I wait at least three weeks. I want the gastronomy site. My experience has been these babies are almost like 2 kilos or smaller. And they got to eat and grow a little bit before I think if you try to put even that little tiny pede neonatal scope in before three weeks, you're going to push the stomach away from the s the gastrostomy site.
Our teaching in the in the past was that you shouldn't try to do a replacement until the kid is upright, so they don't reflux, because all the replacements usually reflux. And so either they have to be able to sit frequently or or up walking, somewhere between six and 12 months to do a a replacement procedure.
If the upper pouch is narrower and smaller than you normally see, you should be suspicious that there is a fistula and be more uh uh insistent on trying to prove it's there with either repeating the bronchoscopy, even repeating the pouchgram.
Esophageal Atresia - Arnold Coran: Update Course 2014
▶Ep 8 · 0:20
quoteWell, what usually happens when you get to be our age is uh you do hernias and orchidopexies and uh don't get involved with big complicated cases. My life has taken an opposite turn of doing recurrent, recurrent, recurrent esophageal cases and rectal cases.↗
▶Ep 8 · 3:51
clinicalCameron Haight performed the first esophageal atresia repair in 1941 and managed over 300 cases during his career.↗
▶Ep 8 · 4:42
quoteI think the most complicated form of esophageal atresia today, the one where we see the most complications is the long gap pure esophageal atresia.↗
▶Ep 8 · 5:39
epidemiologicalThe incidence of proximal fistula in type C esophageal atresia (with distal fistula) is approximately 10% based on a Netherlands study, significantly higher than the previously reported 1%.↗
▶Ep 8 · 5:39
quoteI think it's probably 10% now and and the best series was the one from Netherlands showing that the incidence is much, much higher than we think.↗
▶Ep 8 · 7:40
quoteBut the point of the question is really not whether it's 10% or whether it's 5%, it's not 1%. It's much much higher and for that reason, one has to absolutely prove you don't have it.↗
▶Ep 8 · 8:40
clinicalA pouchogram can help determine the side of the aortic arch when timely cardiology evaluation is not available.↗
▶Ep 8 · 8:40
quoteI know Mac Hammer will probably critique me for being an old fud and getting that. Uh, but I always did those uh in when I was uh chief of surgery at Michigan uh because it helps you in two ways. One, you can see whether or not you have enough fistula, but two, if you're not able to get cardiology uh evaluation in a timely fashion, you could term determine what side the aortic arch is on with a good gram.↗
▶Ep 8 · 10:33
clinicalContrast pouchography using approximately 1.5 cc of water-soluble contrast carries low aspiration risk and can identify proximal fistulas or suggest their presence when the upper pouch appears narrower than expected.↗
▶Ep 8 · 10:33
quoteIf the upper pouch is narrower and smaller than you normally see, you should be suspicious that there is a fistula and be more uh uh insistent on trying to prove it's there with either repeating the bronchoscopy, even repeating the pouchgram.↗
▶Ep 8 · 17:56
guidelineInitial gap assessment should be delayed at least three weeks after gastrostomy placement to allow the gastrostomy site to mature and avoid displacing the stomach during endoscopy.↗
▶Ep 8 · 17:56
quoteI wait at least three weeks. I want the gastronomy site. My experience has been these babies are almost like 2 kilos or smaller. And they got to eat and grow a little bit before I think if you try to put even that little tiny pede neonatal scope in before three weeks, you're going to push the stomach away from the s the gastrostomy site.↗
▶Ep 8 · 20:03
quoteI don't think you need to rush to do this in the early neonatal period at three weeks.↗
▶Ep 8 · 20:03
opinionThere is no need to rush primary repair in the early neonatal period at three weeks; waiting 12 weeks is reasonable as babies grow well with gastrostomy feedings.↗
▶Ep 8 · 20:33
opinionThe Foker procedure is associated with complications including massive gastroesophageal reflux, aspiration, and potentially poor long-term esophageal motility and function.↗
▶Ep 8 · 20:33
quoteI I quite frankly, I don't like the Foker procedure and if those kids followed out 10 and 20 years, their esophageal motility and their esophageal function may not be very good.↗
▶Ep 8 · 21:50
quoteOur teaching in the in the past was that you shouldn't try to do a replacement until the kid is upright, so they don't reflux, because all the replacements usually reflux. And so either they have to be able to sit frequently or or up walking, somewhere between six and 12 months to do a a replacement procedure.↗
▶Ep 8 · 21:50
guidelineTraditional teaching suggests esophageal replacement should not be performed until the child can sit upright or walk (between six and 12 months) to minimize reflux complications.↗
▶Ep 8 · 22:40
clinicalEsophageal replacement options include colon interposition, gastric pull-up, jejunal interposition, and reverse gastric tube.↗
▶Ep 8 · 24:02
quoteI think most of us sort of believe that at about three months you should start your load and it's not going to get any bigger.↗
▶Ep 8 · 24:02
opinionAt approximately three months, the gap should be reassessed and a decision made, as most believe the gap will not grow significantly larger after this time.↗
Arnold's statements about Type C Esophageal Atresia21 statements
Esophageal Atresia - Arnold Coran: Update Course 2014
▶Ep 1 · 0:20
quoteWell, what usually happens when you get to be our age is uh you do hernias and orchidopexies and uh don't get involved with big complicated cases. My life has taken an opposite turn of doing recurrent, recurrent, recurrent esophageal cases and rectal cases.↗
▶Ep 1 · 3:51
clinicalCameron Haight performed the first esophageal atresia repair in 1941 and managed over 300 cases during his career.↗
▶Ep 1 · 4:42
quoteI think the most complicated form of esophageal atresia today, the one where we see the most complications is the long gap pure esophageal atresia.↗
▶Ep 1 · 5:39
epidemiologicalThe incidence of proximal fistula in type C esophageal atresia (with distal fistula) is approximately 10% based on a Netherlands study, significantly higher than the previously reported 1%.↗
▶Ep 1 · 5:39
quoteI think it's probably 10% now and and the best series was the one from Netherlands showing that the incidence is much, much higher than we think.↗
▶Ep 1 · 7:40
quoteBut the point of the question is really not whether it's 10% or whether it's 5%, it's not 1%. It's much much higher and for that reason, one has to absolutely prove you don't have it.↗
▶Ep 1 · 8:40
clinicalA pouchogram can help determine the side of the aortic arch when timely cardiology evaluation is not available.↗
▶Ep 1 · 8:40
quoteI know Mac Hammer will probably critique me for being an old fud and getting that. Uh, but I always did those uh in when I was uh chief of surgery at Michigan uh because it helps you in two ways. One, you can see whether or not you have enough fistula, but two, if you're not able to get cardiology uh evaluation in a timely fashion, you could term determine what side the aortic arch is on with a good gram.↗
▶Ep 1 · 10:33
clinicalContrast pouchography using approximately 1.5 cc of water-soluble contrast carries low aspiration risk and can identify proximal fistulas or suggest their presence when the upper pouch appears narrower than expected.↗
▶Ep 1 · 10:33
quoteIf the upper pouch is narrower and smaller than you normally see, you should be suspicious that there is a fistula and be more uh uh insistent on trying to prove it's there with either repeating the bronchoscopy, even repeating the pouchgram.↗
▶Ep 1 · 17:56
guidelineInitial gap assessment should be delayed at least three weeks after gastrostomy placement to allow the gastrostomy site to mature and avoid displacing the stomach during endoscopy.↗
▶Ep 1 · 17:56
quoteI wait at least three weeks. I want the gastronomy site. My experience has been these babies are almost like 2 kilos or smaller. And they got to eat and grow a little bit before I think if you try to put even that little tiny pede neonatal scope in before three weeks, you're going to push the stomach away from the s the gastrostomy site.↗
▶Ep 1 · 20:03
quoteI don't think you need to rush to do this in the early neonatal period at three weeks.↗
▶Ep 1 · 20:03
opinionThere is no need to rush primary repair in the early neonatal period at three weeks; waiting 12 weeks is reasonable as babies grow well with gastrostomy feedings.↗
▶Ep 1 · 20:33
opinionThe Foker procedure is associated with complications including massive gastroesophageal reflux, aspiration, and potentially poor long-term esophageal motility and function.↗
▶Ep 1 · 20:33
quoteI I quite frankly, I don't like the Foker procedure and if those kids followed out 10 and 20 years, their esophageal motility and their esophageal function may not be very good.↗
▶Ep 1 · 21:50
quoteOur teaching in the in the past was that you shouldn't try to do a replacement until the kid is upright, so they don't reflux, because all the replacements usually reflux. And so either they have to be able to sit frequently or or up walking, somewhere between six and 12 months to do a a replacement procedure.↗
▶Ep 1 · 21:50
guidelineTraditional teaching suggests esophageal replacement should not be performed until the child can sit upright or walk (between six and 12 months) to minimize reflux complications.↗
▶Ep 1 · 22:40
clinicalEsophageal replacement options include colon interposition, gastric pull-up, jejunal interposition, and reverse gastric tube.↗
▶Ep 1 · 24:02
quoteI think most of us sort of believe that at about three months you should start your load and it's not going to get any bigger.↗
▶Ep 1 · 24:02
opinionAt approximately three months, the gap should be reassessed and a decision made, as most believe the gap will not grow significantly larger after this time.↗
