Steven Rothenberg

276 timestamped statements across 5 collections — auto-found in recorded discussions, each timestamp jumps to the exact moment.

Congenital Lung Lesions (CPAM) · guest expert Fetal Surgery · guest expert Pectus Excavatum · guest expert Sarcoma (Ewing/Rhabdo) · guest expert Single Ventricle / HLHS · guest expert

Featured diaries

▶ Ep 8 · 14:29
I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.
quote · Congenital Lung Lesions (CPAM)
▶ Ep 21 · 14:29
I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected.
quote · Single Ventricle / HLHS
▶ Ep 8 · 18:46
I often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection
quote · Congenital Lung Lesions (CPAM)
▶ Ep 21 · 18:46
I often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection
quote · Single Ventricle / HLHS
▶ Ep 14 · 50:43
You cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything.
quote · Fetal Surgery
▶ Ep 17 · 48:53
You cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything.
quote · Fetal Surgery

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Congenital Lung Lesions (CPAM) 115 entries

Congenital Cystic Lung Lesions: Update Course 2014

▶ Ep 4 · 1:16
quote I find that more and more are being, being obtained, but they really don't change what I do at all. ↗
▶ Ep 4 · 10:19
quote Oh, absolutely not. It's so much easier. ↗
▶ Ep 4 · 10:41
clinical Operative time is less and complication rate is lower when congenital lung lesions are resected earlier (3 months) rather than later ↗
▶ Ep 4 · 10:51
clinical Patients with congenital cystic lung disease have subclinical inflammation and infection that increases between 3 and 9 months of age ↗
▶ Ep 4 · 10:55
quote The difference between 3 months and 9 months, is the, the amount of inflammation in, in a fissure or the number of enlarged lymph nodes. ↗
▶ Ep 4 · 10:55
clinical The amount of inflammation in fissures and number of enlarged lymph nodes is significantly greater at 9 months compared to 3 months ↗
▶ Ep 4 · 13:55
clinical Asymptomatic children at one year of age can have massive lymph nodes and massive inflammation in the fissure ↗
▶ Ep 4 · 14:40
clinical A 3 millimeter vessel sealer can safely take vessels up to 5 millimeters in diameter ↗
▶ Ep 4 · 18:55
opinion Anatomic segmental resection is key when performing partial lung resection for congenital lung lesions ↗
▶ Ep 4 · 19:08
clinical One child who had segmental resection has shown evidence of recurrent cystic disease ↗
▶ Ep 4 · 20:36
epidemiological In a series of over 300 lobectomies for cystic lung disease, there were 2 pulmonary blastomas and 1 adenocarcinoma ↗
▶ Ep 4 · 20:50
clinical Neoplastic mucinous proliferations in CPAM may be associated with KRAS mutation, which is also a marker in adult small cell carcinoma and colon cancer ↗
▶ Ep 4 · 21:02
clinical Columbia pathology review found 4 additional cases with neoplastic mucinous proliferations in CPAM specimens ↗
▶ Ep 4 · 21:17
epidemiological 30-40% of children with cystic lung disease will have a significant pulmonary infection at some point during their life ↗
▶ Ep 4 · 21:32
clinical Once congenital lung lesions become infected, they are much more difficult to resect ↗
▶ Ep 4 · 21:35
opinion All thoracoscopic lobectomies for congenital lung lesions should be done thoracoscopically at this point ↗
▶ Ep 4 · 21:35
quote I think all these operations personally should be done thoracoscopically at this point. ↗
▶ Ep 4 · 22:17
epidemiological The incidence of malignancy in congenital cystic lung lesions is almost 2%, certainly 1% ↗
▶ Ep 4 · 23:06
clinical Morsellating tumor tissue does not upgrade the tumor stage and does not change treatment according to hematologist-oncologists ↗
▶ Ep 4 · 24:24
epidemiological All three malignant tumors (blastomas and adenocarcinoma) occurred in children under one year of age ↗

Panel Discussion: Pediatric Thoracic Surgery Part 1-Lung Lesions 2012

▶ Ep 7 · 36:08
quote I think putting talc in a kid is a bad idea. ↗
▶ Ep 7 · 37:22
clinical Apical pleurectomy for pneumothorax typically extends down to the third intercostal space when apical blebs are present ↗

Neonatal Lung Lesions with Dr. Steven Rothenberg

▶ Ep 8 · 5:43
epidemiological 6-40% of prenatally diagnosed lung lesions regress with time and may appear to completely disappear ↗
▶ Ep 8 · 6:11
epidemiological Fetal intervention for lung lesions is extremely rare; CHOP performs open fetal surgery less than once every couple of years ↗
▶ Ep 8 · 7:54
clinical Cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis for fetal lung lesions ↗
▶ Ep 8 · 9:09
clinical Hybrid lesions showing features of both CPAM and sequestration are not uncommon on pathology ↗
▶ Ep 8 · 9:48
clinical Intralobar sequestration shares a common pleura with the lobe, usually the lower lobe ↗
▶ Ep 8 · 9:52
clinical Extralobar sequestration has its own pleural lining and is 90% separate from the lobe ↗
▶ Ep 8 · 10:02
clinical Sequestrations are defined by having a systemic artery coming directly off the aorta ↗
▶ Ep 8 · 10:14
clinical Systemic vessels to sequestrations can come off the abdominal aorta and pass through the diaphragm ↗
▶ Ep 8 · 10:40
clinical CPAM type 3 lesions are more solid and have the worst prognosis ↗
▶ Ep 8 · 10:57
quote I consider these all a broad spectrum. I think they're all related, um, and so I don't get too, too bogged down in the nomenclature of what we're talking about. ↗
▶ Ep 8 · 14:29
quote I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected. ↗
▶ Ep 8 · 14:50
clinical Chest X-ray alone is not adequate to ensure there is no residual lung lesion after prenatal diagnosis ↗
▶ Ep 8 · 15:47
epidemiological 20-40% of untreated congenital lung lesions will develop significant infection at some point ↗
▶ Ep 8 · 15:55
quote I think that, you know, especially with thoracoscopic techniques, the morbidity of, of removing these lesions so that the family and the child never have to worry about it ever again is, is relatively small ↗
▶ Ep 8 · 16:58
epidemiological The incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series ↗
▶ Ep 8 · 16:58
quote The incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant. ↗
▶ Ep 8 · 18:04
opinion Operating by 3 months of age avoids pneumonia or severe respiratory infection before surgery ↗
▶ Ep 8 · 18:20
opinion Surgery is technically easier in younger infants because vessels are smaller and anatomy is fresh ↗
▶ Ep 8 · 18:46
clinical Even asymptomatic patients often have enlarged lymph nodes and inflammation in fissures by one year of age ↗
▶ Ep 8 · 18:46
quote I often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection ↗
▶ Ep 8 · 19:32
clinical Hospital stay, chest tube duration, recovery, and operative time are less in patients under 5 kg compared to those under 10 kg ↗
▶ Ep 8 · 19:46
clinical Most infants undergoing early lobectomy are discharged within 48 hours ↗
▶ Ep 8 · 19:46
clinical By one month post-op, chest X-ray shows no evidence of prior surgery due to compensatory lung growth ↗
▶ Ep 8 · 21:13
quote the key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room ↗
▶ Ep 8 · 23:38
clinical Most asymptomatic infants will tolerate single lung ventilation without problem ↗
▶ Ep 8 · 26:02
clinical Babies initially desaturate after lung collapse but saturations improve once they stop shunting blood to the collapsed lung ↗
▶ Ep 8 · 27:41
clinical End-tidal CO2 in the mid-40s during thoracoscopy does not cause significant acidosis or deleterious effects ↗
▶ Ep 8 · 30:02
opinion Standing at the patient's front provides more room from the chest wall to the hilum than standing at the back ↗
▶ Ep 8 · 30:39
opinion The camera port should be anterior to the tip of the scapula in the mid-axillary line to allow working from front to back ↗
▶ Ep 8 · 33:01
opinion A 4mm scope provides a more wide-angle view comparable to a 5mm scope compared to a 3mm scope ↗
▶ Ep 8 · 33:22
opinion Short scopes (20cm) allow the surgeon to get close to the patient without the assistant getting in the way ↗
▶ Ep 8 · 35:01
clinical 3mm vessel sealing devices can seal vessels up to 5mm in diameter ↗
▶ Ep 8 · 35:15
opinion Making two separate seals 4-5mm apart on vessels and cutting between them maximizes safety ↗
▶ Ep 8 · 35:52
quote vascular control in these cases is everything. You really want to maximize the downside. ↗
▶ Ep 8 · 36:11
opinion Cutting partway through a sealed vessel until seeing the lumen allows detection of bleeding while maintaining control ↗
▶ Ep 8 · 36:36
quote You only lose control once you've completely divided the vessel. ↗
▶ Ep 8 · 36:50
opinion Clips on vessels can be knocked off and are less reliable than vessel sealing ↗
▶ Ep 8 · 37:44
quote I think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble ↗
▶ Ep 8 · 37:44
opinion Using energy devices that seal and cut simultaneously is a mistake that sets up the surgeon for trouble ↗
▶ Ep 8 · 38:30
opinion Every sealing device can fail at some point, so techniques should allow for recovery ↗
▶ Ep 8 · 42:01
opinion The inferior pulmonary ligament should be taken down first to check energy source function and identify systemic vessels ↗
▶ Ep 8 · 42:24
clinical Systemic vessels to sequestrations can be missed on CT scan and should be actively looked for during surgery ↗
▶ Ep 8 · 43:13
opinion Incomplete fissures can be completed by working through tissue layer by layer, similar to finger fracturing in liver surgery ↗
▶ Ep 8 · 45:20
clinical The bronchus sits directly underneath the pulmonary artery and can be felt to aid dissection ↗
▶ Ep 8 · 48:31
clinical The pulmonary vein is directly behind the bronchus in the same plane as the fissure dissection ↗
▶ Ep 8 · 49:11
clinical A 5mm stapler is inadequate for bronchus or vessels in children over 10 kg ↗
▶ Ep 8 · 50:33
clinical The pulmonary vein trunk must never be taken near the pericardium because retraction into the pericardium after device failure causes fatal hemorrhage ↗
▶ Ep 8 · 50:33
quote you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything. ↗
▶ Ep 8 · 51:10
clinical Middle lobe vessels come off just above the right lower lobe pulmonary artery and can be damaged if dissection migrates too cephalad ↗
▶ Ep 8 · 57:38
opinion Large cysts should be decompressed with the sealing device at the beginning of the procedure to improve visualization and lung manipulation ↗
▶ Ep 8 · 58:40
clinical Systemic vessels to sequestrations can number up to 6 and range from small to 15mm in diameter ↗
▶ Ep 8 · 59:55
clinical Using both sealing technology and clips on the same vessel risks delayed bleeding as the vessel changes nature and clips lose secure footing ↗
▶ Ep 8 · 1:00:26
quote either use clips or use vessel sealing, but don't use both on the same vessel. ↗
▶ Ep 8 · 1:00:43
clinical Systemic vessels to sequestrations have higher pressure from the aorta compared to low-pressure pulmonary vessels ↗
▶ Ep 8 · 1:01:07
clinical Extralobar sequestrations become infected and can cause problems even if malignant potential is uncertain ↗
▶ Ep 8 · 1:01:23
opinion Embolization of sequestrations requires general anesthesia and significant arterial intervention with no advantage over thoracoscopic resection ↗
▶ Ep 8 · 1:01:35
clinical Extralobar sequestration resection does not require a chest tube and patients go home the next day ↗
▶ Ep 8 · 1:01:35
quote I believe that we can go in thoracoscopically and remove these with Almost no morbidity ↗
▶ Ep 8 · 1:03:48
opinion Segmentectomy is feasible when disease is confined to the superior segment of lower lobe or lingula with favorable anatomy ↗
▶ Ep 8 · 1:05:33
clinical Average length of stay for lobectomy in patients coming in the morning is about 2.5 days ↗

Neonatal Lung Lesions with Dr. Steven Rothenberg

▶ Ep 23 · 5:43
epidemiological 6-40% of prenatally diagnosed lung lesions regress with time and may appear to completely disappear ↗
▶ Ep 23 · 6:11
epidemiological Fetal surgery for lung lesions is extremely rare, performed less than once every couple of years even at high-volume centers ↗
▶ Ep 23 · 7:54
clinical Cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis in prenatal lung lesions ↗
▶ Ep 23 · 9:09
clinical Hybrid lesions showing features of both CPAM and sequestration are not uncommon on pathology ↗
▶ Ep 23 · 10:57
quote I consider these all a broad spectrum. I think they're all related, um, and so I don't get too, too bogged down in the nomenclature of what we're talking about. ↗
▶ Ep 23 · 13:11
clinical CT scan at 4-6 weeks allows for less atelectasis during the study and easier interpretation compared to earlier imaging ↗
▶ Ep 23 · 14:44
clinical Chest X-ray or ultrasound are inadequate to ensure there is no lesion present after prenatal diagnosis ↗
▶ Ep 23 · 15:55
epidemiological 20-40% of untreated congenital lung lesions will develop significant infection at some point ↗
▶ Ep 23 · 16:58
epidemiological The incidence of malignancy in untreated congenital lung lesions is over 1% ↗
▶ Ep 23 · 17:07
quote One case of cancer would be too many, and, and, you know, 10 out of 100 severe infections, or 10 or 20, I think is way too high as well ↗
▶ Ep 23 · 18:24
clinical Surgery is technically easier in smaller infants because vessels are smaller and anatomy is fresh ↗
▶ Ep 23 · 18:46
clinical Even in asymptomatic children, significantly enlarged lymph nodes and inflammation are often found in the fissures around one year of age ↗
▶ Ep 23 · 19:32
clinical Hospital stay, chest tube duration, recovery, and operative time are less in patients under 5 kg compared to those under 10 kg ↗
▶ Ep 23 · 21:13
quote The key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room ↗
▶ Ep 23 · 23:38
clinical Most asymptomatic children on room air will tolerate single lung ventilation without problem ↗
▶ Ep 23 · 26:02
clinical All babies initially desaturate when the lung is collapsed, sometimes to high 80s or low 90s, but saturations come up once shunting to the collapsed lung stops ↗
▶ Ep 23 · 35:15
clinical Making two separate seals 4-5mm apart on vessels and cutting partway between them allows recovery if the seal fails ↗
▶ Ep 23 · 35:52
quote I think vascular control in these cases is everything. You really want to maximize the downside. ↗
▶ Ep 23 · 36:47
quote You only lose control once you've completely divided the vessel. ↗
▶ Ep 23 · 37:46
clinical Using energy devices that seal and cut simultaneously on major vessels is dangerous and can lead to unrecoverable bleeding ↗
▶ Ep 23 · 38:16
quote I think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover. ↗
▶ Ep 23 · 45:23
clinical The bronchus sits directly underneath the pulmonary artery in the lower lobe and can be felt to aid dissection ↗
▶ Ep 23 · 50:33
clinical The pulmonary vein trunk must not be taken near the pericardium because device failure will cause the vessel to retract and result in fatal bleeding ↗
▶ Ep 23 · 50:43
quote You cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything. ↗
▶ Ep 23 · 58:42
clinical Extra-lobar sequestrations can have up to 6 systemic vessels, with diameters ranging from small to 15mm ↗
▶ Ep 23 · 59:55
clinical Using both sealing technology and clips on the same vessel can cause delayed bleeding as the vessel changes and clips lose secure footing ↗
▶ Ep 23 · 1:05:33
clinical Average length of stay for lobectomy in patients who come in the morning is about 2.5 days ↗

The Full Story on CPAMs

▶ Ep 25 · 36:37
clinical Single-lung ventilation is preferable for thoracoscopic lobectomy, achieved by main stem intubation of contralateral bronchus ↗
▶ Ep 25 · 38:55
clinical For thoracoscopic lobectomy, scope port should be anterior to scapula tip in mid-axillary line over major fissure to allow front-to-back working approach ↗
▶ Ep 25 · 43:06
quote Vascular control in these cases is everything. ↗
▶ Ep 25 · 43:09
clinical Vascular control technique involves making two seals on vessel with space between, then cutting partway to visualize lumen before complete division ↗
▶ Ep 25 · 48:53
clinical Critical safety point: do not take pulmonary vein trunk near pericardium; if device fails, vessel will retract into pericardium causing fatal hemorrhage ↗
▶ Ep 25 · 48:53
quote You cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything. ↗
Fetal Surgery 44 entries

Fetoscopic endoluminal tracheal occlusion and twin-twin transfusion: Fetal...

▶ Ep 10 · 1:19:24
epidemiological Twin-twin transfusion syndrome occurs in 10-20% of monochorionic twin pregnancies ↗
▶ Ep 10 · 1:23:37
clinical Arterio-arterial anastomoses act as bidirectional connections that equilibrate unidirectional AV anastomoses and prevent TTTS ↗
▶ Ep 10 · 1:30:22
clinical Amnio-reduction improves fetal oxygenation by decreasing placental compression from polyhydramnios ↗
▶ Ep 10 · 1:43:50
clinical High-volume laser centers achieve 93-94% survival of at least one twin, 88% overall survival, and 78% dual twin survival ↗
▶ Ep 10 · 1:44:33
clinical Major neurodevelopmental delays after laser photocoagulation occur in 5-6% of cases, minor delays in 7-8% ↗
▶ Ep 10 · 1:47:05
clinical The diode laser is much safer than argon laser for vessel photocoagulation, with lower penetration depth and less risk of vessel rupture ↗
▶ Ep 10 · 1:50:11
clinical Missed vascular connections occur in approximately 0.8% of cases with careful mapping and placental injection studies ↗
▶ Ep 10 · 2:09:43
clinical Type 3 sIUGR is characterized by intermittent absent/reversed end-diastolic flow due to large AA anastomoses causing acute fetal-to-fetal transfusions ↗
▶ Ep 10 · 2:15:40
clinical Type 3 sIUGR has 20-25% risk of periventricular leukomalacia in the normal twin due to recurrent hypovolemic episodes ↗
▶ Ep 10 · 2:16:04
clinical With expectant management of Type 3 sIUGR, there is 48% loss in the smaller twin and 33% loss in the normal twin ↗
▶ Ep 10 · 2:21:22
clinical Bipolar cord cauterization achieves 86% singleton survival; radiofrequency ablation achieves 83% singleton survival ↗

Neonatal Lung Lesions with Dr. Steven Rothenberg

▶ Ep 14 · 5:43
epidemiological 6-40% of prenatally diagnosed lung lesions regress with time and may appear to completely disappear ↗
▶ Ep 14 · 6:11
epidemiological Fetal surgery for lung lesions is extremely rare, performed less than once every couple of years even at high-volume centers ↗
▶ Ep 14 · 7:54
clinical Cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis in prenatal lung lesions ↗
▶ Ep 14 · 9:09
clinical Hybrid lesions showing features of both CPAM and sequestration are not uncommon on pathology ↗
▶ Ep 14 · 10:57
quote I consider these all a broad spectrum. I think they're all related, um, and so I don't get too, too bogged down in the nomenclature of what we're talking about. ↗
▶ Ep 14 · 13:11
clinical CT scan at 4-6 weeks allows for less atelectasis during the study and easier interpretation compared to earlier imaging ↗
▶ Ep 14 · 14:44
clinical Chest X-ray or ultrasound are inadequate to ensure there is no lesion present after prenatal diagnosis ↗
▶ Ep 14 · 15:55
epidemiological 20-40% of untreated congenital lung lesions will develop significant infection at some point ↗
▶ Ep 14 · 16:58
epidemiological The incidence of malignancy in untreated congenital lung lesions is over 1% ↗
▶ Ep 14 · 17:07
quote One case of cancer would be too many, and, and, you know, 10 out of 100 severe infections, or 10 or 20, I think is way too high as well ↗
▶ Ep 14 · 18:24
clinical Surgery is technically easier in smaller infants because vessels are smaller and anatomy is fresh ↗
▶ Ep 14 · 18:46
clinical Even in asymptomatic children, significantly enlarged lymph nodes and inflammation are often found in the fissures around one year of age ↗
▶ Ep 14 · 19:32
clinical Hospital stay, chest tube duration, recovery, and operative time are less in patients under 5 kg compared to those under 10 kg ↗
▶ Ep 14 · 21:13
quote The key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room ↗
▶ Ep 14 · 23:38
clinical Most asymptomatic children on room air will tolerate single lung ventilation without problem ↗
▶ Ep 14 · 26:02
clinical All babies initially desaturate when the lung is collapsed, sometimes to high 80s or low 90s, but saturations come up once shunting to the collapsed lung stops ↗
▶ Ep 14 · 35:15
clinical Making two separate seals 4-5mm apart on vessels and cutting partway between them allows recovery if the seal fails ↗
▶ Ep 14 · 35:52
quote I think vascular control in these cases is everything. You really want to maximize the downside. ↗
▶ Ep 14 · 36:47
quote You only lose control once you've completely divided the vessel. ↗
▶ Ep 14 · 37:46
clinical Using energy devices that seal and cut simultaneously on major vessels is dangerous and can lead to unrecoverable bleeding ↗
▶ Ep 14 · 38:16
quote I think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover. ↗
▶ Ep 14 · 45:23
clinical The bronchus sits directly underneath the pulmonary artery in the lower lobe and can be felt to aid dissection ↗
▶ Ep 14 · 50:33
clinical The pulmonary vein trunk must not be taken near the pericardium because device failure will cause the vessel to retract and result in fatal bleeding ↗
▶ Ep 14 · 50:43
quote You cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything. ↗
▶ Ep 14 · 58:42
clinical Extra-lobar sequestrations can have up to 6 systemic vessels, with diameters ranging from small to 15mm ↗
▶ Ep 14 · 59:55
clinical Using both sealing technology and clips on the same vessel can cause delayed bleeding as the vessel changes and clips lose secure footing ↗
▶ Ep 14 · 1:05:33
clinical Average length of stay for lobectomy in patients who come in the morning is about 2.5 days ↗

The Full Story on CPAMs

▶ Ep 17 · 36:37
clinical Single-lung ventilation is preferable for thoracoscopic lobectomy, achieved by main stem intubation of contralateral bronchus ↗
▶ Ep 17 · 38:55
clinical For thoracoscopic lobectomy, scope port should be anterior to scapula tip in mid-axillary line over major fissure to allow front-to-back working approach ↗
▶ Ep 17 · 43:06
quote Vascular control in these cases is everything. ↗
▶ Ep 17 · 43:09
clinical Vascular control technique involves making two seals on vessel with space between, then cutting partway to visualize lumen before complete division ↗
▶ Ep 17 · 48:53
quote You cannot take, do not take the trunk near the pericardium, because if your device fails, whatever it is, whether you tie, whether you clip, whether you staple, it'll retract into the pericardium and the child will bleed to death before you can do anything. ↗
▶ Ep 17 · 48:53
clinical Critical safety point: do not take pulmonary vein trunk near pericardium; if device fails, vessel will retract into pericardium causing fatal hemorrhage ↗
Pectus Excavatum 22 entries

Update Course Rewind 2021 - Updates in Pectus

▶ Ep 23 · 32:06
quote I was a cryo skeptic. But we, and I'd planned to go out and see Sean do some, and then COVID came ↗
▶ Ep 23 · 32:40
quote we now do the New York time crossword while we do the cryotherapy. So that's one suggestion to help ↗
▶ Ep 23 · 33:05
quote I will tell you that it took me about four cases to realize because most of our patients went home on day two or three, but it's not just when they go home. It's how they feel when they go home and the cryo, it's been unbelievable ↗
▶ Ep 23 · 33:40
clinical Patients at two weeks post-cryoanalgesia do not notice chest wall numbness as a significant issue ↗
▶ Ep 23 · 33:45
quote I feel bad that I waited so long ↗
▶ Ep 23 · 34:19
clinical With cryoanalgesia, 70% of patients discharged home on post-op day one without narcotics ↗
▶ Ep 23 · 46:20
clinical Sternal elevator allows entry at mid-clavicular line, reduces intercostal tears, and improves bar stability in deep stiff pectus cases ↗
▶ Ep 23 · 47:23
clinical Sternal elevator used in approximately 10% of cases—primarily older males over 16 with Haller index over 3.5 and stiff chest walls ↗

Update Course Rewind: Pectus Excavatum 2021

▶ Ep 25 · 4:53
quote I was a cryo skeptic. ↗
▶ Ep 25 · 5:08
opinion Cryoanalgesia changed patient condition at discharge - not just earlier discharge but better functional status at time of discharge ↗
▶ Ep 25 · 5:08
quote It's not just when they go home, it's how they feel when they go home, and the cryo has been unbelievable. ↗
▶ Ep 25 · 5:21
quote I feel bad that I waited so long. ↗
▶ Ep 25 · 6:59
quote I do think that bar flippage is completely a surgical issue. ↗
▶ Ep 25 · 6:59
opinion Bar flippage is completely a surgical technique issue ↗
▶ Ep 25 · 8:27
clinical Sternal elevator use allows less tissue damage and better repair in deep stiff pectus cases ↗

Update Course Rewind: Pectus Excavatum 2021

▶ Ep 26 · 4:53
quote I was a cryo skeptic. ↗
▶ Ep 26 · 5:08
opinion With cryoanalgesia, patients feel significantly better when discharged compared to other pain control methods ↗
▶ Ep 26 · 5:21
quote I mean, I feel bad that I waited so long. ↗
▶ Ep 26 · 5:23
quote I accept Vic's concerns and criticisms, and I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients. ↗
▶ Ep 26 · 6:59
opinion Bar flippage is completely a surgical technique issue ↗
▶ Ep 26 · 6:59
quote I do think that bar flippage is completely a surgical issue. ↗
▶ Ep 26 · 8:19
clinical Sternal elevator is used in about 10% of cases, primarily in really deep stiff pectuses to allow less tissue damage ↗
Sarcoma (Ewing/Rhabdo) 8 entries

Update Course Rewind: Thoracotomy vs VATS for Lung Metastases

▶ Ep 18 · 7:29
quote I'm very happy to see these, these studies have finally come out because we actually did report it on our data almost 20 years ago, but survival didn't change when you had only 3 to 4 nodules on the side ↗
▶ Ep 18 · 7:29
opinion The argument that you needed to put your hand in to feel all the granules means you automatically should do a bilateral thoracotomy because this is a systemic disease, not a unilateral disease ↗
▶ Ep 18 · 7:29
clinical Survival didn't change when you had only 3 to 4 nodules on the side ↗
▶ Ep 18 · 7:52
clinical We can only see 1 or 2 millimeter nodules now even with the best CTs, and you still miss some ↗
▶ Ep 18 · 8:02
quote There's no question that tumor clearing is, is improve survival, but there are ones that you can feel and not see, and there are ones that you can't feel. ↗
▶ Ep 18 · 8:02
clinical There's no question that tumor clearing improves survival ↗
▶ Ep 18 · 8:05
clinical There are ones that you can feel and not see, and there are ones that you can't feel ↗
▶ Ep 18 · 8:12
opinion If there's only 3 to 4 nodules on the side and they're applicable to thoracoscopy, that's how we go just to reduce the morbidity ↗
Single Ventricle / HLHS 87 entries

Neonatal Lung Lesions with Dr. Steven Rothenberg

▶ Ep 21 · 5:43
epidemiological 6-40% of prenatally diagnosed lung lesions regress with time and may appear to completely disappear ↗
▶ Ep 21 · 6:11
epidemiological Fetal intervention for lung lesions is extremely rare; CHOP performs open fetal surgery less than once every couple of years ↗
▶ Ep 21 · 7:54
clinical Cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis for fetal lung lesions ↗
▶ Ep 21 · 9:09
clinical Hybrid lesions showing features of both CPAM and sequestration are not uncommon on pathology ↗
▶ Ep 21 · 9:48
clinical Intralobar sequestration shares a common pleura with the lobe, usually the lower lobe ↗
▶ Ep 21 · 9:52
clinical Extralobar sequestration has its own pleural lining and is 90% separate from the lobe ↗
▶ Ep 21 · 10:02
clinical Sequestrations are defined by having a systemic artery coming directly off the aorta ↗
▶ Ep 21 · 10:14
clinical Systemic vessels to sequestrations can come off the abdominal aorta and pass through the diaphragm ↗
▶ Ep 21 · 10:40
clinical CPAM type 3 lesions are more solid and have the worst prognosis ↗
▶ Ep 21 · 10:57
quote I consider these all a broad spectrum. I think they're all related, um, and so I don't get too, too bogged down in the nomenclature of what we're talking about. ↗
▶ Ep 21 · 14:29
quote I have seen more than a couple kids who were who had a prenatal diagnosis, got a chest X-ray when they when they were born that looked normal, and or occasionally got an ultrasound. I think ultrasound is not a good modality once the kids are born, and we're told they did not see anything. The child then shows up later in life. Most kids I saw anywhere from 9 months to 6 or 7 years of life with pneumonia and on further evaluation have a CPAM which got infected. ↗
▶ Ep 21 · 14:50
clinical Chest X-ray alone is not adequate to ensure there is no residual lung lesion after prenatal diagnosis ↗
▶ Ep 21 · 15:47
epidemiological 20-40% of untreated congenital lung lesions will develop significant infection at some point ↗
▶ Ep 21 · 15:55
quote I think that, you know, especially with thoracoscopic techniques, the morbidity of, of removing these lesions so that the family and the child never have to worry about it ever again is, is relatively small ↗
▶ Ep 21 · 16:58
epidemiological The incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series ↗
▶ Ep 21 · 16:58
quote The incidence of malignancy, and we can talk about this later in the in the patients I've seen is over 1%. I don't consider that insignificant. ↗
▶ Ep 21 · 18:04
opinion Operating by 3 months of age avoids pneumonia or severe respiratory infection before surgery ↗
▶ Ep 21 · 18:20
opinion Surgery is technically easier in younger infants because vessels are smaller and anatomy is fresh ↗
▶ Ep 21 · 18:46
clinical Even asymptomatic patients often have enlarged lymph nodes and inflammation in fissures by one year of age ↗
▶ Ep 21 · 18:46
quote I often find that when the kids have waited, when we've waited or gotten the patients older, at around a year of age or so, that even though they've been completely asymptomatic, when you get in there, there are significantly enlarged lymph nodes that are in the in the fissures around the peribronchial spaces, and sometimes there's inflammation in the fissure, even though the parents will swear. Uh, that the kid never had an infection ↗
▶ Ep 21 · 19:32
clinical Hospital stay, chest tube duration, recovery, and operative time are less in patients under 5 kg compared to those under 10 kg ↗
▶ Ep 21 · 19:46
clinical By one month post-op, chest X-ray shows no evidence of prior surgery due to compensatory lung growth ↗
▶ Ep 21 · 19:46
clinical Most infants undergoing early lobectomy are discharged within 48 hours ↗
▶ Ep 21 · 21:13
quote the key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room ↗
▶ Ep 21 · 23:38
clinical Most asymptomatic infants will tolerate single lung ventilation without problem ↗
▶ Ep 21 · 26:02
clinical Babies initially desaturate after lung collapse but saturations improve once they stop shunting blood to the collapsed lung ↗
▶ Ep 21 · 27:41
clinical End-tidal CO2 in the mid-40s during thoracoscopy does not cause significant acidosis or deleterious effects ↗
▶ Ep 21 · 30:02
opinion Standing at the patient's front provides more room from the chest wall to the hilum than standing at the back ↗
▶ Ep 21 · 30:39
opinion The camera port should be anterior to the tip of the scapula in the mid-axillary line to allow working from front to back ↗
▶ Ep 21 · 33:01
opinion A 4mm scope provides a more wide-angle view comparable to a 5mm scope compared to a 3mm scope ↗
▶ Ep 21 · 33:22
opinion Short scopes (20cm) allow the surgeon to get close to the patient without the assistant getting in the way ↗
▶ Ep 21 · 35:01
clinical 3mm vessel sealing devices can seal vessels up to 5mm in diameter ↗
▶ Ep 21 · 35:15
opinion Making two separate seals 4-5mm apart on vessels and cutting between them maximizes safety ↗
▶ Ep 21 · 35:52
quote vascular control in these cases is everything. You really want to maximize the downside. ↗
▶ Ep 21 · 36:11
opinion Cutting partway through a sealed vessel until seeing the lumen allows detection of bleeding while maintaining control ↗
▶ Ep 21 · 36:36
quote You only lose control once you've completely divided the vessel. ↗
▶ Ep 21 · 36:50
opinion Clips on vessels can be knocked off and are less reliable than vessel sealing ↗
▶ Ep 21 · 37:44
opinion Using energy devices that seal and cut simultaneously is a mistake that sets up the surgeon for trouble ↗
▶ Ep 21 · 37:44
quote I think that's a huge mistake. I think that's the only way you can, you're just setting yourself up to get into trouble ↗
▶ Ep 21 · 38:30
opinion Every sealing device can fail at some point, so techniques should allow for recovery ↗
▶ Ep 21 · 42:01
opinion The inferior pulmonary ligament should be taken down first to check energy source function and identify systemic vessels ↗
▶ Ep 21 · 42:24
clinical Systemic vessels to sequestrations can be missed on CT scan and should be actively looked for during surgery ↗
▶ Ep 21 · 43:13
opinion Incomplete fissures can be completed by working through tissue layer by layer, similar to finger fracturing in liver surgery ↗
▶ Ep 21 · 45:20
clinical The bronchus sits directly underneath the pulmonary artery and can be felt to aid dissection ↗
▶ Ep 21 · 48:31
clinical The pulmonary vein is directly behind the bronchus in the same plane as the fissure dissection ↗
▶ Ep 21 · 49:11
clinical A 5mm stapler is inadequate for bronchus or vessels in children over 10 kg ↗
▶ Ep 21 · 50:33
quote you cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything. ↗
▶ Ep 21 · 50:33
clinical The pulmonary vein trunk must never be taken near the pericardium because retraction into the pericardium after device failure causes fatal hemorrhage ↗
▶ Ep 21 · 51:10
clinical Middle lobe vessels come off just above the right lower lobe pulmonary artery and can be damaged if dissection migrates too cephalad ↗
▶ Ep 21 · 57:38
opinion Large cysts should be decompressed with the sealing device at the beginning of the procedure to improve visualization and lung manipulation ↗
▶ Ep 21 · 58:40
clinical Systemic vessels to sequestrations can number up to 6 and range from small to 15mm in diameter ↗
▶ Ep 21 · 59:55
clinical Using both sealing technology and clips on the same vessel risks delayed bleeding as the vessel changes nature and clips lose secure footing ↗
▶ Ep 21 · 1:00:26
quote either use clips or use vessel sealing, but don't use both on the same vessel. ↗
▶ Ep 21 · 1:00:43
clinical Systemic vessels to sequestrations have higher pressure from the aorta compared to low-pressure pulmonary vessels ↗
▶ Ep 21 · 1:01:07
clinical Extralobar sequestrations become infected and can cause problems even if malignant potential is uncertain ↗
▶ Ep 21 · 1:01:23
opinion Embolization of sequestrations requires general anesthesia and significant arterial intervention with no advantage over thoracoscopic resection ↗
▶ Ep 21 · 1:01:35
clinical Extralobar sequestration resection does not require a chest tube and patients go home the next day ↗
▶ Ep 21 · 1:01:35
quote I believe that we can go in thoracoscopically and remove these with Almost no morbidity ↗
▶ Ep 21 · 1:03:48
opinion Segmentectomy is feasible when disease is confined to the superior segment of lower lobe or lingula with favorable anatomy ↗
▶ Ep 21 · 1:05:33
clinical Average length of stay for lobectomy in patients coming in the morning is about 2.5 days ↗

Neonatal Lung Lesions with Dr. Steven Rothenberg

▶ Ep 29 · 5:43
epidemiological 6-40% of prenatally diagnosed lung lesions regress with time and may appear to completely disappear ↗
▶ Ep 29 · 6:11
epidemiological Fetal surgery for lung lesions is extremely rare, performed less than once every couple of years even at high-volume centers ↗
▶ Ep 29 · 7:54
clinical Cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis in prenatal lung lesions ↗
▶ Ep 29 · 9:09
clinical Hybrid lesions showing features of both CPAM and sequestration are not uncommon on pathology ↗
▶ Ep 29 · 10:57
quote I consider these all a broad spectrum. I think they're all related, um, and so I don't get too, too bogged down in the nomenclature of what we're talking about. ↗
▶ Ep 29 · 13:11
clinical CT scan at 4-6 weeks allows for less atelectasis during the study and easier interpretation compared to earlier imaging ↗
▶ Ep 29 · 14:44
clinical Chest X-ray or ultrasound are inadequate to ensure there is no lesion present after prenatal diagnosis ↗
▶ Ep 29 · 15:55
epidemiological 20-40% of untreated congenital lung lesions will develop significant infection at some point ↗
▶ Ep 29 · 16:58
epidemiological The incidence of malignancy in untreated congenital lung lesions is over 1% ↗
▶ Ep 29 · 17:07
quote One case of cancer would be too many, and, and, you know, 10 out of 100 severe infections, or 10 or 20, I think is way too high as well ↗
▶ Ep 29 · 18:24
clinical Surgery is technically easier in smaller infants because vessels are smaller and anatomy is fresh ↗
▶ Ep 29 · 18:46
clinical Even in asymptomatic children, significantly enlarged lymph nodes and inflammation are often found in the fissures around one year of age ↗
▶ Ep 29 · 19:32
clinical Hospital stay, chest tube duration, recovery, and operative time are less in patients under 5 kg compared to those under 10 kg ↗
▶ Ep 29 · 21:13
quote The key is the key is the setup of the case. If you don't have the right setup, then you need a bigger space, but if you approach the lobe with the right port placement and the and the right setup, then you have plenty of room ↗
▶ Ep 29 · 23:38
clinical Most asymptomatic children on room air will tolerate single lung ventilation without problem ↗
▶ Ep 29 · 26:02
clinical All babies initially desaturate when the lung is collapsed, sometimes to high 80s or low 90s, but saturations come up once shunting to the collapsed lung stops ↗
▶ Ep 29 · 35:15
clinical Making two separate seals 4-5mm apart on vessels and cutting partway between them allows recovery if the seal fails ↗
▶ Ep 29 · 35:52
quote I think vascular control in these cases is everything. You really want to maximize the downside. ↗
▶ Ep 29 · 36:47
quote You only lose control once you've completely divided the vessel. ↗
▶ Ep 29 · 37:46
clinical Using energy devices that seal and cut simultaneously on major vessels is dangerous and can lead to unrecoverable bleeding ↗
▶ Ep 29 · 38:16
quote I think any device like an harmonic or or any other energy device that that seals and cuts at the same time. Um, if it, if it fails, then you're, you're in big trouble and you can't recover. ↗
▶ Ep 29 · 45:23
clinical The bronchus sits directly underneath the pulmonary artery in the lower lobe and can be felt to aid dissection ↗
▶ Ep 29 · 50:33
clinical The pulmonary vein trunk must not be taken near the pericardium because device failure will cause the vessel to retract and result in fatal bleeding ↗
▶ Ep 29 · 50:43
quote You cannot take, do not take the trunk near the pericardium, because if, if your device fails, whatever it is, whether you tie, whether you clip, whether you staple. It'll retract into the pericardium and the child will bleed to death before you can do anything. ↗
▶ Ep 29 · 58:42
clinical Extra-lobar sequestrations can have up to 6 systemic vessels, with diameters ranging from small to 15mm ↗
▶ Ep 29 · 59:55
clinical Using both sealing technology and clips on the same vessel can cause delayed bleeding as the vessel changes and clips lose secure footing ↗
▶ Ep 29 · 1:05:33
clinical Average length of stay for lobectomy in patients who come in the morning is about 2.5 days ↗