Thanks, everybody. This is, uh, great to be here today. Um, I'm gonna start our section on Hirsch, um, on bowel disorders and start with Hirschprung's disease and some of the problems we encounter as surgeons after the surgery has been completed. And, um, as we all know, um, it's not as simple as just pulling out the bowel that has no ganglion cells. Um, it, there are problems that persist in certain patients and, um, it's oftentimes hard to predict. Which one, which patients are gonna have trouble, so we will, um, go through a process that's, um, trying to evaluate how to um take care of these patients. So the first patient that I'm going to present is an ex 35 weeker who did not pass stool in the 1st 48 hours. He had a suction rectal biopsy that confirmed Hirstprung's on day of life 3, underwent an uncomplicated suave-type laparoscopic assisted pull-through on the day of life 9, had a normal expected mid-sigmoid transition zone, and had 5 centimeters of proximal colon that was resected with normal ganglion cells and no hyper nerve trunks during that procedure. He was discharged on the day of life 26 and um was doing OK before discharge. So the first question, I, and I'm not sure any of my questions have one right answer. Um, I think there's a lot of opportunities that, you know, we as a group can come, come to, uh, to help try to make these regimens more standardized, but the first question is, Are there routine regimens that Hirschprung's patients always get sent home on? Are there routine post-op dilatations, routine post-op irrigations, stimulant or osmotic laxatives, or you just send a patient home with no routine therapies and then treat them as problems arise, or is there another plan to treat them? I know I typically, I mean, I'll tell you what I do, and I, again, I'm not sure if there's any correct answer, um, and we'll see what, what the audience thinks. But I typically will send patients home but see them back pretty quickly. Um, typically, as babies just start stooling, um, there are no problems with stooling, but as they, as the healing process goes on and they can have a narrowing of that anastomotic area, they sometimes can come back with, um, stricture or an outlet obstruction type problem that just might need some dilatations. The baby's stool at this age is often very liquidy, and so it doesn't help maintain that, that, um, anastomosis that may be trying to narrow down in the normal healing process. It looks like the poll results are coming in, and uh overwhelming amount of folks are saying, no home regimen, that's the most popular answer is, uh, is nothing. And then, uh, shortly after that, it looks like there are some people who are saying, saying rectal irrigations, uh, and then, uh, daily anal dilations is the third most popular there. I think it may change. I mean, I, I personally will bring you back about 2 weeks or, um, 2 weeks after surgery and I'll calibrate the anus to make sure that anastomosis is OK. And as long as there's no, it doesn't feel like there's a cicatrix or a narrowing there, um, You, you can decide what to do with the patient at that point. But again, very commonly, very early on, there's not problems, it's usually a little bit later, like we'll see in this patient that problems start occurring in the, in the young child. Um, I'll add in my two cents. I, I tend to also probably along with the, based on the, the survey results, um, with the, uh, majority that I don't, um, do any routine therapies afterwards, um, especially initially just because your anastomosis is healing, so any sort of, um, insertion of, uh, either your finger or, uh, a dilator would have the risk of, um, disrupting your anastomosis. Um. And I, I really think that one of the reasons that there's probably not a standard method is because each patient is a little bit different. Um, I think for all of us who are taking care of these patients, you have the realm of, um, where you feel like you've done the exact same surgery on a patient and some just do beautifully and you, um, think about 3 months later what happened to that patient. They, they obviously have not come back to see me cause they haven't had problems and then the patient that's in your office every couple of weeks because you're not doing very well and so I think it's very important to tailor. Your treatment for these patients to that individual, um, uh, patient and their results. And that's a great point. So this patient, um, he, I did see him early on and he did show some early signs of constipation, so we eventually did put him on some laxative, stimulants on a daily basis. Um, at one point, he was lost to follow-up for about 1 year and he presented back with this X-ray. So, at this point, he's about 2 years old. Um, he comes in with fevers, an X-ray that looks like the, the one shown. Um, so, immediately in the ER we did a digital rectal exam. He didn't have a stricture. We then did a barium enema which didn't show a twist or an obstructing cuff. So we admitted him, placed him on IV fluids, we irrigated him, and we placed him on IV antibiotics to help treat the apparent Hirschprung's enter colitis. So we've got this patient in the hospital now and uh what are the next steps cause it's obviously an obstructed post-op post Sprung's patient and so we're gonna work through how to uh work, handle each, handle this patient. So the next question is, do you just do a simple anal Botox injection? You know, you've shown that you don't have a mechanical obstruction from a, a surgery that maybe was done not perfectly. Do you divert him? He's got a very dilated colon on the left-hand side. Is it just time to give him an ostomy? Um, do you do 4 quadrant rectal biopsy and anal Botox, strip rectal bi biopsy and anal botox. Do you just redo his pull through at that time, or do you treat his Hirschprung's entercolitis, let the inflammation get down and come back and do some surgical options in the future? Um And again, I'm not sure there's any right answer. I think some action needs to be taken. Um, that won't be the initial. Thought from the audience. So for me, I would say that I, um, it would depend very much on how that patient has been doing, um, recently or over the course of, of, of the time that he has pulled through. Um, I think if the patient's been doing very well and this is the first episode of enterocolitis, I probably would be more likely to Not intervene very much short of treating the enterocolitis and making sure he recover, he or she recovers appropriately from that. I think if this has become more of a chronic problem or recurrent enterocolitis, I'd be more worried about all the things that we worry about, um, an anatomic problem, um, a, uh, physiologic issue with, um, dysmotility of the, um, the ganglionic segment, um, or something, you know, um, technically wrong with the, the pull through such as the twist. And Eunice and Megan, can you elaborate on what your uh management of enterocolitis is at your hospital? Do you have a fixed amount of NPO time? Do you start TPN? You do irrigations how often? Yeah, so at our hospital, we don't have a fixed NPO time and we don't typically start TPN right away. We do start irrigations, usually about 10 ccs per kilo of normal saline every 8 hours to get at least for the 1st 24 to 40 hours and see how the patient responds. And we typically start IV Flagyl for the patients when they first come in. Ours is similar and um you know, I think one of the goals for us is to have a more um structured protocol for treatment of enterocolitis and that, you know, ASOSaint's been working a lot on that in terms of appropriately defining enterocolitis and then um coming up with a standard uh management for that. Um, but part of it is because it is a bit of a spectrum. because sometimes patients come in, they have a normal white count, they look distended, but they don't have any other signs of sepsis, and then those patients were more inclined to just start IV Flagyl. For patients who have other signs of sepsis, we're more inclined to do broad-spectrum antibiotic, um, add on top of gram native coverage. Uh, we tend to leave them NPO initially because they usually present with vomiting as a symptom, um. And then we're fairly aggressive about initial washouts 2 or 3 times a day until they clinically um uh improve and then really kind of um oral start um just as a, as a clinical decision based on how the patient's looking. And then the question is, do you send them home on a standard flagyl therapy for a few months, or is it a single course? And these are all questions that are currently not, not answered, I don't think so. And do you send them home on irrigations if they've been admitted for enterocolitis? We, I typically do. I don't think as a standard, our hospitals, even we're not even standardized here, but I typically do for at least, at least a few weeks to try to make sure that. They continue to have a good uh stooling process and they're not, not getting backed up again, but these are great opportunities. I'm looking at the poll results and it's interesting. So the vast majority don't really do much. Um, it's about 46.7%. Now, if you take the two, biopsy, uh, biopsy options together, they're both about 15% apiece, so they're a close second. I think that it was, it was split pretty evenly until you started your discussion and then it started to more people, uh, shied away from the biopsy. So one of the questions in the, uh, in the polling that, or in the chat room is about sending them home with probiotics. Do either of you use probiotics? And then the other question was, is there any role in this setting for anorectalidometry? Those are great questions. Um, in terms of probiotics, um, I think, again, there's, there's no standard way and I probably, there's 8 of us here, we probably all give you 8 different answers, but I think the general trend is to use probiotics as a chronic management and less so as acute management of, um, somebody with, um, Hirsch-Brun's analcolitis. In terms of anorectal manometry, we do have that availability here. Um, but we do it in the outpatient clinic setting and so I find it a challenging, um, Uh, uh, diagnostic study to use on the very small child who may not be able to, um, Sort of, uh, um, sit still for the appropriate, uh, measurements. And for me, I think we may have 8 different ideas about how to use probiotics. If you just look at the probiotics in the market, there are, none of them are standardized. So I think that adds another layer of non-standardization to probiotic therapy. So I think, um, even if we are, we are using them, we may not be using the same thing. So I think that's kind of an unknown how beneficial it is, but I do agree it's more of a chronic thing. Um, and, and I think in this patient, you know, with that dilated colon, I think manometry is very useful and I think it does, it is part of the paradigm, but in the, in the situation where you have a very dilated colon, anal, uh, anal manometry, and even, uh, colonic manometry, the results may be varied because you have an actively dilated colon and you haven't, it's not decompressed well enough to get good results. So, after you've treated him now for the Hirschsprung's entercolitis, I guess we've kinda gone into this. What do you do for him then? We've talked about, I would send him home on, on, on, on Flagyl. I would send him home on Some laxatives and probably some rectal irrigation just to keep them moving for um some period of time. Is there anybody out there who, who wouldn't send them home on anything, or is that, is that a choice from uh either a one-time Hirschprung's entercolitis presentation or this child who maybe has a more chronic problem because his, his colon is obviously very dilated, um, on the left-hand side. My bias for this kid is he, he, he's, he's for some reason, one of those kids that dilates their colon. There are some kids who don't. This kid obviously does, so they're sending him home on nothing would just be expecting him to come back in in the same situation a few months later. Something needs to be done more for this child. Yeah. I agree with Megan. I think that, um, so one of the, one of the components for me as I think about patients I care for with Hirschprung's is how to equip the parents appropriately to be able to handle problems at home. And so I think irrigation is one of those things that, um, it's a tool that you have to teach them if you feel like this patient's gonna be somebody who Um, is likely to have some level recurrence of, of this problem and so, um, I, I think one of the challenges for a lot of families are just, um, when do they show up to the emergency room, when, when is the, um, is, is their constipation bad enough to show up to the emergency room, and if you. Um, if you appropriately teach the parents how to do a washout and give them the tools to do so, it just allows them to have to have a little bit more freedom that they could do that initial washout if they see their child getting sick, and, um, it's, I think it, it improves their quality of life at home. That's a good point. I think that's, that's very important, but we've also, so we here have recently come up with a very standardized teaching regimen for our different campuses. Um, we also have found that there was a lot of education that needs to be done on the floor while they are inpatients, and there's, because this is not an everyday common occurrence, the nursing staff very commonly will, um, have a different level of, of education based on Rectal irrigations, rectal enemas, and so there is, we, we, we do have a regular education process that we do to the floor nurses to make sure they understand what a a rectal is and why it's important. And we also have come up with a standardized order form now so that it's much more clear for the nurses about types of tubes, how it's supposed to be done with a, with links to, um, policy. So it's been. It's an education for parental needs but also education for in-hospital to make sure the care, the care is delivered as you expect in the hospital as well. Hey, Megan or Eunice, um, let me ask you a question. Um, as, uh, I was interested as y'all were talking, is there any evidence for anything that, that y'all have mentioned? I mean, it seems like this is the right topic to try to get some better evidence for it, but I'm just interested to know, is there evidence for what y'all are, for any of these uh suggested treatments. No, I, that's why I don't think there's any right answer in this, and I, I'm hoping that we can come, I mean, we, we can come to some Some better plans and recommendations for, for us. Um, but I, I think we're at the beginning stages of kind of coordinating what is, just like Eunice mentioned, what is, what is Hirschpring's entercolitis and coming up with scores to make sure we diagnose it correctly. And then as I'll show you some, um, some pathways of how do you work these patients up. If we're not working them up the same way or treating them the same way, it's really hard to draw conclusions. So I, I think you're right, there's no, there's, there's not a lot of data. Um, but there's a lot of opportunity to try to come up with that in the future. And I think that's something, you know, for those who are interested, the ABSA Hirschprung's, um, interest group is working on that. Um, like Megan said, I think, I think defining enterocolitis, if we could do it appropriately, allows us to actually have better data on outcomes, and we don't define it well. So in, in all the retrospective studies, the, um, appropriate management and outcomes are all, all over the place because, you know, somebody coming in with constipation, you may Categorized as enterocolitis and put them on Flagyl, but that's really not the same patient that comes in hypotensive, tachycardic, uh, with an elevated white count and so to be able to appropriately uh risk stratify patients initially is useful and so yeah, I mean the, the idea of what you should send these patients home with in terms of length of therapy both on, um, washouts and on antibiotics is, um, is, is relatively undefined. So here's, this is one guideline that's come up. Doctor Langer published this um with ABSA Hirschprung's Disease um Research Interest Group. And it just looks like for the kid, the child who has Hirschprung's who is, who's obstructed post-operatively, how do you work them through? And so the first thing is what we've kind of outlined, you examine them, you, um, You make sure there's not a mechanical obstruction. You then proceed on to rectal biopsy. If there's no mechanical obstruction, but, but the signs of obstruction still persist. You're either gonna find that you had a good procedure done before, so that has no significant pathology, um, and then you move on to trying. To treat their obstructive symptoms with their, uh, we all know that with an absent rare, they're gonna have somewhat of an outlet obstruction at their anus and so the Botox has been very helpful to try to overcome some of that, um, intense, uh, contraction of the, of, of the anal sphincter. The problem with the kids that are the ones who don't improve very well and those you do move on to motility workup whether it's sits markers for a transit or you do formal motility studies with either both an indirectal manometry to see if they're withholding, um, or if they have a dysfunctional area of their colon that maybe isn't working well that needs to be resected because it's acting as a common cavity and it's just not letting the normal progression of stool passage occur. Um, and then there's also the children who then are still having some difficulty and then you move on to, uh, a bowel management with either a stoma, which is, um, usually not the family's first choice, or an anti-grade continence catheter or procedure that allows you to wash, um, anti-grade enemas, um, in an integrated fashion. I do have to say, you know, the, the Hirschsprung's kids are a little more difficult than the anorectal malformation kids because they do have an intact sphincter and that outlet obstruction of their anus sometimes is very difficult to manage even with an ACE, um, um, but it can be done and this is the next step for those kids who are acting obstructed, so. I think this kind of thing is the first step to trying to To study kids long term to make sure we're all doing the same thing at the beginning. I have one other patient that we'll talk about, and this is probably more difficult. The babies that are obstructed show up when they're a few months old or a couple of years old, cause if they're not passing stool, it's a very easy sign for parents to see. This child had the opposite. He's, um, hypermodal. He's having fecal incontinence with Hirschprung's disease, and those kids often present a little bit later, not because anything's occurred, but early on in life, if patients are all um in diapers and they're stooling in diapers, then stooling too much may be missed. It's not until they get into kindergarten or school age when the fecal swelling becomes more of a, an identified problem. Um, so this child had Hirschprung disease diagnosed as a newborn. He was treated in an outside facility. He had to pull through on day of life 3, normal transition zone and the descending colon. He, uh, went to kindergarten and then was quickly withdrawn, uh, because he was having so much fecal soiling. He has two older siblings and they both were in, uh, in school, but he needed to be homeschooled due to his fecal soiling. So he had an ACE procedure performed at 7 years of age. He then relocated to Atlanta, came to our outpatient clinic, and he was soiling. He was at that time getting 100 cc's of normal saline and some castile soap flushed through his, his ACE tube, but he was soiling 5 to 6 times a day. Not just smears, but full bowel movements. Very normal kid, very active, very intelligent, but just needed to change his clothes a couple of times a day, and that just wasn't allowing him to function in society where he should have been at his age. So, if he's in clinic with you, what do you do for this kid with that story you have, it's, there's not much you can do while you're actually in clinic. So what do you, what do you tell the family on that first clinic visit? What do you send him home with? What is the next step? And we'll go on to surgical stuff as well, but what do you do for them while you're there? Do you increase his flush volume cause 100 cc's for a 9 year old is pretty small? Do you add glycerin to try to evacuate a little bit better? Do you just try to stop him up now with anti-diarrheals? Do you give him laxatives? Do you give fiber? Do you, do you add him a constipating diet? Um, again, very many options. Not sure if there's any right answer, but any thoughts about what the next step would be? I would say, um, we're, we're running about 40 minutes behind. So why don't we just skip through, like, just get a quick answer and we'll do rapid fire for these. So obviously we need to slow them down. So we slowed him down a little bit and then. We went on to the operating room to try to figure out what the problem is, and this child, his issues potentially was the opposite of the other kid. Did somebody injure his sphincters and his outlet is not working? Can he not sense things, or does he have a motility problem where he's just not able to control what's coming down? And for, for this child himself, he, he underwent, we went exam under anesthesia, intact sphincters. He had an intact dentate line, went on to manometry studies, but he had HAPC, so he had these high amplitude contractions that were up pressures upwards of 400 millimeters of mercury all the way down to his anus, and I don't think anybody can control. That type of pressure coming down to your anus. You know, as a, as a newborn with Hirschprung's, his capacitance organ, his rectum was removed. So now he just had these high flow pressures coming down to his anus and he just wasn't able to physically control them. So in this chart that was published by IM, um, he would be considered to have pseudoincontinence, hypermotility, and we did all the things listed here and we constipated him with Um, diet, um, cholestyramine, Imodium, and, um, we still then use his, his, his, uh, J tube, and we had to move to twice a day irrigations in addition to 24 mg of Imodium a day, 27 g of fiber, and cholestyramine. And he's, we finally got him back in school after about a year, but it took about a year to try to Figure out his system cause everybody's system is a little bit different, um, but, and they, and not one thing works for every single child. That's great, Megan. Uh, there's a lot of great questions being asked in the chat room. I know we're running behind like, uh, Todd was saying, we're gonna try to get through these cases really quickly. Um, so hopefully, uh, you, Beth, and Eunice will have time to answer some of the questions in the chat room as well. Right. Thanks. You know, I think Eunice has a case. Are we going to bed. Yeah, uh, I'm sharing a case. Um, so I'm gonna talk a little bit about rectal prolapse. This is a relatively unusual problem, but we recently had two systematic reviews that came out and so I thought it was worthwhile kind of discussing this. Um, so, um, I'm gonna just start with a quick case presentation. 3.5 year old male presents with episodic rectal prolapse, has had several episodes of circumferential prolapse, um, that spontaneously reduced, but then recently the prolapse required manual reduction in the emergency room, which was what prompted the mother to seek further evaluation. So how would you manage this patient? So I'm gonna allow people to, so we'll talk a little bit about this. So probably the most, most common time we see prolapse are when Kids are in their, um, potty training phase, um, so. I think um it's not common for surgeons to really specifically be involved in these patients. Are you seeing responses and Any comments on that? I'm actually, I'm not seeing responses right now. I think we're having some people with some technical difficulties. Go ahead and type in the chat if you guys have, oh, it's popping up now. Here we go. So go ahead and answer the poll. Uh, but before we get to those answers, I mean, how about some of the, uh, the moderators here? What do you guys think? What do you guys, what's on your mind here? I think this is like a nightmare in clinic, honestly, this is the patient that no one wants to see, right? I mean, rectal prolapses. I it's very distressing to the patient and the family, and we don't really have a lot of, of great options. So, if it's a patient that I've never met before, I typically will address, you know, concerns about the constipation first and sort of prove or disprove whether or not this patient is significantly constipated. Um, I think if they are constipated, that's like the easier patient to deal with, but every once in a while, you get a kid who is well managed on whatever their regimen is, and they're still prolapsing, and then I think the question is, what do you do? And if someone has the answer, I would love, love to learn it. So that's, that's a great point. So what, um, so sorry, my computer decided not to work with me here. Um, so I think that the, the key to this, um, was quickly just to go through, um, most prolapse are, um, are not in need of surgical management. They do occur most commonly in potty training age. Um, they, they usually come from other medical issues such as constipation, um, just sitting on the, on the toilet incorrectly, um, within a squatting position as opposed to a sitting position. It, it happens in kids because of the anatomy of children. They have a very weak pelvic floor and the rectum is very low and so it tends to pop out easily if you strain hard enough. Um, the things that's important to sort out are other medical diseases such as polys, parasites. Definitely cystic fibrosis is something we should think about when we see these patients in our clinics. Um, And then of course forru's patients and rectal malformation patients, that's a subpopulation of people that if you define those people, their management may be a little bit different from this, this population we're gonna talk about. Um, you need to differentiate them from polyps, um, uh, versus insusception and, and other, and hemorrhoids and such. So the physical exam is quite important and then of course management since they most commonly are from medical issues if you treat their constipation and teach them how to sit. Appropriately in the potty, so sometimes that actually entails getting them a smaller seat so they're not falling through the, the toilet and then also giving them a step so that they're sitting properly upright and that they don't spend a lot of time on it. They're not getting an iPad where they're sitting there for half an hour straining, um, and so most commonly this could be management, managed just by medical therapy. You should always teach a patient, the parents how to reduce. The prolapse because it certainly like Beth said, it's kind of stressful to see that in your child, um, and then, uh, so such that they could kind of, um, not, it doesn't get incarcerated just from prolonged, um, um, uh, incarce sort of just being out for a long period of time and it's also helpful for them to take a, take a picture for you so we can make sure that it really is prolapse as opposed to something else. So what if you have a patient, as Beth was talking about, who has been appropriately managed, there's no other medical issues associated with them, and then they have persistent problems. So let's take a 10 year old female who presents with chronic recurrent rectal prolapse despite medical therapy for constipation. So what would be the next best option for management? Curious to hear from the panel of experts. I've got a low threshold for starting with sclerotherapy because it's, it's simple, it's innocuous, and then sometimes they just need that head start, particularly in that last case with a younger kid. They just need that window of a couple of months to not have a prolapse and then they, they start seeing it less frequently. technique for that and what? Yeah, 5 ccs of and injected in 4 quadrants If there's a little left in between. Does anyone else have trouble getting the sclerosing agent approved in their hospital? Because I can't get anything. They have uh safety concerns about uh hypertonic saline. Um, a lot of the other mixtures are actually not technically sterile. Um, they're not, they're not made from completely sterile components, so I've had a lot of issues actually even being able to do this at all. So, you know, I, I, I have a lower threshold, I think, than some of, some others for a suture rectopexy. Uh, and, you know, if you look at the adult literature, uh, if you do a, a suture rec, you know, the, the sclerotherapy doesn't work that well. I've not had a lot of great success for sclerotherapy. Again, like you said, uh, you know, Sean, it's easy. If you, you know, you have them, you're doing an EUA, you can just go ahead and do it then. But uh I have not had a lot of success for that, especially with a patient that's like chronic and recurrent, and you've, I mean, yeah, the 10 year old here is a little bit of a different story. When I say a low threshold for starting with that, it's usually 2 strikes and you're out, but after 2 rounds, then I would do a laparoscopic rectopexy. Yeah, and, and the real question is whether you do a sigmoid resection with that or not, and I do it based on what the enema looks like, if there's a big redundant sigmoid. Um, but the, again, the, in the adult literature suggests that, uh, a sigmoid, uh, colectomy should be part of that, but I don't know if we're treating the same disease process. Hey, Rod, can you go through and rapid-fire read cause the audience has pretty been pretty active with this. Yeah. Yeah, absolutely. You're right, we do have a lot of stuff going on in the chat here. And there are some people who kind of like what we alluded to is talking about toilet positioning and kind of these non, uh, procedural, uh, measures first. Um, there's some talk about some people have access to different resources, some People have, people who are experts in pelvic physiology and they can work with these kids at their centers. Um, and then some people are having results with dextrosclerotherapy as well. Uh, D50, hypertonic saline, there's a lot of things here. We have a couple of questions that, uh, uh, another question I wanted to say here, D-flux can be used in the prolapse question mark. Um, and then also about repeat sclerotherapy. So maybe how many times are we doing this? So I'm glad everybody brought that up. So this kind of brings up and, and I love the fact that everybody talked about different methods and there are a lot of different options out there. So secondary surgical management, um, injections scle therapy is very popular. There are perineal approaches to. Doing a rectal pexy or a rectal resection, uh, whether that be mucosa or full thickness, um, they're open and closed methods, um, depending on how you tack your, your rectal pexy. There's abdominal approaches, the laparoscopic, um, PEXI, uh, um. Recopexy is very popular. So recently there was a systematic review that came out that looked at, um, um, a conglomeration of publications. And so a couple of things I wanted to point out, there are 27 publications included and, um, it spanned, uh, uh, you know, obviously across the whole world in terms of all these publications. Um, there was, um, out of Of these 900 patients, 300 of them were vascular therapy, and so you notice this there were 8 studies and only 3 sclerosclerosing agents involved. In the 600 patients that underwent operative management, there are 22 studies and 17 procedures. So anytime you see that large volume of procedures, you know that we're not exactly sure which is the best procedure for this, uh, for this pathology. So, um. Um, so if you look at in terms of actually operative procedures for this, um, there are many different options, but they do, um, have some, uh, fairly high success rate, um, and to Mark's point about the transabdominal procedures, what has been published have shown that they, they have pretty high success rate of being, um, um, correcting the, um, the, uh, prolapse. So, Um, so then the second point, the second question is, if you are going to utilize skill or therapy agent, which would you use? So I'm gonna move on to the next, uh, next slide for the sake of time. So there was a second publication also in JPS from 2019 that looked at just, uh, uh, a review of publications on skilled therapy for rectal prolapse in children. And again, um, there were 19 studies and, um, if you look at the, uh, the studies, most of them actually were not from Northern America. Um, the mean age of kids who underwent sclerotherapy was 4 years old, which, which surprised me a little bit cause it did seem younger than I, um, in my experience. Um, and then there are multiple different, um, sclerosing agents, um, and, uh, probably the most commonly used is, is alcohol, um, and I have the same. Issue as Beth when we were historically we've done, we've used phenol, however, that's not a product that we could use anymore to inject into a patient and so we, I switched over to alcohol um because of that reason. Um, success rate is very high, um, so, so, this number was very useful to me and that speaks to what Sean was talking about, that your initial success rate is high, um, but if you fail the first, uh, uh, injection, you certainly could give another one, and that will increase your cumulative success rate and, um, so you max out about 80%, a little bit more than 80%. So once you're to the third and it's still not successful, it's probably reasonable to proceed to, um, To an operative intervention such as the laparoscopic, uh, rectal pexy. Um, so, so I think that in this day and age, probably most people use alcohol, 95% alcohol because the success rate is high, it's something that you could obtain in the hospital because your interventional radiologist probably or your vascularom clinic probably utilizes that product on a regular basis for um for sclerotherapy anyhow. Um, and then the best part about using sclero therapy as initial, um, procedure is that the complication rate is, uh, really mostly negligible, and they're, they're acute and there's not really any, um, there's a very minimal risk of long-term problems with sclero therapy. And so with those two publications, this is sort of the algorithm um that um should be considered, um, and part of this was actually published in the uh the, the discussion component of the Morrison paper. Um, so if you have a patient with, uh, rectal prolapse, you should rule out underlying diseases, especially cystic fibrosis, you should make sure that it is a rectal prolapse and not a polyp or hemorrhoid or something else. If it's a small child that is in the potty training phase, certainly having appropriate management, medical management of, of how you'd, um, do potty training is appropriate, and, um, and then make sure they're not constipated and treat that appropriately. If that fails, then skill therapy is probably the best first, um. Therapy because it's relatively effective with minimal uh risk of complications and if it fails within all the um um uh open operative management or um operative management options, uh, laparoscopic, uh, rectalexy is probably the one with the highest success rate with the lowest risk of complications, and so that's the recommended first procedure operatively. All right. I'm gonna just talk about something that um somebody else also brought up, which is the uh the benefit of having your pelvic floor therapist, a pelvic floor rehab program also involved in care, and I thought this was a great paper because partially I had a patient that was 10 years old that had, that was sort of in this category and I, I, I was Uh, glad to find that there was some support in the literature that this is the way to manage them. So 12 year old male presents with chronic recurrent rectal prolapse refractory to medical therapy. He's seeing you for consideration of surgical treatment. He has also been diagnosed with depression and anxiety, which are being treated with medications. What should you inform his patient, his parents about this? Is he not a candidate because he has a psychiatric disorder? Is he likely to have a lower rate, higher rate of recurrence because he has a psychiatric disorder, or would he benefit from multidisciplinary care? And so, shall I just go on since for the sake of time, Todd? Yeah, OK. I would, yeah, but it looks like so far everyone is answering, uh, well, it's changing a little bit, but most people are answering the last choice. OK, um, and that really would be appropriate and really in my experience, that's been very helpful. So in this patient population, Um, they are, so, so this patient came, uh, this, uh, publication came out of Michigan, and it was based on their experience as they were caring for patients with, uh, with, uh, uh, rectal prolapse, and they realized that they were having a lot of patients on the old, especially in the older population that were not isolated rectal prolapse, but they also had other psychiatric diagnosis such as, um, obsessive compulsive disorder, anxiety, uh, depression. Um, and so the question was whether they would have, um, uh, they would be more refractory to any surgical management that you have to offer them. So in their patient population for those who are greater than 3 years old, about half of those patients had a secondary, uh, diagnosis in addition to the, uh, rectal prolapse, and, um. And they did have reasonable success rate utilizing sclerotherapy mostly for this patient population, but, uh, for those patient population, they also refer them to pelvic floor rehab, um, concurrently so that they were being managed, um, both they were getting optimization of management of their psychiatric disorder. as well as um behavior modification with pelvic floor rehabilitation and then um in addition to that, there's surgical management and in my experience that has been very effective because partially it's, it's a feedback loop so they are anxious and they have um rectal prolapse and it becomes this sort of, um, for one of my patients, it was sort of a an emotional release for her to actually prolapse herself and evacuate stool and so it was important that in addition to the sclero therapy, I, I was able to help her, um, uh, support her through, through the, um, the, the anxiety component of that and the pelvic floor, um, Therapy was very useful in strengthening um the pelvic floor musculature such that once you perform the scope therapy, then uh they're likely to have a, a more durable outcome from that procedure. All right. That's awesome. So, um, I, I, obviously, a frustrating problem that all of us see and I've been anxious for you to present this. So I appreciate you presenting this, and this is another good summary that we'll be pushing out for people. Um, so, uh, Eunice, that's all your cases, right? You and Megan are, OK. So, Uh, we, we wanted, uh, to invite Beth Rymeky back again. We, we invited her last year and then changed the time on her, and she had cases. She's, she's one of the busiest surgeons, so it's always hard to grab her. Uh, but we, we got her here and she's gonna present something that I asked her to present. Last year because it blew my mind because I had never heard of something like this and everyone else had already heard of it. So there you go again, I'm behind the times. And uh uh I've been using it since I was taught about this. So, uh, Beth, take it away. So I'm going to talk about adhesive small bowel obstruction specifically um in regards to uh using gastrographin as both diagnostic and therapeutic management. So, the first patient, while not a child, is probably a patient that a lot of us still are dealing with in our hospitals if yours is anything like ours, um, where we have a 29-year-old male who comes to the ER with 24 hours history of, uh, distention and feeding intolerance. He is a neurologically devastated patient, um, with, uh, syndrome and HIE. He's trached. He has a lot of issues including autonomic instability, and he's had multiple, multiple admissions in the past for small bowel obstruction. Uh, he, this is his surgical history. Uh, when he was very young, he had a duodenojagenostomy for, as a bypass for SMA syndrome. He had an openness in G tube. Uh, he had an X-lap for a bowel obstruction 7 years ago. He had an X-lap for a bowel obstruction 6 years ago, which included an ileocystectomy at that time. And then 4 years ago, he had another exop for a bowel obstruction and at that time to facilitate care, um, and based on massive colonic distention, he got an end colostomy. So, this is his presenting x-ray. This is just, uh, this is the supine view, I believe, um, of the most recent presentation. The labs are, you know, a little bit out of whack. Sodium's a little low, chloride's a little low. His baseline creatinine is 0.2, but he's 0.99 today. Um, his, uh, CBC looks fairly hemoconcentrated. Um, so, what would people do next? So do we have choices? There should be a pole popping up, I hope. Yeah, there it is. Oh, there we go. So, um, would you do an NG tube, uh, and G tube decompression, fluid resuscitate and do serial exams? Would you send this patient for a CAT scan based on these images? Would you resuscitate this patient and take him to the operating room? Um, or would you do NG and G tube decompression, fluid resuscitate, and, uh, give a gastrograph and challenge. So Beth, we're gonna wait about 10 seconds. I, uh, let, let me ask the, the faculty while we're waiting here, um. Uh, Mark, and I know what happens in Cincinnati, so let's ask people from other places. So, Wulan, um, anyone, um, Sean, Liz, Bob, Eric, what do you guys do? Eunice? What would you do for a bowel obstruction? How do you manage a bowel obstruction? Yeah, I, I, I would, I mean, at first we just tried decompression, probably sit on them overnight and see what happens. And then, uh, you know, the question, you know, gastrograph, we would use gastrograph and, uh, we might get it, you know, it's not really that much better. We might even do it, just probably just do a CT scan. Uh, with gastrographin, so then you can find out. Gastrographin, uh, Liz, do you guys use grass gastrographing? So we would resuscitate this child, decompress this child, do serial exams and a follow-up X-ray, and if it did not look like it was improved, we'd do a CAT scan. All right, rapid fire. Let's see who else is unmuted. Eunice. Yeah, I think that the key initially is identify whether you think this is. Risk for a complete obstruction versus not. So if you think it's partial, then you could, um, bowel rest, and then I think that patient population for us, we would consider gastrograph and once you're fully resuscitated. So certainly not the first day. But if you're concerned that it is closed loop obstruction, we may either get a CT scan to confirm that, um, or just go straight to the operating room. OK, so I'm not gonna go through everyone. Is there anyone that disagrees with what Eunice just said? I'll just raise my standard thing that I always raise, which is why are we getting a CAT scan? Why are we getting it is laughing? I heard this talk before. OK, go ahead, Beth. OK, so, uh, this patient, uh, we did use our gastrograph and protocol on him. His abdominal exam, while distended, was not concerning for peritonitis. Um, so the, I'll show you the protocol at the end, but it's a pretty standard gastrographin protocol where we administer through either the NG or the G tube and then clamp the tubes, uh, try to leave them clamped until the first X-ray, which is between 8 and 10 hours, um, and then go from there. So, in this patient, the first X-ray here on the, uh, far left of, of the You can see that there's still a contrast sitting in dilated loops of bowel, but the arrow here pointing to this looks like it's in the colon, but in this sort of twisty spine patient, we weren't 100% sure. Um, so we got an additional one which, uh, confirmed that. You can see that there's the contrast has passed through and this is actually his stoma bag cause this is a patient that remember has a colostomy. Um, and then on the 24 hour X-ray, essentially all of the contrast was gone with a small amount of, of residual here in the colon. Um, and then, go ahead. No, I, Miguel, in a second I'm gonna want you to open your mic and chime in cause I see what you wrote in the check. Keep going, Beth. Uh, so, what this allowed us to do is then to, you know, sort of get rid of the NG tube and work towards resuming feedings in this patient since he, you know, clearly did not have a true bowel obstruction. All right, Miguel, what do you got to say? No, I, I just involved that we need to be sure at, at some point that this includes only a mechanical obstruction and there's no any ischemic uh involved with this obstruction. Even if it's pseudo-obstruction or an incomplete obstruction, we can be confident that there's no ischemia in this thing. We can do that, whatever we want, we have the time, but we need to be sure about that. So at some point, maybe the, the CAT scan with an angio scan would be very important or a Doppler maybe sometimes. So I think in our experience, we've just relied on, you know, x-rays and physical exams. So as part of our protocol, it is an absolute requirement that the patient be examined by the attending surgeon. Um, before this is enacted, and they also have to review the X-rays because we did have some rogue behavior at the beginning where, um, people were saying yes, but not actually seeing the patient. So that's, I, I think that's kind of a safety measure that we've, uh, implemented to try to decrease, you know, you don't wanna give a gastrograph to a patient with peritonitis. OK, so, Jay, can you go to the zoom view so we see all the faculty, put them all on the spot here. Go to the zoom view for a second. Tell me when we're there cause I won't know when. OK, raise your hand. Raise your hand if you get CAT scans routinely. I bowel obstructions. Raise your hand. So I can't see everyone. I think I'm guessing I'm the only one raising my hand. I think let's see, we'll see what everyone. I am not raising my hand. I know. I think I'm the only one, so Saint Peter's also raised his hand. Me and Sean, you know, and Sean's really smart, so that puts always Megan raised her hand. I, I hear Megan raised her hand as well. Hey, hey, Todd, are you asking, are you asking if the staff get them or the, uh, fellows get them? I'm, I'm actually asking if you, if they asked you, would you tell them to get a CAT scan? I'm not sure they'd ever ask us. All right, let's keep going. Sorry, Beth. No, that's OK. So, uh, you know, anyone who works with residents probably knows that this is pretty much the, the standard of care in adult surgery now. And, um, and a lot of us sort of learned this protocol by discussion with the residents, and it was one of our residents that really kind of pushed us to start doing this a couple of years ago and said, I don't understand what's wrong with you guys. Why are you not using gastrographin for bowel obstructions? Um, there's less data out there in pediatric patients, but what limited data there is does seem to parallel the adult data in terms of both safety and efficacy. Um, I believe Jay somewhere in the global cast world has some references, um, for some articles if you're interested in reading them. Uh, that's not on the slides. So this is our protocol, which is adopted from multiple sources and sort of uh just made more specific for what we want to do, uh, but it, it It categorizes patients by age. Some people do it by weight and essentially it's a diluted gastrographin that's given. Um, we need, like we said, there, there should be no signs of strangulation peritonitis if they have active malignancy and, uh, it has to be an adhesive bowel obstruction. So this is not for a patient who's never had abdominal surgery. Uh, we do NG NG tube decompression for at least an hour. Um, it's often longer than that. Uh, confirmed by X-ray that the NG tube is where we think it is. Uh, the surgical team then administers the gastrograph and then clamps the tube. Um, obviously, if the patient can't tolerate it at any point during that, we unclamp and place it back to suction, but if they can, uh, tolerate it, we leave it clamped and get another X-ray at 8 to 10 hours. Uh, if the contrast at 8 to 10 hours is already in or past the cecum, then you're basically done. Uh, you've, uh, proven that there's no bowel obstruction. You can take out the NG tube and, and start feeding the patient. Uh, if at 10 hours it's not in the cecum, then you get an X-ray at 24 hours. If it's in the cecum, then you've passed and you take out the NG tube. And if it hasn't, you can much more rapidly move to the operating room than maybe if you were sitting on this patient and just doing NG tube decompression and waiting for 23 days to see if it resolved. So this is our protocol. There are others out there, um, and this is also included in the, in the attachments if anyone's interested in, in looking at this. Um, my case obviously was an adult. Uh, a lot of us see these adult patients, but it does work in kids. Uh, here's this picture on the left is a seven year old with a history of a perforated appendicitis who came in with an X-ray looking like bowel obstruction, um, and had a successful, uh, gastrograph and challenge, uh, seen in the other screen. And it doesn't always work. Uh, this is a 3 year old with a history of gastroschisis. Uh, this is her initial X-ray, lots of dilated loops. There's also a lot of poop down in her rectum and distal colon. At 8 to 10 hours, there was contrast throughout multiple dilated, uh, loops of small bowel, uh, and at 24, the same, so she was taken to the operating room and found to have dense, uh, bands across the base of the mesentery which required surgery. You know, her belly exam was stable and, and benign throughout this. So, I think that's all for my slides and uh interested in any further discussion. I love that case, and by the way, for those of you who didn't take a screenshot when Beth put that algorithm up there, um, we do have that guideline, I think in the Stay Current app. I'm pretty sure, uh. Beth, I'm not positive, but it is in the stay current app, and it'll be an attachment on the Globalcast. One of the poll questions was just asking, has any, like, of the people participating virtually, have people used this? Yes or no, or have they just never heard of this? Yeah, so, um, before, so Rod, go ahead. No, I was just gonna say, if anyone's having trouble, we're also tweeting that slide out with the uh the flow chart there. Right. And so, um, Beth, the answer is that most people, the percent is 53% have used it. Um, a small percentage, 12% have never heard of it. So at least people have heard of it. That's a huge step. Um, and then what about now? So let's see, now it says after seeing this presentation, there's still some holdouts that you didn't convince enough people, Beth. So, you know, you gotta sing and dance next time or whatever it takes. Hey, we'll have to work on it. I'm so glad we got you to do this talk because it's been game-changing for me. I know, I think I have my partners on here in Akron cause I work at Cincinnati and Akron, but I think, um, we, when I learned it there, I started doing it in Akron, and um I know Bob Perry is on here and I think he had a, a, a not so good experience with it, but I wanna hear if he comments on that. So, um, yes, it is on Twitter. I'm reading the comments there, so thank you for that.
