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 Down syndrome 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), L (limb abnormalities) — Dr. Mark Levitt
3:01Plain x-ray of the abdomen can identify vertebral abnormalities including hemivertebra — Dr. Mark Levitt
3:01Cardiac workup should include both physical exam and echocardiogram — Dr. Mark Levitt
3:01NG tube should be passed to rule out esophageal atresia — Dr. Mark Levitt
3:01Kidney ultrasound is needed to evaluate for renal abnormalities — Dr. Mark Levitt
3:01True sacral ratio measurements should wait until the child is three months of age — Dr. Mark Levitt
4:15Pre-sacral masses are rare in typical imperforate anus cases — Dr. Jason Frischer
4:15In anal stenosis or rectal atresia defects, pre-sacral mass is found almost half the time — Dr. Jason Frischer
4:15Patients with pre-sacral mass will need MRI — Dr. Jason Frischer
5:05Cross-table lateral radiograph should be obtained at about 24 hours of life, give or take a few hours — Dr. Jason Frischer
6:01For cross-table lateral, baby is positioned prone with buttock at highest point where air will rise to — Rod Girardo
6:01Cross-table lateral can be obtained at bedside in neonatal unit by placing baby on bump under buttocks — Rod Girardo
7:08Sacral ratio greater than 0.7 connotes very good prognosis for bowel control — Dr. Mark Levitt
7:36Well-formed buttock, good muscle, and true area where sphincter mechanism can be located indicate likely good prognosis — Dr. Jason Frischer
9:11The danger of posterior sagittal approach without knowing rectal location is finding midline white structures like urethra, bladder neck, or bladder itself — Dr. Mark Levitt
9:11Colostomy and distal colostogram allow knowing exactly where rectum is and whether to approach perineally or laparoscopically — Dr. Mark Levitt
10:16Colostomy carries its own complications, as does colostomy closure — Dr. Mark Levitt
10:54If fistula is ignored during primary anaplasty, child can start peeing out their anus postoperatively — Dr. Mark Levitt
12:00During primary repair, opening posterior wall of rectum and inspecting anterior wall can rule out fistula in low rectum cases — Dr. Mark Levitt
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 to rule out the 5% who have fistula — Dr. Mark Levitt

Cases discussed

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

Points of disagreement

8:25Primary PSARP versus diverting colostomy for this case
- Dr. Jason Frischer: In real life practice (not board exam setting), would perform primary posterior sagittal anorectoplasty given the air column is only 8.8mm from skin
- Dr. Mark Levitt: Agrees primary repair would likely be his choice, but emphasizes that the actual surgeon's decision to do colostomy was the safe thing to do and the right choice, with nothing wrong with that approach

Open questions

How to definitively determine intraoperatively whether a fistula is present when performing primary PSARP without prior colostogram
Optimal timing for sacral ratio measurement to balance early prognostic information with measurement accuracy

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:

The Low Rectum With a Hidden Fistula: When Imaging Suggests Simple but Anatomy Disagrees

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 trainees · Case narrative · AI-written, human-reviewed

Presentation

A full-term male neonate presented with an obvious anorectal malformation — a dimple where the anus should be, but no opening and no meconium passage at 20 hours of life 3:01. The buttocks appeared well-formed, suggesting good muscle development and a favorable prognosis 7:36. Initial imaging showed a normal-appearing sacrum on plain radiograph 3:01.

The Decision Point

The cross-table lateral radiograph at 24 hours showed an air column just 8.8 millimeters from the perineal skin — strikingly low 5:05. Combined with the well-formed buttocks and normal sacrum, every visible indicator pointed toward a straightforward low malformation amenable to primary posterior sagittal anorectoplasty (PSARP). "I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me," one discussant stated [q4].

The reasoning was clear: with the rectum that close to the skin, a posterior sagittal incision would immediately encounter the distal rectum rather than other midline structures. "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," one discussant explained [q5]. But here, the rectum's location seemed certain.

Yet the treating surgeon chose colostomy. That decision, though conservative, proved prescient.

What Actually Happened

The distal colostogram revealed a low bulbar rectourethral fistula — unexpected in a defect that appeared so low 12:34. The fistula sat at the anatomic elbow of the urethra, close enough to the rectum that dissection would require careful plane development.

This finding reframed the entire case. A primary PSARP remained technically feasible, but would have required intraoperative identification and management of the fistula. "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," one discussant noted [q8].

The technique for ruling out a fistula during primary repair involves opening the posterior rectal wall and directly inspecting the anterior wall 12:00. This allows visualization of any communication with the urinary tract before completing the anoplasty. Without this step, an unrecognized fistula becomes a delayed complication requiring reoperation.

The Transferable Judgment

Cross-table lateral imaging predicts rectal height, not the presence or absence of a fistula. A low air column makes primary repair technically possible but does not eliminate the need to rule out urinary tract communication. The colostomy-and-colostogram pathway provides that information preoperatively; the primary repair pathway requires intraoperative inspection of the anterior rectal wall.

Both approaches are defensible. Colostomy carries its own morbidity at creation and closure 10:16, but removes uncertainty about anatomy. Primary PSARP in a low defect avoids those complications but demands technical comfort with intraoperative fistula identification. "That was the safe thing to do. Bravo to them. That was the right choice. Nothing wrong with that at all," one discussant said of the colostomy decision [q7].

The case also illustrates why anatomic nomenclature matters. The fistula's location at the urethral elbow defines it as bulbar 12:34 — a descriptor that communicates both the level and the dissection plane to any surgeon who might later operate on this child.

One final consideration: in Down syndrome patients with imperforate anus, 95% have no fistula, but 5% do 13:15. Even in that population, distal colostogram remains indicated 13:15. Assumptions about anatomy based on associated conditions can be as misleading as assumptions based on imaging alone.

Takeaways from this story

A low air column on cross-table lateral indicates rectal height but does not rule out rectourethral fistula.
Primary PSARP for low defects requires intraoperative inspection of the anterior rectal wall to identify fistulas.
Unrecognized fistulas during primary repair can result in postoperative urinary diversion through the anus.
Even in Down syndrome patients with imperforate anus, 5% have fistulas and require distal colostogram.

Primary Anoplasty Decision-Making: When the Cross-Table Lateral Lies

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 specialists · Teaching arc · AI-written, human-reviewed

The workup that matters before you decide anything

VACTERL screening is not a checklist — it is the foundation for every decision that follows 3:01. Plain film identifies vertebral anomalies including hemivertebra 3:01. Cardiac workup requires both exam and echocardiogram, not one or the other 3:01. Pass an NG tube to exclude esophageal atresia 3:01. Renal ultrasound is mandatory 3:01. The sacral ratio measurement waits until three months, but the initial plain film still tells you whether the pelvis developed normally 3:01. The rare but catastrophic miss is the presacral mass — uncommon in typical imperforate anus but present nearly half the time in anal stenosis or rectal atresia 4:15 4:15. If you find one, the patient needs MRI 4:15.

The cross-table lateral tells you where the rectum is, not whether it is safe to operate

Obtain the film at roughly 24 hours, with the baby prone and the buttock elevated so air rises to the distal rectum 5:05 6:01. Mark the expected anal location on the skin before shooting the film — the distance from air column to marker drives the conversation, not the gestalt 6:01 6:01. A sacral ratio above 0.7 predicts good bowel control; well-formed buttocks with visible sphincter mechanism location reinforce that prognosis 7:08 7:36. But proximity of air to skin does not mean you can safely proceed with primary repair. It means you know where the rectum is if you go looking for it.

The danger is not finding the rectum — it is finding something else

The reason to perform colostomy and distal colostogram is not that you lack confidence in your ability to find the rectum 9:11. It is that if you make a posterior sagittal incision without knowing the rectal location, you may encounter a midline white structure — urethra, bladder neck, or bladder itself 9:11. The colostogram tells you whether to approach perineally or laparoscopically 9:11. Colostomy carries its own morbidity, as does closure 10:16. The calculation is not safety versus expedience; it is known anatomy versus blind dissection.

If you proceed with primary repair, you must rule out the fistula intraoperatively

Even when the air column sits close to skin and every prognostic indicator favors primary anoplasty, a rectourethral fistula may be present and very close to the rectum. Missing it means the child will urinate through the anus postoperatively 10:54. During the repair, open the posterior rectal wall and directly inspect the anterior wall 12:00. In a low rectum, careful dissection of the anterior wall off the urinary tract will usually reveal or exclude the fistula. The fistula in this case was bulbar — at the elbow of the urethra, using pure anatomic nomenclature 12:34.

Down syndrome does not eliminate the need for a colostogram

Ninety-five percent of Down syndrome patients with imperforate anus have no fistula, but five percent do 13:15. You cannot assume absence based on the syndrome 13:15. The distal colostogram remains indicated.

The teaching point the discussants most emphasized

The cross-table lateral showing a low air column tempts you to proceed with primary posterior sagittal anoplasty. The well-formed buttocks and normal sacrum reinforce that temptation. But the film does not tell you whether a fistula exists, and it does not tell you how close that fistula sits to the rectum. If you choose primary repair based on favorable imaging, you are committing to open the rectum and inspect the anterior wall before you complete the anoplasty. If you are not prepared to do that, or if you are uncertain about the anatomy despite the imaging, colostomy remains the correct choice. There is no shame in choosing the operation that guarantees you will not injure the urethra.

Takeaways from this story

Presacral mass is rare in typical imperforate anus but present nearly half the time in anal stenosis or rectal atresia
Cross-table lateral proximity of air to skin tells you where the rectum is, not whether primary repair is safe
During primary anoplasty, open posterior rectal wall and inspect anterior wall to rule out fistula before completing repair
Five percent of Down syndrome patients with imperforate anus have a fistula — distal colostogram remains 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 at 24h localizes rectal pouch; position baby prone with buttocks elevated so air rises to defect. (5:05)
Always inspect anterior rectal wall intraoperatively during primary repair to rule out fistula and prevent postop urine per anus. (10:54)
Sacral ratio >0.7 plus well-formed buttocks/muscle indicate very good prognosis for future bowel control. (7:08)
5% of Down syndrome patients with imperforate anus have a fistula; always perform distal colostogram to rule it out. (13:15)

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 hemisacrum trisomy 21

Hashtags

#PediatricSurgery #AnorectalMalformation #NeonatalCare #ColorectalSurgery

Transcript

Click "Show Transcript" to view the full text (13316 characters)

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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