The Colorectal Quiz: Episode 1

Published: 2021-01-13

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rod Girardo — host
Dr. Jason Frischer — guest
Dr. Mark Levitt — guest
Speaker 4

Chapters

0:00Introduction and Speaker Introductions — Introduction to the colorectal quiz podcast format featuring Dr. Jason Frischer from Cincinnati Children's and Dr. Mark Levitt from Children's National Hospital discussing pediatric colorectal surgery cases.
1:50Case Presentation and Initial Workup — Presentation of a full-term neonate with imperforate anus at 20 hours of life with no meconium passage. Discussion of VACTERL workup including vertebral, cardiac, esophageal, renal, and limb abnormalities, plus sacral ratio assessment and pre-sacral mass evaluation.
5:05Cross-Table Lateral Imaging and Prognostic Factors — Review of cross-table lateral radiograph showing air column 8.8 millimeters from skin, normal sacrum, and well-formed buttocks. Discussion of prognostic indicators for bowel control including sacral ratio greater than 0.7.
8:25Surgical Decision-Making: Primary Repair vs Colostomy — Debate between primary posterior sagittal anorectoplasty versus diverting colostomy. Discussion emphasizes knowing rectal location before posterior sagittal incision to avoid encountering urethra or bladder. The actual surgeon chose colostomy as the safer option.
10:54Distal Colostogram Findings and Fistula Management — Distal colostogram reveals unexpected low bulbar rectourethral fistula. Discussion of the danger of missing fistula during primary repair, technique for inspecting anterior rectal wall intraoperatively, and fistula prevalence in trisomy 21 patients (5% have fistula, 95% do not).
13:56Case Summary and Closing — Summary of key teaching points: complete VACTERL workup, cross-table lateral for surgical planning, colostomy as safe choice, and importance of ruling out fistula intraoperatively during PSARP.

Key claims

3:01VACTERL mnemonic stands for: V (vertebral abnormalities), A (anorectal malformations), C (cardiac abnormalities), E (esophageal atresia), R (renal abnormalities), and L (limb abnormalities) — Dr. Mark Levitt
3:01Plain x-ray of the abdomen can identify vertebral abnormalities including hemivertebra in anorectal malformation workup — Dr. Mark Levitt
3:01Cardiac evaluation should include both physical exam and echocardiogram in anorectal malformation patients — Dr. Mark Levitt
3:01NG tube should be passed to rule out esophageal atresia in anorectal malformation workup — Dr. Mark Levitt
3:01Kidney ultrasound is needed to evaluate for renal abnormalities in anorectal malformation patients — Dr. Mark Levitt
3:01True sacral ratio measurements should wait until the child is three months of age — Dr. Mark Levitt
4:15Pre-sacral mass is found almost half the time in anal stenosis or rectal atresia defects — Dr. Jason Frischer
4:15Patients with pre-sacral mass in the setting of anorectal malformation will end up getting an MRI — Dr. Jason Frischer
5:05Cross-table lateral radiograph is typically obtained at about the 24-hour mark to visualize the gas column location — Dr. Jason Frischer
6:01For cross-table lateral, the baby is positioned prone with a bump under the buttocks to make the buttock the highest point where air will rise — Rod Girardo
7:08Sacral ratio greater than 0.7 connotes a very good prognosis for bowel control — Dr. Mark Levitt
7:36Well-formed buttock, good muscle, and true area where sphincter mechanism can be located, combined with well-developed sacrum, indicate likely good prognosis — Dr. Jason Frischer
9:11The danger of posterior sagittal approach without knowing rectal location is finding something midline and white like the urethra, bladder neck, or bladder itself — Dr. Mark Levitt
9:11Colostomy and distal colostogram are done to know exactly where the rectum is and whether to approach it perineally or laparoscopically — Dr. Mark Levitt
10:16Colostomy carries its own complications, as does colostomy closure — Dr. Mark Levitt
10:54If a primary anoplasty is performed without identifying a fistula, the child can start peeing out their anus postoperatively — Dr. Mark Levitt
12:00During primary posterior sagittal approach, the posterior wall of the rectum should be opened and the anterior wall inspected to rule out fistula — Dr. Mark Levitt
12:16In patients with low rectum, dissecting a little bit of the anterior wall and carefully lifting it off the urinary tract will usually rule out fistula — Rod Girardo
12:34Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra — Dr. Jason Frischer
13:1595% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula — Dr. Mark Levitt
13:15Distal colostogram should still be performed in Down syndrome patients with anorectal malformation despite lower fistula prevalence — Dr. Mark Levitt

Cases discussed

1:50Full-term male neonate with imperforate anus, no meconium passage at 20 hours of life, air column 8.8mm from skin on cross-table lateral, normal sacrum, well-formed buttocks, and unexpected low bulbar rectourethral fistula on distal colostogram

Points of disagreement

8:25Primary PSARP versus colostomy for low imperforate anus
- Dr. Jason Frischer: Would perform primary posterior sagittal anorectoplasty given the air column is 8.8mm from skin and imaging shows low rectum
- Dr. Mark Levitt: Agrees primary repair is reasonable in real life for this case, but notes the actual surgeon chose colostomy which was the safe and right choice, acknowledging colostomy avoids the risk of going in blind

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Primary Anoplasty vs. Colostomy: When the Rectum Looks Low but Isn't Simple

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

The VACTERL workup comes first

Begin with systematic evaluation of associated anomalies. In any newborn with anorectal malformation, the mnemonic VACTERL guides the initial assessment: vertebral abnormalities on plain abdominal x-ray (looking for hemivertebra), cardiac evaluation with both exam and echocardiogram, passage of an NG tube to rule out esophageal atresia, renal ultrasound, and physical exam for limb abnormalities 3:01 3:01 3:01 3:01 3:01. The plain film also provides an early look at sacral development, though true sacral ratio measurements should wait until three months of age 3:01. Don't forget the pre-sacral space — ultrasound should evaluate for pre-sacral mass, which appears in nearly half of anal stenosis or rectal atresia cases 4:15 4:15.

Cross-table lateral technique determines the next decision

At approximately 24 hours of life, obtain a cross-table lateral radiograph with the infant prone and a bump under the buttocks. This positions the buttock as the highest point where air will rise, allowing visualization of the gas column's location relative to the perineal skin 5:05 6:01. A marker placed at the expected anal location enables distance measurement. When the air column sits close to the skin, combined with a well-formed sacrum (likely ratio greater than 0.7) and well-developed buttocks with visible sphincter mechanism location, the prognosis for bowel control is excellent 7:08 7:36. These findings provide families with reassurance about future potty training and school attendance.

Knowing where the rectum is prevents catastrophic errors

The decision to proceed with primary posterior sagittal anorectoplasty hinges entirely on certainty about rectal location. The danger of operating without this knowledge is encountering a midline white structure — urethra, bladder neck, or bladder itself — instead of rectum 9:11. This is why colostomy with distal colostogram exists: to definitively localize the rectum and determine whether perineal or laparoscopic approach is appropriate 9:11. While colostomy carries its own complications, as does closure, the safety it provides in uncertain cases justifies the staged approach 10:16.

The fistula you don't look for will find you later

Even when the rectum appears to be in an ideal low position, a rectourethral fistula may be present and must be actively ruled out. Performing a beautiful primary anoplasty while missing a fistula results in the child urinating through the anus postoperatively — a complication seen even in the hands of skilled surgeons 10:54. During primary posterior sagittal approach, the surgeon must open the posterior rectal wall and carefully inspect the anterior wall 12:00. In patients with low rectum, dissecting a portion of the anterior wall and carefully lifting it off the urinary tract will usually reveal or exclude a fistula 12:16. The bulbar fistula — named for its anatomic location at the elbow of the urethra — may lie very close to the rectum, making meticulous dissection in the proper plane essential 12:34.

Down syndrome does not eliminate fistula risk

While 95% of patients with trisomy 21 and anorectal malformation have no fistula, 5% do. Assuming absence of fistula based on syndrome alone is a mistake 13:15. Distal colostogram should still be performed to definitively rule out the minority who have a rectourethral connection 13:15. The lesson applies broadly: clinical patterns provide probabilities, not certainties, and the definitive study remains necessary when the consequence of being wrong is severe.

The case that appears straightforward on cross-table lateral — low rectum, good sacrum, well-formed perineum — may still harbor complexity. The surgeon who chose colostomy over primary repair in this scenario made the safe choice, even though primary repair was technically feasible. Safety in pediatric colorectal surgery comes not from technical confidence alone but from knowing what you don't yet know.

Takeaways from this story

Cross-table lateral at 24 hours requires prone positioning with bump under buttocks so air rises to the highest point
The danger of blind posterior sagittal approach is finding urethra or bladder instead of rectum—colostogram exists to prevent this
During primary anoplasty, open the posterior rectal wall and inspect the anterior wall—missed fistulas cause urination through anus
5% of Down syndrome patients with imperforate anus have a fistula, so distal colostogram is still needed despite lower prevalence
Sacral ratio >0.7, well-formed buttocks, and visible sphincter mechanism location predict good prognosis for bowel control

Low Rectal Pouch with Unexpected Bulbar Fistula: When the Cross-Table Lateral Misleads

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Case narrative · AI-written, human-reviewed

Presentation

A full-term male neonate presented with imperforate anus — a dimple where the anus should be, no meconium passage at 20 hours of life 3:01. The infant was well-perfused and breathing room air [q2]. Physical examination revealed well-formed buttocks and what appeared to be a normal perineal anatomy aside from the absent opening.

The Decision Point

The cross-table lateral at 24 hours showed an air column 8.8 millimeters from the perineal skin — strikingly close [q5]. The sacrum appeared normal, suggesting a sacral ratio that would likely exceed 0.7 and predict good long-term bowel control 7:08. The combination of low rectal gas, well-formed buttocks, good visible muscle, and normal sacral development all pointed toward favorable anatomy 7:36.

The question: primary posterior sagittal anorectoplasty or diverting colostomy?

With the rectum that low, a primary repair seemed reasonable. Opening posterior sagittally would almost certainly encounter rectum first — not urethra, not bladder neck, not bladder 9:11. The danger of a blind posterior sagittal approach is finding "something midline and white" when you don't know where the rectum actually sits [q7]. But here, the imaging removed that uncertainty. The rectum was right there.

Yet the referring surgeon chose colostomy. "That was the safe thing to do. Bravo to them. That was the right choice," one of the discussants said [q8]. A colostomy carries its own morbidity — both the initial procedure and the eventual closure 10:16 — but it makes the definitive repair safer by allowing a distal colostogram to map the anatomy precisely 9:11.

What They Found

The distal colostogram revealed a low bulbar rectourethral fistula — at the elbow of the urethra, in anatomic terms 12:34. This was the trap. Everything about the case suggested a straightforward low malformation, possibly even a perineal fistula that might declare itself with a bubble of meconium. Instead, the fistula sat close to the rectum, along the urethra, in a location that could easily be missed during a primary repair.

If a surgeon had proceeded with primary anoplasty based on the cross-table lateral alone, the risk was clear: a beautiful repair, normal-appearing anus, and then weeks later the child starts urinating through the neoperineum [q9]. The fistula, unrecognized and unaddressed, would remain patent. One of the discussants noted he had seen exactly this outcome, performed by very capable surgeons.

The Technical Solution

For surgeons experienced with primary repairs in low malformations, the approach to avoid this error is intraoperative inspection. After opening the posterior wall of the rectum, the anterior rectal wall must be directly visualized 12:00. In a patient with a low pouch, carefully dissecting a small portion of the anterior wall and lifting it off the urinary tract will usually reveal whether a fistula is present 12:16. The fistula in this case sat very close to the rectum, and separating the two structures requires finding the correct plane — not trivial when they are nearly adjacent [q11].

The colostomy route removes this intraoperative uncertainty. The distal colostogram shows exactly where the fistula is, and the definitive repair can be planned with full knowledge of the anatomy.

What the Case Changes

A low air column on cross-table lateral does not exclude a rectourethral fistula. Even when the rectum is 8.8 millimeters from skin, a fistula can be present and can be missed if the anterior rectal wall is not inspected. The choice between primary repair and colostomy in a case like this is not about technical capability — it is about whether the surgeon is prepared to open the rectum and look for the fistula during the primary procedure. If not, colostomy is the correct choice.

One final consideration: even in trisomy 21, where 95% of patients with anorectal malformations have no fistula, 5% do 13:15. A distal colostogram is still indicated 13:15. Assumptions based on syndrome associations are not sufficient to skip anatomic confirmation.

Takeaways from this story

Low rectal gas (8.8mm from skin) does not exclude rectourethral fistula; anterior rectal wall must be inspected during primary repair.
Colostomy with distal colostogram remains the safest approach when surgeon is not prepared to open rectum and inspect for fistula intraoperatively.
Missed fistula during primary anorectoplasty results in urination through the neoperineum postoperatively — a preventable complication.
In trisomy 21 with anorectal malformation, 5% have fistula despite 95% having none; distal colostogram still indicated.

Topic overview

Two pediatric colorectal surgeons discuss the management of a full-term male neonate with imperforate anus and no meconium passage at 20 hours of life. The case demonstrates the decision-making process between primary posterior sagittal anorectoplasty (PSARP) versus diverting colostomy, emphasizing the importance of cross-table lateral radiography to localize the rectal pouch and the critical need to rule out rectourethral fistula intraoperatively. A distal colostogram revealed an unexpected low bulbar fistula despite imaging suggesting a straightforward low lesion, illustrating that even apparently simple cases require careful intraoperative inspection of the anterior rectal wall to avoid missing a fistula that could result in urine passing through the anus postoperatively.

Key takeaways

Cross-table lateral x-ray at 24h with prone positioning localizes rectal pouch to guide surgical approach. (5:05)
Always inspect anterior rectal wall intraoperatively—missed fistulas cause urine to pass through anus postop. (10:54)
Sacral ratio >0.7 plus well-formed buttocks/sphincter mechanism predict good bowel control prognosis. (7:08)
Even Down syndrome patients (5% fistula rate) require distal colostogram—don't skip based on syndrome alone. (13:15)
VACTERL workup: plain film for vertebrae, echo for cardiac, NG for esophagus, renal US—MRI if presacral mass. (3:01)

Keywords

anorectal malformation imperforate anus rectourethral fistula bulbar fistula vertebral abnormalities hemivertebra cardiac abnormalities esophageal atresia renal abnormalities limb abnormalities pre-sacral mass anal stenosis rectal atresia trisomy 21 Down syndrome

Hashtags

#PediatricSurgery #AnorectalMalformation #ColorectalSurgery #MedicalEducation

Transcript

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Pediatric colorectal surgery. It just sounds really complex, right? These patients can come with anatomic variances, really rare anomalies. Their care can be complex, dynamic, multidisciplinary, and pose a lot of clinical challenges to your everyday pediatric surgeon. I mean, just me mentioning this, I bet there's a case that popped up in your mind that was a real head scratcher that you'd never seen before. At those times, it might be nice to just step inside the mind of a pediatric colorectal surgeon who's been around the block. Oh, this is really exciting, don't you think? Careful what you wish for. I mean, we've known each other for 20 plus years, and now we're doing the Zoom thing. That's Dr. Jason Frischer. He's a pediatric colorectal surgeon at Cincinnati Children's, and he's talking to one of his best friends, pediatric colorectal surgeon out in DC at Children's National Hospital, Dr. Mark Levitt. Jason was visiting Mount Sinai to check out the program, and I was giving my chief resident grand rounds on, guess what, colorectal surgery. This is an honest to true story. Their friendship I can only describe as those two funny uncles at the barbecue. They're smiling, laughing with each other, but they're also two renowned colorectal surgeons who are clearly passionate about this specialty. So without further ado, this is the colorectal quiz. This is a case that was sent to me by a surgeon, and I know what the surgeon did, but we're going to play it out like you are in the neonatal ICU, and there's a brand new baby, full term, born with imperfect anus. He shares the screen and shows an image of a neonate, a male with an obvious anorectal malformation. There's a little dimple there where the anus should be. All right. So this is a full term baby seems to be perfused well, breathing room air, and obviously no anal opening. But I will tell you, it looks like there might be something there, but there's not. There's no meconium that has passed. And now we are at about 20 hours of life. And it still looks like that. So Mark, could I pause you for a second? Yeah. During those first 20 hours, what are some of the key things that you would want to work up on this child as we are sitting here, hoping that we see some meconium come out from that little dimple in the anal area? Yeah, well, you know, of course, this is a baby with an anorectal malformation. So we need to make sure we check out any associated malformations. So remember that mnemonic from general surgery residency, VACTERAL. So V, vertebral abnormalities. Plain x-ray of the abdomen tells you about the spine, make sure there's no hemivertebra. A is anorectal malformations, which is why we're having this podcast. And then C, cardiac abnormalities. We want to make sure we check for any cardiac defect, both on exam and on echo. E is esophageal atresia. So they ought to get an NG2 pass. R for renal abnormalities. So they need a kidney ultrasound. And then L, limb abnormalities. But you should be able to find those mostly on physical exam. I also like to get a sense of the sacrum. I do like to measure the sacral ratio. But of course, wait until the child is three months of age to make the true sacral ratio of measurements. But it does give you a feel for how normal this pelvis has developed. I always worry about a missed pre-sacral mass. Yeah, I think it's one of the other good reasons of viewing an AP view of the spine, because you can see if there's a hemisacrum. Of course, the spinal ultrasound, if your radiologists are attuned to diagnosing the interectal malformation patients, they ought to look at the pre-sacral space with their ultrasound. Luckily, it's pretty rare to find a pre-sacral mass. But of course, if it's an anal stenosis or a rectal atresia defect, then you need to be very worried about finding a pre-sacral mass. And almost half the time, you'll find one. And those patients will end up getting an MRI. This patient looks like a pretty typical imperfect anus with no flow of meconium. And the interesting thing here to me is it looks like the dimple is pretty normal looking and the buttock looks pretty well formed. But despite that, we're at 20 hours with no meconium. So what's the next step? We typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be. And obviously, during this time, we're also making sure the patient is doing well, getting resuscitated, and that the abdomen's not getting extended to a point that we'd need to intervene before waiting this 24 hours for a cross table lateral. Yeah, no, I agree. And of course, it's important that if this baby was born today, we're not rushing to do anything. Because we need time to have this baby declare themselves to either be someone who's going to need a colostomy or someone who might be able to benefit from a primary repair, a meconium, if a perineal fistula bubbles up. Then Dr. Levitt pulls up the cross table lateral film. It's important to note, and I didn't mention that the baby is now prone, putting the buttock really at the highest point where air will rise to. And you can get this x-ray at the bedside in the neonatal unit, just put the baby on a bump under the buttocks. I think it's important, and it's pretty glaring in this x-ray, that you mark where you think the anus is appropriate so you could get your measurements and get an understanding of what the distances are going to be depending on your next steps and potential operative repair or approach. Yeah, I don't know what they put there. It looks like a... Might be a silver dollar. That could be. First of all, it's a beautiful image. It's very straight on, lateral. The air column has really risen very nicely, and boy, is that thing close to the perineal skin. It's right there, isn't it? It's an impressive film. It's a great one. Yeah. The other thing I would note, again, I wouldn't calculate a sacral ratio at this stage, but the sacrum looks quite normal. I bet this kid is going to have a pretty normal sacral ratio, certainly greater than 0.7, which connotes a very good prognosis for bowel control and really peace of mind for the family. They want to know what's going to happen to this baby in four years when they need to potty train and go to school. Just adding to the prognosis and just putting a picture together, when we looked at the baby, the image of the baby, and looking at his perineum at that point, it did look like there was a well-formed buttock, good muscle. It looked like there was a true area where you could determine where the sphincter mechanism was going to be located in alignment with also seeing a well-developed sacrum and all these other things. All these things lead together to likely a good prognosis. So you have a baby with a low rectum, an air column that is just about 8.8 millimeters from the skin, a normal sacrum, and buttocks that appear to be well-developed. So what's next? I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me. You know, I think the key to deciding whether to dive into a perineon posterior sagittally is where is the rectum? You want to know what structure you will find if you make a posterior sagittal or even a mini posterior sagittal incision. And there is no question in my mind that if I open posterior sagittally here, the first structure I would find would be rectum. Because the danger is that you go in posterior sagittally, you don't know where the rectum is, and you find something midline and white, like the urethra or the bladder neck or the bladder itself. And that's why we do colostomies. And that's why we do distal colostograms. So we know exactly where the rectum is, and we know whether we should approach it perineally or whether we should do it laparoscopically. But in this case, we know we're going to find the rectum. Maybe we should just do a primary repair. It goes without saying, and one of our, I think one of our big teaching points is you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum. So I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy. And I want to tell you, that was the safe thing to do. Bravo to them. That was the right choice. Nothing wrong with that at all. But of course, we are giving the child a colostomy. And whatever complications can happen from that, and we are giving the child a colostomy closure and whatever complications can happen from that. So everything in medicine is a balance, but there is no question that the anal part has been made safer by having a colostomy. The next image blows Dr. Fisher's mind. Dr. Levitt pulls up the distal colostogram. Very clearly, there is a low bulbar fistula. So this is sort of scary. Because if you went in and grabbed this rectum and did a primary analplasty and did not know there was a fistula, and unfortunately, I've seen this done by some very good surgeons where they went in, did a beautiful analplasty, but ignored the fistula. And the child down the road started peeing out their anus. And that's what question is. We both agree that probably in real life, we would have done a primary posterior sagittal approach on this patient, and we would have found the rectum, and we could have made that rectum reach the perineum and done our analplasty. How do we handle this? Because I didn't know that there was a fistula there. This is troublesome. Yeah, I mean, I think that's the key point of this case, that I think a lot of people would have done a primary repair because they said, oh, that's a chip shot. The rectum's right there. But when I do that, I open up the posterior wall of the rectum, and I inspect the anterior wall of the rectum. So for Dr. Levitt, he dissects the little bit of the anterior wall, carefully lifting it off the urinary tract. For him, in a patient like this with a low rectum, this will usually rule out the fistula. I think two other points I want to put is that you can see this fistula is very close to the rectum. And if you're going to dissect that free and along the urethra, it's important to make sure that you know that those two structures are not very far apart. And getting that into that proper plane is very important. I'd also like to mention the fact that we said this is a bulbar fistula. The reason why Dr. Levitt or Mark is saying that it's a bulbar fistula is it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the nomenclature we like to use is an anatomic, pure anatomic nomenclature saying that it's a bulbar fistula. My final question for you, Mark, or point is, what if this patient had trisomy 21? Would you have had a different thought process or approach? It's funny you say that question today. I got an email today from a surgeon who said he has a baby with Downs and imperfect anus. Does the baby need a distal colostogram or can he assume that the baby has no fistula? And I said, no, the baby might have a fistula. 95% of Downs patients have no fistula, but 5% do. So I would still do a distal colostogram and some of them might have a fistula. All right, let's summarize the case. So first, make sure that you do a complete workup. There are a lot of associated anomalies with that. Make sure you also get a preoperative cross table lateral x-ray to evaluate the air column and help you with surgical planning. Once you start to look at everything, keep in mind that even if it looks like a chip shot PSARP, colostomy is still a reasonable and safe choice in the meantime. Now, if you do decide to go with the PSARP, make sure to rule out a fistula intraoperatively. Now, here's some closing thoughts from Dr. Frischer and Dr. Levitt. Hey, I got a joke for you. Oh, go ahead. Have you seen the movie about constipation? I have not. It hasn't come out yet. Oh, man. Okay. Thanks, my friend. I hope that you guys enjoyed the first of potentially several colorectal episodes. If you're listening to this on your podcast app, great. Thank you for listening, but you're missing out. So, download the Stay Current Pediatric Surgery app. You can listen to this podcast and click to see the images that Dr. Frischer and Dr. Levitt are talking about. Then you could click over and watch some technique videos or watch a video about colorectal surgery, listen to other colorectal podcasts. It's all there in the Stay Current app. Until next time, I'm Rod Girardo from Cincinnati Children's. And remember, knowledge should be free.

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