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Intussusception - Soft Tissue Abscess - Pilonidal Cyst - Bleeding Meckel's...

Video Published 2018-11-10 Updated 2026-06-10

Timestops (4)

Intussusception Management

Discussion of post-reduction observation protocols, repeat imaging criteria, incidental appendectomy, and age cutoffs fo…

Soft Tissue Abscess

Location of incision and drainage (ED vs OR), packing techniques, admission criteria, and antibiotic use. Includes insti…

Timing of definitive surgery, surgical techniques including Bascom pit excision and off-midline flap closures, and role …

Bleeding Meckel's Diverticulum

Workup after negative Meckel's scan, role of PPI therapy, laparoscopic versus open resection techniques, and debate over…

Topic Overview

A rapid-fire case-based discussion covering management of intussusception, soft tissue abscess, pilonidal cyst, and bleeding Meckel's diverticulum. Key practice points include same-day discharge after successful intussusception reduction (4-hour observation in ED), incision and drainage of abscesses without routine antibiotics or admission, delayed definitive pilonidal surgery after recurrence, and small bowel resection versus stapled diverticulectomy for bleeding Meckel's. Multiple speakers report recent practice changes toward less invasive management and shorter hospital stays.

Key Takeaways

Intussusception patients can safely discharge from ED after 4h observation if stable, tolerating PO, afebrile (1/48 recurred) (0:57)
Soft tissue abscess I&D has 0.9% failure rate with same-day discharge; admit only if cellulitis + fever + leukocytosis together (8:08)
Bascom pit excision under local 10 days post-I&D prevents 70% of pilonidal recurrences; reserve formal excision for failures (10:57)
Bleeding Meckel's requires small bowel resection, not diverticulectomy—ulcer is in Meckel's itself, stapling leaves bleeding source (17:00)
Age >5-6 years raises suspicion for pathologic lead point (30-60% incidence); may still attempt reduction then work up electively (4:22)

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

Speaker 1 — host
Nick Bruns — guest
Speaker 3 — guest
Speaker 4 — guest
Ian Glenn — guest
Speaker 6

Chapters

0:00Intussusception Management — Discussion of post-reduction observation protocols, repeat imaging criteria, incidental appendectomy, and age cutoffs for pathologic lead points.
5:43Soft Tissue Abscess — Location of incision and drainage (ED vs OR), packing techniques, admission criteria, and antibiotic use. Includes institutional data on same-day discharge outcomes.
9:49Pilonidal Cyst — Timing of definitive surgery, surgical techniques including Bascom pit excision and off-midline flap closures, and role of laser hair removal.
15:08Bleeding Meckel's Diverticulum — Workup after negative Meckel's scan, role of PPI therapy, laparoscopic versus open resection techniques, and debate over diverticulectomy versus small bowel resection.

Key claims

0:57Cincinnati changed practice 6-8 months ago to discharge intussusception patients home from ER after 4-hour observation period — Speaker 1
2:0148 patients sent home from ED after intussusception reduction, only one recurred within 48 hours and did not require operation — Nick Bruns
2:14Discharge criteria for intussusception: tolerating oral hydration, hemodynamically stable, afebrile — Nick Bruns
2:36When contrast fills appendix but won't reflux into small bowel, bring patient back for repeat reduction in a few hours — Speaker 1
2:44Inability of contrast to reflux into small bowel attributed to ileocecal edema — Nick Bruns
3:04Repeat enema study after failed reflux proves reduction occurred because edema has decreased, does not actually reduce the intussusception — Speaker 4
3:19Ultrasound after intussusception reduction is difficult to interpret due to inflammation — Speaker 1
3:58Current practice is to leave appendix in place during intussusception reduction to avoid risk of appendiceal stump dehiscence if reoperation needed — Speaker 1
4:22Age 5-6 years is cutoff for high suspicion of pathologic lead point in intussusception — Speaker 1
4:55For suspected pathologic lead point, may attempt reduction then work up electively and perform resection in better circumstances — Speaker 1
5:28Over age 5, 30-60% of intussusception cases have pathologic lead point depending on series — Nick Bruns
6:52Many soft tissue abscesses drained in ED by emergency physicians with sedation — Speaker 1
8:08Admission criteria for abscess: cellulitis, fever, and leukocytosis in combination — Speaker 1
8:31Antibiotics prescribed for abscess only if cellulitis present — Speaker 3
8:57Treatment failure rate (readmission or repeat I&D within 2 weeks) was 0.9% for same-day discharge after abscess drainage — Nick Bruns
9:11Only 2 of 138 patients with leukocytosis had treatment failure after same-day discharge — Nick Bruns
9:26Patients with white counts of 35 sent home after abscess drainage did fine — Nick Bruns
10:27Definitive pilonidal surgery typically performed after second recurrence — Speaker 1
10:57Bascom technique: excise pits at skin level with 11 blade under local, 70% never recur — Speaker 3
11:26Pit excision performed 10 days after I&D once acute infection subsided — Speaker 3
11:37For recurrence after pit excision or large draining sinuses, perform formal excision with off-midline layered closure and drain — Speaker 3
12:24Physical exam findings (deep gluteal fold, excessive hair) affect pilonidal management decisions — Speaker 1
12:50For severe pilonidal disease, may leave wound open with wet-to-dry dressing changes or wound vac — Speaker 1
13:18Karydakis flap superior to excision only and comparable to modified Limberg flap for pilonidal disease — Ian Glenn
13:43Post-operative management is key to pilonidal success: keep patient prone on bed until wound heals — Speaker 1
14:26One patient reported laser hair removal was most painful thing ever experienced, discontinued after half session — Speaker 1
15:34After negative Meckel's scan for hematochezia, perform colonoscopy with intent to do laparoscopy at same anesthetic if colonoscopy negative — Speaker 3
16:14PPI will stop bleeding from Meckel's diverticulum, should never be emergency operation — Speaker 4
17:00For bleeding Meckel's with ulcer at base, perform small bowel resection rather than simple diverticulectomy — Speaker 1
17:29Ulcers in bleeding Meckel's are in the Meckel's itself, not in adjacent small bowel — Speaker 1
17:39Stapling off Meckel's removes acid source but bleeding ulcer remains for next day — Speaker 1
18:09Ectopic gastric mucosa almost always at tip of Meckel's diverticulum — Speaker 1
18:48When resecting Meckel's through umbilicus, let it relax and mark edges with marker before stapling to avoid distortion and narrowing — Speaker 1

Points of disagreement

3:43Appendectomy during intussusception reduction
- Speaker 1: Used to remove appendix, now leaves it in to avoid stump dehiscence risk
- Speaker 6: Takes appendix out
- Speaker 1: Leaves appendix for colorectal surgeons
2:36Management after failed contrast reflux in intussusception
- Speaker 1: Bring back for repeat reduction in a few hours
- Nick Bruns: Observe without repeat study, edema will resolve
17:00Bleeding Meckel's: diverticulectomy versus bowel resection
- Speaker 1: Small bowel resection for bleeding Meckel's with ulcer
- Speaker 4: Staple across base, PPI stops bleeding, no need for bowel resection
- Speaker 1: Stapling leaves bleeding ulcer behind for next day
18:22Meckel's resection technique
- Speaker 1: Pull through umbilicus, mark edges without tension before stapling
- Speaker 4: Laparoscopic stapling adequate, linear staple line not concerning

Open questions

What is the optimal timing for repeat enema after failed contrast reflux in intussusception?
Should white blood cell count influence decision to admit after abscess drainage?
What is the role of ultrasound-guided enema reduction for intussusception?
Does laser hair removal prevent pilonidal recurrence and is it cost-effective?
For bleeding Meckel's, is diverticulectomy with PPI therapy equivalent to small bowel resection?
What is the optimal extent of laser hair removal field for pilonidal disease prevention?

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:

Bleeding Meckel's Diverticulum: Resection Versus Diverticulectomy With Acid Suppression

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Clinical Question

When a bleeding Meckel's diverticulum is identified at laparoscopy in a hemodynamically stable child, two fundamentally different approaches emerge: segmental small bowel resection versus simple diverticulectomy with proton pump inhibitor therapy 16:14 17:00. The disagreement centers on whether removing the acid-secreting gastric mucosa alone is sufficient, or whether the ulcerated tissue itself must be excised 17:00 17:39.

The Case for Segmental Resection

One discussant advocates for small bowel resection when encountering a bleeding Meckel's with an ulcer at its base 17:00. The rationale rests on the location of the pathology: the ulcers form within the Meckel's diverticulum itself, not in the adjacent small bowel 17:29. This represents a shift from earlier teaching that placed the ulcers in the ileum adjacent to the ectopic gastric mucosa 17:29.

The concern with simple diverticulectomy is that stapling across the base removes the acid source but leaves the bleeding ulcer behind 17:39. "You staple it off. You've taken away the source, but that bleeding ulcer is still there. So for the next day they're going to be bleeding still" [q14]. Since the ectopic gastric mucosa concentrates at the tip of the diverticulum 18:09, a stapled diverticulectomy may not adequately address the ulcerated tissue 17:39.

The technical approach matters here 18:48. When performing laparoscopic resection, this discussant pulls the Meckel's through the umbilicus, allows it to relax without tension, and marks the bowel edges with a marker before stapling 18:48. The concern is that laparoscopic stapling while applying traction distorts the anatomy and risks narrowing the lumen 18:48.

The Case for Diverticulectomy With PPI

The opposing view holds that bleeding from a Meckel's diverticulum should never be an emergency operation 16:14. The key intervention is initiating a proton pump inhibitor, which will stop the bleeding 16:14. With the patient stabilized on acid suppression, simple diverticulectomy suffices — there is no need for bowel resection 16:14.

This approach draws an analogy to peptic ulcer disease: removing the acid source allows the ulcer to heal, much as vagotomy treats duodenal ulcer without requiring ulcer excision 16:14. The PPI provides immediate control while the diverticulectomy eliminates the long-term acid source 16:14.

Regarding the technical concern about luminal narrowing, this discussant considers a linear staple line across the base acceptable because the bowel will dilate 18:48. Minor impingement on the lumen is not clinically significant unless a severe stricture is created 18:48.

Where They Agree

Both approaches recognize that ectopic gastric mucosa drives the pathology and must be removed 16:14 18:09. Neither advocates for leaving a Meckel's diverticulum in place once it has bled 16:14 17:00. Both acknowledge that the operation can be performed through a single umbilical incision, whether the stapling occurs inside or outside the abdomen 18:48.

The shared understanding is that this is not a surgical emergency in the traditional sense 16:14. The patient can be stabilized, the diagnosis confirmed, and the operation performed under controlled circumstances rather than as a damage-control procedure 16:14.

What Would Resolve It

The discussants did not identify specific evidence that would settle this question. The disagreement appears to rest on different mental models of ulcer healing: one emphasizes removing all diseased tissue 17:00 17:39, the other emphasizes removing the pathogenic stimulus and allowing healing to occur 16:14.

A comparative study would need to track rebleeding rates, stricture formation, and operative complications between segmental resection and diverticulectomy with PPI therapy. The challenge is that bleeding Meckel's diverticulum is uncommon enough that such a trial would require multicenter collaboration and extended follow-up.

The technical question — whether laparoscopic stapling adequately preserves luminal diameter 18:48 — could be addressed through postoperative contrast studies or long-term symptom tracking, though neither discussant cited data on this point.

What remains clear is that both surgeons have successfully managed these patients with their respective approaches, suggesting that either strategy is defensible when executed with appropriate technique and perioperative management 16:14 17:00 18:48.

Takeaways from this story

Ulcers in bleeding Meckel's form within the diverticulum itself, not in adjacent bowel — a shift from earlier teaching
PPI therapy stops bleeding from Meckel's diverticulum, making this a semi-elective rather than emergency operation
Stapling under tension during laparoscopic resection risks luminal narrowing; exteriorizing and marking without traction may improve precision

Managing Common Pediatric Surgical Emergencies: Intussusception, Abscess, Pilonidal Disease, and Meckel's Diverticulum

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

Intussusception: Aggressive Outpatient Management

Same-day discharge is safe after successful reduction. After radiologic reduction, patients can go home from the emergency department after four hours if they tolerate oral hydration, remain hemodynamically stable, and are afebrile 2:14. In one series, 48 patients discharged from the ED had only one recurrence within 48 hours, and that patient required only repeat reduction, not operation 2:01. This represents a significant shift from traditional overnight observation.

Failed contrast reflux does not mean failed reduction. When contrast fills the appendix but will not reflux into the small bowel, the reduction has likely succeeded — the problem is ileocecal edema 2:44. Bring the patient back for repeat enema in a few hours. The repeat study proves reduction occurred by demonstrating decreased edema; it does not actually reduce the intussusception 3:04. Understanding this distinction prevents unnecessary operations.

Age dictates suspicion for pathologic lead points. The inflection point is age 5-6 years, above which 30-60% of cases have a pathologic lead point 4:22 5:28. For older children with ileocolic intussusception, consider attempting reduction then working up electively rather than proceeding directly to the OR 4:55. This converts an emergency operation on inflamed bowel into an elective resection under better circumstances. Non-ileocolic location raises suspicion at any age.

Soft Tissue Abscess: Minimal Intervention

Drainage alone suffices for most patients. Many abscesses are drained in the ED by emergency physicians under sedation 6:52. Same-day discharge after OR drainage carries a treatment failure rate of only 0.9% 8:57. Even patients with white counts of 35 were safely discharged 9:26. Reserve admission for the combination of cellulitis, fever, and leukocytosis together 8:08 — any single finding does not mandate admission.

Antibiotics are indicated only for cellulitis. If cellulitis is absent after drainage, send the patient home without antibiotics 8:31. The data supporting this practice are strong, yet many surgeons continue prescribing antibiotics reflexively.

Pilonidal Disease: Staged Approach

Pit excision under local anesthesia is first-line definitive treatment. After acute infection subsides (typically 10 days post-I&D), excise the 1mm pits at skin level with an 11 blade under local anesthesia and allow healing by secondary intention 10:57 11:26. By published data, 70% never recur. Reserve formal excision with off-midline layered closure and drain for recurrence after pit excision or for large draining sinuses 11:37.

Post-operative management determines success more than surgical technique. Keep patients prone until the wound heals 13:43. Sitting on the surgical site causes most failures regardless of which flap or closure technique was used. Physical exam findings — deep gluteal fold, excessive hair — should influence your threshold for early definitive surgery 12:24.

Bleeding Meckel's Diverticulum: Medical Temporization

PPI therapy converts emergency to elective operation. When Meckel's diverticulum is suspected as the bleeding source, start a proton pump inhibitor — it will stop the bleeding 16:14. This should never be an emergency operation 16:14. The PPI buys time for proper workup and allows resection under controlled circumstances.

The ulcers are in the Meckel's itself, not adjacent bowel. Ectopic gastric mucosa is almost always at the tip of the diverticulum 18:09, and the ulcers form there 17:29. Simply stapling off the Meckel's removes the acid source but leaves the bleeding ulcer for the next day 17:39. For bleeding Meckel's with ulcer at the base, perform small bowel resection rather than simple diverticulectomy 17:00.

Technique matters when resecting through the umbilicus. Exteriorize the Meckel's and let the bowel relax completely before stapling 18:48. Mark the edges with a marker to visualize the true bowel margin without tension. Pulling on the diverticulum distorts the anatomy and risks inadvertent narrowing of the lumen — a complication that occurs when stapling under tension laparoscopically.

Takeaways from this story

After successful intussusception reduction, 4-hour ED observation with same-day discharge is safe if patient tolerates oral hydration.
Failed contrast reflux after intussusception reduction indicates ileocecal edema, not failed reduction—repeat study in hours to confirm.
For soft tissue abscess, same-day discharge after drainage has 0.9% failure rate; reserve admission for combined cellulitis, fever, and leukocytosis.
Bascom pit excision under local anesthesia achieves 70% cure rate for pilonidal disease; reserve formal excision for recurrence.
PPI stops bleeding from Meckel's diverticulum, converting emergency to elective operation; ulcers are in the diverticulum itself, not adjacent bowel.

Managing Four Common Pediatric Surgical Problems: Intussusception, Abscess, Pilonidal Disease, and Meckel's Diverticulum

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Intussusception: The Shift to Same-Day Discharge

Intussusception reduction has traditionally meant overnight admission, but practice is changing. After successful radiologic reduction, many centers now discharge patients directly from the emergency department following a four-hour observation period 0:57. The discharge criteria are straightforward: tolerating oral hydration, hemodynamically stable, and afebrile 2:14. Data from 48 patients sent home this way showed only one recurrence within 48 hours, and that child required only repeat reduction, not surgery 2:01.

The technical challenge comes when contrast fills the appendix but won't reflux into the small bowel. This reflects ileocecal valve edema, not reduction failure 2:44. The standard approach is to bring the patient back for repeat enema in a few hours — not to reduce the intussusception again, but to prove reduction occurred once the edema resolves 3:04. Ultrasound after reduction is difficult to interpret due to inflammation and is generally not helpful 3:19.

Age matters significantly in intussusception. The inflection point is around five to six years old 4:22. Above this age, 30-60% of cases have a pathologic lead point 5:28. For older children, some surgeons attempt reduction first, then work up the lead point electively and perform resection under better circumstances rather than proceeding directly to emergency laparotomy 4:55. Non-ileocolic location also raises suspicion for a lead point regardless of age.

Incidental appendectomy during intussusception reduction has fallen out of favor. The concern is appendiceal stump dehiscence if the patient requires reoperation 3:58.

Soft Tissue Abscess: Rethinking Admission Criteria

Many pediatric abscesses are now drained in the emergency department by emergency physicians using procedural sedation 6:52. The question is which patients need admission for intravenous antibiotics afterward.

Traditional teaching emphasized admitting patients with fever, leukocytosis, or surrounding cellulitis. Current practice is more selective: antibiotics are prescribed only when cellulitis is present 8:31, and admission requires some combination of cellulitis, fever, and leukocytosis together rather than any single factor 8:08.

Data supporting same-day discharge after operative drainage in the OR shows a treatment failure rate (readmission or repeat incision and drainage within two weeks) of only 0.9% 8:57. Notably, only 2 of 138 patients with leukocytosis had treatment failure 9:11, and patients with markedly elevated white blood cell counts were safely discharged home 9:26. These findings suggest that leukocytosis alone should not drive admission decisions.

Pilonidal Disease: The Bascom Technique and Staged Management

Pilonidal disease typically requires a second recurrence before definitive surgery 10:27. The Bascom pit excision technique offers a minimally invasive first-line approach: under local anesthesia, excise the 1-millimeter pits at skin level with an 11 blade and allow healing by secondary intention 10:57. This is performed about 10 days after incision and drainage once acute infection has subsided 11:26. By the data supporting this technique, 70% of patients never recur after pit excision alone.

For recurrence after pit excision or for patients with large draining sinuses, formal excision with off-midline layered closure and drain placement is indicated 11:37. Physical exam findings — particularly a deep gluteal fold and excessive hair — influence management decisions and may prompt earlier definitive surgery 12:24. For severe disease, some surgeons leave the wound open with wet-to-dry dressing changes or negative pressure wound therapy 12:50.

Flap techniques including the Karydakis flap show superior outcomes to excision alone and comparable results to the modified Limberg flap 13:18. However, surgical technique may matter less than post-operative management: keeping the patient prone until the wound heals appears critical to success 13:43. Laser hair removal is sometimes recommended, though patient tolerance varies significantly 14:26.

Bleeding Meckel's Diverticulum: PPI Therapy and Resection Technique

After a negative Meckel's scan in a child with hematochezia, one approach is colonoscopy with intent to proceed to laparoscopy at the same anesthetic if colonoscopy is negative 15:34. An alternative strategy is starting a proton pump inhibitor, which will stop bleeding from a Meckel's diverticulum by suppressing acid production from ectopic gastric mucosa 16:14. This converts an emergency operation to an elective one.

The critical anatomic point: ulcers in bleeding Meckel's diverticulum are located in the diverticulum itself, not in the adjacent small bowel 17:29. The ectopic gastric mucosa is almost always at the tip of the Meckel's 18:09. This anatomy informs the choice between simple diverticulectomy and small bowel resection. If you staple off the Meckel's without resecting the ulcerated tissue, the acid source is removed but the bleeding ulcer remains 17:39. For a bleeding Meckel's with an ulcer at the base, small bowel resection rather than simple diverticulectomy is indicated 17:00.

Technique matters when resecting laparoscopically. Pulling the Meckel's up to staple it creates tension that distorts anatomy and risks narrowing the bowel lumen 18:48. One approach is to exteriorize the diverticulum through the umbilicus, let it relax completely, and mark the edges with a marker before applying the stapler to avoid inadvertent stricture.

Takeaways from this story

After successful intussusception reduction, patients can be safely discharged from ED after 4 hours if stable and tolerating fluids.
Leukocytosis alone should not drive admission after abscess drainage; treatment failure rate is <1% even with markedly elevated WBC.
Bascom pit excision under local anesthesia prevents recurrence in 70% of pilonidal cases without formal excision.
PPI therapy stops bleeding from Meckel's diverticulum, converting emergency to elective surgery.
Ulcers in bleeding Meckel's are in the diverticulum itself, not adjacent bowel—stapling without resecting leaves the ulcer behind.

Keywords

intussusception soft tissue abscess pilonidal cyst pilonidal disease bleeding Meckel's diverticulum hematochezia cellulitis leukocytosis ileocecal edema pathologic lead point ectopic gastric mucosa radiologic reduction air enema contrast enema ultrasound

Hashtags

#Intussusception #PediatricSurgery #EmergencyMedicine #Radiology #SurgicalManagement #SoftTissueInfection #AbscessTreatment #Antibiotics #Pediatrics #ClinicalGuidelines #SurgicalResidency #PatientCare #Healthcare #MedicalEducation #SurgicalTechniques #InfectionControl #ClinicalPractice #PatientSafety #PostoperativeCare #EvidenceBasedMedicine #EmergencyPediatrics #SurgicalEducation

Transcript

All right, all right, we're gonna move on to my, uh, two, research fellows to finish it off. They're, I know these, they're very fast cause these are just questions. We don't have any informational slides. So, uh, who's going first? I am. I love how they're sitting over there together. Just remember these faces, uh, Nick Bruns and Ian Glenn, who will be coming through the match, uh, in a few years. OK, Nick. OK. Well, I'd like to thank all the faculty for coming here today and thank you to Globalcast for putting on an awesome event. I will keep this short. So I'm talking about Intussusception. Um, so there's a 2 year old boy, he's hemodynamically stable, diagnosed on ultrasound. He has successfully reduced in radiology. How do you manage this afterwards? So do you admit them for observation? And if so, what, what diet do you like to do? Or does anyone discharge them home from the ED? Anyone discharge, observe for 4 hours and send them home. Wow, we changed our practice in Cincinnati half a year ago, 68 months ago, 8 months ago, and we've discharged home from the ER. I think there's a 4 hour observational period. Make sure they tolerate. in the emergency room, not admitted. Wow, David, same thing. We took a reluctant ED group, I think with very little push, got him, but the confusing thing was an intern sent my pyloric home 4 hours after the operation. I was confused and it worked out OK, but that wasn't the intent. In a deception, Pyloris, whatever, they're all the same. Wow, OK, so, so Aaron, we're behind the times here. Are you going to change your management? Sure. Have you guys had anyone come back? Uh, no, the bigger issue that we've, since implementing this protocol, the biggest challenge we've had is that if the ED is really busy, they don't want the patient to sit there for 4 hours and occupy a bed, so they come up briefly and then go home the same day. Um, OK, so it's a, it's a logistical give antibiotics before you do the reduction. I personally don't. OK. And do you have to have a surgical resident there when there's no, OK, good. about that. OK, um, so there's a paper that looked at this, and 48 patients were sent home from the ED and only one recurred in 48 hours, and that patient did not even need an operation. They just got reduced again. So they came up with the protocol and the patient is tolerating just oral hydration, hemodynamically stable, afebrile. They send them home. OK, so, uh, next question, um, Patients in radiology, uh, the radiologist feels like they reduced it but can't get the contrast to reflux into the small bowel. It does fill the appendix. Um, what do you do with this? Bring it back and do it again in a few hours. A few hours. Everyone, OK, we can skip to the next one. We all agree. OK, well, well, my preference would have been to, uh, observe there was a study about 20 years ago in which, uh, they, they attribute it to ileocecal edema that it won't reflux. We'll keep going. Wait, you wouldn't have gotten a repeat study. Um, no, in my vast clinical experience, uh, when are you going through the batch, just to clarify, the repeat study is just to prove what you said was absolutely true. The repeat study doesn't now reduce it. They reduced it the first time. The repeat study is just proving it because now it's less edematous. Is the. Just an ultrasound or a contrast? Typically it's an air enema again, contrast, I think, I think an ultrasound after that point, as we saw yesterday in one of our patients, is a difficult thing to interpret because it's so much inflammation afterwards. So, uh, I think you have to get a contrast, uh, some sort of enema. OK. All right, next, so for the patient that needed reduction in the OR, no bowel resection, um, does anyone take out the appendix? I used to, not anymore. What do you guys do? I take it out, whatever it is, yeah, no. He's a colorectal. No, no, now I love the appendix. Please leave the appendix in. I left it for you. Thank you. I get concerned if you have to go back again about bursting open your, uh, appendiceal stump, so that's the reason I leave it now. Plus I don't think it makes a difference. I used to take it out. All right, we have no answer again. Next, yeah, and then, um, finally, do you have a cutoff, um, that makes you concerned about a pathologic lead point that would lead you straight to the OR? No attempted radiologic reduction. Just go straight to the OR. Any age or factor 6 year old, yeah, if it's a 6 year old, I would go straight to the OR. Uh, I might do a contrast study for diagnosis. Several things. If it's not ileocholic, then I worry about it. If it's ileocholic in an older child, then I might do a contrast study for diagnosis. And, uh, although if you diagnose it on ultrasound, then that's usually right. So it's diagnosed on ultrasound. So I would do laparoscopic. I would don't try to reduce it maybe. I've done that before. I don't know. So I think in this situation I'd try to reduce it. I think after age 5 or so I'd be highly suspicious of a lead point. And then in an elective fashion, non-inflamed bowel, do, do a contrast study or whatever you need to diagnose, make a diagnosis and do your resection in a, I think, a better set of circumstances. OK, fair enough. Interesting. So you would reduce it, yeah, and then go back. You're definitively going to go back and go to. I'm going to definitively work the patient up to find out what the lead point is, OK, and then do that operation, OK. Any other comments? The data seems like the inflection point for having a lead point is about over 5 years old, where depending on the series, it's about 30 to 60% have a pathologic lead point if they're over 5. So that, that's probably the cutoff I would use it were up to me. So now we want to talk very quickly about uh soft tissue abscess. We deal with this a lot before we get there. Is anybody, is anybody doing an ultrasound guided enema reductions? Instead of X-ray guided heard the Chinese, yeah, certainly heard about it, but we have not done that. Chinese radiologists in the states or no, so, so, but it's definitely in the literature. I'm just wondering if, if you asked. Uh, no, uh, there, I mean, there's literature on it. I'm just wondering if that's going to be adopted because it's trying to reduce radiation and all that. It's a great, the original interceptions were reduced truly in China with a bellows. So I mean, the air, they use the idea of using air contrast, and now they use an ultrasound too, but those patients didn't get re-studied or anything, right? What's next? OK, we're going to the hottest topic, abscess. So for the, uh, the standard butt abscess, uh, in your hospital, where do you do an incision and drainage in the ED in the butt. In the in the OR, where do you do it in the butt? Where do you do it? Um, we're just many more often than not, many of these are drained in the emergency by the ER or by frequently by the ED, if not combination than a combination, but with sedation, with sedation, are drained in the ED by ED with sedation, our help occasionally. That would put us out of business. We, we, um, we, uh, have, I think you found a substantial reduction in, or we didn't think. Did you find a reduction in cost between we, we haven't looked at that. We wanted to look at that. Because we do them in the OR and my guess is it's a big cost savings to do these, yeah, but you do need some conscious sedation, otherwise it's just families are right, pretty unhappy and they don't drain well, right? They get scared. They go real quick and they don't pack it or who packed, who are you getting into that? Does anyone pack or use vessel loop or nothing? Pack, pack, use a wick, yeah, wick, there's something in there vessel loop if I'm if I'm at that level, it's a vessel loop. That's, it's changed game changer for me. Oh, I see, because most of them are drained by the ED. So there was that study at ABSA that showed that didn't make a difference, yet none of us follow it. OK, OK. And um, is there any criteria that makes you admit these kids to the hospital for intravenous antibiotics after, after they're drained? Yes, cellulitis. Yeah, I think if they have cellulitis, fever, and leukocytosis, I would admit that kid. All of those together or any of those? Some combination. Some, yeah, if the child's sick, I would admit them because you don't want them to get sicker. You want to make sure they're getting better before you, uh, cut them loose. So you reported your literature, right? Yeah, we'll, we'll get to that. Oh sorry. Uh, one last question, um, do you, do your patients go home with antibiotics? If they have cellulitis. If not, send him home with nothing. OK, great. So we looked at our own data and um did a retrospective review of all the kids that we did incision and drainage. So in the OR and then sent home the same day, usually about 2 or 3 hours after the procedure. And the rate of treatment failure, which we defined as readmission or needing another I&D within two weeks was minimal, so 0.9% of all patients had a treatment failure, and of the patients that had leukocytosis, only 2 out of 138 did, and only one that was febrile during their time in the hospital had a treatment failure as well. So, you know, there are some patients with white counts of 35 that got sent home and did fine, um, which would make me almost not want to know what the white count is. But um They are cost cutting on the antibiotics and. Spending more money on the OR. That's how we like to do things. All right, are you done, Nick? Yep, good job. All right, reading. All right, Ian Glenn. These guys are general surgery residents at the Cleveland Clinic right now, spending 2 years doing research. So continuing our trend of gross skin and soft tissue infections. You see a 12-year-old patient following up with you in clinic. One week previously, you did an I&D for an acutely infected cyst, which are acutely infected pyelonidal cysts, and this patient has no other medical comorbidities. So at what point are you going to attempt a more definitive treatment other than just performing an I&D on these patients? When do you operate? When it comes back, Erin, when do you operate? After 2. After 2 or 3 I transferred to David. I usually tell them after 1, but I stretch it out as long as possible. After 1, well, after the 2nd, 2nd 1, the next one comes back, but I discourage what it looks like does not make you go to the opera moon on the 1st 1. It's a big thing. You still wait for a second episode. OK, so I've bought hook, line and sinker into the best cum technique. This is a group of not organ, uh, taking, taking out pits and then only operating if they have bigger draining sinuses, doing a layered off center clo off, off center midline closure. OK, I know we're way over time, but I tell me how you do this. So you excise out the pits under local. Just take an 11 blade and cut out their 1 millimeter pits just at skin level subcu tissue and let them heal by secondary intent and that by their data 70% are never come back and that they might not come back anyway. They don't have a control group. So and then if there's a large after the first episode, after 10 days after incision and drainage, after it's subsided, you bring them back and take out the pits, right? OK. And then what were you saying about and then if that, if they recur or if they have larger draining sinuses, then they go to the OR for a formal. Excision of the entire affected area off midline layered closure with a drain. Sorry, adaptation of it, yeah, and it's a um it takes a miserable operation uh. Situation makes it a lot less miserable. It's still miserable. Are we jumping ahead on your a little bit? That's sorry. So are there, we're trying to save time. Yeah, I don't know. I've been tempted to try it. Let's see what, what do you got? So, uh, along those lines, are there any factors that would manage or that would affect your management, either timing and treatment or what type of operation? Any of those things change what you just told us, or no? Their age, their body habitus. Recurrence. That's what I waited for recurrence, but there are some patients who just have, you know, such high risk factors. They look, you know, they have a deep gluteal fold, lots of a ton of hair. Those patients, it's, it's a miserable process. So potentially physical exam findings, potentially, yeah. So you guys touched on this a little bit earlier, which operation would you perform for definitive management? Would anyone open it and leave it open? If it's really nasty, you would, if it was really nasty with wet to dry dressing change or a wound back, OK. OK, and then you guys talked about some other off midline closures, right? Anyone do a rhomboid flap? We just tried one. Sort of, OK, so looking at the literature, I was gonna say just briefly looking at the literature, the Kradaki flap was superior to excision only and pretty comparable to this modified Lindbergh flap, and then the less data on the modified elliptical rotation flap, but in the short term it has been shown to have comparable results to the Lindbergh and the Kraakis. What's the nuclear weapon? So when they keep coming back, you've had 3 recurrences. What's the nuclear weapon? Is it marsupialization? Is it a skin graft? Is it a, I think it's post-op management. You put them on a bed prone for until the wound heals. It's a wound healing problem. And when I think that typically is the biggest, it's them sitting on it afterwards, yeah, and you can do some sort of flap to get good tissue over it, but unless you get them off of it. Post-op and that's what our plastics guys will do, you know, when it finally comes to the I can't do this anymore, send them to plastics, they do a flap, leave them on their belly, um, for that's my laser hair removal, my completely undata substantiated feeling, OK. So yeah, like you said, has anybody used or recommended laser hair removal for any of their patients? I have. and the patient came back to me and said it was the most painful thing they had ever had, and he got through like one half a session and said he would never go back again. So having not had it done myself, I was willing to take his word for it, and I have not recommended it since. I haven't had that experience. I've sent a few and they haven't really complained. It's been decent. I've had to almost draw out for the laser hair removal list. Um, where to go because I don't think they're going wide enough or extensive enough, um, and I've even encouraged to try to submit for insurance, um, reimbursement, but have not been successful in that part yet because it is expensive. What's next? All right, so 3-year-old male has been admitted to the hospital with hematochezia. You're consulted. When you see the patient, he's stable with no other medical conditions. So you order a MECel scan and that's negative. So what would you do next? What do you do after a negative Meckels for a bleeding, bright red blood per rectum? Negative meals, bright red blood. Do you do a colonoscopy? Do you do a laparoscopy? Was it done with or wherever, yeah, it was done the right way. So depending on your GI. I guess depending on your GI folks, I probably would do colonoscopy with the intent to do a laparoscopy if the colonoscopy is negative, but at the same setting, same anesthetic, if, if you could, I'm not, I, I would like to do it. I would like that's OK. So you have them suction out as you go. OK. All right. I like the idea. I just don't you not have GI fellows where they're playing around for an hour or two and filling the abdomen with air. Herman can answer that question. All right. Does anyone do something different? I start a PPI. Why? Because if it's a Meckel's, it will stop bleeding and then bleed again. Well, but I'm, I'm not saying that's the end of the therapy. Oh, but that's what I would do next. I would just say do PPIs work that far down. Yes, it will stop the bleeding. It should never be an emergency operation. Wow, I did not know that. I didn't know it stopped it. OK, now I know. Another thing I've learned today. Change my practice. 4:42. 1 hour and 2 minutes over. Every hour I'll learn something new. OK, we'll just keep going. Keep going with it. So you do laparoscopy. You encounter this, you. Determine that's the source of the bleeding. What would be your next step in the operation? Find the Eccles. How do you take it out? Laparoscopically. What do you do? I didn't see the base. If I get staple across the base, if it's a bleeding meckles and you have an ulcer on the bottom, I may do a small bowel resection. Well, if it's bleeding, if it's bleeding meckles, I'll do a small bowel resection. Small bowel resection. I was so hoping you stop the bleeding with the PPI and you take out the meckles with the then you don't do a bowel resection, OK. Go ahead, staple across it if it's, if it's the right, yeah, yeah, yeah, it looks beautiful. Depends on small base, yeah, we staple staple staple. Bill Gazetta taught me at the fellows course this year. That the ulcers are in the meckles. I always thought it was in the small bowel. It doesn't matter if you take out the meckles. It doesn't matter where they are because you're going to fix the ulcer anyway. What people say, unless you use Mac PPI thing, is that you staple it off. You've taken away the source, but that bleeding ulcer is still there. So for the next day they're going to be bleeding still. Yeah, but you've taken away the source of the acid that's causing the ulcer, so you're bleeding. It's like doing a vagotomy for a gastric ulcer, but you take care of the ulcer or duodenal ulcer. Have, OK, have you proven you got point is I don't think you need to do a bowel cells out. I don't, and it's been a while since you did a vagotomy. Yeah. How do you know you got a do them all the time when I take out the esophagus because it's almost always at the tip of the meckles. OK. Next, who does it laparoscopically versus pulling the mechles out of the umbilicus? So do I. What do you do? I haven't actually had to do one yet, believe it or not. Oh, I don't know. I just do it like an appy, probably. Yeah, it's exactly singley my way or an appy your way. My way, of course. You have two choices. Both are single site, either inside single site or outside single site. Let me tell you why I would push for open, and I have good pictures, but I can't show them on the air here technologically. I think that when you do it laparoscopically and you're pulling it up to staple, there's a tendency to, to go a little bit onto the bowel. So what I do is I pull it out through the umbilicus and I let it relax. I'm not pulling on it and I draw with a marker. So I see where the edge of the bowel is without pulling on it, because once you pull it distorts everything. But if it's a linear staple line, who cares because the bowel's going to dilate out anyway. So you're not worried about impinging it a little, not unless you made a huge stricture there. Can't rethink. We should teach you how to do a laparoscopic appendectomy. I know that. I don't know, yeah, OK. What's next? Wow, we are finished an hour and a half over, but we have finished. So, uh, for the people who have survived and are still here, uh, this has been great. I thank you guys very much. This has been, uh, uh, I've changed my management on a lot of different things. I thank you all for staying the entire day, and, uh, again, this will all be available for watching afterwards, and we'll hopefully have this on podcast so you can listen to it. And hopefully we'll be able to do this again next year. So, good morning, good night, and good afternoon, wherever you are.

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