One of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.
One of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.
One of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.
We used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.
We used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.
We used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
▶Ep 16 · 59:25
clinicalFor cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony↗
▶Ep 16 · 59:25
clinicalPatients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging↗
▶Ep 16 · 59:25
epidemiologicalCervical spine injury is about 1 to 2% of all pediatric traumas↗
▶Ep 16 · 59:25
epidemiologicalIn older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns↗
▶Ep 16 · 59:25
epidemiologicalIn younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA↗
▶Ep 16 · 59:25
epidemiologicalAAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years↗
▶Ep 16 · 59:25
epidemiological60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults↗
▶Ep 16 · 59:25
epidemiological46% of institutions don't have a protocol for cervical spine clearance in children↗
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
▶Ep 6 · 16:49
quoteI think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.↗
▶Ep 6 · 20:29
quoteOne of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.↗
▶Ep 6 · 20:29
clinicalPEG tubes are difficult to change to button tubes, often requiring a second anesthetic with GI specialists to remove the PEG endoscopically before placing a button.↗
guidelinePapers by Pastor et al and Gosain et al outline frameworks and clinical guidelines for management of enterocolitis↗
▶Ep 67 · 0:21
clinicalSystemic signs of concern include fever, lethargy, age-adjusted tachycardia, tachypnea, hypotension, or oliguria↗
▶Ep 67 · 0:21
clinicalGI symptoms in HAEC include abdominal distension, vomiting, no or minimal stool, foul smelling stool, or explosive diarrhea↗
▶Ep 67 · 0:21
guidelineThe guideline is most appropriate for patients with either known or suspected Hirschsprung's who present with GI symptoms and/or fever↗
▶Ep 67 · 2:00
guidelineIf the patient is less than four weeks out from surgery, fellows should discuss the rectal exam with an attending surgeon prior to performing it↗
▶Ep 67 · 2:00
guidelineIrrigations should not be delayed for patients to get an x-ray↗
▶Ep 67 · 2:00
guidelineIrrigations should be repeated as frequently as every eight hours, but even every six or four hours as needed for sicker patients↗
▶Ep 67 · 2:00
guidelinePatients should be seen and evaluated as soon as possible, ideally within one hour by someone with clinical expertise such as a surgical fellow or attending↗
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
▶Ep 22 · 59:25
epidemiological46% of institutions don't have a protocol for cervical spine clearance in children↗
▶Ep 22 · 59:25
epidemiologicalCervical spine injury is about 1 to 2% of all pediatric traumas↗
▶Ep 22 · 59:25
epidemiologicalIn older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns↗
▶Ep 22 · 59:25
epidemiologicalIn younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA↗
▶Ep 22 · 59:25
epidemiological60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults↗
▶Ep 22 · 59:25
epidemiologicalAAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years↗
▶Ep 22 · 59:25
clinicalPatients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging↗
▶Ep 22 · 59:25
clinicalFor cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony↗
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
▶Ep 44 · 16:49
quoteI think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.↗
▶Ep 44 · 20:29
quoteOne of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.↗
▶Ep 44 · 20:29
clinicalPEG tubes are difficult to change to button tubes, often requiring a second anesthetic with GI specialists to remove the PEG endoscopically before placing a button.↗
Malrotation with Dr. Meera Kotagal
▶Ep 48 · 1:17
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 48 · 1:17
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 48 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 48 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 48 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 48 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 48 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 48 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 48 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 48 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 48 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 48 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 48 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 48 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 48 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 48 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 48 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 48 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 48 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 48 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 48 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 48 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 48 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 48 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 48 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 48 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 48 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 48 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 48 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 48 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 48 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 48 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 48 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 48 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 48 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 48 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 48 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 48 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
▶Ep 48 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 48 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
▶Ep 48 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
▶Ep 48 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 57 · 1:17
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 57 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 57 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 57 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 57 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 57 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 57 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 57 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 57 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 57 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 57 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 57 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 57 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 57 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 57 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 57 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 57 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 57 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 57 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 57 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 57 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 57 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 57 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 57 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 57 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 57 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 57 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 57 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 57 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 57 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 57 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 57 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 57 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 57 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 57 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
▶Ep 57 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
▶Ep 57 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 57 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 57 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 57 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
▶Ep 57 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
guidelinePapers by Pastor et al and Gosain et al outline frameworks and clinical guidelines for management of enterocolitis↗
▶Ep 1 · 0:21
clinicalSystemic signs of concern include fever, lethargy, age-adjusted tachycardia, tachypnea, hypotension, or oliguria↗
▶Ep 1 · 0:21
clinicalGI symptoms in HAEC include abdominal distension, vomiting, no or minimal stool, foul smelling stool, or explosive diarrhea↗
▶Ep 1 · 0:21
guidelineThe guideline is most appropriate for patients with either known or suspected Hirschsprung's who present with GI symptoms and/or fever↗
▶Ep 1 · 2:00
guidelineIf the patient is less than four weeks out from surgery, fellows should discuss the rectal exam with an attending surgeon prior to performing it↗
▶Ep 1 · 2:00
guidelineIrrigations should be repeated as frequently as every eight hours, but even every six or four hours as needed for sicker patients↗
▶Ep 1 · 2:00
guidelineIrrigations should not be delayed for patients to get an x-ray↗
▶Ep 1 · 2:00
guidelinePatients should be seen and evaluated as soon as possible, ideally within one hour by someone with clinical expertise such as a surgical fellow or attending↗
epidemiologicalThe incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns.↗
▶Ep 7 · 1:26
clinicalDirect hernias are pretty rare in children and are much more commonly found in adolescents.↗
▶Ep 7 · 1:26
epidemiologicalMost inguinal hernias in children are largely indirect, over 90%.↗
▶Ep 7 · 1:26
epidemiologicalThe incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns.↗
▶Ep 7 · 1:26
epidemiologicalThe incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age.↗
▶Ep 7 · 1:26
epidemiologicalFemoral hernias are very rare in children and, as in adults, are more common in females.↗
▶Ep 7 · 1:26
epidemiologicalFemoral hernias are very rare in children and, as in adults, are more common in females.↗
▶Ep 7 · 1:26
clinicalDirect hernias are pretty rare in children and are much more commonly found in adolescents.↗
▶Ep 7 · 1:26
epidemiologicalThe incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age.↗
▶Ep 7 · 1:26
epidemiologicalMost inguinal hernias in children are largely indirect, over 90%.↗
▶Ep 7 · 1:59
clinicalInguinal hernias occur as a result of the failure of the processus vaginalis to fuse.↗
▶Ep 7 · 1:59
clinicalIndirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth.↗
▶Ep 7 · 1:59
clinicalThe right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias.↗
▶Ep 7 · 1:59
clinicalInguinal hernias occur as a result of the failure of the processus vaginalis to fuse.↗
▶Ep 7 · 1:59
clinicalIndirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth.↗
▶Ep 7 · 1:59
clinicalThe right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias.↗
▶Ep 7 · 2:47
clinicalThe number one risk factor for inguinal hernias in children is prematurity.↗
▶Ep 7 · 2:47
quoteThe number one risk factor for inguinal hernias in children is prematurity.↗
▶Ep 7 · 2:47
clinicalOther factors associated with an increased risk of inguinal hernias in kids include male sex, family history of inguinal hernias, a history of undescended testicle or hydrocele, and a connective tissue disorder.↗
▶Ep 7 · 2:47
clinicalThe number one risk factor for inguinal hernias in children is prematurity.↗
▶Ep 7 · 2:47
quoteThe number one risk factor for inguinal hernias in children is prematurity.↗
▶Ep 7 · 2:47
clinicalOther factors associated with an increased risk of inguinal hernias in kids include male sex, family history of inguinal hernias, a history of undescended testicle or hydrocele, and a connective tissue disorder.↗
▶Ep 7 · 4:31
epidemiologicalMore than half of incarcerations are in patients that are less than six months, and two-thirds of incarcerations are in patients who are less than a year.↗
▶Ep 7 · 4:31
quoteMore than half of incarcerations are in patients that are less than six months, and then two-thirds of incarcerations are in patients who are less than a year.↗
▶Ep 7 · 4:31
clinicalIf corrected gestational age is less than 60 weeks, patients have a high risk for premature apnea postoperatively and need to be admitted after surgery to monitor.↗
▶Ep 7 · 4:31
epidemiologicalMore than half of incarcerations are in patients that are less than six months, and two-thirds of incarcerations are in patients who are less than a year.↗
▶Ep 7 · 4:31
quoteMore than half of incarcerations are in patients that are less than six months, and then two-thirds of incarcerations are in patients who are less than a year.↗
▶Ep 7 · 4:31
clinicalIf corrected gestational age is less than 60 weeks, patients have a high risk for premature apnea postoperatively and need to be admitted after surgery to monitor.↗
▶Ep 7 · 5:59
quoteOne of the most important things, I think, in being able to reduce an incarcerated hernia is helping to keep the patient calm.↗
▶Ep 7 · 5:59
quoteYou have to keep applying pressure in a slow, gentle fashion and not just kind of come and go with your hands, because that gentle, slow pressure is what allows you to reduce the hernia.↗
▶Ep 7 · 5:59
quoteOne of the most important things, I think, in being able to reduce an incarcerated hernia is helping to keep the patient calm.↗
▶Ep 7 · 5:59
clinicalFor hernia reduction, one hand guides the contents through the inguinal ring and the other hand applies gentle, steady pressure, which must be maintained in a slow, gentle fashion.↗
▶Ep 7 · 5:59
clinicalOne of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm, sometimes requiring pain control and sedation.↗
▶Ep 7 · 5:59
clinicalOne of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm, sometimes requiring pain control and sedation.↗
▶Ep 7 · 5:59
clinicalFor hernia reduction, one hand guides the contents through the inguinal ring and the other hand applies gentle, steady pressure, which must be maintained in a slow, gentle fashion.↗
▶Ep 7 · 5:59
quoteYou have to keep applying pressure in a slow, gentle fashion and not just kind of come and go with your hands, because that gentle, slow pressure is what allows you to reduce the hernia.↗
▶Ep 7 · 7:34
clinicalIf you can reduce an incarcerated inguinal hernia, you want to go to the OR within the first 24 to 72 hours after the reduction.↗
▶Ep 7 · 7:34
clinicalIf you can reduce an incarcerated inguinal hernia, you want to go to the OR within the first 24 to 72 hours after the reduction.↗
▶Ep 7 · 8:57
quoteUnlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.↗
▶Ep 7 · 8:57
clinicalThe most important point in pediatric inguinal hernia repair is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.↗
▶Ep 7 · 8:57
clinicalUnlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.↗
▶Ep 7 · 8:57
clinicalThe most important point in pediatric inguinal hernia repair is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.↗
▶Ep 7 · 8:57
clinicalUnlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.↗
▶Ep 7 · 8:57
quoteThe most important point is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.↗
▶Ep 7 · 8:57
quoteThe most important point is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.↗
▶Ep 7 · 8:57
quoteUnlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.↗
▶Ep 7 · 9:25
quoteAs with all operations, the most important thing is that you do the operation that you're comfortable with.↗
▶Ep 7 · 9:25
quoteAs with all operations, the most important thing is that you do the operation that you're comfortable with.↗
▶Ep 7 · 9:31
clinicalThe outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic.↗
▶Ep 7 · 9:31
clinicalThe outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic.↗
▶Ep 7 · 9:44
clinicalIf a child needs an orchidopexy in addition to their hernia repair, most would approach that hernia in an open fashion.↗
▶Ep 7 · 9:44
clinicalIf a child needs an orchidopexy in addition to their hernia repair, most would approach that hernia in an open fashion.↗
▶Ep 7 · 10:54
clinicalA floor repair should be considered in children who have longstanding or very large hernias where the floor might be blown out or unsupported.↗
▶Ep 7 · 10:54
clinicalA floor repair should be considered in children who have longstanding or very large hernias where the floor might be blown out or unsupported.↗
▶Ep 7 · 11:10
epidemiologicalThe most common complications after inguinal hernia repair in children are superficial site infection, which occur in less than 1% of kids, and recurrence, with rates varying from 1% to 5%.↗
▶Ep 7 · 11:10
epidemiologicalThe most common complications after inguinal hernia repair in children are superficial site infection, which occur in less than 1% of kids, and recurrence, with rates varying from 1% to 5%.↗
▶Ep 7 · 11:10
clinicalRare complications include testicular atrophy or damage to the vas deferens.↗
▶Ep 7 · 11:10
clinicalRare complications include testicular atrophy or damage to the vas deferens.↗
▶Ep 7 · 12:19
clinicalIn general, we don't try to limit activities in children after a hernia repair; most children can return to normal activities within one to two days.↗
▶Ep 7 · 12:19
clinicalIn general, we don't try to limit activities in children after a hernia repair; most children can return to normal activities within one to two days.↗
▶Ep 7 · 12:31
quoteIn general for children, we don't do this. Most children can return to normal activities within one to two days.↗
▶Ep 7 · 12:31
quoteIn general for children, we don't do this. Most children can return to normal activities within one to two days.↗
▶Ep 7 · 13:26
clinicalA lot of times, once the patient is put under anesthesia, an incarcerated hernia that was unable to be reduced in the emergency department may actually spontaneously reduce with the patient's relaxation.↗
▶Ep 7 · 13:26
clinicalA lot of times, once the patient is put under anesthesia, an incarcerated hernia that was unable to be reduced in the emergency department may actually spontaneously reduce with the patient's relaxation.↗
▶Ep 7 · 13:49
clinicalIf a patient has an undescended testicle that's palpable in the inguinal canal, you should plan to do an orchiopexy at the time of your inguinal hernia repair.↗
▶Ep 7 · 13:49
clinicalIf a patient has an undescended testicle that's palpable in the inguinal canal, you should plan to do an orchiopexy at the time of your inguinal hernia repair.↗
▶Ep 7 · 14:18
clinicalChildren with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period.↗
▶Ep 7 · 14:18
clinicalChildren with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period.↗
▶Ep 7 · 14:35
clinicalIf patients are having significant testicular pain after a hernia repair, the main concern is testicular ischemia, best evaluated with ultrasound looking for Doppler flow.↗
▶Ep 7 · 14:35
clinicalIn cases of testicular ischemia after hernia repair, patients are monitored and observed with pain control, and surgeons only remove a necrotic testicle, not necessarily one that is partially ischemic.↗
▶Ep 7 · 14:35
clinicalIf patients are having significant testicular pain after a hernia repair, the main concern is testicular ischemia, best evaluated with ultrasound looking for Doppler flow.↗
▶Ep 7 · 14:35
clinicalIn cases of testicular ischemia after hernia repair, patients are monitored and observed with pain control, and surgeons only remove a necrotic testicle, not necessarily one that is partially ischemic.↗
Pediatric Inguinal Hernia in Brief: Presentation, Workup, Diagnosis, Perioperative Considerations
▶Ep 11 · 0:00
quoteInguinal hernia repair is the second most common surgery performed by pediatric surgeons.↗
▶Ep 11 · 0:00
epidemiologicalInguinal hernia repair is the second most common surgery performed by pediatric surgeons.↗
▶Ep 11 · 1:00
epidemiologicalThe incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns.↗
▶Ep 11 · 1:15
epidemiologicalThe incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age.↗
▶Ep 11 · 1:30
epidemiologicalMost inguinal hernias in children are largely indirect, over 90%.↗
▶Ep 11 · 1:40
clinicalDirect hernias are pretty rare in children and are much more commonly found in adolescence.↗
▶Ep 11 · 1:50
epidemiologicalFemoral hernias are very rare in children, and as in adults, are more common in females.↗
▶Ep 11 · 2:10
clinicalIndirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth.↗
▶Ep 11 · 2:25
clinicalIndirect inguinal hernias occur as a result of the failure of the processus vaginalis to fuse.↗
▶Ep 11 · 2:45
clinicalThe right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias.↗
▶Ep 11 · 2:45
quoteThe right processus vaginalis usually obliterates after the left, so that explains the higher prevalence of right-sided hernias.↗
▶Ep 11 · 3:30
quoteThe number one risk factor for inguinal hernias in children is prematurity.↗
▶Ep 11 · 3:30
clinicalThe number one risk factor for inguinal hernias in children is prematurity.↗
▶Ep 11 · 7:00
epidemiologicalMore than half of the incarcerations that we see are in patients that are less than six months old.↗
▶Ep 11 · 7:00
quoteIt's actually kind of alarming. I mean, more than half of the incarcerations that we see are in patients that are less than six months old.↗
▶Ep 11 · 7:15
epidemiologicalTwo-thirds of incarcerations are in those patients that are less than a year.↗
▶Ep 11 · 7:30
clinicalIf the corrected gestational age is less than 60 weeks, premature patients are at a pretty increased risk of post-operative apnea, so you got to admit those patients after you do the repair.↗
▶Ep 11 · 9:30
quoteOne of the most important things I think in being able to reduce an incarcerated hernia is helping to keep the patient calm.↗
▶Ep 11 · 9:30
clinicalOne of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm, sometimes that means pain control and sedation.↗
▶Ep 11 · 10:20
clinicalYou have to keep applying pressure in a slow, gentle fashion and not just kind of come and go with your hands, because that gentle, slow pressure is what allows you to release the hernia.↗
▶Ep 11 · 10:50
quoteBut the most valuable piece of this technique, patience.↗
▶Ep 11 · 11:30
clinicalIf you can reduce an incarcerated hernia, then you want to go to the OR within the first 24 to 72 hours after the reduction.↗
▶Ep 11 · 12:10
host_summaryDr. Todd Ponsky states that with laparoscopy, you don't necessarily need to wait for bowel edema to come down because it's really not that much more difficult in a laparoscopic case if there's swelling, and sometimes the edema can help lift the peritoneum off.↗
▶Ep 11 · 12:10
quoteNow that with laparoscopy, you don't necessarily need to wait because it's really not that much more difficult in a laparoscopic case if there's swelling. In fact, sometimes the edema can help lift the peritoneum off.↗
▶Ep 11 · 12:45
host_summaryDr. Todd Ponsky suggests that if it's in the middle of the day and you have time availability and a patient has an incarcerated hernia, you could not even try to reduce it in the emergency room and just go straight to the operating room under laparoscopy.↗
▶Ep 11 · 13:30
clinicalThe most important point in pediatric inguinal hernia repair is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.↗
▶Ep 11 · 13:30
quoteThe most important point is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.↗
▶Ep 11 · 14:10
quoteUnlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.↗
▶Ep 11 · 14:10
clinicalUnlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.↗
▶Ep 11 · 14:25
opinionThe outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic.↗
▶Ep 11 · 14:55
clinicalIf you're considering that the child needs an orchidopexy in addition to their hernia repair, then most would approach that hernia in an open fashion.↗
▶Ep 11 · 15:35
clinicalA floor repair should be considered in children who have long-standing or very large hernias, where you note that the floor might be blown out or unsupported.↗
▶Ep 11 · 16:25
epidemiologicalSuperficial site infections occur in less than 1% of kids after inguinal hernia repair.↗
▶Ep 11 · 16:40
epidemiologicalThe rates of recurrence after pediatric inguinal hernia repair vary from 1 to 5% depending on which studies you look at.↗
▶Ep 11 · 17:25
clinicalIn general, we don't try to limit activities in children after a hernia repair, and most children can return to normal activities within one to two days.↗
▶Ep 11 · 19:45
clinicalIf a patient does have an undescended testicle that's palpable in the inguinal canal, then you should plan to do an orchidopexy at the time of your inguinal hernia repair.↗
▶Ep 11 · 20:30
clinicalChildren with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period.↗
▶Ep 11 · 21:10
clinicalIf patients are having significant testicular pain after a hernia repair, the thing that concerns you most is testicular ischemia, and the best way to evaluate that is to get an ultrasound looking for Doppler flow.↗
▶Ep 11 · 21:40
clinicalIn general, patients with testicular ischemia after hernia repair are monitored and observed with pain control and we only frankly remove a necrotic testicle and not necessarily one that is partially ischemic.↗
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
▶Ep 31 · 59:25
host_summaryIn younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA↗
▶Ep 31 · 59:25
host_summaryCervical spine injury is about 1 to 2% of all pediatric traumas↗
▶Ep 31 · 59:25
host_summaryPatients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging↗
▶Ep 31 · 59:25
epidemiological46% of institutions don't have a protocol for cervical spine clearance in children↗
▶Ep 31 · 59:25
clinicalFor cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony↗
▶Ep 31 · 59:25
epidemiologicalAAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years↗
▶Ep 31 · 59:25
clinicalPatients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging↗
▶Ep 31 · 59:25
host_summary46% of institutions don't have a protocol for cervical spine clearance in children↗
▶Ep 31 · 59:25
host_summaryFor cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony↗
▶Ep 31 · 59:25
host_summaryAAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years↗
▶Ep 31 · 59:25
host_summary60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults↗
▶Ep 31 · 59:25
host_summaryIn older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns↗
▶Ep 31 · 59:25
epidemiologicalCervical spine injury is about 1 to 2% of all pediatric traumas↗
▶Ep 31 · 59:25
epidemiological60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults↗
▶Ep 31 · 59:25
epidemiologicalIn younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA↗
▶Ep 31 · 59:25
epidemiologicalIn older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns↗
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
▶Ep 60 · 16:49
quoteI think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.↗
▶Ep 60 · 20:29
clinicalPEG tubes are difficult to change to button tubes, often requiring a second anesthetic with GI specialists to remove the PEG endoscopically before placing a button.↗
▶Ep 60 · 20:29
quoteOne of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.↗
Malrotation with Dr. Meera Kotagal
▶Ep 70 · 1:17
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 70 · 1:17
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 70 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 70 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 70 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 70 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 70 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 70 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 70 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 70 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 70 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 70 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 70 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 70 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 70 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 70 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 70 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 70 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 70 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 70 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 70 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 70 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 70 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 70 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 70 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 70 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 70 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 70 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 70 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 70 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 70 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 70 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 70 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 70 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 70 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 70 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 70 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
▶Ep 70 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 70 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 70 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
▶Ep 70 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 70 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 5 · 1:17
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 5 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 5 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 5 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 5 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 5 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 5 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 5 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 5 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 5 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 5 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 5 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 5 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 5 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 5 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 5 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 5 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 5 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 5 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 5 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 5 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 5 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 5 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 5 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 5 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 5 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 5 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 5 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 5 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 5 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 5 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 5 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
▶Ep 5 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 5 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 5 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 5 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 5 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 5 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 5 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
▶Ep 5 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 5 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 3 · 1:17
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 3 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 3 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 3 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 3 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 3 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 3 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 3 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 3 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 3 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 3 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 3 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 3 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 3 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 3 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 3 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 3 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 3 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 3 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 3 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 3 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 3 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 3 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 3 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 3 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 3 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 3 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 3 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 3 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 3 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 3 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 3 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 3 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 3 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 3 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
▶Ep 3 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 3 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 3 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 3 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 3 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
▶Ep 3 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
epidemiologicalNeuroblastoma makes up about 8 to 10% of all pediatric cancers and about 15% of cancer-related deaths.↗
▶Ep 17 · 0:23
epidemiologicalNeuroblastoma makes up about 8 to 10% of all pediatric cancers and about 15% of cancer-related deaths.↗
▶Ep 17 · 0:48
quoteFor folks who have relapsed high risk neuroblastoma, the survival rate is 0.↗
▶Ep 17 · 0:48
epidemiologicalFor patients with relapsed high risk neuroblastoma, the survival rate is 0%.↗
▶Ep 17 · 0:48
quoteFor folks who have relapsed high risk neuroblastoma, the survival rate is 0.↗
▶Ep 17 · 0:48
epidemiologicalFor patients with relapsed high risk neuroblastoma, the survival rate is 0%.↗
▶Ep 17 · 2:17
clinical90% of neuroblastomas have elevated HVA and VMA (catecholamine metabolites).↗
▶Ep 17 · 2:17
clinical90% of neuroblastomas have elevated HVA and VMA (catecholamine metabolites).↗
▶Ep 17 · 2:22
clinicalNeuroblastomas are not typically thought of as causing elevated blood pressure despite producing catecholamines.↗
▶Ep 17 · 2:22
clinicalNeuroblastomas are not typically thought of as causing elevated blood pressure despite producing catecholamines.↗
▶Ep 17 · 5:09
clinicalImage-defined risk factors (IDRFs) are best understood as things that touch important structures: vessels, brachial plexus, or trachea.↗
▶Ep 17 · 5:09
quoteThe best way to think about IDRFs are things that touch things that are important, touching the vessels, touching the brachial plaque, touching the trachea, all of those things count as IDRS.↗
▶Ep 17 · 5:09
quoteThe best way to think about IDRFs are things that touch things that are important, touching the vessels, touching the brachial plaque, touching the trachea, all of those things count as IDRS.↗
▶Ep 17 · 5:09
clinicalImage-defined risk factors (IDRFs) are best understood as things that touch important structures: vessels, brachial plexus, or trachea.↗
▶Ep 17 · 7:15
guidelineIntermediate risk neuroblastoma patients receive neoadjuvant chemotherapy with 2, 4, 6, or 8 cycles depending on chromosomal factors, followed by surgical resection.↗
▶Ep 17 · 7:15
guidelineIntermediate risk neuroblastoma patients receive neoadjuvant chemotherapy with 2, 4, 6, or 8 cycles depending on chromosomal factors, followed by surgical resection.↗
▶Ep 17 · 7:38
clinicalThe key surgical principle for neuroblastoma resection is to stay on the vessels and work from normal to abnormal anatomy.↗
▶Ep 17 · 7:38
clinicalThe key surgical principle for neuroblastoma resection is to stay on the vessels and work from normal to abnormal anatomy.↗
▶Ep 17 · 7:52
quoteThe closer you are to the vessels, the safer you are.↗
▶Ep 17 · 7:52
quoteThe closer you are to the vessels, the safer you are.↗
▶Ep 17 · 8:22
clinicalImage-defined risk factors (IDRFs) are associated with increased risk of surgical complications.↗
▶Ep 17 · 8:22
clinicalImage-defined risk factors (IDRFs) are associated with increased risk of surgical complications.↗
▶Ep 17 · 9:13
clinicalWhen percutaneous core biopsies are performed by experienced practitioners who obtain multiple cores, the adequacy of these biopsies significantly improves and they are not inferior to open surgical biopsies.↗
▶Ep 17 · 9:13
clinicalWhen percutaneous core biopsies are performed by experienced practitioners who obtain multiple cores, the adequacy of these biopsies significantly improves and they are not inferior to open surgical biopsies.↗
▶Ep 17 · 9:33
clinicalAt Cincinnati Children's, radiologists obtain 25 cores from different parts of neuroblastoma tumors during percutaneous biopsy.↗
▶Ep 17 · 9:33
clinicalAt Cincinnati Children's, radiologists obtain 25 cores from different parts of neuroblastoma tumors during percutaneous biopsy.↗
▶Ep 17 · 10:44
clinicalFor neuroblastoma, unlike most tumors, the goal is to get as much tumor as possible but complete resection of every ounce of tumor is not expected.↗
▶Ep 17 · 10:44
clinicalFor neuroblastoma, unlike most tumors, the goal is to get as much tumor as possible but complete resection of every ounce of tumor is not expected.↗
▶Ep 17 · 10:55
quoteThere's tumor that extends into the neural foramina or that extends into other places, you're not going to go chasing it.↗
▶Ep 17 · 10:55
clinicalTumor extending into neural foramina or other difficult locations should not be aggressively pursued; the goal is maximal safe resection without causing harm.↗
▶Ep 17 · 10:55
quoteThere's tumor that extends into the neural foramina or that extends into other places, you're not going to go chasing it.↗
▶Ep 17 · 10:55
clinicalTumor extending into neural foramina or other difficult locations should not be aggressively pursued; the goal is maximal safe resection without causing harm.↗
▶Ep 17 · 12:48
guidelineThe observation protocol for infants with neuroblastoma has been expanded from primary adrenal tumors to L1 tumors in children under 6 months.↗
▶Ep 17 · 12:48
guidelineThe observation protocol for infants with neuroblastoma has been expanded from primary adrenal tumors to L1 tumors in children under 6 months.↗
