# Myelomeningocele — GCMD Library living collection

Everything in the library about myelomeningocele — built automatically from dossiers that name it.

Updated: n/a · 8 episodes · 105 cited statements

## Episodes
### Surgical Management
- [Fetoscopic Repair of Myelomeningocele (MMC)](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391) — podcast · 5:52 · [machine version](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391.md)
- [Myelomeningoceles (open spina bifida) -Fetoscopic Intrauterine Myelomeningocele Closure](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326) — video · 3:41 · [machine version](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326.md)

### Evidence & Research
- [Fetal Surgical Intervention for Myelomeningocele: Fetal Surgery 2012](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026) — video · 2:45:47 · [machine version](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026.md)
- [Journal of Pediatric Surgery Article Review: January 2022 APSA Issue](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103) — podcast · 13:09 · [machine version](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103.md)
- [Journal of Pediatric Surgery Article Highlights: April 2022](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554) — podcast · 8:38 · [machine version](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554.md)
- [Journal of Pediatric Surgery Article Review: January 2022 - APSA Issue](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358) — video · 13:09 · [machine version](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358.md)

### Case-Based Learning
- [Case Presentations Part II: Cloaca and Complex ARMs 2015](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012) — video · 14:22 · [machine version](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012.md)
- [Colorectal Quiz Episode 15: Bowel Management in Spinal Patients - Need for a UrologistPart 1](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232) — podcast · 17:26 · [machine version](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232.md)

## Chapters
- [0:00](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=0) Case presentation: 12-month-old with cloaca and 6-centimeter common channel (Ep 1)
- [2:25](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=145) Surgical approach and vaginal reconstruction with sigmoid interposition (Ep 1)
- [7:12](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=432) Rectum preservation and fecal continence considerations (Ep 1)
- [9:50](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=590) 3D animation demonstration and second case introduction (Ep 1)
- [12:00](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=720) Differential diagnosis: cloaca versus intersex disorders (Ep 1)
- [0:00](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=0) General Fetal Surgery Discussion: Steroids for CCAM and SCT (Ep 2)
- [20:00](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=1200) Minimally Invasive Approaches and Technology for Fetal Tumors (Ep 2)
- [45:00](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=2700) Establishing Fetal Surgery Centers: Requirements and Challenges (Ep 2)
- [65:00](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=3900) Video: CHOP Fetal Treatment Center Overview (Ep 2)
- [80:50](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=4850) Myelomeningocele: Pathophysiology and Rationale for Fetal Surgery (Ep 2)
- [111:40](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6700) The MOMS Trial: Design, Execution, and Results (Ep 2)
- [125:00](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=7500) Post-MOMS Experience and Center Development Guidelines (Ep 2)
- [141:40](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=8500) Innovation, Fetoscopic Approaches, and Future Directions (Ep 2)
- [158:20](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=9500) Shunt Criteria Discrepancies and Neurosurgical Perspective (Ep 2)
- [0:00](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=0) Introduction and case presentation setup (Ep 3)
- [2:10](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=130) Initial presentation: 5-month-old with myelomeningocele and constipation (Ep 3)
- [4:10](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=250) Management of senna-induced rash and alternative laxative strategies (Ep 3)
- [6:12](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=372) Transition to enema-based bowel management (Ep 3)
- [9:33](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=573) Surgical planning: Malone procedure and coordination with urology (Ep 3)
- [11:08](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=668) Temporizing measures when urologic plan is uncertain (Ep 3)
- [15:53](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=953) Case summary and key takeaways (Ep 3)
- [0:00](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=0) Introduction to Fetoscopic Myelomeningocele Repair (Ep 4)
- [1:13](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=73) Myelomeningocele Pathology and Timing (Ep 4)
- [1:51](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=111) Surgical Access and Port Placement (Ep 4)
- [3:08](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=188) Placode Untethering (Ep 4)
- [3:44](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=224) Defect Closure with Patches and Skin (Ep 4)
- [4:49](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=289) Procedure Completion and Postoperative Care (Ep 4)
- [0:04](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=4) Introduction to January 2022 APSA Issue Review (Ep 5)
- [1:00](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=60) Academic RVU System for Pediatric Surgical Productivity (Ep 5)
- [5:38](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=338) Standardized Gastroschisis Protocol and Sutureless Closure (Ep 5)
- [9:11](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=551) Placental Mesenchymal Stromal Cells for In Utero Myelomeningocele Repair (Ep 5)
- [0:03](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=3) Introduction and Wilms Tumor with Intravascular Extension (Ep 6)
- [2:10](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=130) Mesenchymal Stromal Cells for Fetal Myelomeningocele Repair (Ep 6)
- [4:37](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=277) Fetal Surgery Subspecialization and Training Patterns (Ep 6)
- [0:01](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=1) Introduction and Background on Myelomeningocele (Ep 7)
- [0:47](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=47) Initial Surgical Access and Uterine Preparation (Ep 7)
- [1:32](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=92) Myelomeningocele Dissection and Neural Placode Reconstruction (Ep 7)
- [2:06](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=126) Dural Closure (Ep 7)
- [2:37](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=157) Skin Closure and Grafting (Ep 7)
- [3:12](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=192) Closure and Summary (Ep 7)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Historically, surgeons have been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have. — Gail Besner (opinion) [Ep 5 · 1:41](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=101)
- The concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work. — Gail Besner (clinical) [Ep 5 · 2:55](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=175)
- Nationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits. — Gail Besner (clinical) [Ep 5 · 3:07](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=187)
- The Nationwide system kept work RVUs as part of the incentivization plan along with other goals that must be achievable. — Gail Besner (clinical) [Ep 5 · 3:27](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=207)
- At Akron Children's Hospital under Bob Perry, the bonus structure required the entire group to reach a certain RVU threshold for everyone to receive 50% of their bonus, eliminating competition for cases. — Todd Ponsky (clinical) [Ep 5 · 5:03](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=303)
- At Saint Justine Hospital, the approach to gastroschisis differed from other institutions in that there was very low use of silos, with pretty much every patient having an attempt at immediate bedside sutureless closure following a protocol developed several years prior. — Charza Jaharifard (clinical) [Ep 5 · 6:58](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=418)
- Before and after protocol implementation at BC Children's Hospital, approximately 75% of gastroschisis patients could be closed immediately, whether in the OR pre-implementation with fascial closure or at bedside post-implementation. — Charza Jaharifard (clinical) [Ep 5 · 7:57](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=477)
- With silo management, parents look at their newborn's intestines through a silo for 5-6 days and cannot hold their baby until the silo is completely reduced. — Charza Jaharifard (clinical) [Ep 5 · 8:27](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=507)
- With immediate closure of gastroschisis, if babies are extubated within 48 hours, parents can hold them within 48 hours, or immediately if managed without intubation. — Charza Jaharifard (clinical) [Ep 5 · 8:43](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=523)
- Spina bifida affects approximately 1500 babies born per year in the US, about 30 per week or 5-6 per day. — Scott Adzik (epidemiological) [Ep 2 · 82:06](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=4926)
- With standard postnatal care, approximately 14% of MMC patients die by age 5, mostly due to symptomatic brain stem compression from hindbrain herniation. — Scott Adzik (clinical) [Ep 2 · 83:20](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=5000)
- About 85% of MMC patients require ventricular shunts with standard postnatal care, with approximately half developing shunt complications within one year. — Scott Adzik (clinical) [Ep 2 · 83:33](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=5013)
- The two-hit hypothesis for MMC proposes that secondary damage occurs in utero from amniotic fluid, meconium, or hydrodynamic forces after the initial failure of neurulation. — Scott Adzik (clinical) [Ep 2 · 83:41](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=5021)
- In fetal sheep models, mid-gestational spinal cord exposure leads to progressive neurologic injury that mimics human MMC, with paralysis and loss of sensation below the lesion level. — Scott Adzik (clinical) [Ep 2 · 86:09](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=5169)
- Hindbrain herniation reverses after prenatal MMC repair because closing the defect prevents CSF leak, reestablishing the pressure column in the spinal canal. — Scott Adzik (clinical) [Ep 2 · 90:15](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=5415)
- In CHOP's pre-MOMS experience with 50 fetal MMC repairs, the shunt rate by one year was 40%, compared to 85% with postnatal repair. — Scott Adzik (clinical) [Ep 2 · 93:10](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=5590)
- Two-thirds of prenatally repaired MMC patients showed motor function two or more levels better than the anatomic lesion level. — Scott Adzik (clinical) [Ep 2 · 93:41](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=5621)
- The MOMS trial was stopped early on December 7, 2010 by the Data Safety Monitoring Board due to demonstrated efficacy of prenatal surgery. — Scott Adzik (clinical) [Ep 2 · 102:18](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6138)
- In the MOMS trial, shunts were placed in 40% of the prenatal surgery group compared to 82% of the postnatal surgery group. — Scott Adzik (clinical) [Ep 2 · 102:55](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6175)
- At 30 months, 42% of babies in the prenatal surgery group could walk independently versus only 21% in the postnatal surgery group. — Scott Adzik (clinical) [Ep 2 · 103:31](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6211)
- Mean gestational age at delivery was 34 weeks in the prenatal surgery group versus 37 weeks in the postnatal group, with 13% of prenatal cases delivered before 30 weeks. — Scott Adzik (clinical) [Ep 2 · 104:57](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6297)
- At the time of delivery in the MOMS trial, the hysterotomy site was intact in about two-thirds of cases, very thin in one-quarter, with dehiscence in 9% and complete dehiscence in one case. — Scott Adzik (clinical) [Ep 2 · 104:32](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6272)
- Since the end of the MOMS trial, CHOP has had 359 referrals, with 202 evaluated on-site, but only 60 (30%) underwent fetal surgery. — Scott Adzik (clinical) [Ep 2 · 107:57](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6477)
- Fetal MRI is mandatory for preoperative evaluation because ultrasound alone can incorrectly identify hindbrain herniation; in 9 cases with absent hindbrain herniation on MRI, ultrasound showed positive or equivocal findings. — Scott Adzik (clinical) [Ep 2 · 109:07](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6547)
- Fetoscopic MMC repair using 3 or more ports leads to membrane fixation and tearing with uterine growth, resulting in premature birth 3-6 weeks after surgery and delivery before 30 weeks as a rule. — Scott Adzik (clinical) [Ep 2 · 109:47](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6587)
- Compared to open fetal MMC repair, fetoscopic repair has higher rates of fetal death, premature rupture of membranes, chorioamnionitis, oligohydramnios, premature delivery, and persistent hindbrain herniation. — Scott Adzik (clinical) [Ep 2 · 110:06](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6606)
- In the US experience with open fetal surgery for MMC, there have been no maternal deaths and no serious maternal complications in recent years. — Todd Ponsky (clinical) [Ep 2 · 133:43](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=8023)
- Longer operating room times and postoperative oligohydramnios correlate with increased risk for preterm birth in fetal MMC repair. — Scott Adzik (clinical) [Ep 2 · 106:17](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6377)
- In Europe, approximately one-third of mothers decline open fetal MMC surgery because it is an open procedure. — Todd Ponsky (epidemiological) [Ep 2 · 146:39](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=8799)
- For proper neurosurgical repair of cystic MMC, it is essential to remove the cyst and excise tissues that don't belong, not simply cover the lesion—a step that may be missing in some fetoscopic approaches. — Todd Ponsky (clinical) [Ep 2 · 147:34](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=8854)
- In the MOMS trial, 51% of prenatally repaired children met shunt criteria, but only 31 actually received shunts (approximately 65% of those meeting criteria), compared to 66 of 74 (89%) in the postnatal group. — Todd Ponsky (clinical) [Ep 2 · 150:23](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=9023)
- MiraLax softens stool but does not provide a 'push' to expel it, which can leave the colon full of soft stool. — Christine Warner (clinical) [Ep 3 · 6:16](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=376)
- Senna and bisacodyl are the two medications that provide a 'kick' or push for stool expulsion; everything else is a stool softener. — Marc Levitt (clinical) [Ep 3 · 6:59](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=419)
- MiraLax is problematic for patients with anorectal malformations who need fullness to detect stool, because it makes soft stool that 'mushes out' without discrete sensation. — Marc Levitt (clinical) [Ep 3 · 7:15](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=435)
- Senna-induced perineal rash is thought to be a chemical burn rather than a true allergy, presenting with blistering. — Jason Frischer (clinical) [Ep 3 · 5:30](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=330)
- Senna rash is treated with silver sulfadiazine and resolves with time; some patients tolerate senna upon reintroduction. — Jason Frischer (clinical) [Ep 3 · 5:38](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=338)
- Timing senna doses in the early morning so that bowel movements occur during the day (when diapers are changed promptly) reduces the risk of senna rash. — Jason Frischer (clinical) [Ep 3 · 5:47](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=347)
- Glycerin is generally better tolerated than castile soap for enemas in children; castile soap commonly causes cramping and discomfort. — Wendy Lewis (clinical) [Ep 3 · 9:10](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=550)
- A Malone appendicostomy provides tube-free access for antegrade enemas via daily catheterization of the channel. — Rebecca Rentea (clinical) [Ep 3 · 9:39](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=579)
- Children with spinal differences may need bladder access later in life, and the appendix is the preferred conduit for a Mitrofanoff urinary channel. — Rebecca Rentea (clinical) [Ep 3 · 9:49](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=589)
- Coordination with urology from the beginning of bowel management planning is essential in spinal patients to preserve the appendix for potential urologic reconstruction. — Marc Levitt (clinical) [Ep 3 · 10:02](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=602)
- A cecostomy tube (placed laparoscopically or by interventional radiology) provides direct access to the cecum for antegrade enemas and preserves the appendix for future reconstruction. — Rebecca Rentea (clinical) [Ep 3 · 11:53](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=713)
- A non-plicating, non-trimmed Malone appendicostomy (tip of appendix sewn to right lower quadrant with a balloon tube, without plication or trimming) preserves the appendix for potential future urologic use or splitting. — Marc Levitt (clinical) [Ep 3 · 12:22](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=742)
- Urologists prefer an appendix of at least 5 cm length for a Mitrofanoff; shorter appendices are not suitable for urologic use. — Marc Levitt (clinical) [Ep 3 · 13:36](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=816)
- An appendix of 2 cm is too short for either colorectal or urologic use; 5 cm goes to urology; 7 cm may be splittable (2 cm for colorectal, 5 cm for urology); longer appendices are certainly splittable. — Marc Levitt (clinical) [Ep 3 · 13:16](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=796)
- For urologic reconstruction, the appendix is preferred over a Monti channel made from small bowel for long-term outcomes. — Marc Levitt (clinical) [Ep 3 · 14:07](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=847)
- A neo-Malone can be created from a flap of colon if the appendix is used for urologic purposes. — Marc Levitt (clinical) [Ep 3 · 14:18](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=858)
- Taking down a cecostomy tube is relatively easy and leaves the appendix free for subsequent use. — Marc Levitt (clinical) [Ep 3 · 15:38](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=938)
- Bisacodyl can be administered as an enema or suppository in infants. — Jason Frischer (clinical) [Ep 3 · 8:31](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=511)
- Prenatal repair is most commonly done between 22 and 26 weeks gestation. — Fung Lim (clinical) [Ep 4 · 1:44](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=104)
- For maternal access, either a transverse incision or a midline incision may be used. — Fung Lim (clinical) [Ep 4 · 1:54](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=114)
- The amniotic cavity is expanded using humidified and heated carbon dioxide, which creates more space to do the repair. — Fung Lim (clinical) [Ep 4 · 2:22](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=142)
- A camera is inserted into the amniotic cavity through the first port to enable visualization inside the womb. — Fung Lim (clinical) [Ep 4 · 2:34](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=154)
- Two additional ports are placed under direct vision to allow placement of instruments for the repair. — Fung Lim (clinical) [Ep 4 · 2:43](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=163)
- A stabilization stitch is placed in the baby's upper back above the spina bifida. — Fung Lim (clinical) [Ep 4 · 2:56](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=176)
- Once the sac is completely open, the placode is freed. — Fung Lim (clinical) [Ep 4 · 3:22](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=202)
- Untethering allows the placode to fall back down nicely into the spinal canal. — Fung Lim (clinical) [Ep 4 · 3:34](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=214)
- To protect the placode, a patch is placed into the defect and anchored on one end to the baby's back using dissolvable sutures. — Fung Lim (clinical) [Ep 4 · 3:57](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=237)
- A second patch is placed to give additional protection and is secured with dissolvable sutures. — Fung Lim (clinical) [Ep 4 · 4:08](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=248)
- The skin is closed over the spinal defect using dissolvable sutures when the baby has enough skin to do so. — Fung Lim (clinical) [Ep 4 · 4:17](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=257)
- When the defect is too big and the two ends of skin cannot be pulled together, a skin patch is used to form a watertight closure. — Fung Lim (clinical) [Ep 4 · 4:26](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=266)
- Port sites are closed with dissolvable sutures. — Fung Lim (clinical) [Ep 4 · 4:49](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=289)
- The amniotic fluid that was removed is replaced with warm fluid and antibiotics are placed into the amniotic cavity. — Fung Lim (clinical) [Ep 4 · 4:57](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=297)
- Dr. Christina Theodoro states this study is a pivotal study in obtaining approval from the FDA for use of clinical grade stem cells in fetal myelomeningocele repair. — Christina Theodorou (clinical) [Ep 6 · 2:54](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=174)
- The technique involves exposing the fetal back, re-exposing the spinal cord, identifying the myelomeningocele defect, placing an extracellular matrix patch with placental stem cells facing the spinal cord in direct contact, closing the skin, and returning the baby to the uterus to continue gestation until term. — Christina Theodorou (clinical) [Ep 6 · 3:27](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=207)
- Lambs repaired with clinical grade placental stem cells have significantly improved motor function compared to lambs that did not receive the stem cells. — Christina Theodorou (clinical) [Ep 6 · 3:54](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=234)
- Dr. Todd Ponsky states that in utero repair of myelomeningocele has already shown benefit, and impregnating the repair with mesenchymal stromal cells provides an even larger benefit in the chance of ambulation. — Todd Ponsky (clinical) [Ep 6 · 4:08](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=248)
- The survey included self-identified specialists within the field of fetal surgery, yet only 4% of those people reported receiving formal training in fetal surgery. — Natalie Lopyan (epidemiological) [Ep 6 · 5:13](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=313)
- Dr. Natalie Lopian suggests it will be interesting to see whether fetal surgery exposure becomes a requirement during training or whether fetal centers become the primary training ground for fetal surgeons as the field expands. — Natalie Lopyan (opinion) [Ep 6 · 6:18](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=378)
- Dr. Todd Ponsky states that disparities in practice patterns are what happens in an emerging field, and it is reasonable to expect different levels of what different hospitals do in fetal surgery. — Todd Ponsky (opinion) [Ep 6 · 6:38](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=398)
- The study was not designed to link subspecialization of fetal surgery to outcomes and was not designed to provide a clear definition of a fetal surgery center. — Natalie Lopyan (clinical) [Ep 6 · 7:26](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=446)
- Under ultrasonic guidance, 4 full thickness sutures are placed through the uterine wall to delineate a 1 centimeter square area through which a 10 French trochar is inserted using Seldinger technique. (clinical) [Ep 7 · 1:00](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=60)
- After removing a portion of the amniotic fluid, the uterus is insufflated with warm, humidified carbon dioxide. (clinical) [Ep 7 · 1:14](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=74)
- Dissection of the myelomeningocele begins lateral to the exposed spinal cord, detaching it from the arachnoid and skin. (clinical) [Ep 7 · 1:32](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=92)
- The spinal cord is circumferentially released, taking care not to injure the ascending spinal cord, lateral dorsal roots, or segmental vasculature. (clinical) [Ep 7 · 1:41](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=101)
- The dura attaches laterally and ventrally to the open skin edge at the junctional zone. (clinical) [Ep 7 · 2:06](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=126)
- The lateral extent of the dura is identified and detached. (clinical) [Ep 7 · 2:12](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=132)
- A running, non-absorbable 6-0 suture is utilized to re-approximate the delicate dura, which will persist long term and act as a useful guide if subsequent untethering is required. (clinical) [Ep 7 · 2:24](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=144)
- In some cases, the size of the skin defect may prevent primary skin closure. (clinical) [Ep 7 · 2:55](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=175)
- A synthetic skin graft may be utilized and sutured to the edges of the healthy skin when primary closure is not possible. (clinical) [Ep 7 · 3:00](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=180)
- The synthetic skin graft will promote eventual epithelialization of the open defect. (clinical) [Ep 7 · 3:07](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=187)
- In high common channel cloacas, the common wall between the rectum, vagina, and bladder are not long common walls and are actually easy to separate the structures. (clinical) [Ep 1 · 2:25](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=145)
- For high common channel cloacas where the rectum is reachable through the abdomen, it is not advisable to search for it posterior sagittally; laparotomy is the preferred approach. (clinical) [Ep 1 · 2:25](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=145)
- Saline perturbation is a technique used intraoperatively to assess the patency of the reproductive tract in all cases when in the abdomen. — Bree (clinical) [Ep 1 · 3:26](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=206)
- When assessing Mullerian structures intraoperatively, if one side is very well developed and the other side is very atritic, it may be advantageous to retain the well developed side and remove the atritic side that might be dangerous at the time of menstruation and not helpful for future childbearing. — Bree (clinical) [Ep 1 · 3:26](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=206)
- When using colon for vaginal interposition, the segment is placed anti-peristaltic due to blood supply considerations and the way it reaches the perineum. — Bree (clinical) [Ep 1 · 3:26](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=206)
- Using the rectum for vaginal replacement may change a patient who is potentially fecally continent into somebody who is not going to be fecally continent, because taking away the rectal reservoir affects continence. — Bree (clinical) [Ep 1 · 7:12](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=432)
- In patients with vestibular fistulas and absent vagina who had the rectum used as a vagina with the colon brought down, bowel control was less than optimal in follow-up through the years. — Pena (clinical) [Ep 1 · 8:24](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=504)
- Preservation of the rectum in patients with good functional prognosis (good sacrum, no tethered cord, and a good malformation) is extremely important for maintaining bowel control. — Pena (clinical) [Ep 1 · 8:24](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=504)
- The rectum is a natural reservoir, and if removed in patients with an anorectal malformation, most likely the patient is going to be incontinent because they cannot tolerate the constant passing of stool that occurs when colon is connected down to the perineum. — Pena (clinical) [Ep 1 · 8:24](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=504)
- Descending colon is increasingly used for vaginal replacement because the arcades are very nice for preserving blood supply, compared to small bowel or rectum. — Pena (clinical) [Ep 1 · 9:50](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=590)
- Approximately 65 cases have been seen where babies had a colostomy at birth in another institution because a phallic-appearing structure led to a diagnosis of intersex, but extensive workup concluded they were chromosomally normal females with cloacas. — Pena (epidemiological) [Ep 1 · 12:00](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=720)
- Doctor Pena has never seen a patient with intersex and a cloaca together. — Pena (clinical) [Ep 1 · 12:00](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=720)
- To differentiate cloaca from adrenal hyperplasia when a patient has a pseudophallus and single perineal orifice, palpate the structure: in real adrenal hyperplasia you will palpate corpora (real penis), whereas in cloaca patients the structure is just folded skin. — Pena (clinical) [Ep 1 · 12:00](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=720)
- The folded skin from the phallic-appearing structure in cloaca patients can be used to facilitate reconstruction of the vagina. — Pena (clinical) [Ep 1 · 12:00](https://origin-library.globalcastmd.com/watch/case-presentations-part-ii-cloaca-and-complex-arms-2015-1012?t=720)
- Casey Kelleher is a pediatric surgeon at Mass General for Children in Boston and chair of the APSA Publications Committee — Casey Kelleher (clinical) [Ep 8 · 0:32](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=32)
- Surgeons have historically been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have — Gail Besner (opinion) [Ep 8 · 1:41](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=101)
- The concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work — Gail Besner (clinical) [Ep 8 · 2:55](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=175)
- Nationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits — Gail Besner (clinical) [Ep 8 · 3:07](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=187)
- At Akron Children's Hospital under Bob Perry, the bonus structure required the entire group to reach a certain RVU threshold (not individual surgeons) to receive 50% of bonus, with the remaining bonus based on individual project performance — Todd Ponsky (clinical) [Ep 8 · 5:04](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=304)
- Shahzad Jaharifar is a pediatric surgeon and assistant clinical professor of surgery at BC Children's Hospital in Vancouver, Canada — Shahzad Jaharifar (clinical) [Ep 8 · 6:09](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=369)
- At Saint Justine Hospital, gastroschisis treatment differed from other institutions by having very low silo use, with pretty much every patient having an attempt at immediate bedside sutureless closure — Shahzad Jaharifar (clinical) [Ep 8 · 6:59](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=419)
- Before and after protocol implementation at BC Children's, approximately 75% of gastroschisis babies can be closed immediately, whether in the OR pre-implementation with fascial closure or at bedside post-implementation — Shahzad Jaharifar (clinical) [Ep 8 · 7:57](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=477)
- With silo management, parents look at their newborn's intestines through a silo for 5-6 days and cannot hold their baby until the silo is completely reduced — Shahzad Jaharifar (clinical) [Ep 8 · 8:27](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=507)
- With immediate gastroschisis closure, if babies are extubated within 48 hours, parents can hold them within 48 hours; if managed without intubation, parents can hold them immediately — Shahzad Jaharifar (clinical) [Ep 8 · 8:43](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=523)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- After implementing the academic RVU system, Nationwide had an increase in presentations, peer-reviewed publications, and external federal research funding. — The host summarizing the discussion [Ep 5 · 3:44](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=224)
- External federal research funding at Nationwide increased from $750,000 to $5.7 million, representing a 7.7-fold increase. — Rod Gerardo summarizing the discussion [Ep 5 · 3:58](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=238)
- The BC Children's Hospital gastroschisis study was a retrospective review comparing outcomes before and after implementation of a protocol in 2012, covering patients from 2008 to 2019. — The host summarizing the discussion [Ep 5 · 5:51](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=351)
- In prior studies of placental mesenchymal stem cells for in utero MMC repair, two surgeries were performed on lambs: one to create the defect and one to repair it, both in utero, with PMSCs used during repair. — The host summarizing the discussion [Ep 5 · 10:17](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=617)
- In the current study, a single operation was performed at approximately 100 days gestational age where the MMC defect was created and repaired simultaneously, with PMSCs placed directly onto the spinal cord. — The host summarizing the discussion [Ep 5 · 10:43](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=643)
- The PMSCs did not persist in the placentas, uteri, or lambs at 3 months follow-up. — The host summarizing the discussion [Ep 5 · 11:23](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=683)
- There was no histological evidence of abnormal growth or tumor development in the ovine model at 3 months. — The host summarizing the discussion [Ep 5 · 11:30](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=690)
- Human trials using PMSCs for in utero myelomeningocele repair have been initiated with the first two patients enrolled. — The host summarizing the discussion [Ep 5 · 11:52](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=712)
- In utero coverage of experimentally created MMC in fetal sheep rescues neurologic function at birth, with lambs able to stand, walk, and maintain continence. — Scott Adzik summarizing a resource [Ep 2 · 86:43](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=5203)
- There have been three maternal deaths associated with open fetal surgery for MMC in South America (one in Colombia, two in Argentina). — Todd Ponsky summarizes what Dr. Scott Adzik said [Ep 2 · 132:16](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=7936)
- A Washington University financial model using MOMS trial data showed that over $3 million would be saved for 100 babies treated prenatally versus postnatally. — Scott Adzik summarizing a resource [Ep 2 · 107:07](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=6427)
- The discrepancy between meeting shunt criteria and receiving shunts occurred because an independent neurosurgical review committee determined criteria, but individual neurosurgeons made placement decisions, and most discrepancies involved criterion 3 (head size/ventricle changes) without accompanying symptoms. — Scott Adzik summarizing a resource [Ep 2 · 154:14](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=9254)
- Using revised shunt criteria based on modified criterion 3, there is a close match between shunt criteria and actual shunt placement in both prenatal (46%) and postnatal (86%) groups. — Scott Adzik summarizing a resource [Ep 2 · 156:43](https://origin-library.globalcastmd.com/watch/fetal-surgical-intervention-for-myelomeningocele-fetal-surgery-2012-1026?t=9403)
- About 5% of colorectal work is surgical and the rest is bowel management. — Rebecca Rentea summarizing the discussion [Ep 3 · 1:48](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=108)
- Senna rash may be related to the formulation (tablet, liquid, or chocolate squares) or to prolonged contact with stool, particularly overnight. — Marc Levitt summarizing the discussion [Ep 3 · 5:07](https://origin-library.globalcastmd.com/watch/colorectal-quiz-episode-15-bowel-management-in-spinal-patients-need-for-a-urolog-4232?t=307)
- Neural tube defects are the most common congenital central nervous system anomaly. — Rod Gerardo summarizes what Dr. Fung Lim said [Ep 4 · 0:42](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=42)
- Myelomeningocele or spina bifida is the most common neural tube defect. — Rod Gerardo summarizes what Dr. Fung Lim said [Ep 4 · 1:20](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=80)
- In myelomeningocele, the patient is born with a cleft in the vertebral column and a defect in the skin, so the meninges and the spinal cord are exposed. — Rod Gerardo summarizes what Dr. Fung Lim said [Ep 4 · 1:25](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=85)
- The patient may be left with neural defects based on the level of the spinal cord where the lesion is. — Rod Gerardo summarizes what Dr. Fung Lim said [Ep 4 · 1:33](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=93)
- Under ultrasound guidance, the first port is placed. — Rod Gerardo summarizes what Dr. Fung Lim said [Ep 4 · 2:17](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=137)
- Anesthesia is induced on the baby via an intragluteal injection. — Rod Gerardo summarizes what Dr. Fung Lim said [Ep 4 · 2:51](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=171)
- The first step is to open the sac, then dissect around the sac circumferentially. — Rod Gerardo summarizes what Dr. Fung Lim said [Ep 4 · 3:08](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=188)
- The placode is the open area of exposed neural tissue. — Rod Gerardo summarizes what Dr. Fung Lim said [Ep 4 · 3:27](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=207)
- A skin flap is created to loosen up the skin, which will help form a watertight closure of the spinal defect. — Rod Gerardo summarizes what Dr. Fung Lim said [Ep 4 · 3:44](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=224)
- The mother and the fetus are monitored postoperatively, and if able, the baby is delivered vaginally at term. — Rod Gerardo summarizes what Dr. Fung Lim said [Ep 4 · 5:14](https://origin-library.globalcastmd.com/watch/fetoscopic-repair-of-myelomeningocele-4391?t=314)
- The first article examines surgical management, staging and outcomes of Wilms tumors with intravascular extension, using results from the SIOP (International Society of Pediatric Oncology) Renal Tumor Study. — Brittany Levy summarizing the discussion [Ep 6 · 0:34](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=34)
- The study looked at children with Wilms tumor where tumor thrombus extended into the renal vein and provided outcomes for when complete resection of tumor thrombus was successful versus when it was not. — Brittany Levy summarizing the discussion [Ep 6 · 0:58](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=58)
- Dr. Paul Tam states that Wilms tumor has been a great success story for pediatric surgery and pediatric oncology. — Brittany Levy summarizing the discussion [Ep 6 · 1:14](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=74)
- Dr. Paul Tam suggests improving outcomes by identifying subgroups of patients who are still not doing well and trying to improve care in those particular areas. — Brittany Levy summarizing the discussion [Ep 6 · 1:39](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=99)
- If half of Wilms tumor patients have complete tumor removal and half do not, and there is an outcome difference, then surgeons should still try hard to remove all of the tumor. — Brittany Levy summarizing the discussion [Ep 6 · 1:54](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=114)
- The second article examines efficacy of clinical grade human placental mesenchymal stromal cells in fetal ovine myelomeningocele repair. — Brittany Levy summarizing the discussion [Ep 6 · 2:13](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=133)
- The article discussed use of mesenchymal stromal cells on an extracellular matrix in ovine fetuses to determine if there was a benefit to motor function in fetal lambs given the intervention. — Brittany Levy summarizing the discussion [Ep 6 · 2:40](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=160)
- The third article is titled 'Current Status of Sub-specialization in Pediatric Surgery, a Focus on fetal Surgery' and surveys practice patterns in fetal surgery across the country. — Rod Gerardo summarizing the discussion [Ep 6 · 4:37](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=277)
- Many survey respondents reported receiving fetal training during their pediatric surgery fellowship training, yet when the question was posed differently, many responded that they did not have exposure to fetal surgery during fellowship training. — Brittany Levy summarizing the discussion [Ep 6 · 5:37](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=337)
- Dr. Paul Tam states that fetal surgery is a frontier for pediatric surgery and the survey provides a reality check on how to develop a treatment which remains rare and often experimental. — Brittany Levy summarizing the discussion [Ep 6 · 5:54](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-highlights-april-2022-5554?t=354)
- Myelomeningocele or open spina bifida is a neural tube defect. — The host summarizing the discussion [Ep 7 · 0:20](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=20)
- Myelomeningocele is when the spinal cord does not close and is exposed on surface through an opening in the spine. — The host summarizing the discussion [Ep 7 · 0:25](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=25)
- Myelomeningocele usually occurs in the low back region. — The host summarizing the discussion [Ep 7 · 0:31](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=31)
- The incidence of neural tube defects is around 0.2 per 1000 live births in the United States. — The host summarizing the discussion [Ep 7 · 0:33](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=33)
- When diagnosed prenatally, neural tube defects can be repaired during the fetal stage of life while in utero. — The host summarizing the discussion [Ep 7 · 0:39](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=39)
- The pregnant patient is placed under general anesthesia and the uterus is approached by a midline laparotomy. — The host summarizing the discussion [Ep 7 · 0:47](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=47)
- An ultrasound is used to map the location of the placenta and major vessels on the uterine surface. — The host summarizing the discussion [Ep 7 · 0:55](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=55)
- Two subsequent trochars are placed under endoscopic visualization. — The host summarizing the discussion [Ep 7 · 1:22](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=82)
- Prior to surgical intervention, the fetus is administered a sedative cocktail of rocuronium, fentanyl, and atropine. — The host summarizing the discussion [Ep 7 · 1:26](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=86)
- The surgeon uses tenotomy scissors and right-angled hook electrocautery to sharply dissect through the tissue, which completely frees the placode. — The host summarizing the discussion [Ep 7 · 1:51](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=111)
- The neural placode is reconstructed with interrupted 6-0 sutures after it is completely untethered from the skin. — The host summarizing the discussion [Ep 7 · 1:59](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=119)
- The dural closure area can be an area of great tension. — The host summarizing the discussion [Ep 7 · 2:16](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=136)
- Lateral fascia and muscle may be freed to allow medialization and primary closure of the dura under less tension. — The host summarizing the discussion [Ep 7 · 2:18](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=138)
- Skin closure should be performed in the mid-sagittal plane when possible. — The host summarizing the discussion [Ep 7 · 2:37](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=157)
- Skin closure may require mobilization of the skin, including subcutaneous fat layer, as the skin's vascular supply comes through this layer. — The host summarizing the discussion [Ep 7 · 2:43](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=163)
- Blunt dissection in the plane between the muscle and subcutaneous fat is the best method to preserve the blood supply. — The host summarizing the discussion [Ep 7 · 2:49](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=169)
- After completing the fetal back closure, the amniotic fluid is replaced in the uterus with warmed, lactated Ringer solution. — The host summarizing the discussion [Ep 7 · 3:12](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=192)
- The ports are removed and the insertion sites are closed, the uterus is returned to the abdominal cavity and the abdominal incision is closed in the standard fashion. — The host summarizing the discussion [Ep 7 · 3:19](https://origin-library.globalcastmd.com/watch/myelomeningoceles-fetoscopic-intrauterine-myelomeningocele-closure-11326?t=199)
- After implementing the academic RVU system, Nationwide had an increase in presentations and peer-reviewed publications, and external federal research funding increased from $750,000 to $5.7 million (a 7.7-fold increase) — Casey Kelleher summarizing the discussion [Ep 8 · 3:48](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=228)
- The BC Children's Hospital gastroschisis study was a retrospective review of patients between 2008 and 2019, comparing outcomes before and after protocol implementation in 2012 — Casey Kelleher summarizing the discussion [Ep 8 · 5:46](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=346)
- Sarah Stokes is a PGY-6 general surgery resident at University of California, Davis — Ellen summarizing a resource [Ep 8 · 9:25](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=565)
- Prior studies on placental mesenchymal stem cells for in utero myelomeningocele repair involved two separate surgeries in lambs: one to create the defect and one to repair it — Ellen summarizing the discussion [Ep 8 · 10:17](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=617)
- In the current study, a single operation was performed at approximately 100 days gestational age where myelomeningocele defects were created and repaired simultaneously with PMSCs placed directly onto the spinal cord — Ellen summarizing the discussion [Ep 8 · 10:36](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=636)
- The study found that PMSCs did not persist in placentas, uteri, or lambs at 3 months, and there was no histological evidence of abnormal growth or tumor development — Ellen summarizing the discussion [Ep 8 · 11:23](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=683)
- Human trials using placental mesenchymal stromal cells for myelomeningocele repair have been initiated with the first two patients enrolled — Ellen summarizing the discussion [Ep 8 · 11:52](https://origin-library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-13358?t=712)

## Changelog
- Sep 24: 1 item added automatically
- Sep 16: 1 item added automatically
- Sep 7: 3 items added automatically
- Sep 7: 3 items added automatically

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