causes dehiscence ↗
▶ Ep 120 · 3:37
clinical Current protocol uses regular IV (no PICC line) and clear liquids or breast milk for 5 days, with very low dehiscence rate ↗
▶ Ep 120 · 5:28
quote I think the key to this will be, um, as minimal amount of perineal body injury by surgery as possible. ↗
▶ Ep 120 · 5:45
clinical Perineal body dehiscence usually leads to no perineal body over several months, requiring redo because anterior anoplasty has no sphincter around it ↗
▶ Ep 120 · 5:59
clinical Patients fed right away and discharged home invariably are the ones seen for redo operations due to perineal body dehiscence ↗
▶ Ep 120 · 9:06
clinical Randomized controlled trial of dilation versus non-dilation for primary PSAP (cloaca excluded) showed 10-15% risk of stricture development in both groups ↗
▶ Ep 120 · 9:25
clinical Backup plan for stricture in non-dilation group is aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty ↗
▶ Ep 120 · 10:25
clinical Many anoplasties look absolutely fine 8 weeks later at colostomy closure if never touched with a dilator ↗
▶ Ep 120 · 10:50
epidemiological Families identified dilations as their biggest concern in caring for patients with anorectal malformation ↗
▶ Ep 120 · 13:45
clinical Jack Langer sees patients weekly in clinic and passes dilator himself rather than having families do it at home ↗
▶ Ep 120 · 16:28
clinical Full continence can be restored with a redo operation, with stricture being one indication ↗
▶ Ep 120 · 17:12
clinical Vast majority of patients needing intervention for stricture are already undergoing surgery for colostomy closure ↗
▶ Ep 120 · 17:21
opinion No family presented with the non-dilation option has chosen routine dilation ↗
▶ Ep 120 · 18:31
quote I think the good news is that there's no right answer, we just have to all work together and suffer together on these difficult problems and try to, uh, improve lives as best we can. ↗
▶ Ep 120 · 19:37
clinical In developing world practice, anoplasties are made slightly bigger knowing there will be contraction, when patients will not return for follow-up ↗
▶ Ep 120 · 20:18
clinical For redo operations, anoplasties are made larger knowing there will be contraction; redos are not dilated but examined under anesthesia at one month ↗
▶ Ep 120 · 20:33
clinical For primary repairs, anoplasty lumen is made to match maximal rectal lumen that fills the sphincter, typically size 13 or 14 ↗

DrBeen Medical Lectures: Dr. Marc Levitt, MD Discusses Hirschsprung Disease

▶ Ep 129 · 3:30
epidemiological Hirschsprung disease occurs in about 1 in 5000 live births ↗
▶ Ep 129 · 4:42
epidemiological 90% of Hirschsprung patients are diagnosed in the first couple of months of life, the vast majority in the first week ↗
▶ Ep 129 · 4:53
clinical Without ganglion cells, the colon cannot relax and therefore stays squeezed, preventing the colon above from emptying through it ↗
▶ Ep 129 · 5:24
quote Imagine they were, they're the, uh, the cell towers uh uh that communicate with each other and pass your signal along as you're trying to use your, uh, your cell phone. ↗
▶ Ep 129 · 6:05
clinical In Hirschsprung disease, bacteria can migrate through the abnormal bowel lining into the bloodstream, creating enterocolitis which is life threatening ↗
▶ Ep 129 · 6:25
quote It's not just the stasis of the stool and the failure to move the stool through, it's also the fact that the bacteria now have a way of getting into the bloodstream and making the baby very sick ↗
▶ Ep 129 · 6:55
clinical If Hirschsprung disease is recognized, it is pretty straightforward to intervene, but a few patients die each year from enterocolitis ↗
▶ Ep 129 · 7:06
clinical Medical treatment with proper irrigation can prevent enterocolitis without necessarily requiring surgery ↗
▶ Ep 129 · 7:14
quote You don't necessarily need surgery to prevent enterocolitis. You just need a good nursing care and know how to do a proper irrigation to get the stool to flow and overcome this obstructed area. ↗
▶ Ep 129 · 8:10
epidemiological About 5% of Hirschsprung patients present after 1 year of life, the vast majority present as babies ↗
▶ Ep 129 · 8:42
quote The healthy part of the bowel is trying very hard to empty. But downstream, it's unable to get through the obstruction, and that's where the crampy pain comes from. ↗
▶ Ep 129 · 9:07
clinical Down syndrome is associated with Hirschsprung disease ↗
▶ Ep 129 · 10:46
clinical 10% of patients with meconium plug actually have Hirschsprung disease as the underlying cause, while 90% just pass the plug and get better ↗
▶ Ep 129 · 11:22
clinical Milk protein allergy can mimic Hirschsprung disease, and biopsy will find ganglion cells but lots of eosinophils ↗
▶ Ep 129 · 13:40
clinical To diagnose Hirschsprung disease, you need both absence of ganglion cells and confirmation that nerve trunks are hypertrophic (thickened) ↗
▶ Ep 129 · 14:31
clinical Hypertrophic nerve trunks greater than 40 microns is abnormal ↗
▶ Ep 129 · 16:37
clinical A permanent section biopsy takes about 2 or 3 days to analyze and requires evaluation of 100 slices to prove Hirschsprung disease ↗
▶ Ep 129 · 16:37
quote I like to say that you cannot um diagnose Hirschprung's with a frozen section, but you can rule it out, i.e., if ganglion cells are present ↗
▶ Ep 129 · 16:37
clinical You cannot diagnose Hirschsprung with a frozen section, but you can rule it out if ganglion cells are present ↗
▶ Ep 129 · 20:41
epidemiological The vast majority of Hirschsprung cases have the problem in the lower part of the colon, the left colon or below ↗
▶ Ep 129 · 20:45
epidemiological In about 15% of cases, Hirschsprung disease extends higher than the splenic flexure ↗
▶ Ep 129 · 22:09
clinical Contrast studies showing the transition zone are accurate about 90% of the time ↗
▶ Ep 129 · 22:43
clinical The dilated colon will shrink down to more normal size once it can successfully empty after the blockade is removed ↗
▶ Ep 129 · 24:01
quote We call it a pull through because the healthy segment is pulled through to the anus and remove and we remove the abnormal segment. ↗
▶ Ep 129 · 24:44
quote Our team shirts say you won't believe what our team can pull through. ↗
▶ Ep 129 · 29:06
clinical You really only need about 10% of your colon to function completely normally and have one bowel movement per day ↗
▶ Ep 129 · 29:06
quote You really only need about 10% of your colon to function completely normally and have one bowel movement per day. ↗
▶ Ep 129 · 29:14
clinical Most Hirschsprung patients only lose about 15 to 20% of their colon because that's where the abnormal segment is ↗
▶ Ep 129 · 29:29
clinical Patients who lose their entire colon and have small bowel brought to the anus tend to have 2 to 6 stools per day ↗
▶ Ep 129 · 29:41
clinical All Hirschsprung patients can maintain bowel control provided the surgeon successfully preserves the anal canal and sphincters during the operation ↗
▶ Ep 129 · 30:46
clinical Sometimes the irrigation tube does not reach high enough into normal bowel and cannot successfully decompress the colon ↗
▶ Ep 129 · 38:04
quote The irrigation is a process whereby you're irrigating and gently getting the stool out and enema, you just squirt it in and walk away. That's certainly not going to work in a patient with Hirschrug's disease. ↗
▶ Ep 129 · 38:16
quote These patients really good, need good surgeons, but also need very good nursing care. ↗
▶ Ep 129 · 38:40
epidemiological If a family has a baby with Hirschsprung disease, the risk of another baby having it is about 1 in 200, compared to the general population risk of 1 in 5000 ↗
▶ Ep 129 · 39:29
clinical Hirschsprung-associated enterocolitis is treated with irrigations, metronidazole antibiotic for anaerobic bacteria, and intravenous hydration ↗
▶ Ep 129 · 41:43
clinical Even after successful Hirschsprung surgery, patients can develop enterocolitis if sphincters don't relax well and slow down flow ↗
▶ Ep 129 · 41:59
clinical Botox injection to the anal sphincters wears off over 3 months, during which time the baby can learn to push and overcome non-relaxing sphincters ↗
▶ Ep 129 · 42:39
clinical In Hirschsprung disease, the internal sphincter tightens at the wrong time instead of relaxing when there is fullness in the rectum ↗
▶ Ep 129 · 43:59
clinical The vast majority of Hirschsprung patients recover very uneventfully, stool normally, and successfully potty train by age 3 or 4 ↗
▶ Ep 129 · 44:52
epidemiological Hirschsprung disease is a source of significant morbidity and mortality in the developing world if unrecognized ↗

ERN eUROGEN ARM Webinar Series: Management of Cloacal Malformations – what is new in 2021?

▶ Ep 130 · 4:03
quote This is not a patient with ambiguous genitalia. This is not a patient with urogenital sinus. ↗
▶ Ep 130 · 4:06
clinical A patient with no anal opening and a single perineal orifice has a cloaca, not ambiguous genitalia or urogenital sinus ↗
▶ Ep 130 · 4:18
quote If the patient has no anal opening in a single perineal orifice, and here's the perineal orifice, one hole, that patient has a cloaca. ↗
▶ Ep 130 · 4:27
clinical Cloacal patients are normal females with typical ovarian anatomy, though various Mullerian anomalies can occur ↗
▶ Ep 130 · 4:40
clinical The common channel in cloaca emanates just below the clitoral hood, not the typical location for female urethra ↗
▶ Ep 130 · 5:04
opinion Leaving the urethral opening in the clitoral location is suboptimal both cosmetically and functionally for intermittent catheterization ↗
▶ Ep 130 · 8:08
clinical In utero ascites in cloaca occurs when urine flows from bladder into vagina, cannot exit the common channel, and backs up through fallopian tubes into peritoneal cavity ↗
▶ Ep 130 · 9:01
clinical The vast majority of hydrocolpos can be drained perineally without abdominal surgery ↗
▶ Ep 130 · 9:33
clinical After hydrocolpos decompression, the bladder will suddenly dilate as distal ureteral obstruction is relieved ↗
▶ Ep 130 · 9:46
clinical A vesicostomy in almost all cloacas is not the correct treatment because it will not solve the distal ureteral obstruction ↗
▶ Ep 130 · 9:46
quote A vesicostomy in almost all cloacass is not the correct treatment because it will not solve the distal ureteral obstruction. ↗
▶ Ep 130 · 10:37
epidemiological About 40% of cloacal patients have a bifid vaginal system ↗
▶ Ep 130 · 10:46
clinical Hydrocolpos only needs management if it is causing hydronephrosis ↗
▶ Ep 130 · 12:10
clinical Critical measurements for surgical planning are common channel length, native urethral length, and bladder neck location ↗
▶ Ep 130 · 12:26
clinical Cloacas form in two groups: low confluence (common channel ≤3cm) and high confluence (common channel >3cm) ↗
▶ Ep 130 · 12:51
opinion Total urogenital mobilization was historically overused for patients who did not have adequately long urethra ↗
▶ Ep 130 · 13:23
clinical A native urethral length greater than 1.5 centimeters is needed for bladder function ↗
▶ Ep 130 · 13:38
clinical Disrupting the urogenital diaphragm or pulling the bladder neck down out of it will result in urinary leakage ↗
▶ Ep 130 · 13:38
quote You do not want to disrupt the urogenital diaphragm. You do not want to pull the bladder neck down out of the urogenital diaphragm. You'll end up with urinary leakage. ↗
▶ Ep 130 · 14:01
clinical In a patient with 3.5cm common channel and only 1.5cm native urethra, the preferred approach is to repair the back of the common channel and let native urethra plus common channel become a 5cm neourethra ↗
▶ Ep 130 · 14:34
quote If you did a TUM on this patient, you would leave the patient with a very short urethra, pulled down all the way to the perineum. ↗
▶ Ep 130 · 16:10
clinical If native urethra cannot be guaranteed to be 1.5cm or greater, a UG separation must be done to let native urethra plus common channel become the neourethra ↗
▶ Ep 130 · 16:28
clinical Normal female urethral length is at least 1.5cm, often greater, based on VCUG studies of patients with UTI ↗
▶ Ep 130 · 17:23
clinical Splitting a long common channel with very little native urethra essentially brings the bladder neck down to the perineum, which must be avoided ↗
▶ Ep 130 · 19:33
clinical A small posterior incision in the common channel allows recessing of the urethral meatus below the clitoral tissue ↗
▶ Ep 130 · 20:24
opinion Sigmoid colon is the ideal choice for vaginal replacement, with small bowel as second choice ↗
▶ Ep 130 · 20:40
clinical The sigmoid colostomy site itself can be used for vaginal replacement, then the colostomy recreated more proximally ↗
▶ Ep 130 · 21:17
opinion Tissue engineering for vaginal reconstruction using patient stem cells is believed to be achievable in our lifetime ↗
▶ Ep 130 · 23:13
clinical The optimal timing for cloacal repair is between 2 months and 1 year of age, most commonly 6-8 months ↗
▶ Ep 130 · 23:53
clinical Leaving a hypospadiac urethra is acceptable only if the patient will not require catheterization and the introitus reaches without full TUM ↗
▶ Ep 130 · 24:06
clinical If a patient has tethered cord, making a more obvious urethral meatus is preferred over leaving it hypospadiac due to likely need for catheterization ↗
▶ Ep 130 · 27:24
epidemiological For patients with common channel greater than 3cm, 80% (4 out of 5) will need intermittent catheterization ↗
▶ Ep 130 · 27:41
epidemiological For patients with common channel 3cm or less, 20% (1 out of 5) need intermittent catheterization ↗
▶ Ep 130 · 28:40
clinical C-section is definitely advised for cloacal patients who become pregnant due to extensive perineal dissection ↗
▶ Ep 130 · 29:05
opinion If vaginal orifice is present post-operatively, leave patient alone until puberty then consider introitoplasty rather than early revision ↗
▶ Ep 130 · 29:43
opinion Laparoscopic or robotic UG separation is elegant and beautiful but cases take a long time ↗
▶ Ep 130 · 32:14
clinical Vaginal switch operation is no longer performed due to high stenosis rates ↗
▶ Ep 130 · 32:40
opinion Neovaginal dilatation is not performed; preference is to allow skin-level stenosis and later perform introitoplasty ↗
▶ Ep 130 · 32:54
clinical The perineal sphincter muscle complex is absolutely preserved during posterior sagittal repair ↗
▶ Ep 130 · 34:12
clinical In UG separation, dissection starts on the back of the vagina as it enters the common channel, lifting it off without touching the common channel to avoid spongiosum tissue ↗
▶ Ep 130 · 35:25
opinion For low confluence below peritoneal reflection, always start posterior sagittally; only start abdominally if vagina and rectum are already in the abdomen ↗
▶ Ep 130 · 36:39
opinion A TUM can always be done in prone position; if it doesn't reach, it likely should have been a separation rather than TUM ↗
▶ Ep 130 · 38:10
clinical The key to saving kidneys in cloaca is aggressive bladder management: keep the bladder empty through intermittent catheterization, and vesicostomy for grade 4-5 reflux ↗
▶ Ep 130 · 38:53
clinical Small bowel blood supply is more tenuous and less forgiving than colon for vaginal replacement ↗
▶ Ep 130 · 40:57
clinical Bladder neck closure is rarely indicated; most urethras are salvageable if the common channel is kept intact to become neourethra ↗
▶ Ep 130 · 41:04
quote I really don't believe there are ever, maybe, maybe rarely, an occasion to close the bladder neck. Because most of these urethras are salvageable if you respect the principle of keeping the common channel intact to become the neourethra. ↗

Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease

▶ Ep 136 · 3:33
clinical Wide rectal dissection in early Hirschsprung surgery injured the nervi erigentes, leading to fecal incontinence, bladder dysfunction, and sexual dysfunction ↗
▶ Ep 136 · 5:07
clinical Dr. Yancey published his submucosal dissection technique in the Journal of the National Medical Association in 1952 ↗
▶ Ep 136 · 5:07
quote I was listening to the APSA presidential address by Henri Ford. And at that time, he mentioned this issue that we are going to be discussing. And that is that Dr. Yancey, Asa Yancey, actually had written a beautiful article 12 years before Suave, exactly describing the submucosal dissection. ↗
▶ Ep 136 · 5:07
epidemiological Dr. Henri Ford mentioned Dr. Yancey's work in his 2018 APSA presidential address, surprising most pediatric surgeons in attendance ↗
▶ Ep 136 · 6:00
clinical Dr. Suave published his submucosal dissection technique in the journal Surgery in 1964, twelve years after Dr. Yancey ↗
▶ Ep 136 · 6:20
clinical Dr. Yancey and Dr. Suave's articles demonstrate essentially an identical technique of submucosal dissection ↗
▶ Ep 136 · 6:40
epidemiological In 1951-1952, Black academics could not publish their work in mainstream surgical journals due to structural inequities ↗
▶ Ep 136 · 14:30
epidemiological The Yancey-Suave nomenclature is now being incorporated into teaching, operative notes, and journal review processes ↗

Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery

▶ Ep 158 · 3:37
quote I encourage you to do examinations under anesthesia. This is a very valuable maneuver for ARM patients who have had a previous surgery. ↗
▶ Ep 158 · 3:37
clinical Examination under anesthesia is valuable for ARM patients with previous surgery to assess anoplasty position, prolapse, stricture, and use electrical stimulation ↗
▶ Ep 158 · 4:15
clinical In males, cystoscopy should be added to rule out fistula remnant and assess bladder emptying ↗
▶ Ep 158 · 5:28
quote what's missing here is sphincters anterior to the anoplasty ↗
▶ Ep 158 · 5:28
clinical Anterior malposition means no sphincter muscle anterior to anoplasty, preventing complete closure and causing incontinence ↗
▶ Ep 158 · 5:54
clinical Anterior malposition is the most common problem requiring redo surgery in females ↗
▶ Ep 158 · 5:54
quote it's the most common problem in females that Jason and I have done redos for ↗
▶ Ep 158 · 6:19
clinical Dehiscence of perineal body leaves C-shaped rather than O-shaped sphincter around anus ↗
▶ Ep 158 · 10:22
clinical Clear liquid diet produces soft, watery stool that does not traumatize perineal repair, unlike hard stool from regular food ↗
▶ Ep 158 · 10:22
quote if you give someone real food. They make harder stool which can then blow through your perineal repair, whereas if you give the patient clear liquids, the stools that they produce are very soft and very watery ↗
▶ Ep 158 · 10:43
opinion Clear liquids avoid need for PICC line, TPN, and NPO, making patients and families happier ↗
▶ Ep 158 · 10:55
clinical At 5 days, if perineal healing looks good, diet is advanced with laxatives to keep stool liquidy ↗
▶ Ep 158 · 11:12
clinical Hard stool going through repair is the problem, not stool itself, as long as wound is kept clean ↗
▶ Ep 158 · 11:12
quote the problem is hard stool going through your repair, not stool ↗
▶ Ep 158 · 11:17
clinical Non-diversion strategy has not caused problems in redo PSARP cases ↗
▶ Ep 158 · 18:13
quote In the United States that line is very blurry. I think it's incredibly problematic, that blurred line ↗
▶ Ep 158 · 18:13
clinical In United States, age line for pediatric vs. adult care is blurry, creating problems ↗
▶ Ep 158 · 18:33
guideline Pediatric nurse practitioners cannot write orders on patients over age 21 due to licensing restrictions ↗
▶ Ep 158 · 18:46
clinical If 40-year-old needs ICU in children's hospital, intensivists are pediatric-trained, not adult-trained ↗
▶ Ep 158 · 20:11
quote bowel management expertise needs to be passed, so this is not just a doctor to doctor exactly transition ↗
▶ Ep 158 · 20:11
opinion Bowel management expertise needs to be passed from nurse to nurse and advanced practice provider to advanced practice provider, not just doctor to doctor ↗
▶ Ep 158 · 20:23
clinical Malone appendicostomy is a valuable operation many adult surgeons have never heard of ↗
▶ Ep 158 · 20:23
quote what is a malone, which I think is a beautiful operation that many of them have never even heard of ↗
▶ Ep 158 · 20:40
clinical Peristeen system allows self-controlled enema administration in adults ↗
▶ Ep 158 · 20:46
opinion In United States, financial incentives favor operations over medical management, which can be problematic for transition ↗
▶ Ep 158 · 20:58
clinical One week of bowel management can convert a patient with decades of soiling to clean continence ↗
▶ Ep 158 · 20:58
quote In one week of bowel management, you can get a patient. Who has, you know, no chance of continence, has been soiling for decades clean with a bowel management program ↗

Colorectal Quiz: Episode 42 - HD Constipation

▶ Ep 169 · 1:38
clinical Hirschsprung disease is a very anatomically fixable problem and with a good operation you should get a good result ↗
▶ Ep 169 · 1:38
quote Hirschprung's disease, I believe, is a very anatomically fixable problem. With a good operation, you should get a good result. ↗
▶ Ep 169 · 1:47
epidemiological Approximately one-third of Hirschsprung patients are constipated post-operatively and need proactive, aggressive management to avoid trouble ↗
▶ Ep 169 · 2:11
clinical Surgeons might leave behind the dilated segment right above the aganglionic segment as an anatomic reason for decompensation ↗
▶ Ep 169 · 2:22
clinical The most relevant reason for decompensation is that the patient never figured out how to successfully empty their sphincters and the pull-through decompensates ↗
▶ Ep 169 · 3:14
clinical Calretinin hangs out with ganglion cells, so normal calretinin staining provides double evidence of good ganglion cells ↗
▶ Ep 169 · 4:27
clinical If there are no ganglion cells and no calretinin staining, that is a retained Hirschsprung and the patient needs a redo to a higher level ↗
▶ Ep 169 · 4:38
clinical Nerve hypertrophy with good ganglion cells could represent transition zone or could represent that the bowel has decompensated over time because it hasn't emptied and gotten dilated ↗
▶ Ep 169 · 6:47
clinical Many patients are going to have an abnormal anorectal manometry but they're OK ↗
▶ Ep 169 · 6:56
clinical Botox helps patients learn to overcome non-relaxing sphincters by other maneuvers like pushing on their abdominal wall ↗
▶ Ep 169 · 7:11
clinical Many patients are completely asymptomatic doing great with Hirschsprung's that have residual absent rectal anal inhibitory reflex ↗
▶ Ep 169 · 7:39
clinical In Hirschsprung patients with constipation, the colon is not the problem; the problem usually is the sphincters or the pelvic floor ↗
▶ Ep 169 · 7:39
quote The colon in, in those patients are not the problem. The the problem usually is the sphincters or the pelvic floor. ↗
▶ Ep 169 · 8:14
clinical If you get an awake anorectal manometry in a cooperative patient with a normal rectal anal inhibitory reflex and can detect the resting pressure, the evaluation is complete without anesthesia or procedure ↗
▶ Ep 169 · 8:29
guideline If the rectal anal inhibitory reflex is absent, you're obligated to do a biopsy and give Botox ↗
▶ Ep 169 · 8:36
clinical Botox is given if the resting pressure of the external sphincter is also high ↗
▶ Ep 169 · 8:41
clinical Pelvic floor dysynergia can be detected on anorectal manometry and is a good indication that pelvic floor physical therapy will help the patient ↗
▶ Ep 169 · 9:55
guideline Colonic manometry should not be done in Hirschsprung patients with obstructive symptoms because it's not the colon but the distal pull-through that's the problem ↗
▶ Ep 169 · 9:55
quote We don't do colonic manometry in Hirschberg's patients who have obstructive symptoms, because It's not the colon, it's the distal pull through, that's the problem. ↗
▶ Ep 169 · 10:11
guideline Anatomic and pathologic causes must be ruled out before any colonic manometry is considered ↗
▶ Ep 169 · 10:18
guideline Colonic manometry in a patient with a distal obstruction is the wrong test ↗
▶ Ep 169 · 11:54
epidemiological In a PCPLC Consortium study of close to 100 patients with functional constipation and segmental dysmotility of the sigmoid, 97% successfully responded to Malone only without needing resection ↗
▶ Ep 169 · 12:18
quote 97% successfully responded to Malone only with segmental dysmotility. This is enormously important, enormously important, because in the old days, and I mean five years ago, Jason and I, and you probably too, Chris, we're taking sigmoids out of those patients. ↗
▶ Ep 169 · 12:28
clinical Five years ago, surgeons were taking sigmoids out of patients with segmental dysmotility, but this practice has changed based on new data ↗
▶ Ep 169 · 13:24
quote I look at I'm alone in that patient, it is a route for medical treatment. Right? You give them alone, you get antegrade access to the colon for the gastroenterologist to give better medical treatment, and in this case, that's a flush. ↗
▶ Ep 169 · 13:24
clinical A Malone procedure is a route for medical treatment, providing antegrade access to the colon for gastroenterologists to give better medical treatment ↗

Colorectal Quiz: Episode 49 – Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)

▶ Ep 177 · 0:48
quote We did something crazy. I uploaded loaded an article that Jason Fisher and I wrote together about the collaborative model in colorectal care, published in seminars in pediatric surgery and loaded that article using AI into a podcast format. ↗
▶ Ep 177 · 2:41
quote I was expecting lots of errors and a very computer sounding experience, and it wasn't that at all. It was a lovely two human sounding voices that were chatting about the article that Jason and I wrote. ↗
▶ Ep 177 · 6:39
clinical A review article that took two weeks to write five years ago can now be produced in minutes using Notebook LM with the same source articles ↗
▶ Ep 177 · 7:04
clinical AI can identify gaps in knowledge from a collection of research articles ↗

Colorectal Quiz: Episode 50 - 16th Annual European Pediatric Colorectal and Pelvic Reconstruction Conference, Stockholm, Sweden, October 2025 - What did we learn?

▶ Ep 190 · 2:45
clinical Total colonic Hirschsprung patients represent the highest risk group for enterocolitis ↗
▶ Ep 190 · 6:44
clinical More surgeons are able to perform robotic surgery on children less than 10 kg because equipment is improving ↗
▶ Ep 190 · 7:40
clinical Goblet cells increase from proximal to distal bowel, producing more mucus distally which has a protective role ↗
▶ Ep 190 · 7:56
clinical The more proximal bowel that needs to be resected, the more at risk the patient is for future enterocolitis because proximal segments don't make as much protective mucus ↗
▶ Ep 190 · 8:37
clinical Mechanical stress and distension on the bowel wall leads to increased gut microbial dysbiosis and breakdown in mucosal lining and barrier function ↗
▶ Ep 190 · 9:04
clinical Bowel wall stress shows upregulation of pro-inflammatory factors affecting immune response, contributing to enterocolitis ↗
▶ Ep 190 · 9:39
clinical Most pull-through decompensation occurs despite originally good pathology, due to inadequate post-operative management ↗
▶ Ep 190 · 9:52
clinical Aggressive management with laxatives when needed and Botox when needed prevents pull-through decompensation ↗
▶ Ep 190 · 11:41
quote I think I say it all the time, like we're pretty useless as surgeons. Felipe, I know you agree, without our nursing partners, uh, we are equals in this mission ↗
▶ Ep 190 · 16:25
clinical The perineal-preserving PSARP avoids perineal body dissection altogether and avoids dehiscence possibility ↗
▶ Ep 190 · 16:36
opinion Perineal-preserving PSARP could potentially avoid colostomies and colostomy closures in many patients ↗
▶ Ep 190 · 16:57
clinical PRAA (posterectal advancement anoplasty) involves mobilization of posterior rectal wall only in males with perineal fistula and some females with perineal fistula when the fistula is in the anteriormost extent of the sphincteric ellipse ↗
▶ Ep 190 · 17:18
clinical In vestibular fistula repair, surgeons do not need to dissect all the way to the areolar plane separating anterior rectum from posterior vagina; they only need to ensure no tension on the rectum during anoplasty ↗
▶ Ep 190 · 19:24
clinical Structures that look atretic may actually grow into real useful structures, supporting a strategy of waiting on Mullerian structures ↗
▶ Ep 190 · 19:50
clinical A bowel neovagina can bridge the gap when native vagina does not reach, and may be removable in the future when native vagina can be pulled through after puberty ↗
▶ Ep 190 · 21:35
clinical There is a higher incidence of perianal disease in children with Crohn's disease, and sometimes perianal disease can be the first hint that the patient will develop Crohn's disease ↗
▶ Ep 190 · 21:53
clinical Enteral nutrition is as effective as steroids in treating transmural inflammation or stenosis of small bowel in Crohn's disease ↗

Colorectal Quiz: Episode 49 - Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)

▶ Ep 222 · 0:40
quote we did something crazy i uploaded an article that jason frischer and i wrote together about the collaborative model in colorectal care published in seminars in pediatric surgery and loaded that article using ai into a podcast format ↗
▶ Ep 222 · 2:30
quote i was expecting lots of errors and a very computer sounding experience and it wasn't that at all it was a lovely two human sounding voices that were chatting about the article ↗
▶ Ep 222 · 5:47
clinical NotebookLM creates content only from uploaded documents, not from external sources, making it function as a custom expert based solely on provided materials ↗
▶ Ep 222 · 5:47
quote when you upload anything to the notebook lm you kind of create your own expert just from the provided document ↗
▶ Ep 222 · 8:33
quote you are my help in curating knowledge in the field that i need to become continue to be knowledgeable about it's one of the main reasons why you stay current because i trust the information that's being provided there ↗

Colorectal Quiz: Episode 47

▶ Ep 223 · 6:29
guideline Anorectal manometry is not part of standard initial workup for anorectal malformation patients ↗
▶ Ep 223 · 6:29
clinical There are many ways to tell if the anus is in proper position, such as electrical stimulation and rectal ultrasound or MRI ↗
▶ Ep 223 · 6:29
quote I never say never and I never say always ↗
▶ Ep 223 · 9:05
quote this would, this would win the Ohio State Fair. This is this deserves its own name. Like it's its separate organ ↗
▶ Ep 223 · 9:05
quote I have one word. Wow ↗
▶ Ep 223 · 9:05
clinical The rectosigmoid can be very inert in ARM patients even when the anus is not strictured ↗
▶ Ep 223 · 10:19
clinical Mega-rectosigmoid in ARM patients can be both inherent and acquired from failure to aggressively treat constipation over many years ↗
▶ Ep 223 · 10:19
quote the answer is both ↗

Colorectal Quiz: Episode 47

▶ Ep 224 · 1:51
quote every patient with a cloacoal history, we have to remember to think about three systems ↗
▶ Ep 224 · 1:51
clinical Every patient with cloaca history requires evaluation of three systems: urologic, gynecologic, and colorectal ↗
▶ Ep 224 · 3:11
clinical Spina bifida bladders and cloaca bladders need to stay empty to prevent kidney damage ↗
▶ Ep 224 · 3:11
clinical Cystatin C is helpful to check GFR and renal function in cloaca patients ↗
▶ Ep 224 · 3:11
epidemiological A 13-year-old cloaca patient historically would often show up with kidney damage, and many unfortunately ended up with renal transplant ↗
▶ Ep 224 · 5:09
clinical Patients can have excellent anatomical repair and still have soiling in anorectal malformation ↗
▶ Ep 224 · 5:09
quote You've done an excellent anatomical repair, and they still have soiling ↗
▶ Ep 224 · 5:09
epidemiological The most common cause for redoing anorectal malformation patients is incorrect anal placement ↗
▶ Ep 224 · 9:05
quote This would win the Ohio State Fair. This deserves its own name. Like it's its separate organ ↗
▶ Ep 224 · 9:05
clinical The rectosigmoid can be inert in ARM patients even without stricture ↗
▶ Ep 224 · 9:05
quote I have one word. Wow ↗
▶ Ep 224 · 10:19
clinical Mega-rectosigmoid etiology is both inherent motility problems and acquired from failure to aggressively treat constipation over many years ↗
▶ Ep 224 · 11:53
clinical The rectum is vitally important for bowel control in anorectal malformation patients ↗
▶ Ep 224 · 11:53
clinical Anorectal malformation patients don't really have anal canal sensation or internal sphincter ↗
▶ Ep 224 · 11:53
clinical Distention of the rectum (proprioception) provides the cue to squeeze the external sphincter and hold in stool ↗
▶ Ep 224 · 11:53
clinical If you remove the rectum, you lose the capacity for proprioception and bowel control ↗
▶ Ep 224 · 11:53
quote the 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 224 · 11:53
quote They don't really have anal canal sensation. They don't really have an anal canal. So that's out ↗
▶ Ep 224 · 13:29
clinical Older patients who had abdominal perineal pull-through can be recognized on contrast study by haustral markings at the anus in the pelvis ↗
▶ Ep 224 · 16:16
quote Like a sleeve gastrectomy ↗
▶ Ep 224 · 17:52
quote That's a 0.1% case ↗
▶ Ep 224 · 17:52
clinical Colons can empty well with antegrade enemas only, potentially avoiding resection ↗
▶ Ep 224 · 19:24
clinical Very often patients with mega-rectosigmoid have analplasty that is not good - either strictured, mislocated, or prolapsed ↗
▶ Ep 224 · 20:14
clinical If the anus is just strictured, making it bigger might allow the colon to decompress and improve ↗

Colorectal Quiz: Episode 46

▶ Ep 225 · 3:17
clinical Not all children with trisomy 21 have their underlying Hirschsprung disease identified early in life; some present later with constipation ↗
▶ Ep 225 · 4:46
clinical Free air is an indication to go directly to the operating room rather than attempt irrigations ↗
▶ Ep 225 · 5:52
clinical In Hirschsprung disease with perforation, the cecum perforates due to Laplace's law when the transition zone is around the hepatic flexure ↗
▶ Ep 225 · 8:11
clinical Proper irrigation involves instilling small aliquots of warm saline (20-40 mLs at a time) and evacuating it, not just infusing into the colon ↗
▶ Ep 225 · 9:52
quote Hirschsprung's is almost never an emergency operation. Almost never. And irrigations usually win the day. ↗
▶ Ep 225 · 9:52
opinion Hirschsprung disease is almost never an emergency operation; irrigations usually win the day ↗
▶ Ep 225 · 11:28
clinical Frozen section can only definitively rule out Hirschsprung disease, not confirm it, because confirmation requires 100 levels with no ganglion cells ↗
▶ Ep 225 · 11:28
quote You must have the absence of ganglion cells in 100 levels and the presence of hypertrophic nerves greater than 40 microns. And that's why frozen section will never be able to tell you for sure it is Hirschsprung's disease. It will only be able to tell you for sure it isn't Hirschsprung's disease because to know it is Hirschsprung's disease, you need 100 levels and no ganglion cells anywhere. ↗
▶ Ep 225 · 11:28
clinical Definitive diagnosis of Hirschsprung disease requires absence of ganglion cells in 100 levels and presence of hypertrophic nerves greater than 40 microns ↗
▶ Ep 225 · 15:20
opinion If a patient is being fed and irrigations are going well, they can go home; if not being fed, diversion is reasonable ↗
▶ Ep 225 · 16:14
clinical For leveling biopsies, start with sigmoid colon; if frozen section shows ganglion cells, no other biopsies are necessary ↗
▶ Ep 225 · 18:06
clinical Do not biopsy the appendix for Hirschsprung mapping; it is not helpful and many patients' appendixes are aganglionic ↗
▶ Ep 225 · 18:06
quote Do not biopsy the appendix, that's not helpful. Save the appendix for maybe future use. In fact, many patients' appendixes are a ganglionic. ↗
▶ Ep 225 · 21:01
clinical In areas without frozen section availability, strategy is to bring up the dilated portion which is more likely to be functional ↗
▶ Ep 225 · 21:01
clinical Ileostomy is not an option in many parts of the world due to risk of dehydration and limited access to medical care ↗
▶ Ep 225 · 21:56
epidemiological 80% of Hirschsprung cases are rectosigmoid disease ↗
▶ Ep 225 · 23:11
clinical Colonic mesentery may be shortened after diverting colostomy due to division and inflammation, making pull-through more difficult ↗
▶ Ep 225 · 24:15
clinical If sphincters are overstretched during pull-through, patients will not get enterocolitis but will have fecal incontinence ↗
▶ Ep 225 · 24:15
quote If you want to prevent enterocolitis, destroy the sphincters, because then you'll never get enterocolitis. ↗
▶ Ep 225 · 26:10
clinical Botox injection at one month post-pull-through did not prevent enterocolitis in a published study ↗

Colorectal Quiz: Episode 46

▶ Ep 226 · 5:52
clinical When cecal perforation occurs in Hirschsprung, the transition zone is probably somewhere around the hepatic flexure ↗
▶ Ep 226 · 8:11
clinical Proper irrigation technique involves instilling small aliquots of warm saline (20-40 mLs at a time) and evacuating it rather than just infusing into the colon lumen ↗
▶ Ep 226 · 9:52
quote Hirschsprung's is almost never an emergency operation. Almost never. And irrigations usually win the day. ↗
▶ Ep 226 · 9:52
clinical Hirschsprung disease is almost never an emergency operation ↗
▶ Ep 226 · 9:52
clinical Irrigations usually win the day in managing Hirschsprung-associated enterocolitis ↗
▶ Ep 226 · 11:28
clinical Frozen section can only definitively rule out Hirschsprung disease, not confirm it, because confirmation requires 100 levels with no ganglion cells ↗
▶ Ep 226 · 11:28
quote To know it is Hirschsprung's disease, you need 100 levels and no ganglion cells anywhere. ↗
▶ Ep 226 · 11:28
clinical Definitive pathologic diagnosis of Hirschsprung requires absence of ganglion cells in 100 levels and presence of hypertrophic nerves greater than 40 microns ↗
▶ Ep 226 · 16:14
clinical For leveling biopsies, the sigmoid is the 'money' location to start because 80% of Hirschsprung cases are rectosigmoid ↗
▶ Ep 226 · 16:33
clinical If ganglion cells are found on frozen section of sigmoid, no further biopsies are necessary ↗
▶ Ep 226 · 18:06
quote Do not biopsy the appendix, that's not helpful. Save the appendix for maybe future use. In fact, many patients' appendixes are a ganglionic. ↗
▶ Ep 226 · 18:06
guideline Do not biopsy the appendix for Hirschsprung diagnosis as it is not helpful and many patients' appendixes are aganglionic ↗
▶ Ep 226 · 21:01
clinical In resource-limited settings without easy access to healthcare, colonic ostomy is preferable to ileostomy due to dehydration risk ↗
▶ Ep 226 · 23:11
opinion Ileostomy is preferred when possible because mesentery from a diverted colostomy can be shortened and inflamed, making it harder to reach during pull-through ↗
▶ Ep 226 · 24:15
clinical Overstretching sphincters during pull-through prevents enterocolitis but causes fecal incontinence ↗
▶ Ep 226 · 24:15
quote If you want to prevent enterocolitis, destroy the sphincters, because then you'll never get enterocolitis. ↗
▶ Ep 226 · 26:10
clinical Botox at one month post-pull-through did not prevent enterocolitis in a published negative study ↗

Colorectal Quiz: Episode 43

▶ Ep 227 · 3:53
quote It's very important to know the type of malformation, the quality of the sacrum, and the quality of the spine and give the patient's family some estimate of the likelihood that they will or not be continent. ↗
▶ Ep 227 · 8:09
quote Frankly, what I learned from physics, you got to write it out every single step, prove to yourself that you can do it. And I think that's very appropriate for surgeons who are training. You've got to put yourself in the position. You got to say, can I do this by myself? Would I need help? And you got to get to that point. ↗
▶ Ep 227 · 8:09
quote I mean, I have to say, I'm sort of speechless that we're talking about physics with Jason Frischer. ↗
▶ Ep 227 · 13:21
clinical Small bowel volvulus around appendix has occurred in two or three cases ↗
▶ Ep 227 · 14:16
clinical When doing neo-Malone, try to orient catheter entry into right colon to avoid retrograde catheterization into ileum ↗
▶ Ep 227 · 20:55
clinical Appendicitis in a Malone is impossible unless the hole closes, because there is no obstruction ↗
▶ Ep 227 · 20:55
quote It's impossible. Well, unless the hole closes. Unless the hole closes. ↗
▶ Ep 227 · 21:26
clinical In South Africa they never take out the appendix as part of laparoscopic appendectomy for other conditions; it is a United States practice ↗
▶ Ep 227 · 21:26
guideline Appendix should not be removed in first Crohn's or anorectal malformation patient or child with spine issues, absent sacrum, or spina bifida ↗
▶ Ep 227 · 22:05
clinical One carcinoid tumor (neuroendocrine tumor) was found in appendiceal tip sent to pathology after Malone creation ↗

Colorectal Quiz: Episode 43

▶ Ep 228 · 3:53
quote It's very important to know the type of malformation, the quality of the sacrum, and the quality of the spine and give the patient's family some estimate of the likelihood that they will or not be continent. ↗
▶ Ep 228 · 8:09
quote Frankly, what I learned from physics, you got to write it out every single step, prove to yourself that you can do it. And I think that's very appropriate for surgeons who are training. You've got to put yourself in the position. You got to say, can I do this by myself? Would I need help? And you got to get to that point. ↗
▶ Ep 228 · 8:09
quote I mean, I have to say, I'm sort of speechless that we're talking about physics with Jason Frischer. ↗
▶ Ep 228 · 13:21
clinical Small bowel volvulus around the appendix stalk has been observed in two or three cases ↗
▶ Ep 228 · 20:55
clinical Appendicitis can only occur in a Malone if the hole closes ↗
▶ Ep 228 · 20:55
clinical Appendicitis is impossible in a patent Malone because there is no obstruction ↗
▶ Ep 228 · 21:26
clinical In South Africa, appendix is never removed as part of laparoscopic appendectomy; it is a United States practice ↗
▶ Ep 228 · 21:26
quote I will tell you, in South Africa, they never take out the appendix as part of a lads. It's just not done. It's a United States thing. ↗
▶ Ep 228 · 21:26
clinical Appendix should not be removed during other procedures in patients with Crohn's disease, anorectal malformation, spine issues, absent sacrum, or spina bifida ↗
▶ Ep 228 · 22:01
clinical Appendix tip should be sent to pathology; one case revealed a carcinoid (neuroendocrine tumor) ↗

Colorectal Quiz: Episode 40

▶ Ep 229 · 2:21
quote When you look in and you see an end of the colon and that's all you see, you do not have to do a divided colostomy. That can be the end. That can be your colostomy. ↗
▶ Ep 229 · 2:21
clinical When laparoscopy reveals a blind-ending colon with no distal segment visible, an end colostomy is preferable to a divided colostomy to preserve blood supply to the distal rectum. ↗
▶ Ep 229 · 4:08
clinical A cloaca is defined by the presence of a single perineal orifice. ↗
▶ Ep 229 · 4:08
quote We're going to have to call this a cloaca because it's a single perineal orifice. ↗
▶ Ep 229 · 5:32
clinical The anatomy in this case is similar to Meyer-Rokitansky-Küster-Hauser syndrome, with ovaries, remnant fallopian tubes, and no other Müllerian structures. ↗
▶ Ep 229 · 5:35
epidemiological Meyer-Rokitansky-like anatomy with anorectal malformation is extremely rare. ↗
▶ Ep 229 · 5:35
quote It is Meyer-Rotakansky-like in that there are ovaries, there are scrawny little tubes, probably remnants, and then nothing else. No midline structure at all. Very, very rare associated with a cloaca, extremely rare. ↗
▶ Ep 229 · 6:37
clinical The more common scenario is recto-vestibular fistula with distal vaginal atresia, where the rectum ends as a fistula in the vestibule with a normal urethra but no vagina. ↗
▶ Ep 229 · 7:18
clinical The sacral anatomy in this case appears foreshortened, suggesting caudal regression syndrome. ↗
▶ Ep 229 · 7:25
quote It looks foreshortened. It looks like everything below that level forgot to develop. ↗
▶ Ep 229 · 10:12
quote I think if I was going to divert in this case, I'd probably do an ileostomy. ↗
▶ Ep 229 · 10:12
opinion In cases with limited dissection and a colocolonic anastomosis plus simple anoplasty, not diverting can be safe without risk of anastomotic breakdown. ↗
▶ Ep 229 · 11:14
quote In the past, a vaginal replacement would have been done at the same time as the rectal repair in these patients. However, time and research have shown that colonic neovaginas are not great for patients 20 years down the road. And we should try very hard to avoid them. ↗
▶ Ep 229 · 11:14
clinical In most cloacas, the native vagina should be able to reach and vaginal replacement should be avoided. ↗
▶ Ep 229 · 11:14
opinion Colonic neovaginas are not great for patients 20 years down the road and should be avoided when possible. ↗
▶ Ep 229 · 12:46
opinion A neovagina could potentially serve as a temporary bridge to allow menstruation, with removal 20 years later when tissue engineering options become available. ↗
▶ Ep 229 · 13:21
clinical Using the colon in this case for vaginal replacement would be risky due to compromised blood supply from the prior divided stoma. ↗
▶ Ep 229 · 15:11
quote I vividly remember a case where we encountered an aberrant external iliac artery that looped up and actually was within the abdominal wall and looked very much like the obliterated umbilical artery and in fact was a blood supply to one of the extremities. ↗
▶ Ep 229 · 15:11
clinical Vascular anomalies associated with anorectal malformations are under-recognized and poorly documented in the literature. ↗
▶ Ep 229 · 17:13
clinical The odds of fecal continence for this child are concerning given the sacral anatomy, though sphincter stimulation response was very good. ↗
▶ Ep 229 · 17:13
quote I also think looking at this, the odds of continence for this child are concerning. ↗

Colorectal Quiz: Episode 40

▶ Ep 230 · 2:21
clinical When you see a blind ending piece of colon during initial laparoscopy, the best approach is to use that as your end stoma rather than doing a divided colostomy to avoid interfering with blood supply to the distal segment ↗
▶ Ep 230 · 2:21
quote When you look in and you see an end of the colon and that's all you see, you do not have to do a divided colostomy. That can be the end. That can be your colostomy. ↗
▶ Ep 230 · 4:08
quote We're going to have to call this a cloaca because it's a single perineal orifice. ↗
▶ Ep 230 · 6:23
clinical The more common scenario in anorectal malformation with absent vagina is a recto-vestibular fistula with completely normal urethra but no vagina in between, which would be called recto-vestibular fistula with distal vaginal atresia ↗
▶ Ep 230 · 7:50
quote Put your thinking caps on, everybody. What shall we do before Chris gives the big reveal? ↗
▶ Ep 230 · 8:31
quote This was obviously a surprise. You couldn't safely dig through all those pulsating vessels with laparoscopes, right? ↗
▶ Ep 230 · 10:12
clinical In this case with limited dissection and a colocolonic anastomosis at the colostomy closure site plus an analplasty with a couple of posterior sutures, not diverting is a safe decision ↗
▶ Ep 230 · 11:14
clinical In most cloacas, you should be able to get the native vagina to reach, avoiding the need for vaginal replacement ↗
▶ Ep 230 · 11:14
opinion Colonic neovaginas are not great for patients 20 years down the road and should be avoided if possible ↗
▶ Ep 230 · 11:14
quote In the past, a vaginal replacement would have been done at the same time as the rectal repair in these patients. However, time and research have shown that colonic neovaginas are not great for patients 20 years down the road. And we should try very hard to avoid them. ↗
▶ Ep 230 · 11:56
opinion Tissue engineering options for vaginal reconstruction are expected to be available within 20 years or potentially shorter ↗
▶ Ep 230 · 11:56
clinical Buccal graft can be laid into the opened introital area as an option for vaginal reconstruction ↗
▶ Ep 230 · 12:46
clinical A neovagina could be provided as a temporary bridge to allow menstruation, then potentially removed 20 years later when better options become available ↗
▶ Ep 230 · 15:11
clinical Vascular anomalies associated with anorectal malformation are a topic that has never been much written about ↗
▶ Ep 230 · 15:11
clinical Aberrant external iliac artery can loop up within the abdominal wall and look like the obliterated umbilical artery while actually supplying blood to an extremity ↗

Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies

▶ Ep 231 · 0:50
quote It's been a while since we've done one of these, I forgot what you look like, Mark. ↗
▶ Ep 231 · 3:53
clinical The patient had a perineal fistula with meconium visible along the scrotal raphae ↗
▶ Ep 231 · 4:06
clinical Presence of an anal dimple, raised area, and good color change suggests a good sphincter ↗
▶ Ep 231 · 4:41
quote Let me say that I don't stand in the way when the NICU gets an echo. I routinely get them all. ↗
▶ Ep 231 · 6:32
clinical In males, perineal fistula dilation is more dangerous because the opening is near the urethra ↗
▶ Ep 231 · 6:32
quote I think we have to talk about two things. One is, does the baby need to go to the OR? Perhaps if you could dilate this patient, you don't need to go to the OR at all. Let them deal with the heart. ↗
▶ Ep 231 · 6:32
clinical Dilation without operating room intervention is possible for perineal fistula, especially in females with vestibular fistula ↗
▶ Ep 231 · 8:15
quote So I actually don't think there's a need to do a colostomy in a baby like this. You can dilate and then do the repair primarily later. ↗
▶ Ep 231 · 9:43
clinical A turnable loop ostomy (95-5 percentage loop) behaves like an end colostomy but allows distal contrast studies ↗
▶ Ep 231 · 10:14
quote Can you share with us some tricks you have for a baby like this in laparoscopy? What pressures do you set it at? Where do you put your ports? How do you do it quickly? ↗
▶ Ep 231 · 10:50
clinical If umbilical line is present, Palmer's Point access with Hasson technique is an alternative to umbilical access ↗
▶ Ep 231 · 12:33
clinical Sacral ratio measurement should wait until three months of age ↗
▶ Ep 231 · 12:33
clinical Low anorectal malformations (perineal fistula) should have good continence prognosis ↗
▶ Ep 231 · 12:33
clinical Continence depends on sensation in anal canal, absence of dentate line, spine anatomy, type of ARM, and sacral anatomy ↗
▶ Ep 231 · 13:56
clinical The fistula tract along the median raphae was left alone because the perineal fistula did not extend up into the raphae itself ↗
▶ Ep 231 · 14:10
clinical The fistula tract is only one millimeter deep and should not be aggressively pursued surgically ↗
▶ Ep 231 · 14:10
quote Do not dive in and try to find that fistula's tract. It will disappear, provided you have a good anoplasty with a good anterior rectal wall mobilization. ↗
▶ Ep 231 · 14:57
clinical If fistula is completely outside the sphincteric ellipse, full mobilization is required ↗

Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies

▶ Ep 232 · 4:06
quote That means there's probably a good sphincter. ↗
▶ Ep 232 · 4:06
clinical An anal dimple with raised area and good color change indicates there is probably a good sphincter ↗
▶ Ep 232 · 6:03
clinical Dilation without going to the OR might be a good choice in a baby you don't want to take to the operating room ↗
▶ Ep 232 · 6:32
clinical In a female patient with vestibular or perineal fistula, there is no rush to operate ↗
▶ Ep 232 · 6:32
clinical In a male, the perineal hole is not always easy to see and dilation is more dangerous because it is near the urethra ↗
▶ Ep 232 · 6:32
quote I think we have to talk about two things. One is, does the baby need to go to the OR? Perhaps if you could dilate this patient, you don't need to go to the OR at all. Let them deal with the heart. ↗
▶ Ep 232 · 6:32
clinical With care and Hagar dilators, you can get egressive stool and never go to the OR ↗
▶ Ep 232 · 8:13
clinical There is no need to do a colostomy in a baby with perineal fistula and cardiac disease; you can dilate and do the repair primarily later ↗
▶ Ep 232 · 8:15
quote So I actually don't think there's a need to do a colostomy in a baby like this. You can dilate and then do the repair primarily later. ↗
▶ Ep 232 · 9:43
clinical A turnable loop ostomy behaves like an end ostomy with a 95-5 percentage split, and no one knows except the surgeon that there is another side where you can do a contrast study ↗
▶ Ep 232 · 9:43
quote Sort of a 95-5 percentage loop. It behaves like an end. And no one knows except for you that there's another side there you can do a contrast. ↗
▶ Ep 232 · 11:08
clinical When accessing the umbilicus, dissect in with a mosquito, make sure you are in without touching any vessel before insufflation, and clear the line of air ↗
▶ Ep 232 · 11:21
clinical A technique for distal irrigation involves having someone look laparoscopically while passing a tube into the distal segment and performing irrigation under direct visualization ↗
▶ Ep 232 · 14:02
clinical Pearls along the raphae can persist into teenage years and young adulthood if not addressed ↗
▶ Ep 232 · 14:02
clinical The pearls along the median raphae should be scraped off at about one millimeter depth; do not dive in to find the fistula tract as it will disappear with good anoplasty and anterior rectal wall mobilization ↗
▶ Ep 232 · 14:02
quote I've seen teenagers and young adults with those beads that never went away. So, yeah, you've got to scrape that off. It's one millimeter deep. Do not dive in and try to find that fistula's tract. It will disappear, provided you have a good anoplasty with a good anterior rectal wall mobilization. ↗
▶ Ep 232 · 14:23
clinical When 50% of the fistula is within the muscle complex and 50% is anterior, leave the anterior wall (the danger zone) and mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction ↗
▶ Ep 232 · 14:23
clinical If the fistula is completely outside the sphincteric ellipse, a full mobilization must be performed ↗

Colorectal Quiz Episode 29: Female ARM

▶ Ep 233 · 1:13
clinical Alberto Pena historically kept patients mandatory NPO for seven days with central line and hyperalimentation, feeding on day seven if healed ↗
▶ Ep 233 · 2:31
quote why exactly are you keeping these patients NPO? And I said, well, because I don't want them to stool. Because if they stool, they're more likely to dehisc their perineal body. And the fellow said, you know, they still stool, even if they're NPO. And I said, yes, but not as much. And he said, this was Carlos Reck, who's now the premier colorectal surgeon in Austria. He said, I think it's about the same. ↗
▶ Ep 233 · 2:31
clinical A study comparing NPO for seven days versus clear liquids for seven days showed the same amount of stool output in both groups ↗
▶ Ep 233 · 3:30
clinical Hard stool passage, not stool passage itself, is the primary risk factor for perineal body dehiscence ↗
▶ Ep 233 · 3:30
quote it's not the pooping that's the problem. It's the hard pooping that's the problem. ↗
▶ Ep 233 · 4:00
clinical Current protocol uses regular IV (no PICC line) and clear liquids or breast milk for five days, with better healing observed by day five than day one or two ↗
▶ Ep 233 · 4:00
quote I have yet to see an article that says post-up day one, regular diet, not breast milk, regular diet, like, you know, food or formula and a very low dehiscence rate. ↗
▶ Ep 233 · 5:23
clinical Perineal body dehiscence usually leads to no perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it ↗
▶ Ep 233 · 6:27
clinical Patients who required redo surgery for perineal body dehiscence were invariably fed right away and discharged home ↗
▶ Ep 233 · 9:05
clinical A randomized controlled trial of dilation versus non-dilation for primary PSARP (cloacas excluded) showed stricture rates of 10-20% in both groups ↗
▶ Ep 233 · 10:40
clinical Many patients' anoplasties look absolutely fine eight weeks later at colostomy closure if never touched with a dilator, when the anoplasty is healthy with no tension and good blood supply ↗
▶ Ep 233 · 10:40
clinical The backup plan for stricture in the non-dilation group was aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty, often performed at the time of colostomy closure ↗
▶ Ep 233 · 11:52
quote what is their biggest concern relative to care of patients with an anorectal malformation. And by far, number one was dilations. ↗
▶ Ep 233 · 11:52
epidemiological Family survey identified dilations as by far the number one concern relative to care of patients with anorectal malformation ↗
▶ Ep 233 · 13:48
clinical Jack Langer's protocol involves seeing patients weekly in clinic and passing a dilator without having families do it at home ↗
▶ Ep 233 · 16:16
clinical Data exists showing patients can be restored to full continence with a redo operation for stricture indication ↗
▶ Ep 233 · 17:36
quote I have yet to meet a family that has chosen dilation. ↗
▶ Ep 233 · 17:36
epidemiological In the dilation study, no family has yet chosen dilation when presented with the option ↗
▶ Ep 233 · 19:37
clinical For redo operations, anoplasties are made slightly larger knowing there will be some contraction, and these patients are not dilated postoperatively but undergo EUA at one month to check for early stricture ↗
▶ Ep 233 · 21:00
clinical For primary repairs, the analplasty lumen is made to match what the maximal rectal lumen can be, filling the sphincter, typically resulting in size 13 or 14 Hegar ↗

Colorectal Quiz Episode 29: Female ARM

▶ Ep 234 · 1:13
quote So are you trying to say that I am a conservative surgeon because I may have a different protocol ↗
▶ Ep 234 · 1:13
clinical Alberto Pena's original protocol required mandatory NPO for 7 days with central line and hyperalimentation, feeding only on day 7 if healed ↗
▶ Ep 234 · 1:13
clinical Breast milk does not cause constipation, while regular diet or formula causes more constipation ↗
▶ Ep 234 · 2:31
clinical A study comparing NPO for 7 days versus clear liquids for 7 days found the same amount of stool output in both groups ↗
▶ Ep 234 · 2:31
quote why exactly are you keeping these patients NPO? And I said, well, because I don't want them to stool. Because if they stool, they're more likely to dehisc their perineal body. ↗
▶ Ep 234 · 3:00
quote you know, they still stool, even if they're NPO. And I said, yes, but not as much. And he said, this was Carlos Reck, who's now the premier colorectal surgeon in Austria. He's in Vienna. He said, I think it's about the same. ↗
▶ Ep 234 · 3:30
quote it's not the pooping that's the problem. It's the hard pooping that's the problem. ↗
▶ Ep 234 · 3:30
clinical The problem is not pooping itself but passage of hard stool that can disrupt the perineal body anastomosis ↗
▶ Ep 234 · 4:00
quote anyone who does feeding right away needs to keep track of their dehiscence rate and publish it. And I have yet to see an article that says post-up day one, regular diet, not breast milk, regular diet, like, you know, food or formula and a very low dehiscence rate. ↗
▶ Ep 234 · 5:23
clinical Perineal body dehiscence usually leads to no perineal body over several months and requires redo surgery because the anterior anoplasty has no sphincter around it ↗
▶ Ep 234 · 5:40
quote the key to this will be as minimal amount of perineal body injury by surgery as possible. ↗
▶ Ep 234 · 6:10
clinical Patients who required redo surgery for dehiscence were invariably fed right away and discharged home ↗
▶ Ep 234 · 8:22
clinical NPO patients still stool very thin and liquidy stool that does not disrupt the anastomosis ↗
▶ Ep 234 · 9:05
clinical A randomized controlled trial of dilation versus non-dilation for primary PSARP (excluding cloacas) showed stricture rates of 10-20% in both groups ↗
▶ Ep 234 · 9:40
clinical The backup plan for strictures in the non-dilation group was aggressive dilations under anesthesia or Heineke-Mikulicz anoplasty ↗
▶ Ep 234 · 10:40
clinical Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if never touched with a dilator ↗
▶ Ep 234 · 11:20
epidemiological When families were asked their biggest concern about anorectal malformation care, dilations were number one by far ↗
▶ Ep 234 · 11:20
quote what prompted the paper was to ask the families what is their biggest concern relative to care of patients with an anorectal malformation. And by far, number one was dilations. ↗
▶ Ep 234 · 13:48
clinical Jack Langer's protocol involves seeing patients weekly in clinic and passing a dilator without having families do it at home ↗
▶ Ep 234 · 14:04
clinical Four patients in the dilation study required redo operations for stricture: two in the dilation arm (both chose not to dilate) and two in the non-dilation arm ↗
▶ Ep 234 · 16:56
quote I have yet to meet a family that has chosen dilation. ↗
▶ Ep 234 · 19:37
clinical Making anoplasties slightly larger in resource-limited settings where patients will not return for follow-up accounts for expected contraction ↗
▶ Ep 234 · 20:00
quote this patient will not be coming back for any follow-up. So, therefore, he likes to make the analplasty... I make my analplasties a little bit bigger so that I know everything's going to be fine when it contracts a little bit. ↗
▶ Ep 234 · 20:30
clinical For primary repairs, the anoplasty lumen is made to match what the maximal rectal lumen can be, filling the sphincter, typically resulting in size 13-14 Hegar ↗
▶ Ep 234 · 20:30
clinical For redo operations, anoplasties are intentionally made larger knowing there will be contraction, and these are not dilated but examined under anesthesia at one month ↗

The Colorectal Quiz Episode 21: The History of Hirschsprung Disease

▶ Ep 236 · 0:26
quote thank you very much for promoting the Swenson. He was 105 when he died. Please tell everybody that it's a good operation ↗
▶ Ep 236 · 0:26
clinical Doing a proper Swenson right on the bowel wall, similar to a PSARP, avoids nerve injury; if you see fat, you can get closer, as the nerves are in the fatty layer ↗
▶ Ep 236 · 0:26
clinical Duhamel's technique leaves the original rectum behind and does a pull through next to it, then mates the two lumens ↗
▶ Ep 236 · 0:26
opinion The Duhamel technique is now only appropriate for an ilio Duhamel, though the speaker would still do an ilioanal ↗
▶ Ep 236 · 0:26
clinical Rabine did a low anterior resection for Hirschsprung disease, leaving about six centimeters behind, and some patients did fine with ganglionated bowel pooping through the aganglionated segment ↗
▶ Ep 236 · 0:26
quote it is Hirschsprung disease, not apostrophe S ↗
▶ Ep 236 · 0:26
quote those are basically Suavesons with a one centimeter cuff ↗
▶ Ep 236 · 0:26
quote you guys are wrong. It's a good operation. You're doing it wrong. You're dissecting too wide ↗
▶ Ep 236 · 0:26
quote If you see fat, you can get closer ↗
▶ Ep 236 · 0:26
guideline The disease is named Hirschsprung disease, not apostrophe S ↗
▶ Ep 236 · 0:26
clinical Harold Hirschsprung figured out that a baby could be sick due to this problem, but he did not understand the pathology ↗
▶ Ep 236 · 0:26
clinical Orvar Swenson figured out the pathology and defined the fact that there were no ganglion cells ↗
▶ Ep 236 · 0:26
clinical Prior to Swenson's work, removal of the dilated colon was the treatment, which was a mistake because it was the distal colon, the narrow colon that was the problem ↗
▶ Ep 236 · 0:26
clinical Swenson developed the first operation for Hirschsprung disease, which is a full thickness rectal dissection ↗
▶ Ep 236 · 0:26
clinical Dr. Yancey was the first surgeon who described a submucosal dissection for Hirschsprung disease, but published in a journal that not many people read ↗
▶ Ep 236 · 0:26
clinical Dr. Suave published his article on submucosal dissection years later in a journal that more people read, so the technique bears his name rather than Yancey's ↗
▶ Ep 236 · 0:26
clinical The Suave technique was developed because people said the Swenson caused fecal and urinary incontinence or voiding dysfunction, though Swenson argued they were doing the dissection too wide ↗
▶ Ep 236 · 5:57
quote you know, Mark, there is a field called pediatric surgery. You could do both ↗
▶ Ep 236 · 5:57
clinical Dr. Boley was the first to do the primary coloanal anastomosis of a Suave, eliminating the need to leave bowel hanging out and return at day seven ↗
▶ Ep 236 · 5:57
guideline The proper description is the Suave technique with the Boley modification, or Suave-Boley ↗
▶ Ep 236 · 5:57
clinical Henry So was the first surgeon to do a primary pull-through, a trans-abdominal procedure with no preceding stoma ↗
▶ Ep 236 · 5:57
epidemiological So performed primary pull-throughs because patients with stomas in the Philippines faced such social stigma that babies were basically left to die by their families ↗
▶ Ep 236 · 10:34
clinical Martin did total proctocolectomy using endorectal techniques from Hirschsprung disease and performed ilioanal anastomosis for ulcerative colitis, before the J pouch modified that technique ↗
▶ Ep 236 · 10:34
clinical The transanal dissection and Suave plane dissection is the same concept as the mucosectomy in ulcerative colitis ↗
▶ Ep 236 · 10:34
clinical Martin published in 1977, before the J pouch, taking the endorectal pull through used for Hirschsprung disease and transferring that technique to ulcerative colitis treatment ↗
▶ Ep 236 · 11:41
clinical Helen Noblet figured out the suction rectal biopsy and is from Melbourne, Australia ↗
▶ Ep 236 · 11:41
clinical Keith Jorgensen did the laparoscopic version of the Suave, with Tom Inge on the original paper ↗
▶ Ep 236 · 11:41
opinion In Jorgensen's original description, they talked about leaving a five centimeter cuff, which nowadays would be way too much ↗
▶ Ep 236 · 11:41
clinical Jack Langer and Luis de la Torre approached Hirschsprung surgery transanally, doing transanal resection of the rectosigmoid with or without laparoscopy or laparotomy ↗
▶ Ep 236 · 11:41
opinion Some places around the world are doing transanal only approaches, and the speaker does that in certain circumstances ↗
▶ Ep 236 · 11:41
clinical Dan Teitelbaum did an incredible amount of work in Hirschsprung disease, particularly significant research in enterocolitis, before passing away from a brain tumor ↗
▶ Ep 236 · 14:13
quote I invited Dr. Hirschsprung's, but he could not make it ↗

Colorectal Quiz Episode 18: Cloaca Part 2

▶ Ep 237 · 14:04
clinical Hardy Hendren was the father of cloacal management in the late 1960s and 70s with specific focus on urology and urethral reconstruction ↗
▶ Ep 237 · 14:35
clinical Alberto Pena developed total urogenital mobilization (TUM) in 1996 as a major advance, keeping urethra and vagina together as a unit to mobilize forward ↗
▶ Ep 237 · 14:50
clinical Prior to 1996, all cloacal patients underwent urogenital separation ↗
▶ Ep 237 · 15:14
clinical The algorithm using common channel length of 3 cm and urethral length of 1.5 cm as decision points was presented in 2017 and represents the next major change after TUM ↗
▶ Ep 237 · 16:10
opinion Hardy Hendren at age 91 endorsed the 2017 algorithm at APSA, stating he agreed with everything presented ↗
▶ Ep 237 · 16:50
quote I just want everyone in the room to know who just asked that incredible question. And I want to give him credit for 50 years of work on this very challenging problem. ↗
▶ Ep 237 · 18:13
clinical The major change in the 2017 algorithm was ensuring measurement of urethral length, whereas previously only common channel length (<3 cm or >3 cm) was considered ↗
▶ Ep 237 · 18:13
quote The major change in this presentation was to make sure you measure the urethral length. Because before that, it was common channel less than 3 or greater than 3 and that was it. ↗

Colorectal Quiz Episode 17: Cloaca Part 1

▶ Ep 238 · 11:08
clinical When catheterizing the common channel, you are more likely to get into the vagina than the bladder due to the anatomy of the urethral takeoff ↗
▶ Ep 238 · 13:11
clinical When the hydrocolpos is drained, the bladder fills, demonstrating that the hydrocolpos was obstructing the ureters ↗
▶ Ep 238 · 13:59
opinion A vesicostomy is the wrong move in almost every cloaca; the hydrocolpos needs to be drained instead ↗
▶ Ep 238 · 13:59
quote A vesicostomy is the wrong move here. In almost every cloaca, a vesicostomy is not necessary, but the hydrocolpos needs to be drained. ↗
▶ Ep 238 · 21:37
clinical For massive hydrocolpos requiring open vaginostomy, use a lower midline incision to get above the hydrocolpos, which is very adherent to the anterior abdominal wall and inflamed ↗
▶ Ep 238 · 22:51
guideline A single perineal orifice with no anal opening is a cloaca and does not need an endocrine workup, whereas a perineal opening with a normal anus is a urogenital sinus and does need an endocrine workup ↗
▶ Ep 238 · 23:40
quote A single perineal orifice with no anal opening is a cloaca and does not need an endocrine workup, whereas a perineal opening with a normal anus is a urogenital sinus and does need an endocrine workup. ↗
▶ Ep 238 · 23:40
clinical Urogenital sinus patients can also have hydrocolpos and hydronephrosis, requiring similar management but without colostomy ↗

The Colorectal Quiz Episode 4

▶ Ep 239 · 6:33
clinical Transanal dissection should take under one hour in a primary pull-through ↗
▶ Ep 239 · 8:16
clinical Port placement includes umbilical port, right lower and upper quadrant ports, with camera switched to right upper quadrant ↗
▶ Ep 239 · 11:42
clinical Must stay right on the bowel during dissection because too wide dissection of distal rectum causes incontinence and urinary retention from nerve injury ↗
▶ Ep 239 · 11:42
quote You need to be right on the bowel. Because in the old days, the old Swenson done through the abdomen, patients were incontinent, non-infrequently, and they had urinary retention, non-frequently. And I believe that it was related to a too wide of a dissection of the distal rectum and an injury to the nerve arogenic case. ↗
▶ Ep 239 · 12:35
clinical For distal disease, can take just distal branches of IMA; for left colon involvement may need to take IMA to get reach ↗
▶ Ep 239 · 14:12
quote My preference is a Swenson, full thickness, looking for the areolar plane. It's basically a bloodless plane. I don't like the submucosal dissection because I don't want to leave a cuff. ↗
▶ Ep 239 · 14:12
opinion Preference is Swenson full thickness dissection in areolar plane which is bloodless, not submucosal dissection with cuff ↗
▶ Ep 239 · 14:12
clinical If doing a cuff, make it very short (about one centimeter) and must split the cuff ↗

Colorectal Quiz: Episode 2

▶ Ep 240 · 1:34
quote How many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? ↗
▶ Ep 240 · 4:30
clinical The original malformation in case 1 was a prostatic fistula ↗
▶ Ep 240 · 4:40
clinical Case 1 patient has a tethered cord and a middle-of-the-road sacral ratio of 0.66 ↗
▶ Ep 240 · 5:50
quote I can tell you, the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work, and is the child going to be clean and in normal underwear, and just like all the other kids. ↗
▶ Ep 240 · 5:50
opinion The family doesn't really care how technically elegant is your anorectoplasty, they care about whether the child is going to be clean and in normal underwear ↗
▶ Ep 240 · 6:15
clinical The higher the malformation, the worse the prognosis ↗
▶ Ep 240 · 6:25
clinical Sacral ratio 0.7 or greater usually means normal or close to normal sphincters ↗
▶ Ep 240 · 6:40
clinical A good sacrum represents good muscle tone and spine innervation of that area ↗
▶ Ep 240 · 6:55
clinical The most common associated spinal anomaly is tethered cord, but the worst is myelomeningocele ↗
▶ Ep 240 · 7:50
clinical It's amazingly common to have a mislocated anus ↗
▶ Ep 240 · 7:50
quote It's amazingly common to have a mislocated anus. ↗
▶ Ep 240 · 8:00
quote A key pitfall is not do that. Mark the sphincters first, then open the PSARP, because then you don't get confused at the end when you're trying to place the analplasty in the correct location. ↗
▶ Ep 240 · 8:00
clinical A key pitfall is opening the PSARP incision first rather than marking the sphincters first ↗
▶ Ep 240 · 8:40
clinical Case 2 patient was born with a vestibular fistula with normal spine and excellent sacrum ↗
▶ Ep 240 · 8:55
clinical Case 2 is a much better prognosis bowel control patient but with similar anatomic problem ↗
▶ Ep 240 · 9:50
clinical The electrical stimulator is the same one that anesthesia uses for their train of four ↗
▶ Ep 240 · 10:00
clinical You have to tell your anesthesiologist not to give skeletal muscle relaxant because the stimulator is weaker than the traditional expensive stimulator ↗
▶ Ep 240 · 12:00
clinical The vast majority of redo operations were for mislocation, then stricture, then less common reasons including remnant fistula and rectal prolapse ↗
▶ Ep 240 · 12:30
clinical Quality of life improved with a redo operation ↗
▶ Ep 240 · 12:40
clinical Patients had improved ability to achieve continence after redo ↗
▶ Ep 240 · 12:55
clinical 20% of patients with a poor sacrum or poor spine developed bowel control after their redo ↗
▶ Ep 240 · 13:10
clinical Patients with good potential (good sacrum and spine) did extremely well after redo ↗
▶ Ep 240 · 13:15
clinical Patients who did not develop voluntary bowel movements were still able to be clean with bowel management program using enemas or antegrade Malone ↗
▶ Ep 240 · 13:21
epidemiological The average age of patients in the study is about three and a half years ↗
▶ Ep 240 · 13:40
opinion There's an advantage to getting the anatomy right the younger the child is ↗
▶ Ep 240 · 13:50
opinion For a two-year-old with mislocated anus or bad prolapse, redo should be offered to let them live with better anatomy in diapers for a year or two before potty training ↗
▶ Ep 240 · 14:10
clinical Many patients present after potty training age because they're incontinent, and evaluation reveals the anus isn't in the right place ↗
▶ Ep 240 · 14:30
clinical For older presenting patients, a Malone is usually added at the time of redo so they can learn control with new anatomy before stopping flushes ↗
▶ Ep 240 · 14:48
clinical The process of learning control with new anatomy may take six to 12 months ↗

The Colorectal Quiz Episode 4

▶ Ep 241 · 10:19
clinical Frozen section biopsy must include submucosa to avoid missing hypertrophic nerves in submucosal layer ↗
▶ Ep 241 · 11:42
quote You need to be right on the bowel. Because in the old days, the old Swenson done through the abdomen, patients were incontinent, non-infrequently, and they had urinary retention, non-frequently. And I believe that it was related to a too wide of a dissection of the distal rectum and an injury to the nerve arogenic case ↗
▶ Ep 241 · 11:42
clinical Historical Swenson operations done through abdomen with wide distal rectal dissection caused incontinence and urinary retention from nerve injury ↗
▶ Ep 241 · 14:12
quote My preference is a Swenson, full thickness, looking for the areolar plane. It's basically a bloodless plane. I don't like the submucosal dissection because I don't want to leave a cuff ↗
▶ Ep 241 · 14:12
clinical If Soave muscular cuff is used it should be very short, approximately one centimeter, and must be split ↗
▶ Ep 241 · 14:12
clinical Swenson full-thickness dissection follows areolar plane which is essentially bloodless ↗

Colorectal Quiz: Episode 2

▶ Ep 242 · 1:34
quote How many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? ↗
▶ Ep 242 · 4:30
clinical The first case patient has a rectal prostatic fistula as the original malformation ↗
▶ Ep 242 · 4:40
clinical The first case patient has a tethered cord ↗
▶ Ep 242 · 4:45
clinical The first case patient has a sacral ratio of 0.66 ↗
▶ Ep 242 · 5:50
clinical The higher the malformation, the worse the prognosis ↗
▶ Ep 242 · 5:55
quote I can tell you, the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work, and is the child going to be clean and in normal underwear, and just like all the other kids. ↗
▶ Ep 242 · 6:00
clinical A sacral ratio of 0.7 or greater usually means normal or close to normal sphincters ↗
▶ Ep 242 · 6:50
clinical Patients with myelomeningocele have much more trouble with continence than those with tethered cord ↗
▶ Ep 242 · 7:50
clinical It's amazingly common to have a mislocated anus ↗
▶ Ep 242 · 7:50
quote It's amazingly common to have a mislocated anus. ↗
▶ Ep 242 · 8:00
quote I think a key pitfall is not do that. Mark the sphincters first, then open the PSARP, because then you don't get confused at the end when you're trying to place the analplasty in the correct location. ↗
▶ Ep 242 · 8:00
clinical A key pitfall is opening the PSARP incision first rather than marking the sphincters first ↗
▶ Ep 242 · 8:40
clinical The second case patient was born with a vestibular fistula, has normal spine and excellent sacrum ↗
▶ Ep 242 · 9:40
clinical The electrical stimulator used is the same one anesthesia uses for train of four ↗
▶ Ep 242 · 10:00
clinical Anesthesiologists should not give skeletal muscle relaxant when using the stimulator because it's weaker than traditional stimulators ↗
▶ Ep 242 · 11:50
clinical The vast majority of redo operations were for mislocation ↗
▶ Ep 242 · 12:00
clinical Stricture was the second most common reason for redo operations ↗
▶ Ep 242 · 12:10
clinical Less common reasons for redo included remnant of original fistula (roof), rectal prolapse, and others ↗
▶ Ep 242 · 12:30
clinical Quality of life improved with a redo operation ↗
▶ Ep 242 · 12:40
clinical Patients had improved ability to achieve continence after redo ↗
▶ Ep 242 · 12:55
clinical 20% of patients with a poor sacrum or poor spine developed bowel control after their redo ↗
▶ Ep 242 · 13:10
clinical Patients with good potential (good sacrum and spine) did extremely well after redo ↗
▶ Ep 242 · 13:10
epidemiological The average age of patients in the study was about three and a half years ↗
▶ Ep 242 · 13:20
clinical Patients who did not develop voluntary bowel movements were still able to be clean with bowel management program using enemas or antegrade Malone ↗
▶ Ep 242 · 13:40
opinion There is an advantage to getting the anatomy right the younger the child is ↗
▶ Ep 242 · 14:30
clinical The process of learning to achieve control with new anatomy after redo may take six to 12 months ↗

The Colorectal Quiz: Episode 1

▶ Ep 243 · 1:50
quote This is a full term baby seems to be perfused well, breathing room air, and obviously no anal opening. But I will tell you, it looks like there might be something there, but there's not. There's no meconium that has passed. And now we are at about 20 hours of life. ↗
▶ Ep 243 · 3:01
clinical Plain x-ray of the abdomen can identify vertebral abnormalities including hemivertebra in anorectal malformation workup ↗
▶ Ep 243 · 3:01
clinical True sacral ratio measurements should wait until the child is three months of age ↗
▶ Ep 243 · 3:01
clinical Kidney ultrasound is needed to evaluate for renal abnormalities in anorectal malformation patients ↗
▶ Ep 243 · 3:01
clinical NG tube should be passed to rule out esophageal atresia in anorectal malformation workup ↗
▶ Ep 243 · 3:01
clinical Cardiac evaluation should include both physical exam and echocardiogram in anorectal malformation patients ↗
▶ Ep 243 · 3:01
clinical VACTERL mnemonic stands for: V (vertebral abnormalities), A (anorectal malformations), C (cardiac abnormalities), E (esophageal atresia), R (renal abnormalities), and L (limb abnormalities) ↗
▶ Ep 243 · 4:15
quote I always worry about a missed pre-sacral mass. ↗
▶ Ep 243 · 7:08
clinical Sacral ratio greater than 0.7 connotes a very good prognosis for bowel control ↗
▶ Ep 243 · 9:11
quote Because the danger is that you go in posterior sagittally, you don't know where the rectum is, and you find something midline and white, like the urethra or the bladder neck or the bladder itself. And that's why we do colostomies. ↗
▶ Ep 243 · 9:11
clinical The danger of posterior sagittal approach without knowing rectal location is finding something midline and white like the urethra, bladder neck, or bladder itself ↗
▶ Ep 243 · 9:11
clinical Colostomy and distal colostogram are done to know exactly where the rectum is and whether to approach it perineally or laparoscopically ↗
▶ Ep 243 · 9:11
quote I think the key to deciding whether to dive into a perineon posterior sagittally is where is the rectum? You want to know what structure you will find if you make a posterior sagittal or even a mini posterior sagittal incision. ↗
▶ Ep 243 · 10:16
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy. And I want to tell you, that was the safe thing to do. Bravo to them. That was the right choice. ↗
▶ Ep 243 · 10:16
clinical Colostomy carries its own complications, as does colostomy closure ↗
▶ Ep 243 · 10:54
quote I've seen this done by some very good surgeons where they went in, did a beautiful analplasty, but ignored the fistula. And the child down the road started peeing out their anus. ↗
▶ Ep 243 · 10:54
clinical If a primary anoplasty is performed without identifying a fistula, the child can start peeing out their anus postoperatively ↗
▶ Ep 243 · 12:00
quote When I do that, I open up the posterior wall of the rectum, and I inspect the anterior wall of the rectum. ↗
▶ Ep 243 · 12:00
clinical During primary posterior sagittal approach, the posterior wall of the rectum should be opened and the anterior wall inspected to rule out fistula ↗
▶ Ep 243 · 13:15
epidemiological 95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula ↗
▶ Ep 243 · 13:15
quote 95% of Downs patients have no fistula, but 5% do. So I would still do a distal colostogram and some of them might have a fistula. ↗
▶ Ep 243 · 13:15
clinical Distal colostogram should still be performed in Down syndrome patients with anorectal malformation despite lower fistula prevalence ↗

The Colorectal Quiz: Episode 1

▶ Ep 244 · 3:01
quote I always worry about a missed pre-sacral mass. ↗
▶ Ep 244 · 3:01
clinical VACTERL mnemonic stands for: V (vertebral abnormalities), A (anorectal malformations), C (cardiac abnormalities), E (esophageal atresia), R (renal abnormalities), L (limb abnormalities) ↗
▶ Ep 244 · 3:01
clinical Plain x-ray of the abdomen can identify vertebral abnormalities including hemivertebra ↗
▶ Ep 244 · 3:01
clinical Cardiac workup should include both physical exam and echocardiogram ↗
▶ Ep 244 · 3:01
clinical NG tube should be passed to rule out esophageal atresia ↗
▶ Ep 244 · 3:01
clinical Kidney ultrasound is needed to evaluate for renal abnormalities ↗
▶ Ep 244 · 3:01
clinical True sacral ratio measurements should wait until the child is three months of age ↗
▶ Ep 244 · 7:08
clinical Sacral ratio greater than 0.7 connotes very good prognosis for bowel control ↗
▶ Ep 244 · 7:08
quote They want to know what's going to happen to this baby in four years when they need to potty train and go to school. ↗
▶ Ep 244 · 9:11
clinical Colostomy and distal colostogram allow knowing exactly where rectum is and whether to approach perineally or laparoscopically ↗
▶ Ep 244 · 9:11
quote Because the danger is that you go in posterior sagittally, you don't know where the rectum is, and you find something midline and white, like the urethra or the bladder neck or the bladder itself. And that's why we do colostomies. And that's why we do distal colostograms. So we know exactly where the rectum is, and we know whether we should approach it perineally or whether we should do it laparoscopically. ↗
▶ Ep 244 · 9:11
clinical The danger of posterior sagittal approach without knowing rectal location is finding midline white structures like urethra, bladder neck, or bladder itself ↗
▶ Ep 244 · 10:16
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy. And I want to tell you, that was the safe thing to do. Bravo to them. That was the right choice. Nothing wrong with that at all. ↗
▶ Ep 244 · 10:16
clinical Colostomy carries its own complications, as does colostomy closure ↗
▶ Ep 244 · 10:54
clinical If fistula is ignored during primary anaplasty, child can start peeing out their anus postoperatively ↗
▶ Ep 244 · 10:54
quote I've seen this done by some very good surgeons where they went in, did a beautiful analplasty, but ignored the fistula. And the child down the road started peeing out their anus. ↗
▶ Ep 244 · 12:00
clinical During primary repair, opening posterior wall of rectum and inspecting anterior wall can rule out fistula in low rectum cases ↗
▶ Ep 244 · 12:00
quote When I do that, I open up the posterior wall of the rectum, and I inspect the anterior wall of the rectum. ↗
▶ Ep 244 · 13:15
epidemiological 95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula ↗
▶ Ep 244 · 13:15
clinical Distal colostogram should still be performed in Down syndrome patients to rule out the 5% who have fistula ↗

Hirschsprung

▶ Ep 245 · 0:55
quote remember there are many other causes of this condition that are not Hirschsprung's disease, both surgical and medical ↗
▶ Ep 245 · 0:55
clinical Many non-Hirschsprung causes can present identically to Hirschsprung's disease in newborns, including maternal magnesium sulfate administration, hypothyroidism, opiate exposure, and milk protein allergy ↗
▶ Ep 245 · 2:00
epidemiological 10% of patients with meconium plug have Hirschsprung's disease ↗
▶ Ep 245 · 2:30
quote meconium plug, 10% of those patients have Hirschsprung's disease ↗
▶ Ep 245 · 3:00
guideline After passing a meconium plug, suction rectal biopsy should still be performed for confirmation, and if positive for Hirschsprung's, the contrast study should be repeated to better visualize the transition zone ↗
▶ Ep 245 · 3:30
clinical In total colonic Hirschsprung's disease, there is often no obvious transition zone on contrast study ↗
▶ Ep 245 · 4:00
guideline Suction rectal biopsy is the gold standard for diagnosing Hirschsprung's disease ↗
▶ Ep 245 · 4:20
quote I don't like going to the operating room without having a little bit of a GPS map of what the colon looks like ↗
▶ Ep 245 · 4:42
clinical Bacterial overgrowth from stasis leads to bacterial translocation because mucosal integrity in Hirschsprung's disease is abnormal ↗
▶ Ep 245 · 5:00
quote the stasis that's imposed by the physiologic obstruction leads to bacterial overgrowth, which leads to bacterial translocation because the mucosal integrity in a baby with Hirschsprung's disease is abnormal ↗
▶ Ep 245 · 5:20
clinical Constipated babies without Hirschsprung's disease do not develop enterocolitis because their mucosal integrity and IgA levels are normal ↗
▶ Ep 245 · 5:20
quote a baby could be constipated and not past stool, but they won't get enterocolitis because their mucosal integrity is normal ↗
▶ Ep 245 · 5:38
clinical Down syndrome patients have worse enterocolitis in Hirschsprung's disease because they have a weaker immune barrier ↗
▶ Ep 245 · 5:44
quote irrigations, first of all, need to be done properly and often they're done improperly and the surgeon can't just depend on the nurse to just do irrigations and make it up on their own ↗
▶ Ep 245 · 5:44
guideline Proper irrigation technique uses a 20 French silicone Foley catheter with warm saline in 10-20cc aliquots, washing the inside of the colon by injecting and allowing drainage, moving the catheter a few centimeters each time, which may take 30 minutes ↗
▶ Ep 245 · 7:00
guideline Irrigations often need to be performed two or three times per day ↗
▶ Ep 245 · 7:10
clinical If irrigations do not reach the transition zone, distension will not improve ↗
▶ Ep 245 · 8:20
clinical An ileostomy does not require pathology confirmation at 3 AM and the baby will reliably start stooling and feel well ↗
▶ Ep 245 · 9:00
quote the last thing you want is to open a colostomy and it's still in transition zone ↗
▶ Ep 245 · 9:10
quote I would rather do three straightforward, successful operations than have two and make one of them bigger and a little bit more risky ↗
▶ Ep 245 · 9:26
clinical A loop ileostomy where both sides are equal is inappropriate because stool will jump across and fill the aganglionic segment, causing continued distension and potential enterocolitis ↗
▶ Ep 245 · 11:51
clinical Post-pull-through patients present with two distinct problems: obstruction or soiling, and these two groups rarely overlap ↗
▶ Ep 245 · 12:10
clinical Obstructed patients typically do well for about six months after pull-through, then develop chronic distension and may have several enterocolitis episodes ↗
▶ Ep 245 · 12:40
clinical A Soave procedure without an adequately cut cuff, or with a cuff that has rolled up or refused, will cause physiologic obstruction ↗
▶ Ep 245 · 13:10
clinical A retained cuff presents as a rubbery circumferential ring outside the pull-through on digital exam ↗
▶ Ep 245 · 13:30
clinical A twisted pull-through (180 or 360 degrees) causes obstruction and can be felt on digital exam when you cannot get into the pelvis and feel like you are hitting a wall ↗
▶ Ep 245 · 14:00
clinical A cuff may show extra space in the presacral area on lateral contrast study because the pull-through is pushed forward instead of hugging the sacrum ↗
▶ Ep 245 · 14:30
clinical In Duhamel procedures, a large pouch reaching into the pelvis can cause obstruction as stool flows through ganglionic bowel, enters the pouch, and sits there ↗
▶ Ep 245 · 15:40
guideline For Duhamel patients, biopsy must be done on the posterior wall because the anterior wall is the original aganglionic rectum ↗
▶ Ep 245 · 16:13
clinical Every child born with Hirschsprung's disease has 100% possibility of having bowel control because the continence mechanism is normal and sphincters are not weak ↗
▶ Ep 245 · 16:30
quote every child born with Hirschsprung's disease has 100% possibility of having bowel control ↗
▶ Ep 245 · 16:50
quote their sphincters are too good ↗
▶ Ep 245 · 17:30
clinical Overstretching of sphincters or starting transanal dissection too low and removing the dentate line will lead to fecal incontinence ↗
▶ Ep 245 · 18:40
clinical If the anus appears closed when the patient is awake, that usually means good sphincters ↗
▶ Ep 245 · 19:20
clinical The vast majority of Hirschsprung's patients are constipated and need stimulant laxatives, not stool softeners ↗
▶ Ep 245 · 19:40
clinical Adding water-soluble fiber to laxatives provides bulk to prevent watery stool, which is difficult to control, while maintaining the propulsion effect of the laxative ↗
▶ Ep 245 · 20:00
quote I've done the absolutely brilliant move of stopping the Senna ↗
▶ Ep 245 · 20:20
clinical A non-dilated colon on X-ray or contrast study in a patient stooling five times per day indicates a fast-moving colon requiring constipating management rather than laxatives ↗
▶ Ep 245 · 20:48
clinical Nighttime soiling occurs because patients are totally dependent on voluntary external sphincter control, which they lose awareness of during sleep ↗
▶ Ep 245 · 21:50
clinical Malone procedures are typically performed between age three and a half and eight or nine years ↗
▶ Ep 245 · 22:10
opinion Most children should be in normal underwear by age three or four ↗

Hirschsprung's Disease with Dr. Marc Levitt

▶ Ep 246 · 0:55
clinical Many non-Hirschsprung causes can mimic the disease including premature rupture of membranes, maternal magnesium sulfate, hypothyroidism, opiate exposure, and milk protein allergy ↗
▶ Ep 246 · 2:00
clinical Anorectal malformation, small left colon syndrome, and colonic atresia are surgical conditions that can present similarly to Hirschsprung's disease ↗
▶ Ep 246 · 2:35
epidemiological 10% of patients with meconium plug have Hirschsprung's disease ↗
▶ Ep 246 · 3:00
guideline Suction rectal biopsy should be performed even after successful passage of meconium plug to rule out Hirschsprung's disease ↗
▶ Ep 246 · 3:15
clinical Contrast study should be repeated after meconium plug passage because the rectosigmoid will be dilated with the plug present, obscuring the transition zone ↗
▶ Ep 246 · 3:40
clinical In total colonic Hirschsprung's disease there is often no obvious transition zone on contrast study ↗
▶ Ep 246 · 4:00
opinion Contrast study serves as a surgical GPS map even though suction rectal biopsy is the gold standard for diagnosis ↗
▶ Ep 246 · 4:41
clinical Bacterial overgrowth from stasis leads to bacterial translocation because mucosal integrity in Hirschsprung's disease is abnormal ↗
▶ Ep 246 · 5:20
clinical Constipated babies without Hirschsprung's disease do not develop enterocolitis because their mucosal integrity and IgA levels are normal ↗
▶ Ep 246 · 5:35
clinical Down syndrome patients have worse enterocolitis because they have a weaker immune barrier ↗
▶ Ep 246 · 5:44
guideline Proper irrigation protocol uses a 20 French silicone Foley catheter with warm saline in 10-20cc aliquots, washing the colon for up to 30 minutes, two to three times per day ↗
▶ Ep 246 · 7:00
clinical If irrigations do not reach the transition zone, distension will not improve and stoma creation should be considered ↗
▶ Ep 246 · 7:25
clinical Leveling colostomy requires bringing dilated bowel to the surface with or without frozen section confirmation ↗
▶ Ep 246 · 7:50
opinion Ileostomy with colonic biopsies is preferred because it is extremely reliable, does not require pathology at 3 AM, and the baby will thrive while awaiting definitive pathology results ↗
▶ Ep 246 · 8:30
clinical Ileostomy is difficult to manage in many parts of the world where babies can become dehydrated quickly ↗
▶ Ep 246 · 9:00
opinion The ileostomy approach requires three operations versus two, but reduces risk by making each operation more straightforward ↗
▶ Ep 246 · 9:00
quote I would rather do three straightforward successful operations than have two and make one of them bigger and a little bit more risky. ↗
▶ Ep 246 · 9:26
clinical A loop ileostomy where both sides are equal is inappropriate because stool will jump across and fill the aganglionic segment, causing continued distension and potential enterocolitis ↗
▶ Ep 246 · 10:10
clinical Turnbull ileostomy technique involves cutting the bowel completely on one side of the loop and folding it over to create an end-appearing stoma with flat distal limb ↗
▶ Ep 246 · 11:26
clinical Post-pull-through patients present with two distinct problems: obstruction or soiling, and these rarely overlap ↗
▶ Ep 246 · 11:50
clinical Obstructed patients typically do well for six months post-pull-through, then develop chronic distension, recurrent enterocolitis, and sometimes failure to thrive ↗
▶ Ep 246 · 12:25
clinical Anatomic causes of obstruction include inadequately cut Soave cuff, rolled-up or fused cuff, twisted pull-through, duhamel spur, large duhamel pouch, transition zone pull-through, and stricture ↗
▶ Ep 246 · 13:00
clinical A retained cuff appears as a rubbery circumferential ring outside the pull-through on digital exam and shows increased presacral space on lateral contrast study ↗
▶ Ep 246 · 13:40
clinical A twisted pull-through prevents the examining finger from entering the pelvis and creates a sensation of hitting a wall when palpating abdominally ↗
▶ Ep 246 · 15:20
guideline In duhamel patients, biopsy must be taken from the posterior wall because the anterior wall is the original aganglionic rectum ↗
▶ Ep 246 · 15:45
guideline Empiric Botox injection is appropriate when physical exam, contrast study, and biopsy reveal no anatomic or pathologic cause of obstruction, suggesting non-relaxing sphincters ↗
▶ Ep 246 · 16:15
clinical Every child born with Hirschsprung's disease has 100% potential for bowel control because the continence mechanism is normal ↗
▶ Ep 246 · 16:15
quote Every child born with Hirschsprung's disease has 100% possibility of having bowel control. Now that may sound crazy, but it's absolutely true. ↗
▶ Ep 246 · 16:50
clinical Hirschsprung's sphincters are too good rather than weak, unlike anorectal malformation where associated spinal problems, poor sacrum, or poor muscles limit continence potential ↗
▶ Ep 246 · 17:25
clinical Overstretching of sphincters or starting transanal dissection too low and removing the dentate line will cause iatrogenic fecal incontinence ↗
▶ Ep 246 · 17:55
guideline Patients with iatrogenically damaged sphincters or dentate line require mechanical bowel management with enemas (peristeen or Malone) rather than medical management ↗
▶ Ep 246 · 18:25
clinical A closed anus appearance when awake usually indicates good sphincters ↗
▶ Ep 246 · 18:40
clinical The vast majority of Hirschsprung's patients are constipated and need stimulant laxatives (senna or bisacodyl), not stool softeners ↗
▶ Ep 246 · 19:05
guideline Adding water-soluble fiber to stimulant laxatives provides bulk to prevent watery stool while maintaining propulsion, creating one to two well-formed stools per day ↗
▶ Ep 246 · 19:35
clinical Botox is often required to help patients overcome withholding or non-relaxing internal sphincter during potty training ↗
▶ Ep 246 · 19:55
clinical Some Hirschsprung's patients have hypermotility and stool too frequently; stopping stimulant laxatives in these patients can achieve continence within two days ↗
▶ Ep 246 · 20:10
quote I've done the absolutely brilliant move of stopping the senna. And within two days, the child is now continent. ↗
▶ Ep 246 · 20:25
clinical X-ray showing no stool accumulation in a child stooling five times daily indicates fast-moving colon; contrast study showing non-dilated colon confirms hypermotility ↗
▶ Ep 246 · 20:25
guideline Hypermotile patients require constipating diet, water-soluble fiber, and occasionally loperamide to achieve one to two formed stools per day ↗
▶ Ep 246 · 21:01
clinical Nighttime soiling occurs because patients are totally dependent on voluntary external sphincter control, which is lost during sleep ↗
▶ Ep 246 · 21:28
guideline Behavioral modifications for nighttime soiling include attempting to stool before bed and giving a small enema before bed to keep the rectum empty for eight hours ↗
▶ Ep 246 · 21:36
guideline Malone antegrade continence enema is appropriate when rectal enemas are not tolerated, peristeen is ineffective, or families prefer not to use the rectal route ↗
▶ Ep 246 · 22:10
clinical Most Malone procedures are performed between ages 3.5 and 8-9 years, around the time of potty training when it becomes clear antegrade flushes are required ↗

Anorectal Malformations Complications

▶ Ep 247 · 2:55
epidemiological Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period ↗
▶ Ep 247 · 3:02
clinical Male with perineal fistula may pass meconium through tiny anterior opening, presenting in first year with severe constipation after rectum and sigmoid dilate ↗
▶ Ep 247 · 4:01
clinical Standard newborn care no longer includes rectal thermometry, making ARM diagnosis harder if perineum not visually examined ↗
▶ Ep 247 · 4:30
quote If you don't look, you might not know. ↗
▶ Ep 247 · 4:53
clinical Relocating perineal fistula into sphincters improves anatomy but does not completely fix inherent constipation ↗
▶ Ep 247 · 5:20
clinical Patients with uncorrected perineal fistula have semblance of continence with formed stool but soil with loose stool or athletic activity because sphincters cannot completely close the anteriorly located hole ↗
▶ Ep 247 · 6:05
clinical Newborn anus should accept Hagar dilator size 12; one-year-old should accept size 15 ↗
▶ Ep 247 · 6:41
clinical Bucket-handle skin tag at perineum indicates underlying perineal fistula even if fistula not directly visible ↗
▶ Ep 247 · 7:28
opinion Perineal fistula in female is most confounding diagnosis in pediatric colorectal surgery with high rates of both missed and overdiagnosis ↗
▶ Ep 247 · 7:50
clinical Female perineal fistula diagnostic criteria: inadequate perineal body, undersized hole, and hole not centered in sphincter ↗
▶ Ep 247 · 8:30
clinical If female anus is adequate size and centered in sphincter, no surgery needed even if perineal body appears short; perineal body will lengthen with growth ↗
▶ Ep 247 · 9:20
quote It's very hard to improve on an asymptomatic patient. ↗
▶ Ep 247 · 9:37
clinical Examination under anesthesia with stimulation can confirm whether opening is properly centered in sphincter when diagnosis uncertain ↗
▶ Ep 247 · 10:50
clinical Anesthesia nerve stimulator ($150) with modified needles works as well as commercial Pena stimulator ($15,000) ↗
▶ Ep 247 · 12:38
epidemiological Vast majority of male ARM patients have rectourethral fistula at bladder neck, prostatic, or bulbar level ↗
▶ Ep 247 · 13:00
guideline Rectourethral fistulas should not be approached primarily because rectal location is uncertain; colostomy with distal colostogram is safe standard ↗
▶ Ep 247 · 13:30
clinical Opening posterior sagittal incision without knowing rectal location will find whitish shiny midline structure that may be bladder neck, not rectum ↗
▶ Ep 247 · 14:00
clinical Cloaca can be missed in newborn period; patient may present at six months with constipation before diagnosis made ↗
▶ Ep 247 · 15:49
clinical Ambiguous genitalia (clitoromegaly from endocrine stimulation) with urogenital sinus has normal anus and is distinct from cloaca (no anus, normal ovaries) ↗
▶ Ep 247 · 17:00
clinical Most common colostomy error is opening too distal in sigmoid, restricting ultimate pull-through ↗
▶ Ep 247 · 17:20
clinical Incompletely diverted loop colostomy allows stool to spill across and contaminate distal segment, causing urinary tract infections ↗
▶ Ep 247 · 18:10
clinical Transverse colostomy with large rectourethral fistula causes left colon to absorb urine, leading to acidosis ↗
▶ Ep 247 · 18:40
guideline Recommended colostomy technique: very proximal sigmoid with separated stomas (tiny flat mucous fistula), now done laparoscopically ↗
▶ Ep 247 · 19:58
clinical Colostomy prolapse is related to mobility of colon segment; mid-transverse can prolapse both sides, proximal sigmoid only distal side can prolapse ↗
▶ Ep 247 · 21:10
guideline Mark anoplasty location on intact perineal skin before making incision by drawing circle around pinkish sphincter ellipse and stimulation zone ↗
▶ Ep 247 · 21:50
clinical Surgeons get lost among jumping muscles after opening posterior sagittal incision and place anus in wrong location; pre-marking prevents this ↗
▶ Ep 247 · 23:29
opinion Distal colostogram is absolutely vital study; many mistakes from poorly done study and misinterpretation ↗
▶ Ep 247 · 23:50
clinical Distal colostogram must answer: where is rectum, how low is it, is it reachable posterior sagittally or better laparoscopically, and what is relationship to urinary tract ↗
▶ Ep 247 · 24:25
clinical Common colostogram error: insufficient contrast and pressure gives false impression rectum is high or no fistula present ↗
▶ Ep 247 · 24:50
clinical Flat rectal bottom at pubococcygeal line on colostogram means insufficient pressure; need to overcome PC line (sphincter compression) to see bulging rectum and fistula ↗
▶ Ep 247 · 25:40
clinical Rectourethral fistula level determined by urethra as reverse-C or elbow: fistula at/below elbow is bulbar, above elbow is prostatic, at bladder neck is bladder neck ↗
▶ Ep 247 · 25:40
clinical Bulbous rectum may be reachable posterior sagittally and hard laparoscopically; tapered rectum better laparoscopically ↗
▶ Ep 247 · 26:52
clinical Opening posterior sagittal without knowing rectal location will find whitish shiny midline structure that may be bladder neck; can be mobilized and brought down as anoplasty, draining liquid (urine) postoperatively ↗
▶ Ep 247 · 28:00
clinical Prostatic fistulas are right under coccyx; bulbar fistulas are distal to coccyx near perineal skin; bladder neck fistulas not reachable posterior sagittally ↗
▶ Ep 247 · 30:03
guideline Bulbar and low prostatic with bulbous rectum best approached posterior sagittally; high prostatic with tapered rectum and bladder neck best approached laparoscopically ↗
▶ Ep 247 · 30:50
clinical Laparoscopy for bulging rectum below peritoneal reflection risks leaving remnant of original fistula (ROOF) if surgeon is timid ↗
▶ Ep 247 · 31:38
quote I never look at it that way. I think that laparoscopy replaces laparotomy. ↗
▶ Ep 247 · 31:38
opinion Laparoscopy replaces laparotomy, not PSARP; should do mini-PSARP with laparoscopy for safe peritoneal entry and posterior rectal tacking to prevent prolapse ↗
▶ Ep 247 · 33:30
epidemiological Rectal prolapse occurs in about 3% of cases when surgical principles respected, particularly in patients without great muscles ↗
▶ Ep 247 · 33:54
clinical Rectal prolapse >3mm should be treated because it causes bleeding, mucus, and impairs continence in patients with good muscles by preventing sphincter closure ↗
▶ Ep 247 · 34:40
clinical Circumferential prolapse can be treated in two staged hemi-circumferential ambulatory procedures, avoiding hospitalization and eliminating need for dilation ↗
▶ Ep 247 · 36:00
epidemiological Perineal body dehiscence is most common cause of reoperation in female ARM repairs ↗
▶ Ep 247 · 36:20
clinical Preventing perineal body dehiscence requires complete anterior rectal wall mobilization to areolar plane with posterior vagina to avoid tension ↗
▶ Ep 247 · 36:50
clinical Traditional seven-day NPO on 10% dextrose after female ARM repair being replaced by clear liquids only for one week; major problem is hard stool, not stool volume ↗
▶ Ep 247 · 37:47
clinical Early perineal body dehiscence (days 5-8) can be salvaged by immediate re-suturing in OR; late recognition requires reoperation ↗
▶ Ep 247 · 39:20
clinical Laparoscopic dissection of bladder neck fistula is challenging; rectum completely dependent on IMA because prior colostomy disrupted left colic collaterals ↗
▶ Ep 247 · 39:40
clinical Taking IMA or branches too close to aorta during laparoscopic mobilization will cause rectal ischemia due to lack of collateralization ↗
▶ Ep 247 · 42:40
clinical ARM continence potential predicted by three factors: malformation type, sacral ratio, and spine quality (ARM continence index) ↗
▶ Ep 247 · 43:20
clinical Bulbar fistula with sacral ratio 1.0 and normal spine should have bowel control; bladder neck with ratio 0.4 and tethered cord has no chance ↗
▶ Ep 247 · 44:00
guideline Initial management of four-year-old with ARM soiling: bowel management with enemas to achieve cleanliness, then trial laxatives in older patients with continence potential ↗
▶ Ep 247 · 44:50
guideline Redo pull-through indicated for any continence potential with imperfect anatomy: misplaced anus, stricture, prolapse, or remnant of original fistula ↗
▶ Ep 247 · 46:40
opinion ARM differs from other surgery because errors manifest years later when continence expected, not immediately; surgeon cannot learn from delayed feedback ↗
▶ Ep 247 · 47:00
quote How are you supposed to, as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? ↗

Anorectal Malformations Complications

▶ Ep 248 · 2:55
epidemiological Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period ↗