And I think the one take home point, if you can remember anything, is that if you have a patient who has had a battery removed and they present later with a bleed, that's an emergency that needs to be taken seriously and have a plan for.
It's important to note that 40 to 60% of babies with Esophageal Atresia can have other associated anomalies. About 20% of them can have other findings within the VACTERL association, and about 5% of them can have genetic syndromes.
It's so important to do a full thickness biopsy, and I like to cut a square, like a cube. And if we're looking at the sides of that cube, you want to make sure that the seromuscular side is the same as the mucosal side.
the overstretching of the sphincters, which can be done if you do an extensive transanal amount of work, is really a morbidity that needs to be avoided. And laparoscopy helps with that.
QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison
▶Ep 17 · 0:58
quoteI think some of us who are peat surgery trained were told initially that tracheomalacia is something that kids will grow out of and will get better and as data has shown recently that there's no long term consequences for soiling into the lungs and having chronic lung lung aspiration and over time that really is detrimental.↗
▶Ep 17 · 0:58
opinionPediatric surgery trainees were initially told that tracheomalacia is something that kids will grow out of and will get better.↗
▶Ep 17 · 1:08
clinicalRecent data has shown that there are long term consequences for soiling into the lungs and having chronic lung aspiration, which over time is detrimental.↗
▶Ep 17 · 1:26
clinicalPreoperative dynamic reconstruction studies give a lot of information for determining which procedure is best for each patient.↗
▶Ep 17 · 1:31
clinicalDynamic expiratory films show what you need to see with the airway that inspiratory films alone do not reveal.↗
▶Ep 17 · 1:41
quoteYou really see what you need to see with the dynamic studies.↗
▶Ep 17 · 1:55
clinicalSurgeons always look for the thymus and make sure that there is enough tissue to remove to be able to bring the trachea up anteriorly.↗
▶Ep 17 · 2:17
quoteOur classification system is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging.↗
▶Ep 17 · 2:17
opinionThe classification system for tracheomalacia is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging.↗
▶Ep 17 · 2:34
quoteThe benefits of minimally invasive to me, the biggest one is that visualization and exposure.↗
▶Ep 17 · 2:34
opinionThe biggest benefit of minimally invasive approach is visualization and exposure.↗
▶Ep 17 · 2:39
opinionDisadvantages of minimally invasive approach include that it takes longer to learn and is more uncomfortable to learn.↗
▶Ep 17 · 2:42
opinionAnesthesia colleagues are sometimes hesitant to allow thoracoscopic cases to go on a little bit longer.↗
▶Ep 17 · 3:33
clinicalFor anterior mediastinal work, babies are positioned with the arm up and a bump underneath so that there is access to the axilla and anteriorly.↗
▶Ep 17 · 3:51
clinicalThe goal of aortopexy is to suspend the aorta.↗
▶Ep 17 · 3:54
clinicalThe first step in aortopexy is taking out the thymus, finding the innominate junction, and then identifying the arch of the aorta.↗
▶Ep 17 · 4:10
quoteIf you go up too high, then you're doing a pericardioexy and it isn't quite as successful or durable.↗
▶Ep 17 · 4:10
clinicalIf you go up too high during aortopexy, then you are doing a pericardiopexy and it is not quite as successful or durable.↗
▶Ep 17 · 4:45
clinicalThe goal of posterior tracheopexy is taking the anterior spinal ligament and fixing it to the posterior membranous trachea.↗
▶Ep 17 · 4:56
clinicalThe area of floppy membrane is distal to the dilated pouch usually.↗
▶Ep 17 · 5:09
clinicalSurgeons can make an indent on the posterior wall of the trachea, and pulmonologists can see it pop up on their bronchoscopy to help guide suture placement.↗
▶Ep 17 · 5:43
clinicalIt usually takes about 2 or 3 sutures for posterior tracheopexy, leaving enough space for the esophagus to come through.↗
▶Ep 17 · 5:48
opinionUsing the knot pusher and tension suture is helpful during tracheopexy.↗
▶Ep 17 · 5:58
opinionGetting the suture to roll through the anterior spinal ligament is the hardest part and is pretty challenging.↗
▶Ep 17 · 5:58
quoteAnd this is the part that I think is honestly the, the hardest. Getting that suture to roll through the anterior spinal ligament is actually pretty, pretty challenging.↗
▶Ep 17 · 6:20
clinicalThere are times when the esophagus is put to the left of the trachea, and times when it is put to the right of the trachea.↗
▶Ep 17 · 6:26
opinionDr. Garrison always worries a little bit about dysphagia when repositioning the esophagus, but it is not something he has seen a ton of.↗
▶Ep 17 · 6:26
quoteI always worry a little bit about dysphagia, but honestly, it's not something that I've, I've seen a ton of.↗
QUAD #4: Surgical Management of Button Battery & Caustic Ingestion with Dr. Aaron Garrison
▶Ep 18 · 1:06
quoteThere are 3 locations in the esophagus where things tend to get stuck, so the upper esophageal sphincter behind the aortic arch, and then at the lower esophageal sphincter.↗
▶Ep 18 · 1:06
clinicalThere are 3 locations in the esophagus where button batteries tend to get stuck: the upper esophageal sphincter, behind the aortic arch, and at the lower esophageal sphincter.↗
▶Ep 18 · 1:33
clinicalHigh-risk criteria include younger patients with smaller esophagus.↗
▶Ep 18 · 1:43
clinicalLonger duration that the battery has been in the esophagus is associated with worse outcomes.↗
▶Ep 18 · 1:52
clinicalIf a patient has had a battery removed and presents later with a bleed, that is an emergency that needs to be taken seriously and requires a plan.↗
▶Ep 18 · 1:52
quoteAnd I think the one take home point, if you can remember anything, is that if you have a patient who has had a battery removed and they present later with a bleed, that's an emergency that needs to be taken seriously and have a plan for.↗
▶Ep 18 · 2:22
quoteAnd almost 25% of the patients in this series died, and what I thought was particularly sad is that 2 of the fatalities presented with the buttons already in the stomach.↗
▶Ep 18 · 2:22
epidemiologicalAlmost 25% of patients in the Colorado series died.↗
▶Ep 18 · 2:22
epidemiologicalTwo of the fatalities in the Colorado series presented with the button batteries already in the stomach.↗
▶Ep 18 · 2:41
clinicalAny small communication between the esophagus and the aorta can be potentially life-threatening.↗
▶Ep 18 · 2:55
clinicalAortoesophageal fistulas do not always happen in the hospital, so having a high index of suspicion and a plan for what to do once the battery is removed is helpful.↗
▶Ep 18 · 2:55
quoteSo it is not something that always happens in the hospital, so I think having a high index of suspicion and a plan for what to do once the battery is removed is helpful.↗
▶Ep 18 · 3:26
guidelineFor sick patients with esophageal foreign bodies and active bleeding or clinical instability, it is recommended to have GI surgery and CT surgery available for the procedure.↗
▶Ep 18 · 3:47
guidelineIf imaging shows injury close to the aorta, continue NPO and antibiotics and repeat MRI in 5 to 7 days to assess the trajectory of inflammation.↗
▶Ep 18 · 4:30
guidelineFor high-risk patients (less than 5 years old, larger battery size), endoscopic evaluation of the esophagus is recommended because the duration of battery presence higher up than the stomach is unknown.↗
▶Ep 18 · 4:43
clinicalThe need for ECMO or cardiopulmonary bypass depends on the location of the fistula and whether you can intubate past the injury enough to ventilate during the case.↗
▶Ep 18 · 4:59
clinicalIf the fistula is near the carina, complex airway reconstruction will be needed and adequate ventilation during the case will not be possible.↗
▶Ep 18 · 5:21
clinicalIn one case with a large tracheoesophageal fistula, the patient was placed on ECMO because they were unable to adequately ventilate.↗
▶Ep 18 · 5:45
clinicalIn the Cincinnati Children's case, an interposition graft was performed by removing a segment of trachea and using that trachea as the front wall of the esophagus.↗
▶Ep 18 · 6:31
clinicalThe airway may take priority in caustic ingestion cases, and patients can present in extremis or with an allergic-reaction-like presentation.↗
▶Ep 18 · 6:31
quoteSometimes I think it's easy to get caught up in what the child drank and to forget that the kind of airway may take priority.↗
▶Ep 18 · 6:56
clinicalFor esophageal perforation, the approach is to maintain the same exposure, debride to viable tissue, achieve layered closure with coverage, and if possible use a muscle flap for coverage.↗
▶Ep 18 · 7:09
clinicalIf the perforation is too big, drain it to allow for delayed repair.↗
Aaron's statements about Button Battery Ingestion23 statements
QUAD #4: Surgical Management of Button Battery & Caustic Ingestion with Dr. Aaron Garrison
▶Ep 5 · 1:06
clinicalThere are 3 locations in the esophagus where button batteries tend to get stuck: the upper esophageal sphincter, behind the aortic arch, and at the lower esophageal sphincter.↗
▶Ep 5 · 1:06
quoteThere are 3 locations in the esophagus where things tend to get stuck, so the upper esophageal sphincter behind the aortic arch, and then at the lower esophageal sphincter.↗
▶Ep 5 · 1:33
clinicalHigh-risk criteria include younger patients with smaller esophagus.↗
▶Ep 5 · 1:43
clinicalLonger duration that the battery has been in the esophagus is associated with worse outcomes.↗
▶Ep 5 · 1:52
quoteAnd I think the one take home point, if you can remember anything, is that if you have a patient who has had a battery removed and they present later with a bleed, that's an emergency that needs to be taken seriously and have a plan for.↗
▶Ep 5 · 1:52
clinicalIf a patient has had a battery removed and presents later with a bleed, that is an emergency that needs to be taken seriously and requires a plan.↗
▶Ep 5 · 2:22
quoteAnd almost 25% of the patients in this series died, and what I thought was particularly sad is that 2 of the fatalities presented with the buttons already in the stomach.↗
▶Ep 5 · 2:22
epidemiologicalTwo of the fatalities in the Colorado series presented with the button batteries already in the stomach.↗
▶Ep 5 · 2:22
epidemiologicalAlmost 25% of patients in the Colorado series died.↗
▶Ep 5 · 2:41
clinicalAny small communication between the esophagus and the aorta can be potentially life-threatening.↗
▶Ep 5 · 2:55
clinicalAortoesophageal fistulas do not always happen in the hospital, so having a high index of suspicion and a plan for what to do once the battery is removed is helpful.↗
▶Ep 5 · 2:55
quoteSo it is not something that always happens in the hospital, so I think having a high index of suspicion and a plan for what to do once the battery is removed is helpful.↗
▶Ep 5 · 3:26
guidelineFor sick patients with esophageal foreign bodies and active bleeding or clinical instability, it is recommended to have GI surgery and CT surgery available for the procedure.↗
▶Ep 5 · 3:47
guidelineIf imaging shows injury close to the aorta, continue NPO and antibiotics and repeat MRI in 5 to 7 days to assess the trajectory of inflammation.↗
▶Ep 5 · 4:30
guidelineFor high-risk patients (less than 5 years old, larger battery size), endoscopic evaluation of the esophagus is recommended because the duration of battery presence higher up than the stomach is unknown.↗
▶Ep 5 · 4:43
clinicalThe need for ECMO or cardiopulmonary bypass depends on the location of the fistula and whether you can intubate past the injury enough to ventilate during the case.↗
▶Ep 5 · 4:59
clinicalIf the fistula is near the carina, complex airway reconstruction will be needed and adequate ventilation during the case will not be possible.↗
▶Ep 5 · 5:21
clinicalIn one case with a large tracheoesophageal fistula, the patient was placed on ECMO because they were unable to adequately ventilate.↗
▶Ep 5 · 5:45
clinicalIn the Cincinnati Children's case, an interposition graft was performed by removing a segment of trachea and using that trachea as the front wall of the esophagus.↗
▶Ep 5 · 6:31
quoteSometimes I think it's easy to get caught up in what the child drank and to forget that the kind of airway may take priority.↗
▶Ep 5 · 6:31
clinicalThe airway may take priority in caustic ingestion cases, and patients can present in extremis or with an allergic-reaction-like presentation.↗
▶Ep 5 · 6:56
clinicalFor esophageal perforation, the approach is to maintain the same exposure, debride to viable tissue, achieve layered closure with coverage, and if possible use a muscle flap for coverage.↗
▶Ep 5 · 7:09
clinicalIf the perforation is too big, drain it to allow for delayed repair.↗
Aaron's statements about Colorectal / ARM & Hirschsprung95 statements
quoteHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 73 · 0:07
quoteAnd I'm Aaron Garrison. We're both pediatric surgeons at Cincinnati Children's.↗
▶Ep 73 · 0:07
quoteHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 73 · 0:07
clinicalHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 73 · 0:07
clinicalHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 73 · 0:07
quoteAnd I'm Aaron Garrison. We're both pediatric surgeons at Cincinnati Children's.↗
▶Ep 73 · 1:03
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21.↗
▶Ep 73 · 1:03
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 73 · 1:03
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history.↗
▶Ep 73 · 1:03
clinicalThere are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease.↗
▶Ep 73 · 1:03
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21.↗
▶Ep 73 · 1:03
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung disease.↗
▶Ep 73 · 1:03
clinicalHirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes.↗
▶Ep 73 · 1:03
quoteSo Hirschsprung disease is actually relatively common in a busy children's hospital. It's got an incidence of about 1 in 5,000 children.↗
▶Ep 73 · 1:03
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 73 · 1:03
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history.↗
▶Ep 73 · 1:03
clinicalThere are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease.↗
▶Ep 73 · 1:03
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung disease.↗
▶Ep 73 · 1:03
clinicalHirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes.↗
▶Ep 73 · 1:03
quoteSo Hirschsprung disease is actually relatively common in a busy children's hospital. It's got an incidence of about 1 in 5,000 children.↗
▶Ep 73 · 5:12
clinicalOlder children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases.↗
▶Ep 73 · 5:12
clinicalEnterocolitis is the life-threatening part of Hirschsprung's disease.↗
▶Ep 73 · 5:12
quoteSo the first thing I usually do is talk to the family and give them education about the disease, because most of them have never heard of it and they're not sure what to expect.↗
▶Ep 73 · 5:12
clinicalNICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 73 · 5:12
clinicalEnterocolitis is the life-threatening part of Hirschsprung's disease.↗
▶Ep 73 · 5:12
clinicalOlder children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases.↗
▶Ep 73 · 5:12
quoteSo the first thing I usually do is talk to the family and give them education about the disease, because most of them have never heard of it and they're not sure what to expect.↗
▶Ep 73 · 5:12
clinicalNICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 73 · 6:59
clinicalThe contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always.↗
▶Ep 73 · 6:59
clinicalThe goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line.↗
▶Ep 73 · 6:59
clinicalThe goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line.↗
▶Ep 73 · 6:59
clinicalThe contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always.↗
▶Ep 73 · 10:15
opinionThe Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures.↗
▶Ep 73 · 10:15
opinionAll three surgical techniques (Swenson, Suave, and Duhamel) are equally effective.↗
▶Ep 73 · 10:15
clinicalChildren who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch.↗
▶Ep 73 · 10:15
clinicalIn the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel.↗
▶Ep 73 · 10:15
clinicalChildren who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch.↗
▶Ep 73 · 10:15
clinicalIn the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel.↗
▶Ep 73 · 10:15
opinionThe Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures.↗
▶Ep 73 · 10:15
clinicalIn the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision.↗
▶Ep 73 · 10:15
opinionAll three surgical techniques (Swenson, Suave, and Duhamel) are equally effective.↗
▶Ep 73 · 10:15
clinicalIn the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision.↗
▶Ep 73 · 11:49
clinicalEarly complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn.↗
▶Ep 73 · 11:49
clinicalEarly complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn.↗
▶Ep 73 · 11:49
clinicalAnastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion.↗
▶Ep 73 · 11:49
clinicalAnastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion.↗
▶Ep 73 · 13:54
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
▶Ep 73 · 13:54
clinicalMost patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten.↗
▶Ep 73 · 13:54
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
▶Ep 73 · 13:54
clinicalMost patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten.↗
clinicalSurgeons should wait for frozen section confirmation before taking mesentery during Hirschsprung pull-through.↗
▶Ep 88 · 9:30
clinicalSurgeons should wait for frozen section confirmation before taking mesentery during Hirschsprung pull-through.↗
▶Ep 88 · 11:13
clinicalMesenteric dissection should stay close to the bowel wall, not deep in the mesentery, as this plane tends to be less bloody.↗
▶Ep 88 · 11:13
clinicalMesenteric dissection should stay close to the bowel wall, not deep in the mesentery, as this plane tends to be less bloody.↗
▶Ep 88 · 15:03
clinicalFor standard rectosigmoid Hirschsprung cases, the patient can remain supine with legs wrapped and fastened to the ether screen, avoiding the need to flip prone.↗
▶Ep 88 · 15:03
clinicalFor standard rectosigmoid Hirschsprung cases, the patient can remain supine with legs wrapped and fastened to the ether screen, avoiding the need to flip prone.↗
▶Ep 88 · 16:30
clinicalTacking sutures on the serosa to the pelvic sidewall at 3 and 9 o'clock positions help anchor the anastomosis in place, though this does not constitute a true two-layer anastomosis.↗
▶Ep 88 · 16:30
clinicalTacking sutures on the serosa to the pelvic sidewall at 3 and 9 o'clock positions help anchor the anastomosis in place, though this does not constitute a true two-layer anastomosis.↗
Hirschsprung Disease in Brief
▶Ep 116 · 0:48
quoteThe ganglion cells don't make it all the way down distally. The colon ends up not being able to contract.↗
▶Ep 116 · 0:48
clinicalIn Hirschsprung disease, the ganglion cells don't make it all the way down distally, and the colon ends up not being able to contract.↗
▶Ep 116 · 1:32
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 116 · 2:55
quoteThe transition zone is from contracted rectum and all of a sudden it opens up into dilated rectum. That's the transition zone.↗
▶Ep 116 · 2:55
clinicalThe transition zone is from contracted rectum (where nerve cells are absent) to dilated rectum (where normal nerve cells are present).↗
▶Ep 116 · 3:23
clinicalInability to evacuate contrast is a finding suggestive of Hirschsprung disease.↗
▶Ep 116 · 3:23
clinicalIn Hirschsprung's disease, the rectum is usually less dilated than the proximal colon, making the rectosigmoid ratio less than 1.↗
▶Ep 116 · 3:23
clinicalIn total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.↗
▶Ep 116 · 4:47
clinicalIn anorectal manometry for Hirschsprung disease, there is a lack of the recto-anal inhibitory reflex (RAIR).↗
▶Ep 116 · 4:47
clinicalThe recto-anal inhibitory reflex may be absent in other conditions besides Hirschsprung disease, and some children have a false positive test.↗
▶Ep 116 · 4:47
clinicalSuction rectal biopsy is painless and commonly done at the bedside in neonates.↗
▶Ep 116 · 6:07
opinionChildren with Hirschsprung disease will need this condition managed for life, but the expectation is that they will live a normal life with close management and care.↗
▶Ep 116 · 6:37
guidelineNPO babies diagnosed with Hirschsprung disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 116 · 7:03
guidelineOlder children with Hirschsprung disease will start on an enema program, and some may need diversion more proximally to give the colon time to decompress.↗
▶Ep 116 · 7:03
clinicalOlder children with Hirschsprung disease are not amenable to just doing a primary pull through in many cases because the colon has become dilated.↗
▶Ep 116 · 8:48
opinionHirschsprung's associated enterocolitis is the main early complication everyone needs to be aware of.↗
▶Ep 116 · 8:48
clinicalAnastomotic leak is a rare but possible early complication after Hirschsprung surgery.↗
▶Ep 116 · 8:48
clinicalEarly postoperative complications include diaper rash and excoriation that can often need to be treated like a burn.↗
▶Ep 116 · 10:09
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
▶Ep 116 · 10:09
opinionAssuming the operation has been done well and there are no transition zone or strictures, most patients with Hirschsprung disease are expected to do very well and be in kindergarten socially confident.↗
The Colorectal Quiz Episode 4
▶Ep 229 · 7:09
quoteIt's so important to do a full thickness biopsy, and I like to cut a square, like a cube. And if we're looking at the sides of that cube, you want to make sure that the seromuscular side is the same as the mucosal side.↗
▶Ep 229 · 7:09
clinicalFull-thickness biopsy must include seromuscular side same size as mucosal side (cube-shaped)↗
▶Ep 229 · 16:30
clinicalTacking sutures from serosa to pelvic sidewall at three and six o'clock positions anchor anastomosis in place↗
The Colorectal Quiz Episode 4
▶Ep 241 · 6:00
clinicalExtensive transanal dissection causes overstretching of the sphincters, which is a morbidity that needs to be avoided, and laparoscopy helps with that.↗
▶Ep 241 · 6:00
clinicalExtensive transanal dissection causes overstretching of the sphincters, which is a morbidity that needs to be avoided, and laparoscopy helps with that.↗
▶Ep 241 · 6:00
quotethe overstretching of the sphincters, which can be done if you do an extensive transanal amount of work, is really a morbidity that needs to be avoided. And laparoscopy helps with that.↗
▶Ep 241 · 6:00
quotethe overstretching of the sphincters, which can be done if you do an extensive transanal amount of work, is really a morbidity that needs to be avoided. And laparoscopy helps with that.↗
▶Ep 241 · 7:09
clinicalFor a full-thickness biopsy, the seromuscular side should be the same size as the mucosal side when cutting a square cube.↗
▶Ep 241 · 7:09
quoteIt's so important to do a full thickness biopsy, and I like to cut a square, like a cube. And if we're looking at the sides of that cube, you want to make sure that the seromuscular side is the same as the mucosal side.↗
▶Ep 241 · 7:09
quoteIt's so important to do a full thickness biopsy, and I like to cut a square, like a cube. And if we're looking at the sides of that cube, you want to make sure that the seromuscular side is the same as the mucosal side.↗
▶Ep 241 · 7:09
clinicalFor a full-thickness biopsy, the seromuscular side should be the same size as the mucosal side when cutting a square cube.↗
▶Ep 241 · 11:00
clinicalWhen taking mesenteric vessels, staying just off the bowel rather than deep in the mesentery tends to be less bloody.↗
▶Ep 241 · 11:00
clinicalWhen taking mesenteric vessels, staying just off the bowel rather than deep in the mesentery tends to be less bloody.↗
▶Ep 241 · 16:06
clinicalA five-centimeter margin above the biopsy site is very safe when determining where to transect the bowel.↗
▶Ep 241 · 16:06
clinicalA five-centimeter margin above the biopsy site is very safe when determining where to transect the bowel.↗
▶Ep 241 · 16:30
clinicalTacking sutures on the serosa to the pelvic sidewall at the three and six o'clock positions anchor the bowel in place.↗
▶Ep 241 · 16:30
clinicalTacking sutures on the serosa to the pelvic sidewall at the three and six o'clock positions anchor the bowel in place.↗
Aaron's statements about Enterocolitis25 statements
clinicalHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 13 · 0:07
quoteAnd I'm Aaron Garrison. We're both pediatric surgeons at Cincinnati Children's.↗
▶Ep 13 · 0:07
quoteHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 13 · 1:03
quoteSo Hirschsprung disease is actually relatively common in a busy children's hospital. It's got an incidence of about 1 in 5,000 children.↗
▶Ep 13 · 1:03
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history.↗
▶Ep 13 · 1:03
clinicalThere are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease.↗
▶Ep 13 · 1:03
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21.↗
▶Ep 13 · 1:03
clinicalHirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes.↗
▶Ep 13 · 1:03
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung disease.↗
▶Ep 13 · 1:03
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 13 · 5:12
clinicalEnterocolitis is the life-threatening part of Hirschsprung's disease.↗
▶Ep 13 · 5:12
quoteSo the first thing I usually do is talk to the family and give them education about the disease, because most of them have never heard of it and they're not sure what to expect.↗
▶Ep 13 · 5:12
clinicalNICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 13 · 5:12
clinicalOlder children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases.↗
▶Ep 13 · 6:59
clinicalThe contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always.↗
▶Ep 13 · 6:59
clinicalThe goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line.↗
▶Ep 13 · 10:15
opinionAll three surgical techniques (Swenson, Suave, and Duhamel) are equally effective.↗
▶Ep 13 · 10:15
clinicalIn the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision.↗
▶Ep 13 · 10:15
clinicalChildren who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch.↗
▶Ep 13 · 10:15
opinionThe Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures.↗
▶Ep 13 · 10:15
clinicalIn the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel.↗
▶Ep 13 · 11:49
clinicalAnastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion.↗
▶Ep 13 · 11:49
clinicalEarly complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn.↗
▶Ep 13 · 13:54
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
▶Ep 13 · 13:54
clinicalMost patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten.↗
Aaron's statements about Enterocolitis25 statements
clinicalHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 13 · 0:07
quoteAnd I'm Aaron Garrison. We're both pediatric surgeons at Cincinnati Children's.↗
▶Ep 13 · 0:07
quoteHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 13 · 1:03
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history.↗
▶Ep 13 · 1:03
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 13 · 1:03
clinicalHirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes.↗
▶Ep 13 · 1:03
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung disease.↗
▶Ep 13 · 1:03
clinicalThere are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease.↗
▶Ep 13 · 1:03
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21.↗
▶Ep 13 · 1:03
quoteSo Hirschsprung disease is actually relatively common in a busy children's hospital. It's got an incidence of about 1 in 5,000 children.↗
▶Ep 13 · 5:12
clinicalEnterocolitis is the life-threatening part of Hirschsprung's disease.↗
▶Ep 13 · 5:12
clinicalOlder children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases.↗
▶Ep 13 · 5:12
clinicalNICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 13 · 5:12
quoteSo the first thing I usually do is talk to the family and give them education about the disease, because most of them have never heard of it and they're not sure what to expect.↗
▶Ep 13 · 6:59
clinicalThe goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line.↗
▶Ep 13 · 6:59
clinicalThe contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always.↗
▶Ep 13 · 10:15
clinicalIn the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel.↗
▶Ep 13 · 10:15
opinionThe Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures.↗
▶Ep 13 · 10:15
opinionAll three surgical techniques (Swenson, Suave, and Duhamel) are equally effective.↗
▶Ep 13 · 10:15
clinicalIn the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision.↗
▶Ep 13 · 10:15
clinicalChildren who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch.↗
▶Ep 13 · 11:49
clinicalEarly complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn.↗
▶Ep 13 · 11:49
clinicalAnastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion.↗
▶Ep 13 · 13:54
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
▶Ep 13 · 13:54
clinicalMost patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten.↗
Aaron's statements about Esophageal Atresia48 statements
Esophageal Atresia in Brief: Presentation, Workup, Diagnosis, and Treatment
▶Ep 29 · 0:25
clinicalEsophageal atresia is a congenital anomaly in which the esophagus doesn't form completely, with multiple different variants, one of the most common including a tracheoesophageal fistula.↗
▶Ep 29 · 1:16
clinicalInfants with isolated esophageal atresia are sometimes diagnosed prenatally because the mother can have polyhydramnios during gestation.↗
▶Ep 29 · 1:58
clinicalX-ray after NG tube placement demonstrates the tube coiled in the upper part of the chest in the proximal pouch of the atretic esophagus.↗
▶Ep 29 · 2:22
epidemiologicalAbout 5% of babies with esophageal atresia can have genetic syndromes.↗
▶Ep 29 · 2:22
epidemiological40 to 60% of babies with esophageal atresia can have other associated anomalies.↗
▶Ep 29 · 2:22
epidemiologicalAbout 20% of babies with esophageal atresia can have other findings within the VACTERL association.↗
▶Ep 29 · 2:22
quoteIt's important to note that 40 to 60% of babies with Esophageal Atresia can have other associated anomalies. About 20% of them can have other findings within the VACTERL association, and about 5% of them can have genetic syndromes.↗
▶Ep 29 · 2:44
clinicalThe VACTERL association includes vertebral anomalies, anorectal malformations, cardiac anomalies, tracheoesophageal fistula, renal defects, and limb anomalies.↗
▶Ep 29 · 4:02
clinicalType C is the most common type of esophageal atresia, which is esophageal atresia with a distal fistula where the esophagus distally fistulizes to the trachea, usually a couple centimeters above the carina.↗
▶Ep 29 · 4:02
epidemiologicalThere are five different types of EA or TEF, with two types accounting for over 90% of presentations.↗
▶Ep 29 · 4:27
epidemiologicalType A (isolated esophageal atresia with no fistula to the trachea) is the next most common type at about 8% of incidence.↗
▶Ep 29 · 5:13
clinicalInitial management involves ensuring the Repogle is in a good position to decompress saliva or secretions and minimize aspiration while completing the workup.↗
▶Ep 29 · 5:57
opinionEvery child with esophageal atresia should undergo bronchoscopy at their initial trip to the operating room.↗
▶Ep 29 · 6:20
clinicalType C esophageal atresia can be repaired thoracoscopically or open, with the operation involving ligation of the tracheoesophageal fistula and bringing the two ends of the esophagus together to create a new anastomosis.↗
▶Ep 29 · 6:46
clinicalChest tubes are almost always used after repair.↗
▶Ep 29 · 7:07
clinicalMost surgeons get an esophagram five to seven days after the operation to check for leak prior to removing the chest tube or starting feeds.↗
▶Ep 29 · 8:08
clinicalLower survival is typically seen in more complex patients with other cardiac, renal, and/or pulmonary anomalies.↗
▶Ep 29 · 8:08
epidemiologicalSurvival of esophageal atresia patients has improved over the years and is now about 85 to 95% overall survival.↗
▶Ep 29 · 8:08
clinicalOther long-term complications include respiratory issues like reactive airway disease and esophageal dysmotility.↗
▶Ep 29 · 8:33
opinionHaving a multidisciplinary approach that's coordinated is important to achieving the best outcomes for these patients in the long term.↗
QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison
▶Ep 53 · 0:58
quoteI think some of us who are peat surgery trained were told initially that tracheomalacia is something that kids will grow out of and will get better and as data has shown recently that there's no long term consequences for soiling into the lungs and having chronic lung lung aspiration and over time that really is detrimental.↗
▶Ep 53 · 0:58
opinionPediatric surgery trainees were initially told that tracheomalacia is something that kids will grow out of and will get better.↗
▶Ep 53 · 1:08
clinicalRecent data has shown that there are long term consequences for soiling into the lungs and having chronic lung aspiration, which over time is detrimental.↗
▶Ep 53 · 1:26
clinicalPreoperative dynamic reconstruction studies give a lot of information for determining which procedure is best for each patient.↗
▶Ep 53 · 1:31
clinicalDynamic expiratory films show what you need to see with the airway that inspiratory films alone do not reveal.↗
▶Ep 53 · 1:41
quoteYou really see what you need to see with the dynamic studies.↗
▶Ep 53 · 1:55
clinicalSurgeons always look for the thymus and make sure that there is enough tissue to remove to be able to bring the trachea up anteriorly.↗
▶Ep 53 · 2:17
opinionThe classification system for tracheomalacia is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging.↗
▶Ep 53 · 2:17
quoteOur classification system is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging.↗
▶Ep 53 · 2:34
quoteThe benefits of minimally invasive to me, the biggest one is that visualization and exposure.↗
▶Ep 53 · 2:34
opinionThe biggest benefit of minimally invasive approach is visualization and exposure.↗
▶Ep 53 · 2:39
opinionDisadvantages of minimally invasive approach include that it takes longer to learn and is more uncomfortable to learn.↗
▶Ep 53 · 2:42
opinionAnesthesia colleagues are sometimes hesitant to allow thoracoscopic cases to go on a little bit longer.↗
▶Ep 53 · 3:33
clinicalFor anterior mediastinal work, babies are positioned with the arm up and a bump underneath so that there is access to the axilla and anteriorly.↗
▶Ep 53 · 3:51
clinicalThe goal of aortopexy is to suspend the aorta.↗
▶Ep 53 · 3:54
clinicalThe first step in aortopexy is taking out the thymus, finding the innominate junction, and then identifying the arch of the aorta.↗
▶Ep 53 · 4:10
quoteIf you go up too high, then you're doing a pericardioexy and it isn't quite as successful or durable.↗
▶Ep 53 · 4:10
clinicalIf you go up too high during aortopexy, then you are doing a pericardiopexy and it is not quite as successful or durable.↗
▶Ep 53 · 4:45
clinicalThe goal of posterior tracheopexy is taking the anterior spinal ligament and fixing it to the posterior membranous trachea.↗
▶Ep 53 · 4:56
clinicalThe area of floppy membrane is distal to the dilated pouch usually.↗
▶Ep 53 · 5:09
clinicalSurgeons can make an indent on the posterior wall of the trachea, and pulmonologists can see it pop up on their bronchoscopy to help guide suture placement.↗
▶Ep 53 · 5:43
clinicalIt usually takes about 2 or 3 sutures for posterior tracheopexy, leaving enough space for the esophagus to come through.↗
▶Ep 53 · 5:48
opinionUsing the knot pusher and tension suture is helpful during tracheopexy.↗
▶Ep 53 · 5:58
opinionGetting the suture to roll through the anterior spinal ligament is the hardest part and is pretty challenging.↗
▶Ep 53 · 5:58
quoteAnd this is the part that I think is honestly the, the hardest. Getting that suture to roll through the anterior spinal ligament is actually pretty, pretty challenging.↗
▶Ep 53 · 6:20
clinicalThere are times when the esophagus is put to the left of the trachea, and times when it is put to the right of the trachea.↗
▶Ep 53 · 6:26
quoteI always worry a little bit about dysphagia, but honestly, it's not something that I've, I've seen a ton of.↗
▶Ep 53 · 6:26
opinionDr. Garrison always worries a little bit about dysphagia when repositioning the esophagus, but it is not something he has seen a ton of.↗
Aaron's statements about Esophageal Atresia28 statements
QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison
▶Ep 27 · 0:58
quoteI think some of us who are peat surgery trained were told initially that tracheomalacia is something that kids will grow out of and will get better and as data has shown recently that there's no long term consequences for soiling into the lungs and having chronic lung lung aspiration and over time that really is detrimental.↗
▶Ep 27 · 0:58
opinionPediatric surgery trainees were initially told that tracheomalacia is something that kids will grow out of and will get better.↗
▶Ep 27 · 1:08
clinicalRecent data has shown that there are long term consequences for soiling into the lungs and having chronic lung aspiration, which over time is detrimental.↗
▶Ep 27 · 1:26
clinicalPreoperative dynamic reconstruction studies give a lot of information for determining which procedure is best for each patient.↗
▶Ep 27 · 1:31
clinicalDynamic expiratory films show what you need to see with the airway that inspiratory films alone do not reveal.↗
▶Ep 27 · 1:41
quoteYou really see what you need to see with the dynamic studies.↗
▶Ep 27 · 1:55
clinicalSurgeons always look for the thymus and make sure that there is enough tissue to remove to be able to bring the trachea up anteriorly.↗
▶Ep 27 · 2:17
quoteOur classification system is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging.↗
▶Ep 27 · 2:17
opinionThe classification system for tracheomalacia is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging.↗
▶Ep 27 · 2:34
quoteThe benefits of minimally invasive to me, the biggest one is that visualization and exposure.↗
▶Ep 27 · 2:34
opinionThe biggest benefit of minimally invasive approach is visualization and exposure.↗
▶Ep 27 · 2:39
opinionDisadvantages of minimally invasive approach include that it takes longer to learn and is more uncomfortable to learn.↗
▶Ep 27 · 2:42
opinionAnesthesia colleagues are sometimes hesitant to allow thoracoscopic cases to go on a little bit longer.↗
▶Ep 27 · 3:33
clinicalFor anterior mediastinal work, babies are positioned with the arm up and a bump underneath so that there is access to the axilla and anteriorly.↗
▶Ep 27 · 3:51
clinicalThe goal of aortopexy is to suspend the aorta.↗
▶Ep 27 · 3:54
clinicalThe first step in aortopexy is taking out the thymus, finding the innominate junction, and then identifying the arch of the aorta.↗
▶Ep 27 · 4:10
quoteIf you go up too high, then you're doing a pericardioexy and it isn't quite as successful or durable.↗
▶Ep 27 · 4:10
clinicalIf you go up too high during aortopexy, then you are doing a pericardiopexy and it is not quite as successful or durable.↗
▶Ep 27 · 4:45
clinicalThe goal of posterior tracheopexy is taking the anterior spinal ligament and fixing it to the posterior membranous trachea.↗
▶Ep 27 · 4:56
clinicalThe area of floppy membrane is distal to the dilated pouch usually.↗
▶Ep 27 · 5:09
clinicalSurgeons can make an indent on the posterior wall of the trachea, and pulmonologists can see it pop up on their bronchoscopy to help guide suture placement.↗
▶Ep 27 · 5:43
clinicalIt usually takes about 2 or 3 sutures for posterior tracheopexy, leaving enough space for the esophagus to come through.↗
▶Ep 27 · 5:48
opinionUsing the knot pusher and tension suture is helpful during tracheopexy.↗
▶Ep 27 · 5:58
opinionGetting the suture to roll through the anterior spinal ligament is the hardest part and is pretty challenging.↗
▶Ep 27 · 5:58
quoteAnd this is the part that I think is honestly the, the hardest. Getting that suture to roll through the anterior spinal ligament is actually pretty, pretty challenging.↗
▶Ep 27 · 6:20
clinicalThere are times when the esophagus is put to the left of the trachea, and times when it is put to the right of the trachea.↗
▶Ep 27 · 6:26
opinionDr. Garrison always worries a little bit about dysphagia when repositioning the esophagus, but it is not something he has seen a ton of.↗
▶Ep 27 · 6:26
quoteI always worry a little bit about dysphagia, but honestly, it's not something that I've, I've seen a ton of.↗
Aaron's statements about Hirschsprung disease68 statements
quoteHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 29 · 0:07
quoteAnd I'm Aaron Garrison. We're both pediatric surgeons at Cincinnati Children's.↗
▶Ep 29 · 0:07
clinicalHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 29 · 0:07
quoteAnd I'm Aaron Garrison. We're both pediatric surgeons at Cincinnati Children's.↗
▶Ep 29 · 0:07
clinicalHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 29 · 0:07
quoteHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 29 · 1:03
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history.↗
▶Ep 29 · 1:03
quoteSo Hirschsprung disease is actually relatively common in a busy children's hospital. It's got an incidence of about 1 in 5,000 children.↗
▶Ep 29 · 1:03
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 29 · 1:03
clinicalThere are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease.↗
▶Ep 29 · 1:03
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21.↗
▶Ep 29 · 1:03
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung disease.↗
▶Ep 29 · 1:03
clinicalHirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes.↗
▶Ep 29 · 1:03
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21.↗
▶Ep 29 · 1:03
clinicalThere are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease.↗
▶Ep 29 · 1:03
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history.↗
▶Ep 29 · 1:03
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 29 · 1:03
quoteSo Hirschsprung disease is actually relatively common in a busy children's hospital. It's got an incidence of about 1 in 5,000 children.↗
▶Ep 29 · 1:03
clinicalHirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes.↗
▶Ep 29 · 1:03
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung disease.↗
▶Ep 29 · 5:12
quoteSo the first thing I usually do is talk to the family and give them education about the disease, because most of them have never heard of it and they're not sure what to expect.↗
▶Ep 29 · 5:12
clinicalEnterocolitis is the life-threatening part of Hirschsprung's disease.↗
▶Ep 29 · 5:12
clinicalNICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 29 · 5:12
clinicalOlder children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases.↗
▶Ep 29 · 5:12
clinicalEnterocolitis is the life-threatening part of Hirschsprung's disease.↗
▶Ep 29 · 5:12
clinicalNICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 29 · 5:12
clinicalOlder children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases.↗
▶Ep 29 · 5:12
quoteSo the first thing I usually do is talk to the family and give them education about the disease, because most of them have never heard of it and they're not sure what to expect.↗
▶Ep 29 · 6:59
clinicalThe contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always.↗
▶Ep 29 · 6:59
clinicalThe goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line.↗
▶Ep 29 · 6:59
clinicalThe goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line.↗
▶Ep 29 · 6:59
clinicalThe contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always.↗
▶Ep 29 · 10:15
clinicalChildren who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch.↗
▶Ep 29 · 10:15
opinionThe Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures.↗
▶Ep 29 · 10:15
clinicalIn the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel.↗
▶Ep 29 · 10:15
opinionAll three surgical techniques (Swenson, Suave, and Duhamel) are equally effective.↗
▶Ep 29 · 10:15
clinicalIn the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision.↗
▶Ep 29 · 10:15
clinicalIn the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel.↗
▶Ep 29 · 10:15
opinionThe Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures.↗
▶Ep 29 · 10:15
clinicalChildren who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch.↗
▶Ep 29 · 10:15
clinicalIn the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision.↗
▶Ep 29 · 10:15
opinionAll three surgical techniques (Swenson, Suave, and Duhamel) are equally effective.↗
▶Ep 29 · 11:49
clinicalEarly complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn.↗
▶Ep 29 · 11:49
clinicalAnastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion.↗
▶Ep 29 · 11:49
clinicalAnastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion.↗
▶Ep 29 · 11:49
clinicalEarly complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn.↗
▶Ep 29 · 13:54
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
▶Ep 29 · 13:54
clinicalMost patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten.↗
▶Ep 29 · 13:54
clinicalMost patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten.↗
▶Ep 29 · 13:54
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
clinicalSurgeons should wait for frozen section confirmation before taking mesentery during Hirschsprung pull-through.↗
▶Ep 36 · 9:30
clinicalSurgeons should wait for frozen section confirmation before taking mesentery during Hirschsprung pull-through.↗
▶Ep 36 · 11:13
clinicalMesenteric dissection should stay close to the bowel wall, not deep in the mesentery, as this plane tends to be less bloody.↗
▶Ep 36 · 11:13
clinicalMesenteric dissection should stay close to the bowel wall, not deep in the mesentery, as this plane tends to be less bloody.↗
▶Ep 36 · 15:03
clinicalFor standard rectosigmoid Hirschsprung cases, the patient can remain supine with legs wrapped and fastened to the ether screen, avoiding the need to flip prone.↗
▶Ep 36 · 15:03
clinicalFor standard rectosigmoid Hirschsprung cases, the patient can remain supine with legs wrapped and fastened to the ether screen, avoiding the need to flip prone.↗
▶Ep 36 · 16:30
clinicalTacking sutures on the serosa to the pelvic sidewall at 3 and 9 o'clock positions help anchor the anastomosis in place, though this does not constitute a true two-layer anastomosis.↗
▶Ep 36 · 16:30
clinicalTacking sutures on the serosa to the pelvic sidewall at 3 and 9 o'clock positions help anchor the anastomosis in place, though this does not constitute a true two-layer anastomosis.↗
The Colorectal Quiz Episode 4
▶Ep 91 · 7:09
clinicalFull-thickness biopsy must include seromuscular side same size as mucosal side (cube-shaped)↗
▶Ep 91 · 7:09
quoteIt's so important to do a full thickness biopsy, and I like to cut a square, like a cube. And if we're looking at the sides of that cube, you want to make sure that the seromuscular side is the same as the mucosal side.↗
▶Ep 91 · 16:30
clinicalTacking sutures from serosa to pelvic sidewall at three and six o'clock positions anchor anastomosis in place↗
The Colorectal Quiz Episode 4
▶Ep 95 · 6:00
clinicalExtensive transanal dissection causes overstretching of the sphincters, which is a morbidity that needs to be avoided, and laparoscopy helps with that.↗
▶Ep 95 · 6:00
quotethe overstretching of the sphincters, which can be done if you do an extensive transanal amount of work, is really a morbidity that needs to be avoided. And laparoscopy helps with that.↗
▶Ep 95 · 7:09
quoteIt's so important to do a full thickness biopsy, and I like to cut a square, like a cube. And if we're looking at the sides of that cube, you want to make sure that the seromuscular side is the same as the mucosal side.↗
▶Ep 95 · 7:09
clinicalFor a full-thickness biopsy, the seromuscular side should be the same size as the mucosal side when cutting a square cube.↗
▶Ep 95 · 11:00
clinicalWhen taking mesenteric vessels, staying just off the bowel rather than deep in the mesentery tends to be less bloody.↗
▶Ep 95 · 16:06
clinicalA five-centimeter margin above the biopsy site is very safe when determining where to transect the bowel.↗
▶Ep 95 · 16:30
clinicalTacking sutures on the serosa to the pelvic sidewall at the three and six o'clock positions anchor the bowel in place.↗
Aaron's statements about Hirschsprung Disease49 statements
clinicalHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 4 · 0:07
quoteHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 4 · 0:07
quoteAnd I'm Aaron Garrison. We're both pediatric surgeons at Cincinnati Children's.↗
▶Ep 4 · 1:03
clinicalHirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes.↗
▶Ep 4 · 1:03
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung disease.↗
▶Ep 4 · 1:03
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history.↗
▶Ep 4 · 1:03
clinicalThere are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease.↗
▶Ep 4 · 1:03
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21.↗
▶Ep 4 · 1:03
quoteSo Hirschsprung disease is actually relatively common in a busy children's hospital. It's got an incidence of about 1 in 5,000 children.↗
▶Ep 4 · 1:03
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 4 · 5:12
quoteSo the first thing I usually do is talk to the family and give them education about the disease, because most of them have never heard of it and they're not sure what to expect.↗
▶Ep 4 · 5:12
clinicalEnterocolitis is the life-threatening part of Hirschsprung's disease.↗
▶Ep 4 · 5:12
clinicalNICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 4 · 5:12
clinicalOlder children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases.↗
▶Ep 4 · 6:59
clinicalThe goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line.↗
▶Ep 4 · 6:59
clinicalThe contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always.↗
▶Ep 4 · 10:15
opinionThe Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures.↗
▶Ep 4 · 10:15
opinionAll three surgical techniques (Swenson, Suave, and Duhamel) are equally effective.↗
▶Ep 4 · 10:15
clinicalIn the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision.↗
▶Ep 4 · 10:15
clinicalChildren who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch.↗
▶Ep 4 · 10:15
clinicalIn the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel.↗
▶Ep 4 · 11:49
clinicalAnastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion.↗
▶Ep 4 · 11:49
clinicalEarly complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn.↗
▶Ep 4 · 13:54
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
▶Ep 4 · 13:54
clinicalMost patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten.↗
clinicalSurgeons should wait for frozen section confirmation before taking mesentery during Hirschsprung pull-through.↗
▶Ep 9 · 11:13
clinicalMesenteric dissection should stay close to the bowel wall, not deep in the mesentery, as this plane tends to be less bloody.↗
▶Ep 9 · 15:03
clinicalFor standard rectosigmoid Hirschsprung cases, the patient can remain supine with legs wrapped and fastened to the ether screen, avoiding the need to flip prone.↗
▶Ep 9 · 16:30
clinicalTacking sutures on the serosa to the pelvic sidewall at 3 and 9 o'clock positions help anchor the anastomosis in place, though this does not constitute a true two-layer anastomosis.↗
Hirschsprung Disease in Brief
▶Ep 18 · 0:48
clinicalIn Hirschsprung disease, the ganglion cells don't make it all the way down distally, and the colon ends up not being able to contract.↗
▶Ep 18 · 0:48
quoteThe ganglion cells don't make it all the way down distally. The colon ends up not being able to contract.↗
▶Ep 18 · 1:32
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 18 · 2:55
quoteThe transition zone is from contracted rectum and all of a sudden it opens up into dilated rectum. That's the transition zone.↗
▶Ep 18 · 2:55
clinicalThe transition zone is from contracted rectum (where nerve cells are absent) to dilated rectum (where normal nerve cells are present).↗
▶Ep 18 · 3:23
clinicalIn total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.↗
▶Ep 18 · 3:23
clinicalIn Hirschsprung's disease, the rectum is usually less dilated than the proximal colon, making the rectosigmoid ratio less than 1.↗
▶Ep 18 · 3:23
clinicalInability to evacuate contrast is a finding suggestive of Hirschsprung disease.↗
▶Ep 18 · 4:47
clinicalIn anorectal manometry for Hirschsprung disease, there is a lack of the recto-anal inhibitory reflex (RAIR).↗
▶Ep 18 · 4:47
clinicalThe recto-anal inhibitory reflex may be absent in other conditions besides Hirschsprung disease, and some children have a false positive test.↗
▶Ep 18 · 4:47
clinicalSuction rectal biopsy is painless and commonly done at the bedside in neonates.↗
▶Ep 18 · 6:07
opinionChildren with Hirschsprung disease will need this condition managed for life, but the expectation is that they will live a normal life with close management and care.↗
▶Ep 18 · 6:37
guidelineNPO babies diagnosed with Hirschsprung disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 18 · 7:03
guidelineOlder children with Hirschsprung disease will start on an enema program, and some may need diversion more proximally to give the colon time to decompress.↗
▶Ep 18 · 7:03
clinicalOlder children with Hirschsprung disease are not amenable to just doing a primary pull through in many cases because the colon has become dilated.↗
▶Ep 18 · 8:48
opinionHirschsprung's associated enterocolitis is the main early complication everyone needs to be aware of.↗
▶Ep 18 · 8:48
clinicalAnastomotic leak is a rare but possible early complication after Hirschsprung surgery.↗
▶Ep 18 · 8:48
clinicalEarly postoperative complications include diaper rash and excoriation that can often need to be treated like a burn.↗
▶Ep 18 · 10:09
opinionAssuming the operation has been done well and there are no transition zone or strictures, most patients with Hirschsprung disease are expected to do very well and be in kindergarten socially confident.↗
▶Ep 18 · 10:09
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
Aaron's statements about Hirschsprung Disease: Diagnosis to Long-Term Management3 statements
quoteIt's so important to do a full thickness biopsy, and I like to cut a square, like a cube. And if we're looking at the sides of that cube, you want to make sure that the seromuscular side is the same as the mucosal side.↗
▶Ep 10 · 7:09
clinicalFull-thickness biopsy must include seromuscular side same size as mucosal side (cube-shaped)↗
▶Ep 10 · 16:30
clinicalTacking sutures from serosa to pelvic sidewall at three and six o'clock positions anchor anastomosis in place↗
Aaron's statements about Tracheoesophageal Fistula20 statements
Esophageal Atresia in Brief: Presentation, Workup, Diagnosis, and Treatment
▶Ep 20 · 0:25
clinicalEsophageal atresia is a congenital anomaly in which the esophagus doesn't form completely, with multiple different variants, one of the most common including a tracheoesophageal fistula.↗
▶Ep 20 · 1:16
clinicalInfants with isolated esophageal atresia are sometimes diagnosed prenatally because the mother can have polyhydramnios during gestation.↗
▶Ep 20 · 1:58
clinicalX-ray after NG tube placement demonstrates the tube coiled in the upper part of the chest in the proximal pouch of the atretic esophagus.↗
▶Ep 20 · 2:22
epidemiologicalAbout 5% of babies with esophageal atresia can have genetic syndromes.↗
▶Ep 20 · 2:22
epidemiological40 to 60% of babies with esophageal atresia can have other associated anomalies.↗
▶Ep 20 · 2:22
quoteIt's important to note that 40 to 60% of babies with Esophageal Atresia can have other associated anomalies. About 20% of them can have other findings within the VACTERL association, and about 5% of them can have genetic syndromes.↗
▶Ep 20 · 2:22
epidemiologicalAbout 20% of babies with esophageal atresia can have other findings within the VACTERL association.↗
▶Ep 20 · 2:44
clinicalThe VACTERL association includes vertebral anomalies, anorectal malformations, cardiac anomalies, tracheoesophageal fistula, renal defects, and limb anomalies.↗
▶Ep 20 · 4:02
epidemiologicalThere are five different types of EA or TEF, with two types accounting for over 90% of presentations.↗
▶Ep 20 · 4:02
clinicalType C is the most common type of esophageal atresia, which is esophageal atresia with a distal fistula where the esophagus distally fistulizes to the trachea, usually a couple centimeters above the carina.↗
▶Ep 20 · 4:27
epidemiologicalType A (isolated esophageal atresia with no fistula to the trachea) is the next most common type at about 8% of incidence.↗
▶Ep 20 · 5:13
clinicalInitial management involves ensuring the Repogle is in a good position to decompress saliva or secretions and minimize aspiration while completing the workup.↗
▶Ep 20 · 5:57
opinionEvery child with esophageal atresia should undergo bronchoscopy at their initial trip to the operating room.↗
▶Ep 20 · 6:20
clinicalType C esophageal atresia can be repaired thoracoscopically or open, with the operation involving ligation of the tracheoesophageal fistula and bringing the two ends of the esophagus together to create a new anastomosis.↗
▶Ep 20 · 6:46
clinicalChest tubes are almost always used after repair.↗
▶Ep 20 · 7:07
clinicalMost surgeons get an esophagram five to seven days after the operation to check for leak prior to removing the chest tube or starting feeds.↗
▶Ep 20 · 8:08
clinicalOther long-term complications include respiratory issues like reactive airway disease and esophageal dysmotility.↗
▶Ep 20 · 8:08
epidemiologicalSurvival of esophageal atresia patients has improved over the years and is now about 85 to 95% overall survival.↗
▶Ep 20 · 8:08
clinicalLower survival is typically seen in more complex patients with other cardiac, renal, and/or pulmonary anomalies.↗
▶Ep 20 · 8:33
opinionHaving a multidisciplinary approach that's coordinated is important to achieving the best outcomes for these patients in the long term.↗
Aaron's statements about Tracheomalacia28 statements
QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison
▶Ep 5 · 0:58
quoteI think some of us who are peat surgery trained were told initially that tracheomalacia is something that kids will grow out of and will get better and as data has shown recently that there's no long term consequences for soiling into the lungs and having chronic lung lung aspiration and over time that really is detrimental.↗
▶Ep 5 · 0:58
opinionPediatric surgery trainees were initially told that tracheomalacia is something that kids will grow out of and will get better.↗
▶Ep 5 · 1:08
clinicalRecent data has shown that there are long term consequences for soiling into the lungs and having chronic lung aspiration, which over time is detrimental.↗
▶Ep 5 · 1:26
clinicalPreoperative dynamic reconstruction studies give a lot of information for determining which procedure is best for each patient.↗
▶Ep 5 · 1:31
clinicalDynamic expiratory films show what you need to see with the airway that inspiratory films alone do not reveal.↗
▶Ep 5 · 1:41
quoteYou really see what you need to see with the dynamic studies.↗
▶Ep 5 · 1:55
clinicalSurgeons always look for the thymus and make sure that there is enough tissue to remove to be able to bring the trachea up anteriorly.↗
▶Ep 5 · 2:17
opinionThe classification system for tracheomalacia is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging.↗
▶Ep 5 · 2:17
quoteOur classification system is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging.↗
▶Ep 5 · 2:34
quoteThe benefits of minimally invasive to me, the biggest one is that visualization and exposure.↗
▶Ep 5 · 2:34
opinionThe biggest benefit of minimally invasive approach is visualization and exposure.↗
▶Ep 5 · 2:39
opinionDisadvantages of minimally invasive approach include that it takes longer to learn and is more uncomfortable to learn.↗
▶Ep 5 · 2:42
opinionAnesthesia colleagues are sometimes hesitant to allow thoracoscopic cases to go on a little bit longer.↗
▶Ep 5 · 3:33
clinicalFor anterior mediastinal work, babies are positioned with the arm up and a bump underneath so that there is access to the axilla and anteriorly.↗
▶Ep 5 · 3:51
clinicalThe goal of aortopexy is to suspend the aorta.↗
▶Ep 5 · 3:54
clinicalThe first step in aortopexy is taking out the thymus, finding the innominate junction, and then identifying the arch of the aorta.↗
▶Ep 5 · 4:10
quoteIf you go up too high, then you're doing a pericardioexy and it isn't quite as successful or durable.↗
▶Ep 5 · 4:10
clinicalIf you go up too high during aortopexy, then you are doing a pericardiopexy and it is not quite as successful or durable.↗
▶Ep 5 · 4:45
clinicalThe goal of posterior tracheopexy is taking the anterior spinal ligament and fixing it to the posterior membranous trachea.↗
▶Ep 5 · 4:56
clinicalThe area of floppy membrane is distal to the dilated pouch usually.↗
▶Ep 5 · 5:09
clinicalSurgeons can make an indent on the posterior wall of the trachea, and pulmonologists can see it pop up on their bronchoscopy to help guide suture placement.↗
▶Ep 5 · 5:43
clinicalIt usually takes about 2 or 3 sutures for posterior tracheopexy, leaving enough space for the esophagus to come through.↗
▶Ep 5 · 5:48
opinionUsing the knot pusher and tension suture is helpful during tracheopexy.↗
▶Ep 5 · 5:58
quoteAnd this is the part that I think is honestly the, the hardest. Getting that suture to roll through the anterior spinal ligament is actually pretty, pretty challenging.↗
▶Ep 5 · 5:58
opinionGetting the suture to roll through the anterior spinal ligament is the hardest part and is pretty challenging.↗
▶Ep 5 · 6:20
clinicalThere are times when the esophagus is put to the left of the trachea, and times when it is put to the right of the trachea.↗
▶Ep 5 · 6:26
opinionDr. Garrison always worries a little bit about dysphagia when repositioning the esophagus, but it is not something he has seen a ton of.↗
▶Ep 5 · 6:26
quoteI always worry a little bit about dysphagia, but honestly, it's not something that I've, I've seen a ton of.↗
quoteHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 2 · 0:07
quoteHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 2 · 0:07
clinicalHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 2 · 0:07
quoteAnd I'm Aaron Garrison. We're both pediatric surgeons at Cincinnati Children's.↗
▶Ep 2 · 0:07
clinicalHirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction.↗
▶Ep 2 · 0:07
quoteAnd I'm Aaron Garrison. We're both pediatric surgeons at Cincinnati Children's.↗
▶Ep 2 · 1:03
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung disease.↗
▶Ep 2 · 1:03
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung disease.↗
▶Ep 2 · 1:03
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21.↗
▶Ep 2 · 1:03
quoteSo Hirschsprung disease is actually relatively common in a busy children's hospital. It's got an incidence of about 1 in 5,000 children.↗
▶Ep 2 · 1:03
clinicalThere are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease.↗
▶Ep 2 · 1:03
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history.↗
▶Ep 2 · 1:03
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 2 · 1:03
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 2 · 1:03
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history.↗
▶Ep 2 · 1:03
clinicalThere are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease.↗
▶Ep 2 · 1:03
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21.↗
▶Ep 2 · 1:03
clinicalHirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes.↗
▶Ep 2 · 1:03
quoteSo Hirschsprung disease is actually relatively common in a busy children's hospital. It's got an incidence of about 1 in 5,000 children.↗
▶Ep 2 · 1:03
clinicalHirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes.↗
▶Ep 2 · 5:12
clinicalOlder children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases.↗
▶Ep 2 · 5:12
quoteSo the first thing I usually do is talk to the family and give them education about the disease, because most of them have never heard of it and they're not sure what to expect.↗
▶Ep 2 · 5:12
clinicalNICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 2 · 5:12
quoteSo the first thing I usually do is talk to the family and give them education about the disease, because most of them have never heard of it and they're not sure what to expect.↗
▶Ep 2 · 5:12
clinicalOlder children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases.↗
▶Ep 2 · 5:12
clinicalEnterocolitis is the life-threatening part of Hirschsprung's disease.↗
▶Ep 2 · 5:12
clinicalNICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 2 · 5:12
clinicalEnterocolitis is the life-threatening part of Hirschsprung's disease.↗
▶Ep 2 · 6:59
clinicalThe goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line.↗
▶Ep 2 · 6:59
clinicalThe goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line.↗
▶Ep 2 · 6:59
clinicalThe contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always.↗
▶Ep 2 · 6:59
clinicalThe contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always.↗
▶Ep 2 · 10:15
clinicalIn the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision.↗
▶Ep 2 · 10:15
clinicalIn the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel.↗
▶Ep 2 · 10:15
opinionThe Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures.↗
▶Ep 2 · 10:15
clinicalChildren who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch.↗
▶Ep 2 · 10:15
opinionAll three surgical techniques (Swenson, Suave, and Duhamel) are equally effective.↗
▶Ep 2 · 10:15
opinionThe Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures.↗
▶Ep 2 · 10:15
clinicalIn the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel.↗
▶Ep 2 · 10:15
clinicalChildren who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch.↗
▶Ep 2 · 10:15
clinicalIn the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision.↗
▶Ep 2 · 10:15
opinionAll three surgical techniques (Swenson, Suave, and Duhamel) are equally effective.↗
▶Ep 2 · 11:49
clinicalEarly complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn.↗
▶Ep 2 · 11:49
clinicalAnastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion.↗
▶Ep 2 · 11:49
clinicalAnastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion.↗
▶Ep 2 · 11:49
clinicalEarly complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn.↗
▶Ep 2 · 13:54
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
▶Ep 2 · 13:54
clinicalMost patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten.↗
▶Ep 2 · 13:54
clinicalMost patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten.↗
▶Ep 2 · 13:54
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
Hirschsprung Disease in Brief
▶Ep 3 · 0:48
clinicalIn Hirschsprung disease, the ganglion cells don't make it all the way down distally, and the colon ends up not being able to contract.↗
▶Ep 3 · 0:48
quoteThe ganglion cells don't make it all the way down distally. The colon ends up not being able to contract.↗
▶Ep 3 · 1:32
epidemiologicalHirschsprung disease has an incidence of about 1 in 5,000 children.↗
▶Ep 3 · 2:55
clinicalThe transition zone is from contracted rectum (where nerve cells are absent) to dilated rectum (where normal nerve cells are present).↗
▶Ep 3 · 2:55
quoteThe transition zone is from contracted rectum and all of a sudden it opens up into dilated rectum. That's the transition zone.↗
▶Ep 3 · 3:23
clinicalIn total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.↗
▶Ep 3 · 3:23
clinicalIn Hirschsprung's disease, the rectum is usually less dilated than the proximal colon, making the rectosigmoid ratio less than 1.↗
▶Ep 3 · 3:23
clinicalInability to evacuate contrast is a finding suggestive of Hirschsprung disease.↗
▶Ep 3 · 4:47
clinicalIn anorectal manometry for Hirschsprung disease, there is a lack of the recto-anal inhibitory reflex (RAIR).↗
▶Ep 3 · 4:47
clinicalThe recto-anal inhibitory reflex may be absent in other conditions besides Hirschsprung disease, and some children have a false positive test.↗
▶Ep 3 · 4:47
clinicalSuction rectal biopsy is painless and commonly done at the bedside in neonates.↗
▶Ep 3 · 6:07
opinionChildren with Hirschsprung disease will need this condition managed for life, but the expectation is that they will live a normal life with close management and care.↗
▶Ep 3 · 6:37
guidelineNPO babies diagnosed with Hirschsprung disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended.↗
▶Ep 3 · 7:03
clinicalOlder children with Hirschsprung disease are not amenable to just doing a primary pull through in many cases because the colon has become dilated.↗
▶Ep 3 · 7:03
guidelineOlder children with Hirschsprung disease will start on an enema program, and some may need diversion more proximally to give the colon time to decompress.↗
▶Ep 3 · 8:48
clinicalEarly postoperative complications include diaper rash and excoriation that can often need to be treated like a burn.↗
▶Ep 3 · 8:48
opinionHirschsprung's associated enterocolitis is the main early complication everyone needs to be aware of.↗
▶Ep 3 · 8:48
clinicalAnastomotic leak is a rare but possible early complication after Hirschsprung surgery.↗
▶Ep 3 · 10:09
epidemiologicalAbout 80% of kids with Hirschsprung's disease are constipated and will need some kind of management.↗
▶Ep 3 · 10:09
opinionAssuming the operation has been done well and there are no transition zone or strictures, most patients with Hirschsprung disease are expected to do very well and be in kindergarten socially confident.↗
Summaries Aaron gave as host
· 8 summaries
Recaps of other experts' statements, not Aaron's own clinical position.
Summaries Aaron gave as host · Aerodigestive / ENT2 summaries
QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison
▶Ep 17 · 3:03
host summaryAaron Garrison summarizing a resource: A paper in Anesthesiology looked at open, thoracoscopic, and converted patients and found no difference in blood gases and metabolic derangements during surgery.↗
▶Ep 17 · 3:17
host summaryAaron Garrison summarizing a resource: The same study found no difference when looking at blood pressure with acidosis and hypoxia between open and thoracoscopic approaches.↗
Summaries Aaron gave as host · Esophageal Atresia2 summaries
QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison
▶Ep 53 · 3:03
host summaryAaron Garrison summarizing a resource: A paper in Anesthesiology looked at open, thoracoscopic, and converted patients and found no difference in blood gases and metabolic derangements during surgery.↗
▶Ep 53 · 3:17
host summaryAaron Garrison summarizing a resource: The same study found no difference when looking at blood pressure with acidosis and hypoxia between open and thoracoscopic approaches.↗
Summaries Aaron gave as host · Esophageal Atresia2 summaries
QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison
▶Ep 27 · 3:03
host summaryAaron Garrison summarizing a resource: A paper in Anesthesiology looked at open, thoracoscopic, and converted patients and found no difference in blood gases and metabolic derangements during surgery.↗
▶Ep 27 · 3:17
host summaryAaron Garrison summarizing a resource: The same study found no difference when looking at blood pressure with acidosis and hypoxia between open and thoracoscopic approaches.↗
Summaries Aaron gave as host · Tracheomalacia2 summaries
QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison
▶Ep 5 · 3:03
host summaryAaron Garrison summarizing a resource: A paper in Anesthesiology looked at open, thoracoscopic, and converted patients and found no difference in blood gases and metabolic derangements during surgery.↗
▶Ep 5 · 3:17
host summaryAaron Garrison summarizing a resource: The same study found no difference when looking at blood pressure with acidosis and hypoxia between open and thoracoscopic approaches.↗
