If I have a patient who has a stricture that's been dilated 2 or 3 times, my next move would be to address reflux. Most of the patients we leave on anti-reflux medications when they are discharged from the hospital. I would argue that virtually all patients have some degree of gastroesophageal reflux. If they have a stricture that is not responsive to dilations, it dilates easily and then restrictures. I personally am very aggressive about doing a fundoplication on those patients
They published a series a year ago or so in JPS looking at their results, and, and it was a very carefully well documented report of their results, and the data are striking if you Have a patient who has a primary atresia that you address, then in 98% of patients they're able to get the two ends of the esophagus together. In contrast, if it's a patient who's had previous surgeries and it's a secondary approach, then only 2/3 of those patients ever get the esophagus together.
I completely agree, and I think that you have to be very careful. I personally like to just use a blade, electric cautery and with a little buzz and then mostly blunt dissection with the flat end of the blade, and I think that. That can help you and staying right on the esophagus, which is usually very thickened because it's an obstructed piece of bowel. I would rather be in the esophagus than be in the trachea up high in the chest.
You can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.
Our method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap.
the data are striking if you Have a patient who has a primary atresia that you address, then in 98% of patients they're able to get the two ends of the esophagus together. In contrast, if it's a patient who's had previous surgeries and it's a secondary approach, then only 2/3 of those patients ever get the esophagus together.
clinicalIn younger patients, neuroblastoma is often picked up either prenatally on ultrasound, or in younger kids (two-year-old or three-year-old) as a solid abdominal mass.↗
▶Ep 1 · 0:41
quoteSo in the younger patients, they're oftentimes picked up either prenatally on ultrasound, or in younger kids, say two-year-old or three-year-old, it might be picked up as a solid abdominal mass.↗
▶Ep 1 · 0:41
clinicalWhen neuroblastoma patients have metastatic disease, they may present with either bony pain or potentially neurologic symptoms from cord compression.↗
▶Ep 1 · 1:07
clinicalWhen considering neuroblastoma as part of the differential diagnosis, it is important to get catecholamines (either urine or serum) as one of the most diagnostic laboratory tests for this tumor.↗
▶Ep 1 · 1:39
clinicalMost children with suspected neuroblastoma would get a cross-sectional imaging study, either a CT scan or an MRI.↗
▶Ep 1 · 1:39
clinicalIf imaging suggests neuroblastoma (central abdominal mass or adrenal mass rather than kidney mass), the next test would be a nuclear medicine study, typically an MIBG study.↗
▶Ep 1 · 1:39
clinicalThe MIBG study is helpful for confirming the diagnosis of neuroblastoma and can also demonstrate metastatic disease.↗
▶Ep 1 · 2:20
clinicalSome centers, including Cincinnati Children's Hospital, would get a PET scan looking for tumor uptake as well as potential metastatic disease.↗
▶Ep 1 · 2:20
clinicalAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 1 · 2:20
quoteAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 1 · 2:45
guidelineBased on the most recent iteration of the neuroblastoma staging system (INRGSS), it is possible to assign a stage before any invasive procedure is performed.↗
▶Ep 1 · 2:45
guidelineIn the INRGSS system, tumors that are localized are categorized as L1; if localized but have image-defined risk factors (encasing nerves or vessels), they are L2; if they have metastatic disease, they are M.↗
▶Ep 1 · 2:45
guidelineThere is a special category MS for children less than 18 months of age who have metastases to either the bone marrow or the skin.↗
▶Ep 1 · 3:36
guidelineThe prior neuroblastoma staging system required tissue diagnosis before assigning a stage.↗
▶Ep 1 · 3:36
guidelineThe INRGSS pre-biopsy staging system was specifically created to allow studies from different centers in different countries to be compared based on the pre-surgical staging of the patient.↗
▶Ep 1 · 4:06
opinionSome surgeons would approach resection of a localized neuroblastoma with laparoscopy depending on the size of the tumor.↗
▶Ep 1 · 4:06
clinicalA child with an adrenal mass on the right side and a positive MIBG scan but no evidence of metastases could potentially be treated with a primary resection of the mass via laparotomy.↗
▶Ep 1 · 4:44
clinicalFor very large masses that encase the aorta, cava, or other major vasculature, all you really want is tissue for diagnosis, which can be obtained through open biopsy, laparoscopic biopsy, or core needle biopsies done by an interventional radiologist.↗
▶Ep 1 · 5:14
clinicalThe most important biologic risk determinant to obtain from neuroblastoma biopsy tissue is the NMIC status.↗
▶Ep 1 · 5:14
clinicalIn addition to NMIC status, you want to look for 1P and 11Q deletions and Shimada histology in neuroblastoma biopsy tissue.↗
▶Ep 1 · 5:45
clinicalBiologic risk determinants from biopsy will tell you what risk category the patient falls into: very low risk, low risk, intermediate risk, or high risk.↗
▶Ep 1 · 5:45
epidemiologicalNeuroblastoma risk is divided about 50-50 between the low risk categories and the high risk category, with a smaller percentage being intermediate risk.↗
▶Ep 1 · 6:11
clinicalPatients with high risk neuroblastoma receive aggressive chemotherapy including peripheral stem cell transplant times 2, aggressive surgery with the goal of greater than 90% resection of the tumor, followed by radiation, immunotherapy after chemotherapy, and potentially retinoic acid therapy.↗
▶Ep 1 · 6:11
clinicalNMIC amplification and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 1 · 6:11
quoteNMIC and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 1 · 6:51
clinicalFor intermediate risk neuroblastoma, the goal at the time of debulking or resecting the primary tumor is to achieve at least a 50% response from the initial volume of the primary tumor through the combination of neoadjuvant chemotherapy and surgical resection.↗
▶Ep 1 · 6:51
clinicalIntermediate risk neuroblastoma tumors get varying cycles of chemotherapy based on the biologic risk factors they have.↗
▶Ep 1 · 7:22
clinicalJed Nocturne led a study through the Children's Oncology Group looking at patients less than six months of age with either a prenatally diagnosed or shortly postnatally diagnosed localized mass, showing these patients can be observed with the expectation that the vast majority will avoid any type of surgical procedure.↗
▶Ep 1 · 7:22
clinicalThe low risk neuroblastoma group, depending on the actual age of the patient and how it is diagnosed, could potentially be followed simply with observation.↗
▶Ep 1 · 7:55
clinicalPatients with metastatic neuroblastoma typically receive four or five cycles of neoadjuvant chemotherapy and then are reassessed.↗
▶Ep 1 · 7:55
clinicalIf the tumor and metastatic disease are responding to neoadjuvant chemotherapy, one would attack the primary tumor site with a resection, with many advocating for attempting a greater than 90% resection.↗
▶Ep 1 · 7:55
clinicalIf the metastatic disease is progressing on neoadjuvant chemotherapy, then surgery is not indicated.↗
▶Ep 1 · 7:55
clinicalMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow (specifically not bone, not cortical bone) and is less than 18 months of age.↗
▶Ep 1 · 7:55
clinicalIn patients with MS disease, simple observation can be the treatment path.↗
▶Ep 1 · 7:55
clinicalIf MS disease patients progress or develop respiratory issues because of an enlarging liver mass, treatment might be elected because of the complication of the size of the tumor, but the tumor itself usually does not have to be treated.↗
▶Ep 1 · 7:55
quoteMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow, specifically not bone, not cortical bone, and is less than 18 months of age.↗
▶Ep 1 · 8:55
clinicalYou can biopsy the skin lesions in MS disease and that will give you the diagnosis.↗
Neuroblastoma
▶Ep 2 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 2 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 2 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 2 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 2 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 2 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 2 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 2 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 2 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 2 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
▶Ep 2 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
Daniel's statements about Aerodigestive / ENT6 statements
Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula
▶Ep 3 · 9:58
clinicalIf a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse.↗
▶Ep 3 · 14:02
clinicalRoutine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues.↗
▶Ep 3 · 19:37
clinicalDual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings.↗
quoteThe tissue damage extends beyond what you can appreciate with the naked eye, and the progression of it probably extends beyond what you would think is the normal time frame.↗
▶Ep 3 · 1:52:36
clinicalIn a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured.↗
Daniel's statements about Appendicitis12 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 4 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 4 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 4 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 4 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 4 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 7 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 7 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 7 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 7 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 7 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 7 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Daniel's statements about Appendicitis12 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 5 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 5 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 5 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 5 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 5 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 5 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 10 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 10 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 10 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 10 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 10 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 10 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Daniel's statements about Biliary Atresia12 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 6 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 6 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 6 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 6 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 6 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 6 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 10 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 10 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 10 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 10 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 10 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 10 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Daniel's statements about CHARGE Syndrome12 statements
Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula
▶Ep 1 · 9:58
clinicalIf a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse.↗
▶Ep 1 · 9:58
clinicalIf a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse.↗
▶Ep 1 · 14:02
clinicalRoutine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues.↗
▶Ep 1 · 14:02
clinicalRoutine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues.↗
▶Ep 1 · 19:37
clinicalDual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings.↗
▶Ep 1 · 19:37
clinicalDual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings.↗
quoteThe tissue damage extends beyond what you can appreciate with the naked eye, and the progression of it probably extends beyond what you would think is the normal time frame.↗
▶Ep 1 · 56:27
quoteThe tissue damage extends beyond what you can appreciate with the naked eye, and the progression of it probably extends beyond what you would think is the normal time frame.↗
▶Ep 1 · 1:52:36
clinicalIn a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured.↗
▶Ep 1 · 1:52:36
clinicalIn a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured.↗
Daniel's statements about Colorectal / ARM & Hirschsprung17 statements
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 74 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 74 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 74 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 74 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 74 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 74 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 74 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 74 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 74 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
▶Ep 74 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 76 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 76 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 76 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 76 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 76 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 76 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Daniel's statements about Congenital Lung Lesions (CPAM)30 statements
clinicalBaseline chest X-ray may be useful if patient later presents with respiratory symptoms and consolidation, providing comparison↗
▶Ep 22 · 6:34
clinicalBaseline chest X-ray may be useful if patient later presents with respiratory symptoms and consolidation, providing comparison↗
▶Ep 22 · 25:54
clinicalIf crura come together easily during paraesophageal hernia repair, primary closure without mesh is preferred↗
▶Ep 22 · 25:54
clinicalIf crura come together easily during paraesophageal hernia repair, primary closure without mesh is preferred↗
▶Ep 22 · 29:25
clinicalPosterior defect is the usual problem site in paraesophageal hernia; mesh should cover the posterior repair↗
▶Ep 22 · 29:25
clinicalPosterior defect is the usual problem site in paraesophageal hernia; mesh should cover the posterior repair↗
▶Ep 22 · 33:35
clinicalWaiting only 3-4 weeks for revision risks operating during maximal inflammation period↗
▶Ep 22 · 33:35
clinicalWaiting only 3-4 weeks for revision risks operating during maximal inflammation period↗
▶Ep 22 · 44:09
quoteI hate this operation, whether it's open or laparoscopic, because you're trying to do a mechanical fix to a physiologic problem, and it's uh miserable.↗
▶Ep 22 · 44:09
opinionFundoplication attempts mechanical fix for physiologic problem, making it inherently difficult operation↗
▶Ep 22 · 44:09
opinionFundoplication attempts mechanical fix for physiologic problem, making it inherently difficult operation↗
▶Ep 22 · 44:09
quoteI hate this operation, whether it's open or laparoscopic, because you're trying to do a mechanical fix to a physiologic problem, and it's uh miserable.↗
▶Ep 22 · 45:22
clinicalGastric disconnect is excellent operation in cognitively impaired patients who don't eat much and have refractory reflux or multiple failed fundoplications↗
▶Ep 22 · 45:22
clinicalGastric disconnect is excellent operation in cognitively impaired patients who don't eat much and have refractory reflux or multiple failed fundoplications↗
▶Ep 22 · 49:43
clinicalDextrocardia makes thoracoscopic visualization challenging for EA/TEF repair↗
▶Ep 22 · 49:43
clinicalDextrocardia makes thoracoscopic visualization challenging for EA/TEF repair↗
▶Ep 22 · 49:56
clinicalFor unstable EA/TEF patient, laparotomy with G-tube and vessel loop around GE junction allows fistula control and ventilation, deferring thoracic repair until patient stabilizes↗
▶Ep 22 · 49:56
clinicalFor unstable EA/TEF patient, laparotomy with G-tube and vessel loop around GE junction allows fistula control and ventilation, deferring thoracic repair until patient stabilizes↗
▶Ep 22 · 54:34
clinicalBronchoscopy should be performed in all EA/TEF cases to identify additional fistulas↗
▶Ep 22 · 54:34
clinicalBronchoscopy should be performed in all EA/TEF cases to identify additional fistulas↗
▶Ep 22 · 58:19
clinicalTracheal reconstruction for esophageal lung can be performed via median sternotomy: divide trachea, repair esophagus posteriorly, reconstruct trachea and fish-mouth abnormal bronchus to create lung connection↗
▶Ep 22 · 58:19
clinicalTracheal reconstruction for esophageal lung can be performed via median sternotomy: divide trachea, repair esophagus posteriorly, reconstruct trachea and fish-mouth abnormal bronchus to create lung connection↗
▶Ep 22 · 59:03
clinicalIf initial TEF ligation is performed too far from trachea (2cm), significant esophageal length is lost, potentially preventing primary anastomosis↗
▶Ep 22 · 59:03
clinicalIf initial TEF ligation is performed too far from trachea (2cm), significant esophageal length is lost, potentially preventing primary anastomosis↗
▶Ep 22 · 59:24
clinicalMagnet anastomosis can be attempted when esophageal ends are tacked together but gap prevents primary anastomosis↗
▶Ep 22 · 59:24
clinicalMagnet anastomosis can be attempted when esophageal ends are tacked together but gap prevents primary anastomosis↗
clinicalBaseline chest X-ray may be useful if patient later presents with respiratory symptoms and consolidation, providing comparison↗
▶Ep 19 · 25:54
clinicalIf crura come together easily during paraesophageal hernia repair, primary closure without mesh is preferred↗
▶Ep 19 · 29:25
clinicalPosterior defect is the usual problem site in paraesophageal hernia; mesh should cover the posterior repair↗
▶Ep 19 · 33:35
clinicalWaiting only 3-4 weeks for revision risks operating during maximal inflammation period↗
▶Ep 19 · 44:09
opinionFundoplication attempts mechanical fix for physiologic problem, making it inherently difficult operation↗
▶Ep 19 · 44:09
quoteI hate this operation, whether it's open or laparoscopic, because you're trying to do a mechanical fix to a physiologic problem, and it's uh miserable.↗
▶Ep 19 · 45:22
clinicalGastric disconnect is excellent operation in cognitively impaired patients who don't eat much and have refractory reflux or multiple failed fundoplications↗
▶Ep 19 · 49:43
clinicalDextrocardia makes thoracoscopic visualization challenging for EA/TEF repair↗
▶Ep 19 · 49:56
clinicalFor unstable EA/TEF patient, laparotomy with G-tube and vessel loop around GE junction allows fistula control and ventilation, deferring thoracic repair until patient stabilizes↗
▶Ep 19 · 54:34
clinicalBronchoscopy should be performed in all EA/TEF cases to identify additional fistulas↗
▶Ep 19 · 58:19
clinicalTracheal reconstruction for esophageal lung can be performed via median sternotomy: divide trachea, repair esophagus posteriorly, reconstruct trachea and fish-mouth abnormal bronchus to create lung connection↗
▶Ep 19 · 59:03
clinicalIf initial TEF ligation is performed too far from trachea (2cm), significant esophageal length is lost, potentially preventing primary anastomosis↗
▶Ep 19 · 59:24
clinicalMagnet anastomosis can be attempted when esophageal ends are tacked together but gap prevents primary anastomosis↗
clinicalBaseline chest X-ray may be useful if patient later presents with respiratory symptoms and consolidation, providing comparison↗
▶Ep 19 · 25:54
clinicalIf crura come together easily during paraesophageal hernia repair, primary closure without mesh is preferred↗
▶Ep 19 · 29:25
clinicalPosterior defect is the usual problem site in paraesophageal hernia; mesh should cover the posterior repair↗
▶Ep 19 · 33:35
clinicalWaiting only 3-4 weeks for revision risks operating during maximal inflammation period↗
▶Ep 19 · 44:09
opinionFundoplication attempts mechanical fix for physiologic problem, making it inherently difficult operation↗
▶Ep 19 · 44:09
quoteI hate this operation, whether it's open or laparoscopic, because you're trying to do a mechanical fix to a physiologic problem, and it's uh miserable.↗
▶Ep 19 · 45:22
clinicalGastric disconnect is excellent operation in cognitively impaired patients who don't eat much and have refractory reflux or multiple failed fundoplications↗
▶Ep 19 · 49:43
clinicalDextrocardia makes thoracoscopic visualization challenging for EA/TEF repair↗
▶Ep 19 · 49:56
clinicalFor unstable EA/TEF patient, laparotomy with G-tube and vessel loop around GE junction allows fistula control and ventilation, deferring thoracic repair until patient stabilizes↗
▶Ep 19 · 54:34
clinicalBronchoscopy should be performed in all EA/TEF cases to identify additional fistulas↗
▶Ep 19 · 58:19
clinicalTracheal reconstruction for esophageal lung can be performed via median sternotomy: divide trachea, repair esophagus posteriorly, reconstruct trachea and fish-mouth abnormal bronchus to create lung connection↗
▶Ep 19 · 59:03
clinicalIf initial TEF ligation is performed too far from trachea (2cm), significant esophageal length is lost, potentially preventing primary anastomosis↗
▶Ep 19 · 59:24
clinicalMagnet anastomosis can be attempted when esophageal ends are tacked together but gap prevents primary anastomosis↗
guidelineContrast enema plus suction rectal biopsy is the standard initial workup for newborn distal bowel obstruction suspected to be Hirschsprung disease, not upper GI series.↗
▶Ep 2 · 10:00
clinicalLaparoscopic-assisted pull-through is preferred over purely transanal approach because contrast enema underestimates transition zone level in approximately 8% of cases (Manu Proctor's data).↗
▶Ep 2 · 11:00
epidemiologicalFemale patients may have higher incidence of long-segment Hirschsprung (50-50 ratio for total colonic aganglionosis in girls) compared to males.↗
quoteI've been burned so many times by that, what looks like an obvious low transition zone and you end up just chasing it and chasing it↗
▶Ep 2 · 13:00
quoteWe actually published a paper of false positive contrast enemas in newborns. So there was a transition zone that looked like Hirschsprung's, and it was not Hirschprung.↗
▶Ep 2 · 13:00
guidelineTissue diagnosis is mandatory before operating for Hirschsprung disease; contrast enema alone is insufficient due to false-positive transition zones in newborns.↗
▶Ep 2 · 14:00
quotethere is an occasional patient who is really sick from enterocolitis and you may not wanna wait for a tissue diagnosis. It might take a couple of days to get.↗
▶Ep 2 · 14:00
clinicalIn sick patients with enterocolitis, diversion may be necessary before obtaining tissue diagnosis if pathology results will be delayed several days.↗
▶Ep 2 · 18:00
clinicalUltra-short segment Hirschsprung has two definitions: (1) aganglionosis less than 5cm from dentate line, or (2) absent recto-anal inhibitory reflex with normal ganglion cells (internal sphincter achalasia). The latter is not true Hirschsprung disease.↗
▶Ep 2 · 18:00
quoteThere are two definitions for ultra short segment Hirschmann's disease that people use, and these kinds of discussions get get foiled because one person's using one definition, another person's using another one.↗
▶Ep 2 · 19:00
clinicalManometry showing normal recto-anal inhibitory reflex rules out Hirschsprung disease in older cooperative children (age 5-6+); if reflex is absent, biopsy is still required due to false-negative manometry.↗
▶Ep 2 · 19:00
quoteif there's a normal reflex. Uh-huh. Now, if they don't have a normal reflex, then, then you have to biopsy them because the, the, there can be false, false, whatever you want, I don't know, negative, positive, false absence of the of the reflex↗
▶Ep 2 · 19:00
quoteit's hard for me to imagine how Doctor Pena could not believe in that. You know, why would there be a disease where there's a minimum of 5 centimeters of a ganglionosis?↗
▶Ep 2 · 20:00
clinicalHypertrophic nerves on biopsy indicate Hirschsprung disease; they should not be present in normal anal canal biopsies even though ganglion cells are normally absent in the anal canal.↗
▶Ep 2 · 21:00
clinicalThe anal canal in adults is 3-4 centimeters long (versus 1cm in infants), so biopsies at 3cm in a 16-year-old may actually be sampling anal canal rather than rectum.↗
▶Ep 2 · 23:00
clinicalCecal perforation in Hirschsprung disease usually occurs with shorter-segment disease (not total colonic aganglionosis) because the cecum becomes most distended, similar to rectal cancer causing cecal perforation.↗
▶Ep 2 · 24:00
clinicalFor cecal perforation from Hirschsprung: close the perforation, create loop ileostomy, and perform serial colonic biopsies if patient is stable to identify transition zone level.↗
▶Ep 2 · 24:00
quotethe cecum gets more distended and pops. So, uh, I would close the cecal perforation, bring out a loop ileostomy, and if the baby was stable enough, I would do some serial biopsies in the colon↗
▶Ep 2 · 26:00
clinicalLong-segment Hirschsprung patients should wait 6-12 months after diversion before definitive pull-through to allow stoma output to thicken and prevent severe perianal excoriation.↗
▶Ep 2 · 26:00
quoteI tend to wait longer in long segment disease because they have terrible perianal excoriation if you, if you pull them through too early.↗
▶Ep 2 · 29:00
opinionWhen transition zone is in the cecum or ascending colon, pulling down the cecum as a pouch leads to stasis and enterocolitis; ileal Duhamel (sacrificing the cecum) may have better outcomes.↗
▶Ep 2 · 29:00
quotemy experience with, um, with a very, very short pull, pull through like using the cecum essentially have not been very good. So in general, when I'm faced with that anatomy, I just do a, treat it like total colon disease and I do an ileal duhamel.↗
▶Ep 2 · 30:00
clinicalIf transition zone is at hepatic flexure or beyond, preserve the colon; if only cecum is ganglionic, consider ileal Duhamel instead.↗
▶Ep 2 · 30:00
quotewhen it's just the cecum, it's, it's this big bag of stuff, and, and they end up with a lot of stasis and enterocolitis.↗
▶Ep 2 · 32:00
clinicalSuction rectal biopsy should not be performed in children older than approximately 15-18 months due to patient cooperation issues; open rectal biopsy under general anesthesia is preferred.↗
▶Ep 2 · 33:00
quoteyou gotta, even though you might, the, the specimen may come out, the logistics of taking a 2 year old and, uh, holding them they can fight back. They're too old.↗
▶Ep 2 · 34:00
clinicalIn older children (age 3+) with severely dilated colon from Hirschsprung, primary pull-through without diversion risks anastomotic complications; leveling colostomy with resection of dilated segment is preferred.↗
▶Ep 2 · 34:00
quoteWe've been really leaning towards doing diversion after just to protect our anastomosis.↗
▶Ep 2 · 34:30
quoteif we do this, take the, try to resect these colons transanally. The stretch that we put on the sphincter is enormous, and their, uh, continence postoperatively is definitely, definitely suffers.↗
▶Ep 2 · 35:00
quotethat thing that you showed, um, is so mammothly dilated, I don't think that would close. That's why I was initially going to say, Divert, but I think that that's not going to come down no matter how long you wait.↗
▶Ep 2 · 36:00
clinicalMassively dilated colon in older Hirschsprung patients may shrink after 6-8 months of diversion in younger children (age 3) but is less likely to shrink in adolescents (age 17).↗
▶Ep 2 · 36:00
quoteI have had success in, uh, getting that distal bowel to, uh, shrink in size. Um-hum. With the stoma for 6 or 8 months.↗
▶Ep 2 · 36:30
quotethe older the kid, the less likely that it's going to shrink down in size. But, uh, at this age OK. Uh, I think it will.↗
▶Ep 2 · 37:00
quotepatient was at a well-known institution in Ohio. And had, was seen by GI and had multiple biopsies that were normal. Those were done by colonoscopy, um, and then, so the chart read no Hirschprung's disease↗
▶Ep 2 · 37:00
clinicalColonoscopic biopsies for Hirschsprung diagnosis in older children can be unreliable and miss the diagnosis; full-thickness rectal biopsy is more reliable.↗
▶Ep 2 · 38:00
quotejust caution to watch out what type of biopsy was performed and how Hirschprung's was ruled out. It's, it's an argument for the manometry uh diagnosis because biopsies in an older child can be unreliable.↗
▶Ep 2 · 38:00
clinicalInitial management of Hirschsprung-associated enterocolitis: IV broad-spectrum antibiotics and saline rectal irrigations. Consider diversion only if patient has peritonitis, sepsis, or SIRS.↗
▶Ep 2 · 38:50
quotewe actually published a, uh, that Botox decreased the number of hospitalizations for enterocolitis in, in those children. It doesn't always work, though.↗
▶Ep 2 · 38:50
clinicalChronic oral metronidazole is used liberally for recurrent Hirschsprung-associated enterocolitis, sometimes for months; symptoms may recur when medication is stopped.↗
▶Ep 2 · 38:50
quotewe have a lot of kids on chronic, uh, metronidazole. And when they, you know, they can be on it for three months and then you try taking them off and they start getting symptoms again.↗
▶Ep 2 · 38:50
clinicalBotox injection decreases the number of hospitalizations for enterocolitis in post-pull-through Hirschsprung patients, though it does not work in all cases.↗
▶Ep 2 · 39:00
quoteThe incidence of enterocolitis is significantly higher in children with trisomy 21, as much as double the incidence in genetically normal kids.↗
▶Ep 2 · 39:00
epidemiologicalIncidence of enterocolitis is significantly higher (approximately double) in children with trisomy 21 compared to genetically normal children with Hirschsprung disease.↗
▶Ep 2 · 40:00
clinicalFor recurrent enterocolitis post-pull-through: perform exam under anesthesia with biopsies to rule out residual aganglionosis or distal obstruction before treating the enterocolitis itself.↗
Daniel's statements about Enterocolitis45 statements
guidelineContrast enema plus suction rectal biopsy is the standard initial workup for newborn distal bowel obstruction suspected to be Hirschsprung disease, not upper GI series.↗
▶Ep 2 · 10:00
clinicalLaparoscopic-assisted pull-through is preferred over purely transanal approach because contrast enema underestimates transition zone level in approximately 8% of cases (Manu Proctor's data).↗
▶Ep 2 · 11:00
epidemiologicalFemale patients may have higher incidence of long-segment Hirschsprung (50-50 ratio for total colonic aganglionosis in girls) compared to males.↗
quoteI've been burned so many times by that, what looks like an obvious low transition zone and you end up just chasing it and chasing it↗
▶Ep 2 · 13:00
guidelineTissue diagnosis is mandatory before operating for Hirschsprung disease; contrast enema alone is insufficient due to false-positive transition zones in newborns.↗
▶Ep 2 · 13:00
quoteWe actually published a paper of false positive contrast enemas in newborns. So there was a transition zone that looked like Hirschsprung's, and it was not Hirschprung.↗
▶Ep 2 · 14:00
quotethere is an occasional patient who is really sick from enterocolitis and you may not wanna wait for a tissue diagnosis. It might take a couple of days to get.↗
▶Ep 2 · 14:00
clinicalIn sick patients with enterocolitis, diversion may be necessary before obtaining tissue diagnosis if pathology results will be delayed several days.↗
▶Ep 2 · 18:00
quoteThere are two definitions for ultra short segment Hirschmann's disease that people use, and these kinds of discussions get get foiled because one person's using one definition, another person's using another one.↗
▶Ep 2 · 18:00
clinicalUltra-short segment Hirschsprung has two definitions: (1) aganglionosis less than 5cm from dentate line, or (2) absent recto-anal inhibitory reflex with normal ganglion cells (internal sphincter achalasia). The latter is not true Hirschsprung disease.↗
▶Ep 2 · 19:00
clinicalManometry showing normal recto-anal inhibitory reflex rules out Hirschsprung disease in older cooperative children (age 5-6+); if reflex is absent, biopsy is still required due to false-negative manometry.↗
▶Ep 2 · 19:00
quoteif there's a normal reflex. Uh-huh. Now, if they don't have a normal reflex, then, then you have to biopsy them because the, the, there can be false, false, whatever you want, I don't know, negative, positive, false absence of the of the reflex↗
▶Ep 2 · 19:00
quoteit's hard for me to imagine how Doctor Pena could not believe in that. You know, why would there be a disease where there's a minimum of 5 centimeters of a ganglionosis?↗
▶Ep 2 · 20:00
clinicalHypertrophic nerves on biopsy indicate Hirschsprung disease; they should not be present in normal anal canal biopsies even though ganglion cells are normally absent in the anal canal.↗
▶Ep 2 · 21:00
clinicalThe anal canal in adults is 3-4 centimeters long (versus 1cm in infants), so biopsies at 3cm in a 16-year-old may actually be sampling anal canal rather than rectum.↗
▶Ep 2 · 23:00
clinicalCecal perforation in Hirschsprung disease usually occurs with shorter-segment disease (not total colonic aganglionosis) because the cecum becomes most distended, similar to rectal cancer causing cecal perforation.↗
▶Ep 2 · 24:00
clinicalFor cecal perforation from Hirschsprung: close the perforation, create loop ileostomy, and perform serial colonic biopsies if patient is stable to identify transition zone level.↗
▶Ep 2 · 24:00
quotethe cecum gets more distended and pops. So, uh, I would close the cecal perforation, bring out a loop ileostomy, and if the baby was stable enough, I would do some serial biopsies in the colon↗
▶Ep 2 · 26:00
quoteI tend to wait longer in long segment disease because they have terrible perianal excoriation if you, if you pull them through too early.↗
▶Ep 2 · 26:00
clinicalLong-segment Hirschsprung patients should wait 6-12 months after diversion before definitive pull-through to allow stoma output to thicken and prevent severe perianal excoriation.↗
▶Ep 2 · 29:00
opinionWhen transition zone is in the cecum or ascending colon, pulling down the cecum as a pouch leads to stasis and enterocolitis; ileal Duhamel (sacrificing the cecum) may have better outcomes.↗
▶Ep 2 · 29:00
quotemy experience with, um, with a very, very short pull, pull through like using the cecum essentially have not been very good. So in general, when I'm faced with that anatomy, I just do a, treat it like total colon disease and I do an ileal duhamel.↗
▶Ep 2 · 30:00
quotewhen it's just the cecum, it's, it's this big bag of stuff, and, and they end up with a lot of stasis and enterocolitis.↗
▶Ep 2 · 30:00
clinicalIf transition zone is at hepatic flexure or beyond, preserve the colon; if only cecum is ganglionic, consider ileal Duhamel instead.↗
▶Ep 2 · 32:00
clinicalSuction rectal biopsy should not be performed in children older than approximately 15-18 months due to patient cooperation issues; open rectal biopsy under general anesthesia is preferred.↗
▶Ep 2 · 33:00
quoteyou gotta, even though you might, the, the specimen may come out, the logistics of taking a 2 year old and, uh, holding them they can fight back. They're too old.↗
▶Ep 2 · 34:00
clinicalIn older children (age 3+) with severely dilated colon from Hirschsprung, primary pull-through without diversion risks anastomotic complications; leveling colostomy with resection of dilated segment is preferred.↗
▶Ep 2 · 34:00
quoteWe've been really leaning towards doing diversion after just to protect our anastomosis.↗
▶Ep 2 · 34:30
quoteif we do this, take the, try to resect these colons transanally. The stretch that we put on the sphincter is enormous, and their, uh, continence postoperatively is definitely, definitely suffers.↗
▶Ep 2 · 35:00
quotethat thing that you showed, um, is so mammothly dilated, I don't think that would close. That's why I was initially going to say, Divert, but I think that that's not going to come down no matter how long you wait.↗
▶Ep 2 · 36:00
quoteI have had success in, uh, getting that distal bowel to, uh, shrink in size. Um-hum. With the stoma for 6 or 8 months.↗
▶Ep 2 · 36:00
clinicalMassively dilated colon in older Hirschsprung patients may shrink after 6-8 months of diversion in younger children (age 3) but is less likely to shrink in adolescents (age 17).↗
▶Ep 2 · 36:30
quotethe older the kid, the less likely that it's going to shrink down in size. But, uh, at this age OK. Uh, I think it will.↗
▶Ep 2 · 37:00
clinicalColonoscopic biopsies for Hirschsprung diagnosis in older children can be unreliable and miss the diagnosis; full-thickness rectal biopsy is more reliable.↗
▶Ep 2 · 37:00
quotepatient was at a well-known institution in Ohio. And had, was seen by GI and had multiple biopsies that were normal. Those were done by colonoscopy, um, and then, so the chart read no Hirschprung's disease↗
▶Ep 2 · 38:00
quotejust caution to watch out what type of biopsy was performed and how Hirschprung's was ruled out. It's, it's an argument for the manometry uh diagnosis because biopsies in an older child can be unreliable.↗
▶Ep 2 · 38:00
clinicalInitial management of Hirschsprung-associated enterocolitis: IV broad-spectrum antibiotics and saline rectal irrigations. Consider diversion only if patient has peritonitis, sepsis, or SIRS.↗
▶Ep 2 · 38:50
quotewe have a lot of kids on chronic, uh, metronidazole. And when they, you know, they can be on it for three months and then you try taking them off and they start getting symptoms again.↗
▶Ep 2 · 38:50
clinicalChronic oral metronidazole is used liberally for recurrent Hirschsprung-associated enterocolitis, sometimes for months; symptoms may recur when medication is stopped.↗
▶Ep 2 · 38:50
clinicalBotox injection decreases the number of hospitalizations for enterocolitis in post-pull-through Hirschsprung patients, though it does not work in all cases.↗
▶Ep 2 · 38:50
quotewe actually published a, uh, that Botox decreased the number of hospitalizations for enterocolitis in, in those children. It doesn't always work, though.↗
▶Ep 2 · 39:00
epidemiologicalIncidence of enterocolitis is significantly higher (approximately double) in children with trisomy 21 compared to genetically normal children with Hirschsprung disease.↗
▶Ep 2 · 39:00
quoteThe incidence of enterocolitis is significantly higher in children with trisomy 21, as much as double the incidence in genetically normal kids.↗
▶Ep 2 · 40:00
clinicalFor recurrent enterocolitis post-pull-through: perform exam under anesthesia with biopsies to rule out residual aganglionosis or distal obstruction before treating the enterocolitis itself.↗
Daniel's statements about Esophageal Atresia344 statements
Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula
▶Ep 9 · 9:58
clinicalIf a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse.↗
▶Ep 9 · 14:02
clinicalRoutine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues.↗
▶Ep 9 · 19:37
clinicalDual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings.↗
quoteThe tissue damage extends beyond what you can appreciate with the naked eye, and the progression of it probably extends beyond what you would think is the normal time frame.↗
▶Ep 9 · 1:52:36
clinicalIn a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured.↗
Tracheoesophageal Fistula with Dr. Daniel von Allmen
▶Ep 11 · 1:36
quoteIt certainly is an interest that we have here with a whole group here in Cincinnati, but it can be an incredibly difficult, challenging problem. It's one of the great cases in pediatric surgery and one of the most difficult cases, so it really runs the whole spectrum for sure.↗
▶Ep 11 · 2:01
clinicalCincinnati Children's has a multidisciplinary aerodigestive center that includes ENT airway surgeons, GI, pulmonary, general surgeons, nurse practitioners, geneticists, and dietitians↗
▶Ep 11 · 2:46
clinicalThe aerodigestive center typically receives more complicated patients referred from outside through either esophageal or airway pathways↗
▶Ep 11 · 3:55
clinicalPhysical examination findings in suspected esophageal atresia include assessment for scaphoid versus distended abdomen and respiratory distress↗
▶Ep 11 · 4:20
clinicalPersonal confirmation of NG tube passage is important as some patients started on treatment for esophageal atresia are later found to have tubes that pass normally↗
▶Ep 11 · 4:20
quoteI personally like to try to pass the NG tube myself, having been burned with NG tubes that wouldn't go down, and the patient was started on treatment as an oesophageal atresia and subsequently found that the NG tube passes just fine.↗
▶Ep 11 · 4:55
clinicalInjecting air into the NG tube and obtaining a plain film helps visualize the proximal pouch and assess GI tract gas pattern↗
▶Ep 11 · 5:10
quoteIf I can't see a distended proximal pouch, then I worry. I worry that either one of two things either that the diagnosis is incorrect and in fact it is not an esophageal atresia, or that there could be a proximal fistula which is allowing that proximal pouch to decompress.↗
▶Ep 11 · 5:10
clinicalLack of visible distended proximal pouch on plain film raises concern for either incorrect diagnosis or presence of proximal fistula allowing pouch decompression↗
▶Ep 11 · 5:42
clinicalContrast studies can be performed when there is high suspicion of anatomic variants, with no contraindication as long as radiologist is aware of potential obstruction↗
▶Ep 11 · 6:25
clinicalPreoperative echocardiogram is essential to assess cardiac anatomy and rule out right-sided aortic arch↗
▶Ep 11 · 6:54
clinicalRenal ultrasound and spine evaluation for tethered cord are needed but are elective and not necessary before addressing esophageal atresia↗
▶Ep 11 · 7:27
guidelineConventional wisdom for right-sided aortic arch is to perform left thoracotomy rather than right thoracotomy↗
▶Ep 11 · 7:27
quoteI think that faced with that, that's what I would do if, if the echo was pretty clear and suggest that there's a right sided aortic arch, I would probably approach it through a left thoracotomy.↗
▶Ep 11 · 7:51
clinicalLeft thoracotomy for right-sided arch is somewhat more difficult with heart more in the way and harder proximal pouch mobilization↗
▶Ep 11 · 8:20
clinicalIt is possible to complete the repair from right thoracotomy even with right-sided arch, though some reports suggest higher incidence of swallowing problems↗
▶Ep 11 · 8:20
quoteI think that in most cases it is possible to get the esophagus together and to have a good result.↗
▶Ep 11 · 9:31
quoteI think that in a larger baby who's stable from a respiratory standpoint, not intubated in particular, I think it's perfectly legitimate to wait until you have all the resources that you would have in the middle of the day↗
▶Ep 11 · 9:31
clinicalIn stable larger babies not intubated, it is reasonable to wait until all resources are available in the middle of the day, even waiting until the next day↗
▶Ep 11 · 9:56
clinicalProlonged delay should be avoided due to concern for colonizing GI tract and soiling lungs↗
▶Ep 11 · 10:15
quoteI've not found personally that an oscillator makes a whole lot of difference. I think if the child has a, has a large fistula, and typically it's actually, I believe this tends to be a bigger problem in younger, that is more premature infants who have more significant lung disease↗
▶Ep 11 · 10:15
clinicalOscillator ventilation has not been found to make significant difference in managing unstable TEF patients↗
▶Ep 11 · 10:35
clinicalAir preferentially entering GI tract versus lungs tends to be a bigger problem in more premature infants with significant lung disease and poor lung compliance↗
▶Ep 11 · 10:56
clinicalTreating with surfactant and improving lung compliance helps as much as changing ventilator type in managing air leak through fistula↗
▶Ep 11 · 11:21
quoteI think one of the risks is to wait too long to make a decision, and I've made that mistake myself, and then it becomes an emergency if you can't ventilate the child.↗
▶Ep 11 · 11:21
clinicalRisk of waiting too long to make a decision in deteriorating patient can lead to emergency situation where ventilation becomes impossible↗
▶Ep 11 · 11:40
clinicalFor reasonably stable but worsening patient, approach is urgent right thoracotomy with fistula ligation↗
▶Ep 11 · 12:00
clinicalBronchoscopic placement of Fogarty balloon in fistula is difficult unless expertise and equipment are immediately available↗
▶Ep 11 · 12:25
clinicalG-tube decompression may paradoxically worsen ventilation by making stomach lower resistance path, allowing more air to go there rather than to lungs↗
▶Ep 11 · 12:25
quoteDecompressing the stomach may just allow that to become, in effect, the even lower resistance and allow more air to go there, making it even more difficult to ventilate.↗
▶Ep 11 · 12:50
clinicalLaparotomy with vessel loop around esophagogastric junction at hiatus with gentle traction (Rommel tourniquet technique) can temporize unstable patient for several days↗
▶Ep 11 · 13:51
clinicalIn stable child with associated duodenal atresia, consider fixing duodenal atresia first to avoid repairing esophagus upstream from obstruction↗
▶Ep 11 · 14:13
clinicalBoth esophageal and duodenal atresia can potentially be repaired in same operative setting if child is stable enough↗
▶Ep 11 · 14:13
quoteI think that our pediatric anesthesia has gotten good enough and if the child is old enough and stable enough you could potentially do both procedures at the same time.↗
▶Ep 11 · 14:35
clinicalRoutine intraoperative bronchoscopy is important to document fistula location, assess for proximal fistula, and rule out laryngeal cleft↗
▶Ep 11 · 14:55
quoteThe airway surgeons here have convinced me that it is really important to do a bronchoscopy↗
▶Ep 11 · 15:10
quotewe have seen that many times in patients who are referred who've had multiple thoracotomies. Nobody ever did a bronchoscopy and the child actually has a laryngeal cleft↗
▶Ep 11 · 15:10
clinicalLaryngeal clefts are easily missed and have been seen many times in referred patients who had multiple thoracotomies without anyone doing bronchoscopy↗
▶Ep 11 · 15:30
epidemiologicalSecond fistulas are very uncommon, occurring in perhaps 1% of cases, and can be difficult to diagnose↗
▶Ep 11 · 15:52
clinicalHigh fistulas can be seen bronchoscopically ahead of time and range from trifurcation of carina to fistulas potentially approachable through the neck↗
▶Ep 11 · 16:35
clinicalBronchoscopy allows guidance of anesthesiologist for ET tube placement relative to fistula location↗
▶Ep 11 · 17:00
clinicalFor fistula at carina (trifurcation), ET tube should be placed higher as it cannot pass the fistula; for high fistula, tube should be placed distal to fistula↗
▶Ep 11 · 17:16
clinicalExtrapleural approach offers advantage of potentially limiting soilage of pleural space if there is postoperative leak↗
▶Ep 11 · 17:16
quoteI do an extra plural approach and that's the way I was trained. I think it offers the advantage of potentially limiting any soilage of the plural space if there is a leak postoperatively.↗
▶Ep 11 · 17:41
quoteI think there's no morbidity associated with that, so dividing the azygus gives you better access. In fact, frequently will guide you to the fistula.↗
▶Ep 11 · 17:41
clinicalDividing azygos vein has no morbidity and gives better access, frequently guiding to the fistula↗
▶Ep 11 · 17:59
clinicalFor open repair, azygos is typically ligated and divided with suture↗
▶Ep 11 · 19:35
clinicalSpreading intercostal muscles with heel of right angle on ribs nicely shows extrapleural plane↗
▶Ep 11 · 20:00
clinicalMobilizing pleura up around apex of lung is important to have access for proximal pouch mobilization↗
▶Ep 11 · 20:24
clinicalDistal esophageal segment is controlled with vessel loop to allow proximal dissection to identify fistula↗
▶Ep 11 · 21:10
quoteI think we have learned that, you know, the standard teaching has been that you shouldn't mobilize the distal esophagus at all, and I think we've learned that in fact you can mobilize that segment a fair amount, especially laterally.↗
▶Ep 11 · 21:10
clinicalStandard teaching has been not to mobilize distal esophagus, but it can be mobilized extensively laterally and to some degree medially with care for blood supply↗
▶Ep 11 · 21:40
clinicalExtensive proximal pouch mobilization is most important for gaining length to approximate the ends↗
▶Ep 11 · 22:20
quoteI completely agree, and I think that you have to be very careful. I personally like to just use a blade, electric cautery and with a little buzz and then mostly blunt dissection with the flat end of the blade↗
▶Ep 11 · 22:20
clinicalBlade electrocautery with light buzz and mostly blunt dissection with flat end of blade, staying right on thickened obstructed esophagus, is preferred technique for proximal dissection↗
▶Ep 11 · 22:40
quoteI would rather be in the esophagus than be in the trachea up high in the chest.↗
▶Ep 11 · 22:44
clinicalBetter to be in esophagus than in trachea high in chest during proximal dissection↗
▶Ep 11 · 22:51
clinicalLarge tracheal defect would require sleeve resection, with trachea being incredibly mobile, and placement of pericardium or autologous tissue between trachea and esophageal repair↗
▶Ep 11 · 23:15
quoteThe trachea is incredibly mobile. Another thing that I have learned from my ENT colleagues so that you could effectively do a slide to pull the distal trachea up to the proximal portion to cover that defect.↗
▶Ep 11 · 23:59
opinionPersonal preference is 5-0 PDS for anastomosis, favoring absorbable monofilament over silk or other sutures↗
▶Ep 11 · 23:59
quoteI personally use PDS. I probably use 50 PDS. I like absorbable suture. I like monofilament suture. I'm not a big fan of silk↗
▶Ep 11 · 24:42
opinionCircular myotomies are not favored as they potentially create even more dysfunctional esophageal segment in patients who already have abnormal motility↗
▶Ep 11 · 24:50
quoteI personally am not a big fan of myotomy. I think it. Potentially creates an even more dysfunctional segment of the esophagus than already exists.↗
▶Ep 11 · 25:10
clinicalFor long-gap cases, approach is to ligate ends, tack both on tension to prevertebral fascia, close, let patient grow for several weeks, then return for anastomosis↗
▶Ep 11 · 25:10
quotemy approach to this is usually if I really try and I think it's going to be way too tight. Then I would ligate the ends, ligate the distal end after dividing the fistula, and then tack both ends on some tension to the prevertebral fascia, close and let the patient grow for a couple of weeks↗
▶Ep 11 · 25:38
quoteI believe very firmly in the physiology of traction or pressure. Actually it's sort of the reverse, is a very strong stimulus to growth all over the place in the cardiovascular system in the lungs↗
▶Ep 11 · 25:38
clinicalTraction or pressure is a strong stimulus to growth throughout the body including cardiovascular system and lungs↗
▶Ep 11 · 26:00
clinicalInternal Foker technique uses traction sutures in proximal and distal ends brought out through crossed trocar sites with tension, allowing rapid lengthening within about a week↗
▶Ep 11 · 27:38
epidemiologicalBoston series by Jennings and Foker showed 98% success getting ends together in primary atresia versus only 67% in secondary cases after previous surgeries↗
▶Ep 11 · 27:38
quotethe data are striking if you Have a patient who has a primary atresia that you address, then in 98% of patients they're able to get the two ends of the esophagus together. In contrast, if it's a patient who's had previous surgeries and it's a secondary approach, then only 2/3 of those patients ever get the esophagus together.↗
▶Ep 11 · 28:10
clinicalFoker technique requires patients to be intubated and paralyzed, spending weeks in ICU, which is significant cost but may be worth it for good result↗
▶Ep 11 · 29:18
clinicalFor thoracoscopic approach, patient is rotated past 90 degrees to allow gravity to move lungs out of the way↗
▶Ep 11 · 29:40
clinicalStandard thoracoscopic port placement uses camera in center with posterior port inferiorly and anterior port superiorly↗
▶Ep 11 · 29:52
clinical3mm instruments are used for thoracoscopic TEF repair↗
▶Ep 11 · 30:10
clinicalThoracoscopic visualization is very helpful for mobilizing proximal pouch↗
▶Ep 11 · 30:10
quoteI think it's important to do the same operation or at least the same quality operation that you would do open and Frankly, I think that's one of the challenges with the thoracoscopic repair of a TEF is to actually sew the anastomosis.↗
▶Ep 11 · 30:30
clinicalAnastomosis is the most difficult part of thoracoscopic repair, requiring significant experience with minimally invasive suturing techniques↗
▶Ep 11 · 31:00
opinionClips are preferred for dividing fistula thoracoscopically, with less concern about them falling off esophagus than blood vessels↗
▶Ep 11 · 31:00
quoteI'm less worried about them falling off the esophagus than I am having them fall off a blood vessel.↗
▶Ep 11 · 31:21
clinicalHook electrocautery can safely divide vessels if used carefully with up-and-down motion ensuring coagulation↗
▶Ep 11 · 31:21
quoteIt is amazing what you can divide with the electric cautery, with the hook electric cautery if you just get used to it↗
▶Ep 11 · 31:50
opinion3mm surgical sealer is ideal device for this size patient and vessel size↗
▶Ep 11 · 31:50
quoteI think the 3 millimeter sealer is a, is a great device for this size patient and that size vessel.↗
▶Ep 11 · 32:00
clinicalHanging stitch technique (first stitch brought out of chest) helps line up anastomosis similar to duodenal atresia repair↗
▶Ep 11 · 33:54
clinicalHanging stitch helps release tension as first stitches are placed and allows visualization of mucosa in both proximal and distal lumens↗
▶Ep 11 · 33:54
quoteTo me, the important part, and I beat on our residents about this when they're doing this anastomosis, is you have to be able to see. You want to make sure that you incorporate mucosa on every stitch↗
▶Ep 11 · 34:15
clinicalIncorporating mucosa on every stitch is critical and easier to verify with thoracoscopic visualization↗
▶Ep 11 · 34:23
clinicalVentilator management is more dependent on anesthesiologist comfort and attention than ventilator type↗
▶Ep 11 · 34:23
quoteI think it's more dependent on the anesthesiologist than it is on the type of ventilator, and you have to have an anesthesiologist who's comfortable with doing this and understands what you're trying to accomplish↗
▶Ep 11 · 34:45
clinicalAnesthesiologist must understand goals and pay attention during operation, as they can significantly help or hurt with ventilation approach↗
▶Ep 11 · 35:20
clinicalLittle CO2 insufflation with time will collapse lung as long as anesthesiologist is not fighting with positive pressure↗
▶Ep 11 · 35:58
clinicalConcern about reintubation is balanced by greater concern that positive pressure puts pressure on tracheal repair↗
▶Ep 11 · 35:58
quoteI agree it is a concern that the patient may require reintubation. However, I'm equally concerned that positive pressure is putting pressure on my tracheal repair↗
▶Ep 11 · 36:15
quoteI would much rather have the patient be breathing spontaneously to have, in fact, the opposite effect of a negative pressure in the trachea.↗
▶Ep 11 · 36:15
clinicalSpontaneous breathing creates negative pressure in trachea, which is preferable to positive pressure on repair↗
▶Ep 11 · 36:34
clinicalFor patients with good preoperative lung function and smooth operation, advocate extubating as soon as possible, even in operating room↗
▶Ep 11 · 36:43
clinicalContrast esophagram is obtained at 5-7 days postoperatively before pulling chest drain↗
▶Ep 11 · 36:43
quoteI do honestly, I'm a little bit old school in that. I still get an esophagram.↗
▶Ep 11 · 37:15
clinicalSmall TLS drains are used rather than formal chest tube, especially for open extrapleural approach↗
▶Ep 11 · 37:20
clinicalTrans-anastomotic tubes are not used based on Midwest Pediatric Surgical Consortium study showing much higher stricture and leak rates with their use↗
▶Ep 11 · 37:20
quoteI do not actually. I again, a practice of mine that has changed based on our results from the Midwest Pediatric Surgical Consortium study in which the patients who Had a trans anastomotic tube had a much higher stricture and leak rate↗
▶Ep 11 · 37:53
clinicalUnless stricture is incredibly tight, would wait several weeks before first dilation to avoid complete obstruction↗
▶Ep 11 · 38:15
clinicalProximal pouch is always dilated so there is always reported narrowing at anastomosis; as long as contrast flows freely distally, can wait on dilation↗
▶Ep 11 · 38:15
quotethere's always reported a narrowing because the proximal pouch is always dilated, so it always looks like there's a narrowing at the anastomosis.↗
clinicalIf case goes well and post-op study looks great, do not get routine follow-up esophagrams; study only based on clinical symptoms suggesting stricture↗
▶Ep 11 · 39:21
quoteI think that again, having trained using bougie dilators, a balloon or radial dilation is, is less traumatic for the tissue↗
▶Ep 11 · 39:21
clinicalBalloon or radial dilation is less traumatic to tissue than bougie dilators↗
▶Ep 11 · 39:44
quoteI would absolutely wait and do nothing. I would leave the drain in and usually that presents with some saliva in the drain, and I would just wait, and the vast majority of those close.↗
▶Ep 11 · 39:44
clinicalFor small leak in non-sick child, absolutely wait and do nothing, leaving drain in place; vast majority close spontaneously↗
▶Ep 11 · 40:09
clinicalIndications for operative intervention for leak are child getting sicker, wide open leak, or large uncontrollable pneumothorax↗
▶Ep 11 · 40:34
clinicalEven reasonably significant leaks will heal, then stricture can be dealt with postoperatively↗
▶Ep 11 · 40:40
clinicalTypically wait one week between esophagrams for leak, though timing is somewhat arbitrary↗
▶Ep 11 · 41:11
opinionPediatric surgeons do not do a fantastic job of long-term follow-up with TEF patients↗
▶Ep 11 · 41:11
quoteI think that first of all I would make the comment that that's a great point and it's interesting to participate in the International oesophageal atresia. A meeting that occurs every 2 years and to go and see the patients because that meeting is multidisciplinary, including even patients, and you see these patients who come back who are in their 20s or 30s or 40s and they talk about the long term issues that they have and we tend to follow patients until they're, you know, until they're eating well and then they're gone↗
▶Ep 11 · 41:30
clinicalInternational esophageal atresia meetings show patients in their 20s-40s with long-term issues that surgeons are unaware of because patients are lost after age 18↗
▶Ep 11 · 42:15
opinionPersonal practice is to follow patients for at least a couple years, which is probably not long enough↗
▶Ep 11 · 42:30
quoteThe patients that worry me more honestly are the patients who have ongoing reflux, and we don't know the long term impact of that on things like Barrett's esophagus and Potential long term risk for malignant change↗
▶Ep 11 · 42:30
opinionPatients with ongoing reflux are more concerning than those with recurrent strictures due to unknown long-term impact on Barrett's esophagus and malignant change risk↗
▶Ep 11 · 42:45
clinicalMost patients are discharged on anti-reflux medications↗
▶Ep 11 · 42:55
clinicalVirtually all TEF patients have some degree of gastroesophageal reflux↗
▶Ep 11 · 42:55
quoteI would argue that virtually all patients have some degree of gastroesophageal reflux.↗
▶Ep 11 · 43:10
clinicalAfter 2-3 dilations for recurrent stricture, next move is to address reflux with fundoplication↗
▶Ep 11 · 43:10
quoteI personally am very aggressive about doing a fundoplication on those patients↗
▶Ep 11 · 43:26
clinicalFor patients with poor esophageal motility, still perform Nissen but make it loose and short using 2 or at most 3 stitches↗
▶Ep 11 · 43:56
clinicalFor pure esophageal atresia, approach is G-tube placement with gap calibration using distal catheter and proximal NG tube↗
▶Ep 11 · 44:20
clinicalWait 4-6 weeks to see how close ends come together, then attempt primary repair once within 2 vertebral bodies↗
Complications and Beyond
▶Ep 2 · 6:34
clinicalBaseline chest X-ray may be useful if patient later presents with respiratory symptoms and consolidation, providing comparison↗
▶Ep 2 · 25:54
clinicalIf crura come together easily during paraesophageal hernia repair, primary closure without mesh is preferred↗
▶Ep 2 · 29:25
clinicalPosterior defect is the usual problem site in paraesophageal hernia; mesh should cover the posterior repair↗
▶Ep 2 · 33:35
clinicalWaiting only 3-4 weeks for revision risks operating during maximal inflammation period↗
▶Ep 2 · 44:09
quoteI hate this operation, whether it's open or laparoscopic, because you're trying to do a mechanical fix to a physiologic problem, and it's uh miserable.↗
▶Ep 2 · 44:09
opinionFundoplication attempts mechanical fix for physiologic problem, making it inherently difficult operation↗
▶Ep 2 · 45:22
clinicalGastric disconnect is excellent operation in cognitively impaired patients who don't eat much and have refractory reflux or multiple failed fundoplications↗
▶Ep 2 · 49:43
clinicalDextrocardia makes thoracoscopic visualization challenging for EA/TEF repair↗
▶Ep 2 · 49:56
clinicalFor unstable EA/TEF patient, laparotomy with G-tube and vessel loop around GE junction allows fistula control and ventilation, deferring thoracic repair until patient stabilizes↗
▶Ep 2 · 54:34
clinicalBronchoscopy should be performed in all EA/TEF cases to identify additional fistulas↗
▶Ep 2 · 58:19
clinicalTracheal reconstruction for esophageal lung can be performed via median sternotomy: divide trachea, repair esophagus posteriorly, reconstruct trachea and fish-mouth abnormal bronchus to create lung connection↗
▶Ep 2 · 59:03
clinicalIf initial TEF ligation is performed too far from trachea (2cm), significant esophageal length is lost, potentially preventing primary anastomosis↗
▶Ep 2 · 59:24
clinicalMagnet anastomosis can be attempted when esophageal ends are tacked together but gap prevents primary anastomosis↗
clinicalTracheal reconstruction for esophageal lung is performed on cardiopulmonary bypass↗
Tracheoesophageal Fistula with Dr. Daniel von Allmen
▶Ep 26 · 1:36
quoteIt certainly is an interest that we have here with a whole group here in Cincinnati, but it can be an incredibly difficult, challenging problem. It's one of the great cases in pediatric surgery and one of the most difficult cases, so it really runs the whole spectrum for sure.↗
▶Ep 26 · 2:01
clinicalCincinnati Children's has a multidisciplinary aerodigestive center including ENT airway surgeons, GI, pulmonary, general surgeons, nurse practitioners, geneticists, and dietitians↗
▶Ep 26 · 2:46
clinicalThe aerodigestive center typically receives more complicated patients referred from outside through either esophageal or airway arms↗
▶Ep 26 · 3:55
clinicalPhysical examination should assess for scaphoid versus full or distended abdomen and respiratory distress↗
▶Ep 26 · 4:20
clinicalThe surgeon should personally attempt to pass the NG tube rather than relying on nursing reports, as tubes reported as not passing sometimes pass easily↗
▶Ep 26 · 4:20
quoteI personally like to try to pass the NG tube myself, having been burned with NG tubes that wouldn't go down, and the patient was started on treatment as an oesophageal atresia and subsequently found that the NG tube passes just fine.↗
▶Ep 26 · 4:55
clinicalInjecting air into the NG tube and obtaining a plain film helps visualize proximal pouch distention and assess distal GI gas pattern↗
▶Ep 26 · 5:01
clinicalLack of visible distended proximal pouch raises concern for either incorrect diagnosis or presence of proximal fistula allowing pouch decompression↗
▶Ep 26 · 5:01
quoteIf I can't see a distended proximal pouch, then I worry. I worry that either one of two things either that the diagnosis is incorrect and in fact it is not an esophageal atresia, or that there could be a proximal fistula which is allowing that proximal pouch to decompress.↗
▶Ep 26 · 5:42
clinicalContrast studies can be performed if there is high suspicion of unusual anatomy, as long as the radiologist knows the esophagus may be obstructed↗
▶Ep 26 · 6:25
clinicalEchocardiogram is the most important preoperative study to assess cardiac anatomy and rule out right-sided aortic arch↗
▶Ep 26 · 6:25
quoteThe most important one prior to taking the patient to the operating room is to get an echocardiogram, and the utility of that is, is obviously to assess the cardiac anatomy, but more as importantly, I would say is to assess to be sure that the patient does not have a right-sided aortic arch.↗
▶Ep 26 · 6:54
clinicalRenal ultrasound and spine evaluation for tethered cord are needed but are elective and not necessary before addressing esophageal atresia↗
▶Ep 26 · 7:27
guidelineConventional wisdom is to perform left thoracotomy for right-sided aortic arch↗
▶Ep 26 · 7:51
clinicalLeft thoracotomy for right-sided arch is somewhat more difficult with the heart more in the way and harder proximal pouch mobilization↗
▶Ep 26 · 8:20
clinicalIt is possible to complete the repair from the right side if right-sided arch is discovered intraoperatively, though some reports suggest higher incidence of swallowing problems↗
▶Ep 26 · 9:31
clinicalIn a stable larger baby not intubated, it is reasonable to wait until all resources are available in the middle of the day, even waiting 1-2 days↗
▶Ep 26 · 9:56
clinicalShould not wait a long time before repair due to risk of colonizing GI tract and soiling lungs↗
▶Ep 26 · 10:15
opinionOscillator ventilation does not make a significant difference in managing large fistulas with abdominal distention↗
▶Ep 26 · 10:15
clinicalLarge fistula with distention tends to be a bigger problem in more premature infants with significant lung disease, where poor lung compliance drives air into GI tract↗
▶Ep 26 · 10:15
quoteI've not found personally that an oscillator makes a whole lot of difference. I think if the child has a, has a large fistula, and typically it's actually, I believe this tends to be a bigger problem in younger, that is more premature infants who have more significant lung disease, and their compliance of their lungs is really what drives the The air into the GI tract as opposed to into the lungs.↗
▶Ep 26 · 10:56
clinicalTreating with surfactant and improving lung compliance helps as much as changing ventilator type↗
▶Ep 26 · 11:21
clinicalRisk of waiting too long to make a decision in worsening distention can lead to emergency situation where child cannot be ventilated↗
▶Ep 26 · 11:21
quoteI think this is a difficult clinical scenario, and, and I think one of the risks is to wait too long to make a decision, and I've made that mistake myself, and then it becomes an emergency if you can't ventilate the child.↗
▶Ep 26 · 12:00
opinionBronchoscopic Fogarty balloon placement sounds good but is difficult unless expertise and equipment are immediately available↗
▶Ep 26 · 12:00
clinicalFor reasonably stable but worsening distention, would take child urgently to OR for right thoracotomy and fistula ligation↗
▶Ep 26 · 12:00
clinicalG-tube decompression may paradoxically worsen ventilation by making stomach lower resistance, allowing more air to go there instead of lungs↗
▶Ep 26 · 12:00
quoteDecompressing the stomach may just allow that to become, in effect, the even lower resistance and allow more air to go there, making it even more difficult to ventilate. You relieve the abdominal distention, but you don't fix the flow of gas from the Trachea to the GI tract as opposed to from the trachea to the lungs.↗
▶Ep 26 · 12:50
clinicalLaparotomy with vessel loop around esophagogastric junction at hiatus with gentle traction (Rommel tourniquet technique) can temporize severe cases, leaving in place for several days before definitive repair↗
▶Ep 26 · 13:36
clinicalFor associated duodenal atresia in stable child, would potentially fix duodenal atresia first to avoid fixing esophagus upstream from obstruction↗
▶Ep 26 · 14:05
clinicalBoth duodenal and esophageal atresia could potentially be fixed at same time if child is old enough and stable enough↗
▶Ep 26 · 14:35
clinicalMany referred patients with multiple thoracotomies never had bronchoscopy and actually have laryngeal cleft↗
▶Ep 26 · 14:35
clinicalVon Allmen changed practice to always perform intraoperative bronchoscopy after exposure to Cincinnati's complex patient population↗
▶Ep 26 · 14:35
clinicalBronchoscopy documents fistula location, assesses for proximal fistula, and most importantly rules out laryngeal cleft which is easily missed↗
▶Ep 26 · 14:35
quoteThat is one of the things that I have changed in my management after coming here and having exposure to the patient population that we see, the complex patients that we see with the esophageal center and the neurodigestive center, and The airway surgeons here have convinced me that it is really important to do a bronchoscopy↗
▶Ep 26 · 14:35
quoteWe have seen that many times in patients who are referred who've had multiple thoracotomies. Nobody ever did a bronchoscopy and the child actually has a laryngeal cleft↗
▶Ep 26 · 15:35
epidemiologicalSecond fistula occurs in approximately 1% of cases and can be very difficult to diagnose↗
▶Ep 26 · 15:52
clinicalHigh fistulas can range from trifurcation of carina (suggesting difficulty getting ends together) to very high fistulas potentially approachable through neck↗
▶Ep 26 · 16:35
clinicalFor fistula at carina (trifurcation), ET tube should be placed higher as it cannot pass the fistula; for high fistula, tube should be placed distal to fistula but not into the fistula itself↗
▶Ep 26 · 16:35
clinicalBronchoscopy allows guidance of ET tube placement by anesthesiologist based on fistula location↗
▶Ep 26 · 17:19
clinicalExtrapleural approach offers advantage of potentially limiting soilage of pleural space if there is postoperative leak↗
▶Ep 26 · 17:19
quoteI do an extra plural approach and that's the way I was trained. I think it offers the advantage of potentially limiting any soilage of the plural space if there is a leak postoperatively.↗
▶Ep 26 · 17:41
quoteI think there's no morbidity associated with that, so dividing the azygus gives you better access. In fact, frequently will guide you to the fistula.↗
▶Ep 26 · 17:41
clinicalDividing azygos has no morbidity, gives better access, and frequently guides to the fistula↗
▶Ep 26 · 17:59
clinicalOpen azygos division is done by ligation and division; thoracoscopically can use energy devices or clips↗
▶Ep 26 · 18:51
quoteIt is amazing what you can divide with the electric cautery, with the hook electric cautery if you just get used to it, and I learned that doing actually robotic Nissans that you can divide the short gastrics in a teenager with the with the hook electric cautery.↗
▶Ep 26 · 18:51
clinicalHook cautery can safely divide vessels if done slowly going up and down to ensure coagulation, learned from robotic Nissen experience dividing short gastrics↗
▶Ep 26 · 18:51
opinion3mm surgical sealer is ideal device for this size patient and vessel↗
▶Ep 26 · 19:35
clinicalAfter azygos division, identify distal esophagus and control with vessel loop, then dissect proximally to identify fistula site↗
▶Ep 26 · 19:35
clinicalImportant to mobilize pleura up around apex of lung to have access for proximal pouch mobilization↗
▶Ep 26 · 19:35
clinicalSpreading heel of right angle on ribs nicely shows extrapleural plane when going through intercostal muscles↗
▶Ep 26 · 20:28
opinionMuscle-sparing thoracotomy can make exposure more difficult; has not seen significant morbidity from standard posterolateral thoracotomy↗
▶Ep 26 · 21:10
clinicalMust be careful with medial mobilization of distal esophagus due to blood supply concerns↗
▶Ep 26 · 21:10
clinicalExtensive proximal pouch mobilization gives the most length to get ends together↗
▶Ep 26 · 21:10
opinionThoracoscopic approach advantage is clearer visualization for proximal pouch mobilization↗
▶Ep 26 · 21:10
clinicalStandard teaching has been not to mobilize distal esophagus, but can actually mobilize it significantly especially laterally all the way to diaphragm↗
▶Ep 26 · 21:10
quoteI think we have learned that, you know, the standard teaching has been that you shouldn't mobilize the distal esophagus at all, and I think we've learned that in fact you can mobilize that segment a fair amount, especially laterally.↗
▶Ep 26 · 22:20
quoteI completely agree, and I think that you have to be very careful. I personally like to just use a blade, electric cautery and with a little buzz and then mostly blunt dissection with the flat end of the blade, and I think that. That can help you and staying right on the esophagus, which is usually very thickened because it's an obstructed piece of bowel. I would rather be in the esophagus than be in the trachea up high in the chest.↗
▶Ep 26 · 22:20
clinicalBetter to be in esophagus than trachea during high chest dissection; esophagus is thickened from obstruction↗
▶Ep 26 · 22:20
clinicalRisk of entering trachea during proximal dissection; must be very careful using blade cautery with light buzz and mostly blunt dissection with flat end of blade↗
▶Ep 26 · 23:01
clinicalFor significant tracheal defect, could perform sleeve resection as trachea is incredibly mobile, then place pericardium or autologous tissue between trachea and esophageal repair↗
▶Ep 26 · 23:59
opinionPersonal preference is 5-0 PDS - absorbable monofilament suture; not a fan of silk↗
▶Ep 26 · 24:42
quoteI personally am not a big fan of myotomy. I think it. Potentially creates an even more dysfunctional segment of the esophagus than already exists. The motility is clearly abnormal in patients with oesophageal atresia, and doing a myotomy just makes that problem worse.↗
▶Ep 26 · 24:42
opinionNot a fan of myotomies as they potentially create even more dysfunctional esophageal segment; motility is already clearly abnormal in esophageal atresia↗
▶Ep 26 · 24:42
clinicalFor cases too tight for primary repair, would ligate ends, tack both on tension to prevertebral fascia, close, let patient grow for couple weeks, then return to put together↗
▶Ep 26 · 25:38
clinicalTraction or pressure is very strong stimulus to growth throughout cardiovascular system and lungs↗
▶Ep 26 · 25:38
quoteI believe very firmly in the physiology of traction or pressure. Actually it's sort of the reverse, is a very strong stimulus to growth all over the place in the cardiovascular system in the lungs↗
▶Ep 26 · 26:10
clinicalFor thoracoscopic approach, can place traction sutures in proximal and distal ends brought out through crossed trocar sites with tension, allowing return within a week for anastomosis↗
▶Ep 26 · 26:10
opinionWould not do classic Foker technique with prolonged paralysis and sequential suture tensioning↗
▶Ep 26 · 27:38
clinicalFoker technique requires patients intubated and paralyzed spending weeks in ICU, which is probably worth it if you get good result↗
▶Ep 26 · 27:38
epidemiologicalRusty Jennings and Foker published series in JPS showing 98% success getting ends together in primary atresia versus only 67% in secondary approaches after previous surgeries↗
▶Ep 26 · 27:38
quoteThey published a series a year ago or so in JPS looking at their results, and, and it was a very carefully well documented report of their results, and the data are striking if you Have a patient who has a primary atresia that you address, then in 98% of patients they're able to get the two ends of the esophagus together. In contrast, if it's a patient who's had previous surgeries and it's a secondary approach, then only 2/3 of those patients ever get the esophagus together.↗
▶Ep 26 · 29:18
clinicalFor thoracoscopic procedure, rotate patient past 90 degrees to allow gravity to move lungs out of way↗
▶Ep 26 · 29:18
clinicalStandard port placement: camera in center, posterior port inferiorly, anterior port superiorly↗
▶Ep 26 · 29:52
clinicalUses 3mm instruments for thoracoscopic TEF repair↗
▶Ep 26 · 30:10
opinionSimulation courses for TEF repair will be great advantage for trainees as these cases are not done often enough to get practice↗
▶Ep 26 · 30:10
opinionImportant to do same quality operation thoracoscopically as would do open↗
▶Ep 26 · 30:10
opinionThoracoscopic visualization is very helpful for mobilizing proximal pouch↗
▶Ep 26 · 30:10
opinionWould use clips for dividing fistula thoracoscopically, less worried about them falling off esophagus than blood vessel↗
▶Ep 26 · 30:10
clinicalSewing the anastomosis is one of the challenges with thoracoscopic TEF repair and requires most experience with minimally invasive techniques↗
▶Ep 26 · 30:10
quoteI think as with most minimally invasive operations, I think it's important to do the same operation or at least the same quality operation that you would do open and Frankly, I think that's one of the challenges with the thoracoscopic repair of a TEF is to actually sew the anastomosis.↗
▶Ep 26 · 30:10
quoteI'm less worried about them falling off the esophagus than I am having them fall off a blood vessel.↗
▶Ep 26 · 34:30
clinicalThoracoscopic ventilation management depends more on anesthesiologist than ventilator type; need anesthesiologist comfortable with procedure who pays attention during operation↗
▶Ep 26 · 34:30
quoteI think it's more dependent on the anesthesiologist than it is on the type of ventilator, and you have to have an anesthesiologist who's comfortable with doing this and understands what you're trying to accomplish and is paying attention while you're actually doing the operation because they can either help you a lot or hurt you a lot with how they ventilate the child.↗
▶Ep 26 · 35:20
clinicalAnesthesiologists can get scared seeing initial shunting but things settle down if they wait↗
▶Ep 26 · 35:20
clinicalLittle CO2 insufflation with some time will collapse lung as long as anesthesiologist isn't fighting with positive pressure↗
▶Ep 26 · 36:05
quoteI agree it is a concern that the patient may require reintubation. However, I'm equally concerned that positive pressure is putting pressure on my tracheal repair, and I would much rather have the patient be breathing spontaneously to have, in fact, the opposite effect of a negative pressure in the trachea.↗
▶Ep 26 · 36:05
clinicalConcern about reintubation exists, but equally concerned that positive pressure puts pressure on tracheal repair↗
▶Ep 26 · 36:05
opinionPrefer spontaneous breathing with negative pressure in trachea rather than positive pressure↗
▶Ep 26 · 36:05
clinicalIf patient had good lung function preoperatively and operation went smoothly, advocate extubating as soon as possible, even conceivably in operating room↗
▶Ep 26 · 36:35
clinicalGets contrast study at 5-7 days before pulling chest drain, timing depends on avoiding weekends↗
▶Ep 26 · 36:35
clinicalUses small TLS drain rather than formal chest tube, especially for open extrapleural approach↗
▶Ep 26 · 36:35
quoteI do honestly, I'm a little bit old school in that. I still get an esophagram. I usually wait for about 5 days.↗
▶Ep 26 · 37:20
clinicalDoes not use transanastomotic tube based on Midwest Pediatric Surgical Consortium study showing much higher stricture and leak rate with transanastomotic tubes↗
▶Ep 26 · 37:20
quoteI do not actually. I again, a practice of mine that has changed based on our results from the Midwest Pediatric Surgical Consortium study in which the patients who Had a trans anastomotic tube had a much higher stricture and leak rate than patients that did not have that.↗
▶Ep 26 · 37:37
clinicalMidwest consortium study was presented at APSA and should be published in JPS soon↗
▶Ep 26 · 37:55
clinicalAlways appears to be narrowing at anastomosis because proximal pouch is dilated; as long as patent with free contrast flow distally, would hold off on dilation↗
▶Ep 26 · 37:55
clinicalUnless incredibly tight stricture risking complete obstruction, would wait several weeks before first dilation↗
▶Ep 26 · 37:55
quoteUnless it's an incredibly tight stricture, I would wait several weeks before doing a dilation unless I was worried there was going to be a complete obstruction.↗
▶Ep 26 · 37:55
quoteThere's always reported a narrowing because the proximal pouch is always dilated, so it always looks like there's a narrowing at the anastomosis. As long as it's patent and contrast flows freely down the distal esophagus, I would hold off on. Uh, dialing it, dilating it probably several weeks if possible.↗
clinicalHuge spectrum from very tight strictures requiring many dilations to kids fine after one dilation↗
▶Ep 26 · 38:23
clinicalIf case goes well and post-op study looks great, does not get routine follow-up esophagrams; studies based on clinical symptoms suggesting stricture↗
▶Ep 26 · 39:19
clinicalBalloon or radial dilation is less traumatic for tissue than bougie dilators↗
▶Ep 26 · 39:19
clinicalDilations done with GI colleagues in aerodigestive center for bigger kids or with interventional radiologists↗
▶Ep 26 · 39:19
quoteI think that again, having trained using bougie dilators, a balloon or radial dilation is, is less traumatic for the tissue↗
▶Ep 26 · 39:51
clinicalFor small leak with child not sick, would absolutely wait and do nothing, leaving drain in; vast majority close↗
▶Ep 26 · 39:51
quoteI would absolutely wait and do nothing. I would leave the drain in and usually that presents with some saliva in the drain, and I would just wait, and the vast majority of those close.↗
▶Ep 26 · 40:09
clinicalWould only go to OR for leak if child getting sicker, wide open leak, or large uncontrollable pneumothorax↗
▶Ep 26 · 40:09
clinicalEven reasonably significant leaks will heal, then can deal with stricture postoperatively↗
▶Ep 26 · 40:34
clinicalUsually waits one week between esophagrams for leak; if child continues to do well, restudies↗
▶Ep 26 · 40:34
clinicalSometimes little outpouching where leak happened makes it unclear if still leaking; if nothing from tube and nothing goes further, leak probably healed and would remove tube↗
▶Ep 26 · 41:19
quoteI think that first of all I would make the comment that that's a great point and it's interesting to participate in the International oesophageal atresia. A meeting that occurs every 2 years and to go and see the patients because that meeting is multidisciplinary, including even patients, and you see these patients who come back who are in their 20s or 30s or 40s and they talk about the long term issues that they have and we tend to follow patients until they're, you know, until they're eating well and then they're gone↗
▶Ep 26 · 41:19
clinicalInternational esophageal atresia meeting occurs every 2 years and is multidisciplinary including patients↗
▶Ep 26 · 41:19
clinicalPatients in their 20s-40s at international meeting discuss long-term issues; surgeons tend to follow until eating well or age 18 then never see them again↗
▶Ep 26 · 41:19
opinionHave a lot to learn about long-term complications; personally follows patients for at least couple years which is probably not long enough↗
▶Ep 26 · 42:15
clinicalBiggest challenges in long-term follow-up are reflux and recurrent strictures↗
▶Ep 26 · 42:15
clinicalMore concerning are patients with ongoing reflux due to unknown long-term impact on Barrett's esophagus and potential malignant change↗
▶Ep 26 · 42:15
quoteThe patients that worry me more honestly are the patients who have ongoing reflux, and we don't know the long term impact of that on things like Barrett's esophagus and Potential long term risk for malignant change and those sorts of things.↗
▶Ep 26 · 42:45
quoteIf I have a patient who has a stricture that's been dilated 2 or 3 times, my next move would be to address reflux. Most of the patients we leave on anti-reflux medications when they are discharged from the hospital. I would argue that virtually all patients have some degree of gastroesophageal reflux. If they have a stricture that is not responsive to dilations, it dilates easily and then restrictures. I personally am very aggressive about doing a fundoplication on those patients↗
▶Ep 26 · 42:45
clinicalVery aggressive about fundoplication for strictures not responsive to dilations (dilates easily then restrictures)↗
▶Ep 26 · 42:45
clinicalVirtually all patients have some degree of gastroesophageal reflux↗
▶Ep 26 · 42:45
clinicalMost patients left on anti-reflux medications when discharged from hospital↗
▶Ep 26 · 42:45
clinicalIf patient has stricture dilated 2-3 times, next move would be to address reflux↗
▶Ep 26 · 43:26
quoteI do, but as with most Nissans, I make them loose and I make them short, so I usually use two or at most 3 stitches for the wrap and make sure that it is loose around the distal esophagus.↗
▶Ep 26 · 43:26
clinicalWould wait 4-6 weeks to see how close ends come together, then attempt primary repair once within 2 vertebral bodies↗
▶Ep 26 · 43:26
clinicalDoes Nissen fundoplication in patients with poor esophageal motility but makes them loose and short, using 2 or at most 3 stitches↗
▶Ep 26 · 43:26
clinicalFor pure esophageal atresia, approach is G-tube placement with calibration of gap length using distal catheter pushed up and NG tube in proximal pouch↗
Esophageal Atresia in Brief: Presentation, Workup, Diagnosis, and Treatment
▶Ep 29 · 0:00
quoteEsophageal Atresia affects one in 2,500 live births. So it's a really important condition for pediatric surgeons to know about.↗
▶Ep 29 · 0:00
epidemiologicalEsophageal atresia affects 1 in 2,500 live births.↗
▶Ep 29 · 0:51
quotePeople frequently use the term Tracheoesophageal Fistula when they really mean Esophageal Atresia. So it's important to be careful about the terminology that you use when you discuss this anomaly.↗
▶Ep 29 · 1:37
clinicalPatients with tracheoesophageal fistula usually don't present until after birth when they have problems feeding, and a Repogle tube meets resistance at typically 10 to 12 centimeters.↗
▶Ep 29 · 1:58
clinicalInjecting air into the NG tube prior to X-ray will distend the proximal pouch; if it doesn't distend, either the diagnosis is wrong or there could be a proximal fistula.↗
▶Ep 29 · 1:58
quoteIt's often very helpful to prior to taking the X-ray of during the diagnostic process to inject air into the NG tube, because that will distend the proximal pouch. And if it doesn't distend, then either you have the wrong diagnosis, or it could be a clue that there's a proximal fistula.↗
▶Ep 29 · 3:10
clinicalVACTERL workup includes renal ultrasound and spine ultrasound, which doesn't need to be done immediately after birth.↗
▶Ep 29 · 3:10
clinicalThe most pressing study needed is an echocardiogram to look at cardiac function and ensure there are no other congenital heart anomalies, and to identify which side the aortic arch is on.↗
▶Ep 29 · 4:02
clinicalTo be considered truly VACTERL, you need at least three of the associations.↗
▶Ep 29 · 4:48
clinicalH-type (more accurately N-type) esophageal atresia has an intact esophagus but a fistula between the trachea and esophagus, typically high, and is uncommon.↗
▶Ep 29 · 4:48
clinicalOther very uncommon types include proximal fistula or proximal and distal fistula to the trachea.↗
▶Ep 29 · 5:36
clinicalFor the most common type of esophageal atresia, management is to stabilize the patient and get them to the OR, with almost all babies needing surgery within the first day or two depending on stability and medical comorbidities.↗
▶Ep 29 · 5:57
quoteSo we feel that it's really important that every child with Esophageal Atresia undergo bronchoscopy at their initial trip to the operating room to evaluate for multiple things.↗
▶Ep 29 · 5:57
clinicalBronchoscopy is performed to evaluate for the location of a proximal fistula, evaluate the degree of tracheomalacia, and help position the endotracheal tube to minimize the risk of insufflating the GI tract.↗
▶Ep 29 · 6:46
clinicalExtubation is attempted in one to two days, minimizing the risk of using high flow or CPAP following extubation, so the child should be in good respiratory shape when the tube is pulled.↗
▶Ep 29 · 7:43
clinicalRecurrent fistula is a less common early complication.↗
▶Ep 29 · 7:43
clinicalOne of the most common short-term complications is a leak following repair, usually diagnosed with spit coming out of the chest tube, and managed with observation.↗
▶Ep 29 · 7:43
clinicalThe second most common complication is stricture.↗
Update Course 2021: MAGNET THERAPY FOR ESOPHAGEAL ATRESIA
▶Ep 30 · 0:50
quotewe're going to finish up once again with a completely non controversial topic for which the therapy is very straightforward and that is long gap esophagial atresia.↗
▶Ep 30 · 21:07
clinicalDr. Von Allmen's single magnet case worked but resulted in dense stricture requiring lots of dilation and G-tube feeds for long time, though avoided reoperation.↗
Esophageal Replacement with Dr. Dan von Allmen
▶Ep 39 · 0:51
quoteWe have a tendency to say TEF when we mean esophageal atresia, so just be very careful when you're talking about these things that you're clear about what you're talking about, because when you say, oh, the patient had a TEF when really. They had is a pure esophageal atresia. That's just not correct.↗
▶Ep 39 · 1:12
epidemiologicalChromosomal anomalies are fairly common in esophageal atresia, with recurrence risk of 0.5 to 2% among parents who have one affected child↗
▶Ep 39 · 1:12
epidemiologicalEsophageal atresia occurs in 1 in 4500 births in the United States with a slight male predominance↗
▶Ep 39 · 1:36
clinicalPrenatal ultrasound detects only about half of esophageal atresia cases, primarily detecting pure atresia cases due to significant proximal pouch dilation↗
▶Ep 39 · 1:55
clinicalThe most common type of esophageal atresia is proximal atresia with a distal fistula (type C)↗
▶Ep 39 · 2:42
epidemiologicalEsophageal atresia associated with significant cardiac anomalies and low birth weight has only 27 to 30% survival rate↗
clinicalVACTERL is an association, not a syndrome, requiring 3 of the defects (vertebral, anorectal, cardiac, tracheoesophageal, renal, limb) for diagnosis↗
▶Ep 39 · 3:14
quoteBasically, the problem with this is that the low resistance pathway is into the intestine, and that's why the air is going into the intestine instead of into the lungs.↗
▶Ep 39 · 3:14
clinicalIn type C fistula with respiratory distress, the low resistance pathway is into the intestine rather than the lungs, causing air to continuously enter the intestine and increase stomach size↗
▶Ep 39 · 3:14
clinicalGastric decompression with G-tube or needle helps temporarily but air still preferentially exits through the G-tube rather than entering the lungs; placing G-tube end underwater provides some resistance but doesn't completely fix the problem↗
▶Ep 39 · 4:19
clinicalPlacing a vessel loop around the distal esophagus is easier than dividing the fistula when in trouble during the procedure↗
▶Ep 39 · 4:30
clinicalEvery child with tracheoesophageal fistula or esophageal atresia needs a bronchoscopy due to 10-15% association of airway issues↗
▶Ep 39 · 4:30
quoteWe believe quite strongly that every child with a tracheoesophageal fistula or esophageal atresia needs a bronchoscopy.↗
▶Ep 39 · 4:57
clinicalVirtually all children with esophageal atresia have some element of tracheomalacia, though bronchoscopy can show anatomic tracheomalacia but cannot determine if it is clinically significant↗
▶Ep 39 · 4:57
quoteVirtually all kids with esophageal atresia have some element of tracheomalacia. The question is whether it's significant or not.↗
▶Ep 39 · 5:25
quoteI personally believe that there is some Growth in the esophagus and typically our approach is to wait several weeks. I think once you get past probably 4 to 6 weeks, there's not going to be any more growth.↗
▶Ep 39 · 5:25
clinicalFor long-gap cases, the approach at Cincinnati Children's is to support the child with enteral bolus feedings to stretch the distal esophagus, obtain sequential gap studies, and take the child to OR at 6 weeks↗
▶Ep 39 · 5:25
opinionThere is some growth in the esophagus over time in long-gap cases, with maximal growth occurring by 4-6 weeks↗
▶Ep 39 · 6:01
opinionThoracoscopic visualization of the esophagus is better than open surgery when the camera port is placed looking straight down at the esophagus↗
▶Ep 39 · 6:33
clinicalThe azygos vein guides to the level of the fistula because the fistula typically occurs right about the level of the azygos vein↗
▶Ep 39 · 6:55
clinicalWhen clipping the fistula, the clip must be flush with the trachea to avoid leaving a long pouch that can pool secretions and cause problems↗
▶Ep 39 · 6:55
quoteIt's really important to make sure that it is flushed with the trachea. You don't want to leave a long. A pouch because that pouch can pool secretions and would potentially cause problems.↗
▶Ep 39 · 7:15
clinicalAnesthesiologist must push down repeatedly to help locate the proximal esophageal pouch during surgery↗
▶Ep 39 · 7:30
clinicalIt is safer to put a hole in the esophageal pouch than in the trachea during dissection↗
▶Ep 39 · 7:30
quoteYou would much rather put a hole in the esophageal pouch than in the trachea.↗
▶Ep 39 · 7:30
clinicalIatrogenic tracheal injury during thoracoscopy can be detected by sudden elevation of end-tidal CO2 as CO2 from the thoracoscopy enters the trachea↗
▶Ep 39 · 8:14
clinicalThe Foker procedure uses traction sutures brought through the chest wall with sequential tightening to stimulate esophageal growth↗
▶Ep 39 · 8:46
opinionNo esophageal replacement technique is superior to others; the most common is gastric pull-up, but reverse gastric tube, colon interposition, and duodenal interposition are also used↗
▶Ep 39 · 8:46
epidemiologicalPrimary Foker procedure cases spent more than 1 month in ICU on average and were paralyzed for more than 2 weeks↗
▶Ep 39 · 8:46
epidemiologicalSecondary Foker cases spent a mean of 110 days in ICU and were paralyzed for more than 1 month↗
▶Ep 39 · 8:46
quoteI would say that none is any better than the other.↗
▶Ep 39 · 8:46
epidemiologicalIn primary Foker cases, esophageal connection was achieved 96% of the time, compared to only 67% in secondary cases with previous operations↗
▶Ep 39 · 9:43
clinicalReverse gastric tube is created from the greater curve of the stomach and requires preservation of the gastroepiploic artery when placing initial G-tube↗
▶Ep 39 · 9:43
opinionReverse gastric tube has many problems and is not used at Cincinnati Children's↗
▶Ep 39 · 10:06
clinicalColon interposition provides tremendous length, allowing anastomosis to the pharynx in caustic ingestion patients with no remaining esophagus↗
▶Ep 39 · 10:06
quoteThe advantages of the colon are that you can get tremendous length. We've had caustic congestion patients where we literally pushed down on the pharynx and we anastoize the colon to the pharynx because there was no esophagus left.↗
▶Ep 39 · 10:32
clinicalThe biggest challenge with colon interposition is that the colon dilates and elongates over time, causing food to collect and not empty properly↗
▶Ep 39 · 10:32
clinicalContrary to initial teaching, colon interposition grafts are not hard to revise and do not necessarily damage blood supply during revision↗
▶Ep 39 · 10:32
quoteWe were taught initially that these are hard to revise because you damage the blood supply to the colon, but that's actually not true.↗
▶Ep 39 · 10:55
epidemiologicalIn Cincinnati Children's first 13 colon interpositions, 12 of 13 patients were NPO at presentation, and there has been no graft loss since the initial case↗
▶Ep 39 · 10:55
quoteOne of my patients coined the term the callophagus.↗
▶Ep 39 · 12:00
clinicalPosterior tracheopexy involves placing sutures into the membranous trachea to hold it back and manage tracheomalacia↗
▶Ep 39 · 12:00
quoteI am a believer in the posterior tracheopexy, which is putting some sutures into that membranous trachea to hold it, uh, back.↗
▶Ep 39 · 12:00
opinionIt is unknown which patients need posterior tracheopexy, but performing it prophylactically during initial repair takes only 15 minutes and avoids reoperation through previously operated field↗
▶Ep 39 · 12:35
quoteAs surgeons, we're frequently trained that we need to be the captain of the ship, and it's all about us, and we need to do everything. And one of the best things that happened to me when I came here and started doing these esophageal cases was partnering with our ENT group.↗
▶Ep 39 · 12:35
opinionAt Cincinnati Children's, complex esophageal cases including colon interpositions are performed jointly with ENT surgeons, prioritizing patient outcomes over individual surgeon ego↗
Daniel's statements about Esophageal Atresia261 statements
Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula
▶Ep 6 · 9:58
clinicalIf a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse.↗
▶Ep 6 · 14:02
clinicalRoutine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues.↗
▶Ep 6 · 19:37
clinicalDual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings.↗
quoteThe tissue damage extends beyond what you can appreciate with the naked eye, and the progression of it probably extends beyond what you would think is the normal time frame.↗
▶Ep 6 · 1:52:36
clinicalIn a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured.↗
Tracheoesophageal Fistula with Dr. Daniel von Allmen
▶Ep 8 · 1:36
quoteIt certainly is an interest that we have here with a whole group here in Cincinnati, but it can be an incredibly difficult, challenging problem. It's one of the great cases in pediatric surgery and one of the most difficult cases, so it really runs the whole spectrum for sure.↗
▶Ep 8 · 2:01
clinicalCincinnati Children's has a multidisciplinary aerodigestive center that includes ENT airway surgeons, GI, pulmonary, general surgeons, nurse practitioners, geneticists, and dietitians↗
▶Ep 8 · 2:46
clinicalThe aerodigestive center typically receives more complicated patients referred from outside through either esophageal or airway pathways↗
▶Ep 8 · 3:55
clinicalPhysical examination findings in suspected esophageal atresia include assessment for scaphoid versus distended abdomen and respiratory distress↗
▶Ep 8 · 4:20
clinicalPersonal confirmation of NG tube passage is important as some patients started on treatment for esophageal atresia are later found to have tubes that pass normally↗
▶Ep 8 · 4:20
quoteI personally like to try to pass the NG tube myself, having been burned with NG tubes that wouldn't go down, and the patient was started on treatment as an oesophageal atresia and subsequently found that the NG tube passes just fine.↗
▶Ep 8 · 4:55
clinicalInjecting air into the NG tube and obtaining a plain film helps visualize the proximal pouch and assess GI tract gas pattern↗
▶Ep 8 · 5:10
clinicalLack of visible distended proximal pouch on plain film raises concern for either incorrect diagnosis or presence of proximal fistula allowing pouch decompression↗
▶Ep 8 · 5:10
quoteIf I can't see a distended proximal pouch, then I worry. I worry that either one of two things either that the diagnosis is incorrect and in fact it is not an esophageal atresia, or that there could be a proximal fistula which is allowing that proximal pouch to decompress.↗
▶Ep 8 · 5:42
clinicalContrast studies can be performed when there is high suspicion of anatomic variants, with no contraindication as long as radiologist is aware of potential obstruction↗
▶Ep 8 · 6:25
clinicalPreoperative echocardiogram is essential to assess cardiac anatomy and rule out right-sided aortic arch↗
▶Ep 8 · 6:54
clinicalRenal ultrasound and spine evaluation for tethered cord are needed but are elective and not necessary before addressing esophageal atresia↗
▶Ep 8 · 7:27
guidelineConventional wisdom for right-sided aortic arch is to perform left thoracotomy rather than right thoracotomy↗
▶Ep 8 · 7:27
quoteI think that faced with that, that's what I would do if, if the echo was pretty clear and suggest that there's a right sided aortic arch, I would probably approach it through a left thoracotomy.↗
▶Ep 8 · 7:51
clinicalLeft thoracotomy for right-sided arch is somewhat more difficult with heart more in the way and harder proximal pouch mobilization↗
▶Ep 8 · 8:20
clinicalIt is possible to complete the repair from right thoracotomy even with right-sided arch, though some reports suggest higher incidence of swallowing problems↗
▶Ep 8 · 8:20
quoteI think that in most cases it is possible to get the esophagus together and to have a good result.↗
▶Ep 8 · 9:31
quoteI think that in a larger baby who's stable from a respiratory standpoint, not intubated in particular, I think it's perfectly legitimate to wait until you have all the resources that you would have in the middle of the day↗
▶Ep 8 · 9:31
clinicalIn stable larger babies not intubated, it is reasonable to wait until all resources are available in the middle of the day, even waiting until the next day↗
▶Ep 8 · 9:56
clinicalProlonged delay should be avoided due to concern for colonizing GI tract and soiling lungs↗
▶Ep 8 · 10:15
quoteI've not found personally that an oscillator makes a whole lot of difference. I think if the child has a, has a large fistula, and typically it's actually, I believe this tends to be a bigger problem in younger, that is more premature infants who have more significant lung disease↗
▶Ep 8 · 10:15
clinicalOscillator ventilation has not been found to make significant difference in managing unstable TEF patients↗
▶Ep 8 · 10:35
clinicalAir preferentially entering GI tract versus lungs tends to be a bigger problem in more premature infants with significant lung disease and poor lung compliance↗
▶Ep 8 · 10:56
clinicalTreating with surfactant and improving lung compliance helps as much as changing ventilator type in managing air leak through fistula↗
▶Ep 8 · 11:21
clinicalRisk of waiting too long to make a decision in deteriorating patient can lead to emergency situation where ventilation becomes impossible↗
▶Ep 8 · 11:21
quoteI think one of the risks is to wait too long to make a decision, and I've made that mistake myself, and then it becomes an emergency if you can't ventilate the child.↗
▶Ep 8 · 11:40
clinicalFor reasonably stable but worsening patient, approach is urgent right thoracotomy with fistula ligation↗
▶Ep 8 · 12:00
clinicalBronchoscopic placement of Fogarty balloon in fistula is difficult unless expertise and equipment are immediately available↗
▶Ep 8 · 12:25
quoteDecompressing the stomach may just allow that to become, in effect, the even lower resistance and allow more air to go there, making it even more difficult to ventilate.↗
▶Ep 8 · 12:25
clinicalG-tube decompression may paradoxically worsen ventilation by making stomach lower resistance path, allowing more air to go there rather than to lungs↗
▶Ep 8 · 12:50
clinicalLaparotomy with vessel loop around esophagogastric junction at hiatus with gentle traction (Rommel tourniquet technique) can temporize unstable patient for several days↗
▶Ep 8 · 13:51
clinicalIn stable child with associated duodenal atresia, consider fixing duodenal atresia first to avoid repairing esophagus upstream from obstruction↗
▶Ep 8 · 14:13
quoteI think that our pediatric anesthesia has gotten good enough and if the child is old enough and stable enough you could potentially do both procedures at the same time.↗
▶Ep 8 · 14:13
clinicalBoth esophageal and duodenal atresia can potentially be repaired in same operative setting if child is stable enough↗
▶Ep 8 · 14:35
clinicalRoutine intraoperative bronchoscopy is important to document fistula location, assess for proximal fistula, and rule out laryngeal cleft↗
▶Ep 8 · 14:55
quoteThe airway surgeons here have convinced me that it is really important to do a bronchoscopy↗
▶Ep 8 · 15:10
quotewe have seen that many times in patients who are referred who've had multiple thoracotomies. Nobody ever did a bronchoscopy and the child actually has a laryngeal cleft↗
▶Ep 8 · 15:10
clinicalLaryngeal clefts are easily missed and have been seen many times in referred patients who had multiple thoracotomies without anyone doing bronchoscopy↗
▶Ep 8 · 15:30
epidemiologicalSecond fistulas are very uncommon, occurring in perhaps 1% of cases, and can be difficult to diagnose↗
▶Ep 8 · 15:52
clinicalHigh fistulas can be seen bronchoscopically ahead of time and range from trifurcation of carina to fistulas potentially approachable through the neck↗
▶Ep 8 · 16:35
clinicalBronchoscopy allows guidance of anesthesiologist for ET tube placement relative to fistula location↗
▶Ep 8 · 17:00
clinicalFor fistula at carina (trifurcation), ET tube should be placed higher as it cannot pass the fistula; for high fistula, tube should be placed distal to fistula↗
▶Ep 8 · 17:16
clinicalExtrapleural approach offers advantage of potentially limiting soilage of pleural space if there is postoperative leak↗
▶Ep 8 · 17:16
quoteI do an extra plural approach and that's the way I was trained. I think it offers the advantage of potentially limiting any soilage of the plural space if there is a leak postoperatively.↗
▶Ep 8 · 17:41
clinicalDividing azygos vein has no morbidity and gives better access, frequently guiding to the fistula↗
▶Ep 8 · 17:41
quoteI think there's no morbidity associated with that, so dividing the azygus gives you better access. In fact, frequently will guide you to the fistula.↗
▶Ep 8 · 17:59
clinicalFor open repair, azygos is typically ligated and divided with suture↗
▶Ep 8 · 19:35
clinicalSpreading intercostal muscles with heel of right angle on ribs nicely shows extrapleural plane↗
▶Ep 8 · 20:00
clinicalMobilizing pleura up around apex of lung is important to have access for proximal pouch mobilization↗
▶Ep 8 · 20:24
clinicalDistal esophageal segment is controlled with vessel loop to allow proximal dissection to identify fistula↗
▶Ep 8 · 21:10
quoteI think we have learned that, you know, the standard teaching has been that you shouldn't mobilize the distal esophagus at all, and I think we've learned that in fact you can mobilize that segment a fair amount, especially laterally.↗
▶Ep 8 · 21:10
clinicalStandard teaching has been not to mobilize distal esophagus, but it can be mobilized extensively laterally and to some degree medially with care for blood supply↗
▶Ep 8 · 21:40
clinicalExtensive proximal pouch mobilization is most important for gaining length to approximate the ends↗
▶Ep 8 · 22:20
quoteI completely agree, and I think that you have to be very careful. I personally like to just use a blade, electric cautery and with a little buzz and then mostly blunt dissection with the flat end of the blade↗
▶Ep 8 · 22:20
clinicalBlade electrocautery with light buzz and mostly blunt dissection with flat end of blade, staying right on thickened obstructed esophagus, is preferred technique for proximal dissection↗
▶Ep 8 · 22:40
quoteI would rather be in the esophagus than be in the trachea up high in the chest.↗
▶Ep 8 · 22:44
clinicalBetter to be in esophagus than in trachea high in chest during proximal dissection↗
▶Ep 8 · 22:51
clinicalLarge tracheal defect would require sleeve resection, with trachea being incredibly mobile, and placement of pericardium or autologous tissue between trachea and esophageal repair↗
▶Ep 8 · 23:15
quoteThe trachea is incredibly mobile. Another thing that I have learned from my ENT colleagues so that you could effectively do a slide to pull the distal trachea up to the proximal portion to cover that defect.↗
▶Ep 8 · 23:59
quoteI personally use PDS. I probably use 50 PDS. I like absorbable suture. I like monofilament suture. I'm not a big fan of silk↗
▶Ep 8 · 23:59
opinionPersonal preference is 5-0 PDS for anastomosis, favoring absorbable monofilament over silk or other sutures↗
▶Ep 8 · 24:42
opinionCircular myotomies are not favored as they potentially create even more dysfunctional esophageal segment in patients who already have abnormal motility↗
▶Ep 8 · 24:50
quoteI personally am not a big fan of myotomy. I think it. Potentially creates an even more dysfunctional segment of the esophagus than already exists.↗
▶Ep 8 · 25:10
quotemy approach to this is usually if I really try and I think it's going to be way too tight. Then I would ligate the ends, ligate the distal end after dividing the fistula, and then tack both ends on some tension to the prevertebral fascia, close and let the patient grow for a couple of weeks↗
▶Ep 8 · 25:10
clinicalFor long-gap cases, approach is to ligate ends, tack both on tension to prevertebral fascia, close, let patient grow for several weeks, then return for anastomosis↗
▶Ep 8 · 25:38
clinicalTraction or pressure is a strong stimulus to growth throughout the body including cardiovascular system and lungs↗
▶Ep 8 · 25:38
quoteI believe very firmly in the physiology of traction or pressure. Actually it's sort of the reverse, is a very strong stimulus to growth all over the place in the cardiovascular system in the lungs↗
▶Ep 8 · 26:00
clinicalInternal Foker technique uses traction sutures in proximal and distal ends brought out through crossed trocar sites with tension, allowing rapid lengthening within about a week↗
▶Ep 8 · 27:38
epidemiologicalBoston series by Jennings and Foker showed 98% success getting ends together in primary atresia versus only 67% in secondary cases after previous surgeries↗
▶Ep 8 · 27:38
quotethe data are striking if you Have a patient who has a primary atresia that you address, then in 98% of patients they're able to get the two ends of the esophagus together. In contrast, if it's a patient who's had previous surgeries and it's a secondary approach, then only 2/3 of those patients ever get the esophagus together.↗
▶Ep 8 · 28:10
clinicalFoker technique requires patients to be intubated and paralyzed, spending weeks in ICU, which is significant cost but may be worth it for good result↗
▶Ep 8 · 29:18
clinicalFor thoracoscopic approach, patient is rotated past 90 degrees to allow gravity to move lungs out of the way↗
▶Ep 8 · 29:40
clinicalStandard thoracoscopic port placement uses camera in center with posterior port inferiorly and anterior port superiorly↗
▶Ep 8 · 29:52
clinical3mm instruments are used for thoracoscopic TEF repair↗
▶Ep 8 · 30:10
quoteI think it's important to do the same operation or at least the same quality operation that you would do open and Frankly, I think that's one of the challenges with the thoracoscopic repair of a TEF is to actually sew the anastomosis.↗
▶Ep 8 · 30:10
clinicalThoracoscopic visualization is very helpful for mobilizing proximal pouch↗
▶Ep 8 · 30:30
clinicalAnastomosis is the most difficult part of thoracoscopic repair, requiring significant experience with minimally invasive suturing techniques↗
▶Ep 8 · 31:00
opinionClips are preferred for dividing fistula thoracoscopically, with less concern about them falling off esophagus than blood vessels↗
▶Ep 8 · 31:00
quoteI'm less worried about them falling off the esophagus than I am having them fall off a blood vessel.↗
▶Ep 8 · 31:21
quoteIt is amazing what you can divide with the electric cautery, with the hook electric cautery if you just get used to it↗
▶Ep 8 · 31:21
clinicalHook electrocautery can safely divide vessels if used carefully with up-and-down motion ensuring coagulation↗
▶Ep 8 · 31:50
opinion3mm surgical sealer is ideal device for this size patient and vessel size↗
▶Ep 8 · 31:50
quoteI think the 3 millimeter sealer is a, is a great device for this size patient and that size vessel.↗
▶Ep 8 · 32:00
clinicalHanging stitch technique (first stitch brought out of chest) helps line up anastomosis similar to duodenal atresia repair↗
▶Ep 8 · 33:54
clinicalHanging stitch helps release tension as first stitches are placed and allows visualization of mucosa in both proximal and distal lumens↗
▶Ep 8 · 33:54
quoteTo me, the important part, and I beat on our residents about this when they're doing this anastomosis, is you have to be able to see. You want to make sure that you incorporate mucosa on every stitch↗
▶Ep 8 · 34:15
clinicalIncorporating mucosa on every stitch is critical and easier to verify with thoracoscopic visualization↗
▶Ep 8 · 34:23
clinicalVentilator management is more dependent on anesthesiologist comfort and attention than ventilator type↗
▶Ep 8 · 34:23
quoteI think it's more dependent on the anesthesiologist than it is on the type of ventilator, and you have to have an anesthesiologist who's comfortable with doing this and understands what you're trying to accomplish↗
▶Ep 8 · 34:45
clinicalAnesthesiologist must understand goals and pay attention during operation, as they can significantly help or hurt with ventilation approach↗
▶Ep 8 · 35:20
clinicalLittle CO2 insufflation with time will collapse lung as long as anesthesiologist is not fighting with positive pressure↗
▶Ep 8 · 35:58
clinicalConcern about reintubation is balanced by greater concern that positive pressure puts pressure on tracheal repair↗
▶Ep 8 · 35:58
quoteI agree it is a concern that the patient may require reintubation. However, I'm equally concerned that positive pressure is putting pressure on my tracheal repair↗
▶Ep 8 · 36:15
clinicalSpontaneous breathing creates negative pressure in trachea, which is preferable to positive pressure on repair↗
▶Ep 8 · 36:15
quoteI would much rather have the patient be breathing spontaneously to have, in fact, the opposite effect of a negative pressure in the trachea.↗
▶Ep 8 · 36:34
clinicalFor patients with good preoperative lung function and smooth operation, advocate extubating as soon as possible, even in operating room↗
▶Ep 8 · 36:43
clinicalContrast esophagram is obtained at 5-7 days postoperatively before pulling chest drain↗
▶Ep 8 · 36:43
quoteI do honestly, I'm a little bit old school in that. I still get an esophagram.↗
▶Ep 8 · 37:15
clinicalSmall TLS drains are used rather than formal chest tube, especially for open extrapleural approach↗
▶Ep 8 · 37:20
clinicalTrans-anastomotic tubes are not used based on Midwest Pediatric Surgical Consortium study showing much higher stricture and leak rates with their use↗
▶Ep 8 · 37:20
quoteI do not actually. I again, a practice of mine that has changed based on our results from the Midwest Pediatric Surgical Consortium study in which the patients who Had a trans anastomotic tube had a much higher stricture and leak rate↗
▶Ep 8 · 37:53
clinicalUnless stricture is incredibly tight, would wait several weeks before first dilation to avoid complete obstruction↗
▶Ep 8 · 38:15
clinicalProximal pouch is always dilated so there is always reported narrowing at anastomosis; as long as contrast flows freely distally, can wait on dilation↗
▶Ep 8 · 38:15
quotethere's always reported a narrowing because the proximal pouch is always dilated, so it always looks like there's a narrowing at the anastomosis.↗
clinicalIf case goes well and post-op study looks great, do not get routine follow-up esophagrams; study only based on clinical symptoms suggesting stricture↗
▶Ep 8 · 39:21
clinicalBalloon or radial dilation is less traumatic to tissue than bougie dilators↗
▶Ep 8 · 39:21
quoteI think that again, having trained using bougie dilators, a balloon or radial dilation is, is less traumatic for the tissue↗
▶Ep 8 · 39:44
clinicalFor small leak in non-sick child, absolutely wait and do nothing, leaving drain in place; vast majority close spontaneously↗
▶Ep 8 · 39:44
quoteI would absolutely wait and do nothing. I would leave the drain in and usually that presents with some saliva in the drain, and I would just wait, and the vast majority of those close.↗
▶Ep 8 · 40:09
clinicalIndications for operative intervention for leak are child getting sicker, wide open leak, or large uncontrollable pneumothorax↗
▶Ep 8 · 40:34
clinicalEven reasonably significant leaks will heal, then stricture can be dealt with postoperatively↗
▶Ep 8 · 40:40
clinicalTypically wait one week between esophagrams for leak, though timing is somewhat arbitrary↗
▶Ep 8 · 41:11
opinionPediatric surgeons do not do a fantastic job of long-term follow-up with TEF patients↗
▶Ep 8 · 41:11
quoteI think that first of all I would make the comment that that's a great point and it's interesting to participate in the International oesophageal atresia. A meeting that occurs every 2 years and to go and see the patients because that meeting is multidisciplinary, including even patients, and you see these patients who come back who are in their 20s or 30s or 40s and they talk about the long term issues that they have and we tend to follow patients until they're, you know, until they're eating well and then they're gone↗
▶Ep 8 · 41:30
clinicalInternational esophageal atresia meetings show patients in their 20s-40s with long-term issues that surgeons are unaware of because patients are lost after age 18↗
▶Ep 8 · 42:15
opinionPersonal practice is to follow patients for at least a couple years, which is probably not long enough↗
▶Ep 8 · 42:30
quoteThe patients that worry me more honestly are the patients who have ongoing reflux, and we don't know the long term impact of that on things like Barrett's esophagus and Potential long term risk for malignant change↗
▶Ep 8 · 42:30
opinionPatients with ongoing reflux are more concerning than those with recurrent strictures due to unknown long-term impact on Barrett's esophagus and malignant change risk↗
▶Ep 8 · 42:45
clinicalMost patients are discharged on anti-reflux medications↗
▶Ep 8 · 42:55
clinicalVirtually all TEF patients have some degree of gastroesophageal reflux↗
▶Ep 8 · 42:55
quoteI would argue that virtually all patients have some degree of gastroesophageal reflux.↗
▶Ep 8 · 43:10
quoteI personally am very aggressive about doing a fundoplication on those patients↗
▶Ep 8 · 43:10
clinicalAfter 2-3 dilations for recurrent stricture, next move is to address reflux with fundoplication↗
▶Ep 8 · 43:26
clinicalFor patients with poor esophageal motility, still perform Nissen but make it loose and short using 2 or at most 3 stitches↗
▶Ep 8 · 43:56
clinicalFor pure esophageal atresia, approach is G-tube placement with gap calibration using distal catheter and proximal NG tube↗
▶Ep 8 · 44:20
clinicalWait 4-6 weeks to see how close ends come together, then attempt primary repair once within 2 vertebral bodies↗
Tracheoesophageal Fistula with Dr. Daniel von Allmen
▶Ep 21 · 1:36
quoteIt certainly is an interest that we have here with a whole group here in Cincinnati, but it can be an incredibly difficult, challenging problem. It's one of the great cases in pediatric surgery and one of the most difficult cases, so it really runs the whole spectrum for sure.↗
▶Ep 21 · 2:01
clinicalCincinnati Children's has a multidisciplinary aerodigestive center including ENT airway surgeons, GI, pulmonary, general surgeons, nurse practitioners, geneticists, and dietitians↗
▶Ep 21 · 2:46
clinicalThe aerodigestive center typically receives more complicated patients referred from outside through either esophageal or airway arms↗
▶Ep 21 · 3:55
clinicalPhysical examination should assess for scaphoid versus full or distended abdomen and respiratory distress↗
▶Ep 21 · 4:20
clinicalThe surgeon should personally attempt to pass the NG tube rather than relying on nursing reports, as tubes reported as not passing sometimes pass easily↗
▶Ep 21 · 4:20
quoteI personally like to try to pass the NG tube myself, having been burned with NG tubes that wouldn't go down, and the patient was started on treatment as an oesophageal atresia and subsequently found that the NG tube passes just fine.↗
▶Ep 21 · 4:55
clinicalInjecting air into the NG tube and obtaining a plain film helps visualize proximal pouch distention and assess distal GI gas pattern↗
▶Ep 21 · 5:01
clinicalLack of visible distended proximal pouch raises concern for either incorrect diagnosis or presence of proximal fistula allowing pouch decompression↗
▶Ep 21 · 5:01
quoteIf I can't see a distended proximal pouch, then I worry. I worry that either one of two things either that the diagnosis is incorrect and in fact it is not an esophageal atresia, or that there could be a proximal fistula which is allowing that proximal pouch to decompress.↗
▶Ep 21 · 5:42
clinicalContrast studies can be performed if there is high suspicion of unusual anatomy, as long as the radiologist knows the esophagus may be obstructed↗
▶Ep 21 · 6:25
clinicalEchocardiogram is the most important preoperative study to assess cardiac anatomy and rule out right-sided aortic arch↗
▶Ep 21 · 6:25
quoteThe most important one prior to taking the patient to the operating room is to get an echocardiogram, and the utility of that is, is obviously to assess the cardiac anatomy, but more as importantly, I would say is to assess to be sure that the patient does not have a right-sided aortic arch.↗
▶Ep 21 · 6:54
clinicalRenal ultrasound and spine evaluation for tethered cord are needed but are elective and not necessary before addressing esophageal atresia↗
▶Ep 21 · 7:27
guidelineConventional wisdom is to perform left thoracotomy for right-sided aortic arch↗
▶Ep 21 · 7:51
clinicalLeft thoracotomy for right-sided arch is somewhat more difficult with the heart more in the way and harder proximal pouch mobilization↗
▶Ep 21 · 8:20
clinicalIt is possible to complete the repair from the right side if right-sided arch is discovered intraoperatively, though some reports suggest higher incidence of swallowing problems↗
▶Ep 21 · 9:31
clinicalIn a stable larger baby not intubated, it is reasonable to wait until all resources are available in the middle of the day, even waiting 1-2 days↗
▶Ep 21 · 9:56
clinicalShould not wait a long time before repair due to risk of colonizing GI tract and soiling lungs↗
▶Ep 21 · 10:15
clinicalLarge fistula with distention tends to be a bigger problem in more premature infants with significant lung disease, where poor lung compliance drives air into GI tract↗
▶Ep 21 · 10:15
opinionOscillator ventilation does not make a significant difference in managing large fistulas with abdominal distention↗
▶Ep 21 · 10:15
quoteI've not found personally that an oscillator makes a whole lot of difference. I think if the child has a, has a large fistula, and typically it's actually, I believe this tends to be a bigger problem in younger, that is more premature infants who have more significant lung disease, and their compliance of their lungs is really what drives the The air into the GI tract as opposed to into the lungs.↗
▶Ep 21 · 10:56
clinicalTreating with surfactant and improving lung compliance helps as much as changing ventilator type↗
▶Ep 21 · 11:21
clinicalRisk of waiting too long to make a decision in worsening distention can lead to emergency situation where child cannot be ventilated↗
▶Ep 21 · 11:21
quoteI think this is a difficult clinical scenario, and, and I think one of the risks is to wait too long to make a decision, and I've made that mistake myself, and then it becomes an emergency if you can't ventilate the child.↗
▶Ep 21 · 12:00
quoteDecompressing the stomach may just allow that to become, in effect, the even lower resistance and allow more air to go there, making it even more difficult to ventilate. You relieve the abdominal distention, but you don't fix the flow of gas from the Trachea to the GI tract as opposed to from the trachea to the lungs.↗
▶Ep 21 · 12:00
clinicalFor reasonably stable but worsening distention, would take child urgently to OR for right thoracotomy and fistula ligation↗
▶Ep 21 · 12:00
opinionBronchoscopic Fogarty balloon placement sounds good but is difficult unless expertise and equipment are immediately available↗
▶Ep 21 · 12:00
clinicalG-tube decompression may paradoxically worsen ventilation by making stomach lower resistance, allowing more air to go there instead of lungs↗
▶Ep 21 · 12:50
clinicalLaparotomy with vessel loop around esophagogastric junction at hiatus with gentle traction (Rommel tourniquet technique) can temporize severe cases, leaving in place for several days before definitive repair↗
▶Ep 21 · 13:36
clinicalFor associated duodenal atresia in stable child, would potentially fix duodenal atresia first to avoid fixing esophagus upstream from obstruction↗
▶Ep 21 · 14:05
clinicalBoth duodenal and esophageal atresia could potentially be fixed at same time if child is old enough and stable enough↗
▶Ep 21 · 14:35
clinicalVon Allmen changed practice to always perform intraoperative bronchoscopy after exposure to Cincinnati's complex patient population↗
▶Ep 21 · 14:35
clinicalBronchoscopy documents fistula location, assesses for proximal fistula, and most importantly rules out laryngeal cleft which is easily missed↗
▶Ep 21 · 14:35
clinicalMany referred patients with multiple thoracotomies never had bronchoscopy and actually have laryngeal cleft↗
▶Ep 21 · 14:35
quoteWe have seen that many times in patients who are referred who've had multiple thoracotomies. Nobody ever did a bronchoscopy and the child actually has a laryngeal cleft↗
▶Ep 21 · 14:35
quoteThat is one of the things that I have changed in my management after coming here and having exposure to the patient population that we see, the complex patients that we see with the esophageal center and the neurodigestive center, and The airway surgeons here have convinced me that it is really important to do a bronchoscopy↗
▶Ep 21 · 15:35
epidemiologicalSecond fistula occurs in approximately 1% of cases and can be very difficult to diagnose↗
▶Ep 21 · 15:52
clinicalHigh fistulas can range from trifurcation of carina (suggesting difficulty getting ends together) to very high fistulas potentially approachable through neck↗
▶Ep 21 · 16:35
clinicalFor fistula at carina (trifurcation), ET tube should be placed higher as it cannot pass the fistula; for high fistula, tube should be placed distal to fistula but not into the fistula itself↗
▶Ep 21 · 16:35
clinicalBronchoscopy allows guidance of ET tube placement by anesthesiologist based on fistula location↗
▶Ep 21 · 17:19
clinicalExtrapleural approach offers advantage of potentially limiting soilage of pleural space if there is postoperative leak↗
▶Ep 21 · 17:19
quoteI do an extra plural approach and that's the way I was trained. I think it offers the advantage of potentially limiting any soilage of the plural space if there is a leak postoperatively.↗
▶Ep 21 · 17:41
quoteI think there's no morbidity associated with that, so dividing the azygus gives you better access. In fact, frequently will guide you to the fistula.↗
▶Ep 21 · 17:41
clinicalDividing azygos has no morbidity, gives better access, and frequently guides to the fistula↗
▶Ep 21 · 17:59
clinicalOpen azygos division is done by ligation and division; thoracoscopically can use energy devices or clips↗
▶Ep 21 · 18:51
quoteIt is amazing what you can divide with the electric cautery, with the hook electric cautery if you just get used to it, and I learned that doing actually robotic Nissans that you can divide the short gastrics in a teenager with the with the hook electric cautery.↗
▶Ep 21 · 18:51
opinion3mm surgical sealer is ideal device for this size patient and vessel↗
▶Ep 21 · 18:51
clinicalHook cautery can safely divide vessels if done slowly going up and down to ensure coagulation, learned from robotic Nissen experience dividing short gastrics↗
▶Ep 21 · 19:35
clinicalImportant to mobilize pleura up around apex of lung to have access for proximal pouch mobilization↗
▶Ep 21 · 19:35
clinicalSpreading heel of right angle on ribs nicely shows extrapleural plane when going through intercostal muscles↗
▶Ep 21 · 19:35
clinicalAfter azygos division, identify distal esophagus and control with vessel loop, then dissect proximally to identify fistula site↗
▶Ep 21 · 20:28
opinionMuscle-sparing thoracotomy can make exposure more difficult; has not seen significant morbidity from standard posterolateral thoracotomy↗
▶Ep 21 · 21:10
clinicalStandard teaching has been not to mobilize distal esophagus, but can actually mobilize it significantly especially laterally all the way to diaphragm↗
▶Ep 21 · 21:10
clinicalMust be careful with medial mobilization of distal esophagus due to blood supply concerns↗
▶Ep 21 · 21:10
clinicalExtensive proximal pouch mobilization gives the most length to get ends together↗
▶Ep 21 · 21:10
opinionThoracoscopic approach advantage is clearer visualization for proximal pouch mobilization↗
▶Ep 21 · 21:10
quoteI think we have learned that, you know, the standard teaching has been that you shouldn't mobilize the distal esophagus at all, and I think we've learned that in fact you can mobilize that segment a fair amount, especially laterally.↗
▶Ep 21 · 22:20
quoteI completely agree, and I think that you have to be very careful. I personally like to just use a blade, electric cautery and with a little buzz and then mostly blunt dissection with the flat end of the blade, and I think that. That can help you and staying right on the esophagus, which is usually very thickened because it's an obstructed piece of bowel. I would rather be in the esophagus than be in the trachea up high in the chest.↗
▶Ep 21 · 22:20
clinicalRisk of entering trachea during proximal dissection; must be very careful using blade cautery with light buzz and mostly blunt dissection with flat end of blade↗
▶Ep 21 · 22:20
clinicalBetter to be in esophagus than trachea during high chest dissection; esophagus is thickened from obstruction↗
▶Ep 21 · 23:01
clinicalFor significant tracheal defect, could perform sleeve resection as trachea is incredibly mobile, then place pericardium or autologous tissue between trachea and esophageal repair↗
▶Ep 21 · 23:59
opinionPersonal preference is 5-0 PDS - absorbable monofilament suture; not a fan of silk↗
▶Ep 21 · 24:42
opinionNot a fan of myotomies as they potentially create even more dysfunctional esophageal segment; motility is already clearly abnormal in esophageal atresia↗
▶Ep 21 · 24:42
quoteI personally am not a big fan of myotomy. I think it. Potentially creates an even more dysfunctional segment of the esophagus than already exists. The motility is clearly abnormal in patients with oesophageal atresia, and doing a myotomy just makes that problem worse.↗
▶Ep 21 · 24:42
clinicalFor cases too tight for primary repair, would ligate ends, tack both on tension to prevertebral fascia, close, let patient grow for couple weeks, then return to put together↗
▶Ep 21 · 25:38
quoteI believe very firmly in the physiology of traction or pressure. Actually it's sort of the reverse, is a very strong stimulus to growth all over the place in the cardiovascular system in the lungs↗
▶Ep 21 · 25:38
clinicalTraction or pressure is very strong stimulus to growth throughout cardiovascular system and lungs↗
▶Ep 21 · 26:10
opinionWould not do classic Foker technique with prolonged paralysis and sequential suture tensioning↗
▶Ep 21 · 26:10
clinicalFor thoracoscopic approach, can place traction sutures in proximal and distal ends brought out through crossed trocar sites with tension, allowing return within a week for anastomosis↗
▶Ep 21 · 27:38
quoteThey published a series a year ago or so in JPS looking at their results, and, and it was a very carefully well documented report of their results, and the data are striking if you Have a patient who has a primary atresia that you address, then in 98% of patients they're able to get the two ends of the esophagus together. In contrast, if it's a patient who's had previous surgeries and it's a secondary approach, then only 2/3 of those patients ever get the esophagus together.↗
▶Ep 21 · 27:38
clinicalFoker technique requires patients intubated and paralyzed spending weeks in ICU, which is probably worth it if you get good result↗
▶Ep 21 · 27:38
epidemiologicalRusty Jennings and Foker published series in JPS showing 98% success getting ends together in primary atresia versus only 67% in secondary approaches after previous surgeries↗
▶Ep 21 · 29:18
clinicalStandard port placement: camera in center, posterior port inferiorly, anterior port superiorly↗
▶Ep 21 · 29:18
clinicalFor thoracoscopic procedure, rotate patient past 90 degrees to allow gravity to move lungs out of way↗
▶Ep 21 · 29:52
clinicalUses 3mm instruments for thoracoscopic TEF repair↗
▶Ep 21 · 30:10
opinionSimulation courses for TEF repair will be great advantage for trainees as these cases are not done often enough to get practice↗
▶Ep 21 · 30:10
quoteI think as with most minimally invasive operations, I think it's important to do the same operation or at least the same quality operation that you would do open and Frankly, I think that's one of the challenges with the thoracoscopic repair of a TEF is to actually sew the anastomosis.↗
▶Ep 21 · 30:10
quoteI'm less worried about them falling off the esophagus than I am having them fall off a blood vessel.↗
▶Ep 21 · 30:10
opinionThoracoscopic visualization is very helpful for mobilizing proximal pouch↗
▶Ep 21 · 30:10
clinicalSewing the anastomosis is one of the challenges with thoracoscopic TEF repair and requires most experience with minimally invasive techniques↗
▶Ep 21 · 30:10
opinionWould use clips for dividing fistula thoracoscopically, less worried about them falling off esophagus than blood vessel↗
▶Ep 21 · 30:10
opinionImportant to do same quality operation thoracoscopically as would do open↗
▶Ep 21 · 34:30
quoteI think it's more dependent on the anesthesiologist than it is on the type of ventilator, and you have to have an anesthesiologist who's comfortable with doing this and understands what you're trying to accomplish and is paying attention while you're actually doing the operation because they can either help you a lot or hurt you a lot with how they ventilate the child.↗
▶Ep 21 · 34:30
clinicalThoracoscopic ventilation management depends more on anesthesiologist than ventilator type; need anesthesiologist comfortable with procedure who pays attention during operation↗
▶Ep 21 · 35:20
clinicalLittle CO2 insufflation with some time will collapse lung as long as anesthesiologist isn't fighting with positive pressure↗
▶Ep 21 · 35:20
clinicalAnesthesiologists can get scared seeing initial shunting but things settle down if they wait↗
▶Ep 21 · 36:05
clinicalConcern about reintubation exists, but equally concerned that positive pressure puts pressure on tracheal repair↗
▶Ep 21 · 36:05
opinionPrefer spontaneous breathing with negative pressure in trachea rather than positive pressure↗
▶Ep 21 · 36:05
clinicalIf patient had good lung function preoperatively and operation went smoothly, advocate extubating as soon as possible, even conceivably in operating room↗
▶Ep 21 · 36:05
quoteI agree it is a concern that the patient may require reintubation. However, I'm equally concerned that positive pressure is putting pressure on my tracheal repair, and I would much rather have the patient be breathing spontaneously to have, in fact, the opposite effect of a negative pressure in the trachea.↗
▶Ep 21 · 36:35
clinicalGets contrast study at 5-7 days before pulling chest drain, timing depends on avoiding weekends↗
▶Ep 21 · 36:35
clinicalUses small TLS drain rather than formal chest tube, especially for open extrapleural approach↗
▶Ep 21 · 36:35
quoteI do honestly, I'm a little bit old school in that. I still get an esophagram. I usually wait for about 5 days.↗
▶Ep 21 · 37:20
clinicalDoes not use transanastomotic tube based on Midwest Pediatric Surgical Consortium study showing much higher stricture and leak rate with transanastomotic tubes↗
▶Ep 21 · 37:20
quoteI do not actually. I again, a practice of mine that has changed based on our results from the Midwest Pediatric Surgical Consortium study in which the patients who Had a trans anastomotic tube had a much higher stricture and leak rate than patients that did not have that.↗
▶Ep 21 · 37:37
clinicalMidwest consortium study was presented at APSA and should be published in JPS soon↗
▶Ep 21 · 37:55
quoteUnless it's an incredibly tight stricture, I would wait several weeks before doing a dilation unless I was worried there was going to be a complete obstruction.↗
▶Ep 21 · 37:55
quoteThere's always reported a narrowing because the proximal pouch is always dilated, so it always looks like there's a narrowing at the anastomosis. As long as it's patent and contrast flows freely down the distal esophagus, I would hold off on. Uh, dialing it, dilating it probably several weeks if possible.↗
▶Ep 21 · 37:55
clinicalAlways appears to be narrowing at anastomosis because proximal pouch is dilated; as long as patent with free contrast flow distally, would hold off on dilation↗
▶Ep 21 · 37:55
clinicalUnless incredibly tight stricture risking complete obstruction, would wait several weeks before first dilation↗
▶Ep 21 · 38:23
clinicalIf case goes well and post-op study looks great, does not get routine follow-up esophagrams; studies based on clinical symptoms suggesting stricture↗
clinicalHuge spectrum from very tight strictures requiring many dilations to kids fine after one dilation↗
▶Ep 21 · 39:19
clinicalDilations done with GI colleagues in aerodigestive center for bigger kids or with interventional radiologists↗
▶Ep 21 · 39:19
clinicalBalloon or radial dilation is less traumatic for tissue than bougie dilators↗
▶Ep 21 · 39:19
quoteI think that again, having trained using bougie dilators, a balloon or radial dilation is, is less traumatic for the tissue↗
▶Ep 21 · 39:51
quoteI would absolutely wait and do nothing. I would leave the drain in and usually that presents with some saliva in the drain, and I would just wait, and the vast majority of those close.↗
▶Ep 21 · 39:51
clinicalFor small leak with child not sick, would absolutely wait and do nothing, leaving drain in; vast majority close↗
▶Ep 21 · 40:09
clinicalWould only go to OR for leak if child getting sicker, wide open leak, or large uncontrollable pneumothorax↗
▶Ep 21 · 40:09
clinicalEven reasonably significant leaks will heal, then can deal with stricture postoperatively↗
▶Ep 21 · 40:34
clinicalUsually waits one week between esophagrams for leak; if child continues to do well, restudies↗
▶Ep 21 · 40:34
clinicalSometimes little outpouching where leak happened makes it unclear if still leaking; if nothing from tube and nothing goes further, leak probably healed and would remove tube↗
▶Ep 21 · 41:19
quoteI think that first of all I would make the comment that that's a great point and it's interesting to participate in the International oesophageal atresia. A meeting that occurs every 2 years and to go and see the patients because that meeting is multidisciplinary, including even patients, and you see these patients who come back who are in their 20s or 30s or 40s and they talk about the long term issues that they have and we tend to follow patients until they're, you know, until they're eating well and then they're gone↗
▶Ep 21 · 41:19
clinicalInternational esophageal atresia meeting occurs every 2 years and is multidisciplinary including patients↗
▶Ep 21 · 41:19
opinionHave a lot to learn about long-term complications; personally follows patients for at least couple years which is probably not long enough↗
▶Ep 21 · 41:19
clinicalPatients in their 20s-40s at international meeting discuss long-term issues; surgeons tend to follow until eating well or age 18 then never see them again↗
▶Ep 21 · 42:15
clinicalMore concerning are patients with ongoing reflux due to unknown long-term impact on Barrett's esophagus and potential malignant change↗
▶Ep 21 · 42:15
quoteThe patients that worry me more honestly are the patients who have ongoing reflux, and we don't know the long term impact of that on things like Barrett's esophagus and Potential long term risk for malignant change and those sorts of things.↗
▶Ep 21 · 42:15
clinicalBiggest challenges in long-term follow-up are reflux and recurrent strictures↗
▶Ep 21 · 42:45
quoteIf I have a patient who has a stricture that's been dilated 2 or 3 times, my next move would be to address reflux. Most of the patients we leave on anti-reflux medications when they are discharged from the hospital. I would argue that virtually all patients have some degree of gastroesophageal reflux. If they have a stricture that is not responsive to dilations, it dilates easily and then restrictures. I personally am very aggressive about doing a fundoplication on those patients↗
▶Ep 21 · 42:45
clinicalVery aggressive about fundoplication for strictures not responsive to dilations (dilates easily then restrictures)↗
▶Ep 21 · 42:45
clinicalVirtually all patients have some degree of gastroesophageal reflux↗
▶Ep 21 · 42:45
clinicalMost patients left on anti-reflux medications when discharged from hospital↗
▶Ep 21 · 42:45
clinicalIf patient has stricture dilated 2-3 times, next move would be to address reflux↗
▶Ep 21 · 43:26
clinicalDoes Nissen fundoplication in patients with poor esophageal motility but makes them loose and short, using 2 or at most 3 stitches↗
▶Ep 21 · 43:26
clinicalFor pure esophageal atresia, approach is G-tube placement with calibration of gap length using distal catheter pushed up and NG tube in proximal pouch↗
▶Ep 21 · 43:26
clinicalWould wait 4-6 weeks to see how close ends come together, then attempt primary repair once within 2 vertebral bodies↗
▶Ep 21 · 43:26
quoteI do, but as with most Nissans, I make them loose and I make them short, so I usually use two or at most 3 stitches for the wrap and make sure that it is loose around the distal esophagus.↗
Daniel's statements about Esophageal Atresia149 statements
Tracheoesophageal Fistula with Dr. Daniel von Allmen
▶Ep 2 · 1:36
quoteIt certainly is an interest that we have here with a whole group here in Cincinnati, but it can be an incredibly difficult, challenging problem. It's one of the great cases in pediatric surgery and one of the most difficult cases, so it really runs the whole spectrum for sure.↗
▶Ep 2 · 2:01
clinicalCincinnati Children's has a multidisciplinary aerodigestive center including ENT airway surgeons, GI, pulmonary, general surgeons, nurse practitioners, geneticists, and dietitians↗
▶Ep 2 · 2:46
clinicalThe aerodigestive center typically receives more complicated patients referred from outside through either esophageal or airway arms↗
▶Ep 2 · 3:55
clinicalPhysical examination should assess for scaphoid versus full or distended abdomen and respiratory distress↗
▶Ep 2 · 4:20
clinicalThe surgeon should personally attempt to pass the NG tube rather than relying on nursing reports, as tubes reported as not passing sometimes pass easily↗
▶Ep 2 · 4:20
quoteI personally like to try to pass the NG tube myself, having been burned with NG tubes that wouldn't go down, and the patient was started on treatment as an oesophageal atresia and subsequently found that the NG tube passes just fine.↗
▶Ep 2 · 4:55
clinicalInjecting air into the NG tube and obtaining a plain film helps visualize proximal pouch distention and assess distal GI gas pattern↗
▶Ep 2 · 5:01
clinicalLack of visible distended proximal pouch raises concern for either incorrect diagnosis or presence of proximal fistula allowing pouch decompression↗
▶Ep 2 · 5:01
quoteIf I can't see a distended proximal pouch, then I worry. I worry that either one of two things either that the diagnosis is incorrect and in fact it is not an esophageal atresia, or that there could be a proximal fistula which is allowing that proximal pouch to decompress.↗
▶Ep 2 · 5:42
clinicalContrast studies can be performed if there is high suspicion of unusual anatomy, as long as the radiologist knows the esophagus may be obstructed↗
▶Ep 2 · 6:25
clinicalEchocardiogram is the most important preoperative study to assess cardiac anatomy and rule out right-sided aortic arch↗
▶Ep 2 · 6:25
quoteThe most important one prior to taking the patient to the operating room is to get an echocardiogram, and the utility of that is, is obviously to assess the cardiac anatomy, but more as importantly, I would say is to assess to be sure that the patient does not have a right-sided aortic arch.↗
▶Ep 2 · 6:54
clinicalRenal ultrasound and spine evaluation for tethered cord are needed but are elective and not necessary before addressing esophageal atresia↗
▶Ep 2 · 7:27
guidelineConventional wisdom is to perform left thoracotomy for right-sided aortic arch↗
▶Ep 2 · 7:51
clinicalLeft thoracotomy for right-sided arch is somewhat more difficult with the heart more in the way and harder proximal pouch mobilization↗
▶Ep 2 · 8:20
clinicalIt is possible to complete the repair from the right side if right-sided arch is discovered intraoperatively, though some reports suggest higher incidence of swallowing problems↗
▶Ep 2 · 9:31
clinicalIn a stable larger baby not intubated, it is reasonable to wait until all resources are available in the middle of the day, even waiting 1-2 days↗
▶Ep 2 · 9:56
clinicalShould not wait a long time before repair due to risk of colonizing GI tract and soiling lungs↗
▶Ep 2 · 10:15
clinicalLarge fistula with distention tends to be a bigger problem in more premature infants with significant lung disease, where poor lung compliance drives air into GI tract↗
▶Ep 2 · 10:15
opinionOscillator ventilation does not make a significant difference in managing large fistulas with abdominal distention↗
▶Ep 2 · 10:15
quoteI've not found personally that an oscillator makes a whole lot of difference. I think if the child has a, has a large fistula, and typically it's actually, I believe this tends to be a bigger problem in younger, that is more premature infants who have more significant lung disease, and their compliance of their lungs is really what drives the The air into the GI tract as opposed to into the lungs.↗
▶Ep 2 · 10:56
clinicalTreating with surfactant and improving lung compliance helps as much as changing ventilator type↗
▶Ep 2 · 11:21
quoteI think this is a difficult clinical scenario, and, and I think one of the risks is to wait too long to make a decision, and I've made that mistake myself, and then it becomes an emergency if you can't ventilate the child.↗
▶Ep 2 · 11:21
clinicalRisk of waiting too long to make a decision in worsening distention can lead to emergency situation where child cannot be ventilated↗
▶Ep 2 · 12:00
quoteDecompressing the stomach may just allow that to become, in effect, the even lower resistance and allow more air to go there, making it even more difficult to ventilate. You relieve the abdominal distention, but you don't fix the flow of gas from the Trachea to the GI tract as opposed to from the trachea to the lungs.↗
▶Ep 2 · 12:00
clinicalG-tube decompression may paradoxically worsen ventilation by making stomach lower resistance, allowing more air to go there instead of lungs↗
▶Ep 2 · 12:00
opinionBronchoscopic Fogarty balloon placement sounds good but is difficult unless expertise and equipment are immediately available↗
▶Ep 2 · 12:00
clinicalFor reasonably stable but worsening distention, would take child urgently to OR for right thoracotomy and fistula ligation↗
▶Ep 2 · 12:50
clinicalLaparotomy with vessel loop around esophagogastric junction at hiatus with gentle traction (Rommel tourniquet technique) can temporize severe cases, leaving in place for several days before definitive repair↗
▶Ep 2 · 13:36
clinicalFor associated duodenal atresia in stable child, would potentially fix duodenal atresia first to avoid fixing esophagus upstream from obstruction↗
▶Ep 2 · 14:05
clinicalBoth duodenal and esophageal atresia could potentially be fixed at same time if child is old enough and stable enough↗
▶Ep 2 · 14:35
quoteWe have seen that many times in patients who are referred who've had multiple thoracotomies. Nobody ever did a bronchoscopy and the child actually has a laryngeal cleft↗
▶Ep 2 · 14:35
clinicalMany referred patients with multiple thoracotomies never had bronchoscopy and actually have laryngeal cleft↗
▶Ep 2 · 14:35
clinicalBronchoscopy documents fistula location, assesses for proximal fistula, and most importantly rules out laryngeal cleft which is easily missed↗
▶Ep 2 · 14:35
clinicalVon Allmen changed practice to always perform intraoperative bronchoscopy after exposure to Cincinnati's complex patient population↗
▶Ep 2 · 14:35
quoteThat is one of the things that I have changed in my management after coming here and having exposure to the patient population that we see, the complex patients that we see with the esophageal center and the neurodigestive center, and The airway surgeons here have convinced me that it is really important to do a bronchoscopy↗
▶Ep 2 · 15:35
epidemiologicalSecond fistula occurs in approximately 1% of cases and can be very difficult to diagnose↗
▶Ep 2 · 15:52
clinicalHigh fistulas can range from trifurcation of carina (suggesting difficulty getting ends together) to very high fistulas potentially approachable through neck↗
▶Ep 2 · 16:35
clinicalFor fistula at carina (trifurcation), ET tube should be placed higher as it cannot pass the fistula; for high fistula, tube should be placed distal to fistula but not into the fistula itself↗
▶Ep 2 · 16:35
clinicalBronchoscopy allows guidance of ET tube placement by anesthesiologist based on fistula location↗
▶Ep 2 · 17:19
clinicalExtrapleural approach offers advantage of potentially limiting soilage of pleural space if there is postoperative leak↗
▶Ep 2 · 17:19
quoteI do an extra plural approach and that's the way I was trained. I think it offers the advantage of potentially limiting any soilage of the plural space if there is a leak postoperatively.↗
▶Ep 2 · 17:41
clinicalDividing azygos has no morbidity, gives better access, and frequently guides to the fistula↗
▶Ep 2 · 17:41
quoteI think there's no morbidity associated with that, so dividing the azygus gives you better access. In fact, frequently will guide you to the fistula.↗
▶Ep 2 · 17:59
clinicalOpen azygos division is done by ligation and division; thoracoscopically can use energy devices or clips↗
▶Ep 2 · 18:51
quoteIt is amazing what you can divide with the electric cautery, with the hook electric cautery if you just get used to it, and I learned that doing actually robotic Nissans that you can divide the short gastrics in a teenager with the with the hook electric cautery.↗
▶Ep 2 · 18:51
clinicalHook cautery can safely divide vessels if done slowly going up and down to ensure coagulation, learned from robotic Nissen experience dividing short gastrics↗
▶Ep 2 · 18:51
opinion3mm surgical sealer is ideal device for this size patient and vessel↗
▶Ep 2 · 19:35
clinicalAfter azygos division, identify distal esophagus and control with vessel loop, then dissect proximally to identify fistula site↗
▶Ep 2 · 19:35
clinicalImportant to mobilize pleura up around apex of lung to have access for proximal pouch mobilization↗
▶Ep 2 · 19:35
clinicalSpreading heel of right angle on ribs nicely shows extrapleural plane when going through intercostal muscles↗
▶Ep 2 · 20:28
opinionMuscle-sparing thoracotomy can make exposure more difficult; has not seen significant morbidity from standard posterolateral thoracotomy↗
▶Ep 2 · 21:10
opinionThoracoscopic approach advantage is clearer visualization for proximal pouch mobilization↗
▶Ep 2 · 21:10
clinicalMust be careful with medial mobilization of distal esophagus due to blood supply concerns↗
▶Ep 2 · 21:10
quoteI think we have learned that, you know, the standard teaching has been that you shouldn't mobilize the distal esophagus at all, and I think we've learned that in fact you can mobilize that segment a fair amount, especially laterally.↗
▶Ep 2 · 21:10
clinicalExtensive proximal pouch mobilization gives the most length to get ends together↗
▶Ep 2 · 21:10
clinicalStandard teaching has been not to mobilize distal esophagus, but can actually mobilize it significantly especially laterally all the way to diaphragm↗
▶Ep 2 · 22:20
quoteI completely agree, and I think that you have to be very careful. I personally like to just use a blade, electric cautery and with a little buzz and then mostly blunt dissection with the flat end of the blade, and I think that. That can help you and staying right on the esophagus, which is usually very thickened because it's an obstructed piece of bowel. I would rather be in the esophagus than be in the trachea up high in the chest.↗
▶Ep 2 · 22:20
clinicalBetter to be in esophagus than trachea during high chest dissection; esophagus is thickened from obstruction↗
▶Ep 2 · 22:20
clinicalRisk of entering trachea during proximal dissection; must be very careful using blade cautery with light buzz and mostly blunt dissection with flat end of blade↗
▶Ep 2 · 23:01
clinicalFor significant tracheal defect, could perform sleeve resection as trachea is incredibly mobile, then place pericardium or autologous tissue between trachea and esophageal repair↗
▶Ep 2 · 23:59
opinionPersonal preference is 5-0 PDS - absorbable monofilament suture; not a fan of silk↗
▶Ep 2 · 24:42
opinionNot a fan of myotomies as they potentially create even more dysfunctional esophageal segment; motility is already clearly abnormal in esophageal atresia↗
▶Ep 2 · 24:42
clinicalFor cases too tight for primary repair, would ligate ends, tack both on tension to prevertebral fascia, close, let patient grow for couple weeks, then return to put together↗
▶Ep 2 · 24:42
quoteI personally am not a big fan of myotomy. I think it. Potentially creates an even more dysfunctional segment of the esophagus than already exists. The motility is clearly abnormal in patients with oesophageal atresia, and doing a myotomy just makes that problem worse.↗
▶Ep 2 · 25:38
quoteI believe very firmly in the physiology of traction or pressure. Actually it's sort of the reverse, is a very strong stimulus to growth all over the place in the cardiovascular system in the lungs↗
▶Ep 2 · 25:38
clinicalTraction or pressure is very strong stimulus to growth throughout cardiovascular system and lungs↗
▶Ep 2 · 26:10
opinionWould not do classic Foker technique with prolonged paralysis and sequential suture tensioning↗
▶Ep 2 · 26:10
clinicalFor thoracoscopic approach, can place traction sutures in proximal and distal ends brought out through crossed trocar sites with tension, allowing return within a week for anastomosis↗
▶Ep 2 · 27:38
quoteThey published a series a year ago or so in JPS looking at their results, and, and it was a very carefully well documented report of their results, and the data are striking if you Have a patient who has a primary atresia that you address, then in 98% of patients they're able to get the two ends of the esophagus together. In contrast, if it's a patient who's had previous surgeries and it's a secondary approach, then only 2/3 of those patients ever get the esophagus together.↗
▶Ep 2 · 27:38
epidemiologicalRusty Jennings and Foker published series in JPS showing 98% success getting ends together in primary atresia versus only 67% in secondary approaches after previous surgeries↗
▶Ep 2 · 27:38
clinicalFoker technique requires patients intubated and paralyzed spending weeks in ICU, which is probably worth it if you get good result↗
▶Ep 2 · 29:18
clinicalFor thoracoscopic procedure, rotate patient past 90 degrees to allow gravity to move lungs out of way↗
▶Ep 2 · 29:18
clinicalStandard port placement: camera in center, posterior port inferiorly, anterior port superiorly↗
▶Ep 2 · 29:52
clinicalUses 3mm instruments for thoracoscopic TEF repair↗
▶Ep 2 · 30:10
quoteI think as with most minimally invasive operations, I think it's important to do the same operation or at least the same quality operation that you would do open and Frankly, I think that's one of the challenges with the thoracoscopic repair of a TEF is to actually sew the anastomosis.↗
▶Ep 2 · 30:10
quoteI'm less worried about them falling off the esophagus than I am having them fall off a blood vessel.↗
▶Ep 2 · 30:10
clinicalSewing the anastomosis is one of the challenges with thoracoscopic TEF repair and requires most experience with minimally invasive techniques↗
▶Ep 2 · 30:10
opinionWould use clips for dividing fistula thoracoscopically, less worried about them falling off esophagus than blood vessel↗
▶Ep 2 · 30:10
opinionThoracoscopic visualization is very helpful for mobilizing proximal pouch↗
▶Ep 2 · 30:10
opinionSimulation courses for TEF repair will be great advantage for trainees as these cases are not done often enough to get practice↗
▶Ep 2 · 30:10
opinionImportant to do same quality operation thoracoscopically as would do open↗
▶Ep 2 · 34:30
clinicalThoracoscopic ventilation management depends more on anesthesiologist than ventilator type; need anesthesiologist comfortable with procedure who pays attention during operation↗
▶Ep 2 · 34:30
quoteI think it's more dependent on the anesthesiologist than it is on the type of ventilator, and you have to have an anesthesiologist who's comfortable with doing this and understands what you're trying to accomplish and is paying attention while you're actually doing the operation because they can either help you a lot or hurt you a lot with how they ventilate the child.↗
▶Ep 2 · 35:20
clinicalLittle CO2 insufflation with some time will collapse lung as long as anesthesiologist isn't fighting with positive pressure↗
▶Ep 2 · 35:20
clinicalAnesthesiologists can get scared seeing initial shunting but things settle down if they wait↗
▶Ep 2 · 36:05
clinicalIf patient had good lung function preoperatively and operation went smoothly, advocate extubating as soon as possible, even conceivably in operating room↗
▶Ep 2 · 36:05
opinionPrefer spontaneous breathing with negative pressure in trachea rather than positive pressure↗
▶Ep 2 · 36:05
clinicalConcern about reintubation exists, but equally concerned that positive pressure puts pressure on tracheal repair↗
▶Ep 2 · 36:05
quoteI agree it is a concern that the patient may require reintubation. However, I'm equally concerned that positive pressure is putting pressure on my tracheal repair, and I would much rather have the patient be breathing spontaneously to have, in fact, the opposite effect of a negative pressure in the trachea.↗
▶Ep 2 · 36:35
quoteI do honestly, I'm a little bit old school in that. I still get an esophagram. I usually wait for about 5 days.↗
▶Ep 2 · 36:35
clinicalUses small TLS drain rather than formal chest tube, especially for open extrapleural approach↗
▶Ep 2 · 36:35
clinicalGets contrast study at 5-7 days before pulling chest drain, timing depends on avoiding weekends↗
▶Ep 2 · 37:20
clinicalDoes not use transanastomotic tube based on Midwest Pediatric Surgical Consortium study showing much higher stricture and leak rate with transanastomotic tubes↗
▶Ep 2 · 37:20
quoteI do not actually. I again, a practice of mine that has changed based on our results from the Midwest Pediatric Surgical Consortium study in which the patients who Had a trans anastomotic tube had a much higher stricture and leak rate than patients that did not have that.↗
▶Ep 2 · 37:37
clinicalMidwest consortium study was presented at APSA and should be published in JPS soon↗
▶Ep 2 · 37:55
clinicalUnless incredibly tight stricture risking complete obstruction, would wait several weeks before first dilation↗
▶Ep 2 · 37:55
clinicalAlways appears to be narrowing at anastomosis because proximal pouch is dilated; as long as patent with free contrast flow distally, would hold off on dilation↗
▶Ep 2 · 37:55
quoteUnless it's an incredibly tight stricture, I would wait several weeks before doing a dilation unless I was worried there was going to be a complete obstruction.↗
▶Ep 2 · 37:55
quoteThere's always reported a narrowing because the proximal pouch is always dilated, so it always looks like there's a narrowing at the anastomosis. As long as it's patent and contrast flows freely down the distal esophagus, I would hold off on. Uh, dialing it, dilating it probably several weeks if possible.↗
▶Ep 2 · 38:23
clinicalIf case goes well and post-op study looks great, does not get routine follow-up esophagrams; studies based on clinical symptoms suggesting stricture↗
clinicalHuge spectrum from very tight strictures requiring many dilations to kids fine after one dilation↗
▶Ep 2 · 39:19
clinicalBalloon or radial dilation is less traumatic for tissue than bougie dilators↗
▶Ep 2 · 39:19
quoteI think that again, having trained using bougie dilators, a balloon or radial dilation is, is less traumatic for the tissue↗
▶Ep 2 · 39:19
clinicalDilations done with GI colleagues in aerodigestive center for bigger kids or with interventional radiologists↗
▶Ep 2 · 39:51
clinicalFor small leak with child not sick, would absolutely wait and do nothing, leaving drain in; vast majority close↗
▶Ep 2 · 39:51
quoteI would absolutely wait and do nothing. I would leave the drain in and usually that presents with some saliva in the drain, and I would just wait, and the vast majority of those close.↗
▶Ep 2 · 40:09
clinicalEven reasonably significant leaks will heal, then can deal with stricture postoperatively↗
▶Ep 2 · 40:09
clinicalWould only go to OR for leak if child getting sicker, wide open leak, or large uncontrollable pneumothorax↗
▶Ep 2 · 40:34
clinicalUsually waits one week between esophagrams for leak; if child continues to do well, restudies↗
▶Ep 2 · 40:34
clinicalSometimes little outpouching where leak happened makes it unclear if still leaking; if nothing from tube and nothing goes further, leak probably healed and would remove tube↗
▶Ep 2 · 41:19
clinicalInternational esophageal atresia meeting occurs every 2 years and is multidisciplinary including patients↗
▶Ep 2 · 41:19
clinicalPatients in their 20s-40s at international meeting discuss long-term issues; surgeons tend to follow until eating well or age 18 then never see them again↗
▶Ep 2 · 41:19
opinionHave a lot to learn about long-term complications; personally follows patients for at least couple years which is probably not long enough↗
▶Ep 2 · 41:19
quoteI think that first of all I would make the comment that that's a great point and it's interesting to participate in the International oesophageal atresia. A meeting that occurs every 2 years and to go and see the patients because that meeting is multidisciplinary, including even patients, and you see these patients who come back who are in their 20s or 30s or 40s and they talk about the long term issues that they have and we tend to follow patients until they're, you know, until they're eating well and then they're gone↗
▶Ep 2 · 42:15
clinicalMore concerning are patients with ongoing reflux due to unknown long-term impact on Barrett's esophagus and potential malignant change↗
▶Ep 2 · 42:15
clinicalBiggest challenges in long-term follow-up are reflux and recurrent strictures↗
▶Ep 2 · 42:15
quoteThe patients that worry me more honestly are the patients who have ongoing reflux, and we don't know the long term impact of that on things like Barrett's esophagus and Potential long term risk for malignant change and those sorts of things.↗
▶Ep 2 · 42:45
quoteIf I have a patient who has a stricture that's been dilated 2 or 3 times, my next move would be to address reflux. Most of the patients we leave on anti-reflux medications when they are discharged from the hospital. I would argue that virtually all patients have some degree of gastroesophageal reflux. If they have a stricture that is not responsive to dilations, it dilates easily and then restrictures. I personally am very aggressive about doing a fundoplication on those patients↗
▶Ep 2 · 42:45
clinicalVirtually all patients have some degree of gastroesophageal reflux↗
▶Ep 2 · 42:45
clinicalVery aggressive about fundoplication for strictures not responsive to dilations (dilates easily then restrictures)↗
▶Ep 2 · 42:45
clinicalMost patients left on anti-reflux medications when discharged from hospital↗
▶Ep 2 · 42:45
clinicalIf patient has stricture dilated 2-3 times, next move would be to address reflux↗
▶Ep 2 · 43:26
clinicalDoes Nissen fundoplication in patients with poor esophageal motility but makes them loose and short, using 2 or at most 3 stitches↗
▶Ep 2 · 43:26
clinicalWould wait 4-6 weeks to see how close ends come together, then attempt primary repair once within 2 vertebral bodies↗
▶Ep 2 · 43:26
quoteI do, but as with most Nissans, I make them loose and I make them short, so I usually use two or at most 3 stitches for the wrap and make sure that it is loose around the distal esophagus.↗
▶Ep 2 · 43:26
clinicalFor pure esophageal atresia, approach is G-tube placement with calibration of gap length using distal catheter pushed up and NG tube in proximal pouch↗
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
▶Ep 5 · 0:46
clinicalAt Cincinnati Children's, if a child has no gas in the abdomen, they place a G-tube and may put something up the distal esophagus for a fluoro shot, then wait a couple of weeks for a protocol gap measurement in interventional radiology.↗
▶Ep 5 · 0:46
quoteOur method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap.↗
▶Ep 5 · 2:10
quoteBut the philosophy here is that with traction, you can get the two ends of the esophagus to grow. And if you can get them to grow far enough, you can put them together.↗
▶Ep 5 · 2:10
quoteThe physiology, which I believe in intensely, is that stretch is a very strong promoter of growth. And then if you put things on tension, they will actually grow over time. That's how the cardiovascular system develops in utero.↗
▶Ep 5 · 2:10
clinicalThe philosophy of traction-based elongation is that with traction, you can get the two ends of the esophagus to grow, and if you can get them to grow far enough, you can put them together.↗
▶Ep 5 · 2:10
clinicalStretch is a very strong promoter of growth, and if you put things on tension they will actually grow over time, which is how the cardiovascular system develops in utero.↗
▶Ep 5 · 4:36
clinicalThe colon can be used as an interposition for esophageal replacement.↗
▶Ep 5 · 4:36
quoteYou can actually use the colon as an interposition as well. I personally was trained to do colon interpositions.↗
▶Ep 5 · 8:00
quoteCommon problems with this are that they dilate and they can become tortuous. It's not uncommon to get kind of a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 5 · 8:00
clinicalCommon problems with colonic interposition are that the colon can dilate and become tortuous, and it's not uncommon to get a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 5 · 8:17
opinionColonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 5 · 8:17
quoteI was taught initially that you can't fix that and that it's too dangerous and that you'll risk the blood supply to the colon interposition. But I found that actually that's not really true.↗
▶Ep 5 · 8:17
quoteI pass the interposition posterior to the stomach, which leaves the vascular pedicle along the spine. And you can mobilize the colon. You can divide the gastric dual aporotomy, divide the colon attachment to the stomach, and then mobilize that sigmoid redundancy transhiatally, and then reinestimose the colon to the stomach.↗
▶Ep 5 · 8:17
quoteSo I wouldn't pretend to say that these don't need to be revised sometimes, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 5 · 8:17
clinicalVon Allman passes the colonic interposition posterior to the stomach, which leaves the vascular pedicle along the spine, allowing mobilization of the colon by dividing the gastric duodenotomy and colon attachment to the stomach, then mobilizing the sigmoid redundancy transhiatally and reanastomosing the colon to the stomach.↗
▶Ep 5 · 8:17
opinionVon Allman was initially taught that sigmoid redundancy in colonic interposition can't be fixed and that it's too dangerous because it will risk the blood supply, but he found that this is not really true.↗
▶Ep 5 · 9:03
clinicalYou can get extraordinary length with colonic interposition, allowing treatment of cases with caustic injuries extending to the pharynx by sewing the colon to the pharynx and down to the stomach, which is tough to do with a gastric pull-up.↗
▶Ep 5 · 9:03
quoteYou can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.↗
▶Ep 5 · 9:56
quoteAnd yet there's very good physiologic data that tension is a growth promoter, not necessarily in the esophagus, but in other organs. So I think that it's an area ripe for a little more basic science.↗
▶Ep 5 · 9:56
opinionVon Allman states we don't know whether esophageal elongation is growth or stretch and should do studies to understand that, but notes that tension is a very good physiologic growth promoter in other organs, making this an area ripe for more basic science.↗
▶Ep 5 · 9:56
quoteI don't think we know we should do the studies to understand that. But I would say that this gets back to David van der Zee's comment about, go have a cup of coffee and come back and it'll be fine. Clearly, that's not growth, that's stretch.↗
Daniel's statements about Etiologies (Gastroschisis/NEC/Atresia/Volvulus)6 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 26 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 26 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 26 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 26 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 26 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 26 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Daniel's statements about Gastroesophageal Reflux7 statements
quoteDo they have data to support that statement, the significant morbidity?↗
▶Ep 1 · 10:15
quoteThere's lots of articles that many in this room have authored that show that the immediate morbidity and mortality of a fundoplication, of a laparoscopic fundoplication, even in infants is very low. It's a safe operation.↗
▶Ep 1 · 10:15
clinicalImmediate morbidity and mortality of laparoscopic fundoplication, even in infants, is very low and it is a safe operation↗
▶Ep 1 · 16:28
clinicalPPIs do not stop vomiting; they make refluxed material less acidic↗
▶Ep 1 · 16:28
quoteDo PPIs stop vomiting? No. I, I never understood that acid reflux less acidic, right?↗
▶Ep 1 · 25:20
quoteI started doing is I put an NG tube down, and if they do well with an NG tube, I just do a G tube. If they don't, I do a Nissan. That's as simple as I make it.↗
▶Ep 1 · 25:40
clinicalTrial of bolus NG tube feeding predicts whether infant needs fundoplication: if they do well with NG tube, perform G-tube alone; if they don't, perform Nissen↗
Daniel's statements about Gastroesophageal Reflux Disease7 statements
quoteDo they have data to support that statement, the significant morbidity?↗
▶Ep 5 · 10:15
clinicalImmediate morbidity and mortality of laparoscopic fundoplication, even in infants, is very low and it is a safe operation↗
▶Ep 5 · 10:15
quoteThere's lots of articles that many in this room have authored that show that the immediate morbidity and mortality of a fundoplication, of a laparoscopic fundoplication, even in infants is very low. It's a safe operation.↗
▶Ep 5 · 16:28
quoteDo PPIs stop vomiting? No. I, I never understood that acid reflux less acidic, right?↗
▶Ep 5 · 16:28
clinicalPPIs do not stop vomiting; they make refluxed material less acidic↗
▶Ep 5 · 25:20
quoteI started doing is I put an NG tube down, and if they do well with an NG tube, I just do a G tube. If they don't, I do a Nissan. That's as simple as I make it.↗
▶Ep 5 · 25:40
clinicalTrial of bolus NG tube feeding predicts whether infant needs fundoplication: if they do well with NG tube, perform G-tube alone; if they don't, perform Nissen↗
Daniel's statements about Gastroesophageal Reflux Disease7 statements
quoteDo they have data to support that statement, the significant morbidity?↗
▶Ep 5 · 10:15
quoteThere's lots of articles that many in this room have authored that show that the immediate morbidity and mortality of a fundoplication, of a laparoscopic fundoplication, even in infants is very low. It's a safe operation.↗
▶Ep 5 · 10:15
clinicalImmediate morbidity and mortality of laparoscopic fundoplication, even in infants, is very low and it is a safe operation↗
▶Ep 5 · 16:28
quoteDo PPIs stop vomiting? No. I, I never understood that acid reflux less acidic, right?↗
▶Ep 5 · 16:28
clinicalPPIs do not stop vomiting; they make refluxed material less acidic↗
▶Ep 5 · 25:20
quoteI started doing is I put an NG tube down, and if they do well with an NG tube, I just do a G tube. If they don't, I do a Nissan. That's as simple as I make it.↗
▶Ep 5 · 25:40
clinicalTrial of bolus NG tube feeding predicts whether infant needs fundoplication: if they do well with NG tube, perform G-tube alone; if they don't, perform Nissen↗
Daniel's statements about High-risk Neuroblastoma14 statements
quoteI think that the, the main controversy, at least from my perspective, that still persists is what to do with the high-risk patients.↗
▶Ep 2 · 0:42
epidemiologicalSurvival rate for high-risk neuroblastoma patients is in the 38 to 40% range↗
▶Ep 2 · 6:31
quoteThe difference between what a surgeon says they did in the operating room and and what the postoperative imaging says they did in the operating room, and those are not necessarily the same.↗
▶Ep 2 · 6:52
clinicalSurgeon-reported degree of resection showed only 66% concordance with radiologist assessment of postoperative imaging in tandem transplant pilot study↗
▶Ep 2 · 7:33
clinicalRepeat study in recent COG high-risk trial showed same 66% concordance rate between surgeon op notes and postoperative imaging, with surgeons underestimating and radiologists overcalling resection completeness↗
▶Ep 2 · 8:16
quoteWe don't have a very good definition of what is a greater than 90% resection.↗
▶Ep 2 · 10:17
opinionMore chemotherapy or other agents like MIBG may make tumor more fibrotic and make subadventitial dissection more difficult↗
▶Ep 2 · 10:17
quoteThe more chemotherapy you give or other agents, and now things like MIBG, which is local radiation, um. Uh, that you actually make the tumor more fibrotic, and it makes that technique of getting down on the vessels and splitting it off much more difficult.↗
▶Ep 2 · 13:07
epidemiologicalComplication rate for aggressive neuroblastoma resection is approximately 30% morbidity with mortality less than 1%↗
▶Ep 2 · 15:10
clinicalHigh-risk neuroblastoma treatment includes tandem peripheral blood stem cell transplants, with second transplant given as soon as patient recovers from first, followed by immunotherapy and Retin-A↗
▶Ep 2 · 19:37
quoteThis is very important to support the aggressive approach that everybody in this room has suggested that they would, uh, that they would pursue. There actually now is some data to support that.↗
▶Ep 2 · 21:56
opinionCOG 3973 study's inability to demonstrate overall survival benefit may be type 2 error due to smaller sample size (230 vs 1,300 patients in European study)↗
▶Ep 2 · 23:30
quoteIf you're not comfortable taking care of them, you should send them to somebody that is.↗
▶Ep 2 · 25:38
clinicalImmunotherapy is effective in neuroblastoma in the setting of minimal residual disease↗
Daniel's statements about Intestinal Failure12 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 3 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 3 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 3 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 3 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 3 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 3 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 7 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 7 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 7 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 7 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 7 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 7 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Daniel's statements about Intestinal Rehab12 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 14 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 14 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 14 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 14 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 14 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 14 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 35 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 35 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 35 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 35 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 35 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 35 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Daniel's statements about Intestinal Transplant6 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 5:31
opinionDr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results.↗
▶Ep 4 · 5:31
quoteI personally used to use them in my practice, but based on this study have stopped using them.↗
▶Ep 4 · 8:01
quoteThe whole point of this is to preserve the native liver.↗
▶Ep 4 · 9:09
clinicalTwo proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant).↗
▶Ep 4 · 10:08
quoteI think that you have to always be careful about generalizing studies, and in this study it is specifically testing a fairly long course, 1413 week course of high dose steroids.↗
▶Ep 4 · 10:09
clinicalThe START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen.↗
Daniel's statements about Long-gap Esophageal Atresia21 statements
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
▶Ep 3 · 0:46
clinicalAt Cincinnati Children's, if a child has no gas in the abdomen, they place a G-tube and may put something up the distal esophagus for a fluoro shot, then wait a couple of weeks for a protocol gap measurement in interventional radiology.↗
▶Ep 3 · 0:46
quoteOur method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap.↗
▶Ep 3 · 2:10
quoteBut the philosophy here is that with traction, you can get the two ends of the esophagus to grow. And if you can get them to grow far enough, you can put them together.↗
▶Ep 3 · 2:10
quoteThe physiology, which I believe in intensely, is that stretch is a very strong promoter of growth. And then if you put things on tension, they will actually grow over time. That's how the cardiovascular system develops in utero.↗
▶Ep 3 · 2:10
clinicalThe philosophy of traction-based elongation is that with traction, you can get the two ends of the esophagus to grow, and if you can get them to grow far enough, you can put them together.↗
▶Ep 3 · 2:10
clinicalStretch is a very strong promoter of growth, and if you put things on tension they will actually grow over time, which is how the cardiovascular system develops in utero.↗
▶Ep 3 · 4:36
clinicalThe colon can be used as an interposition for esophageal replacement.↗
▶Ep 3 · 4:36
quoteYou can actually use the colon as an interposition as well. I personally was trained to do colon interpositions.↗
▶Ep 3 · 8:00
quoteCommon problems with this are that they dilate and they can become tortuous. It's not uncommon to get kind of a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 3 · 8:00
clinicalCommon problems with colonic interposition are that the colon can dilate and become tortuous, and it's not uncommon to get a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 3 · 8:17
opinionVon Allman was initially taught that sigmoid redundancy in colonic interposition can't be fixed and that it's too dangerous because it will risk the blood supply, but he found that this is not really true.↗
▶Ep 3 · 8:17
opinionColonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 3 · 8:17
quoteI pass the interposition posterior to the stomach, which leaves the vascular pedicle along the spine. And you can mobilize the colon. You can divide the gastric dual aporotomy, divide the colon attachment to the stomach, and then mobilize that sigmoid redundancy transhiatally, and then reinestimose the colon to the stomach.↗
▶Ep 3 · 8:17
quoteI was taught initially that you can't fix that and that it's too dangerous and that you'll risk the blood supply to the colon interposition. But I found that actually that's not really true.↗
▶Ep 3 · 8:17
clinicalVon Allman passes the colonic interposition posterior to the stomach, which leaves the vascular pedicle along the spine, allowing mobilization of the colon by dividing the gastric duodenotomy and colon attachment to the stomach, then mobilizing the sigmoid redundancy transhiatally and reanastomosing the colon to the stomach.↗
▶Ep 3 · 8:17
quoteSo I wouldn't pretend to say that these don't need to be revised sometimes, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 3 · 9:03
quoteYou can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.↗
▶Ep 3 · 9:03
clinicalYou can get extraordinary length with colonic interposition, allowing treatment of cases with caustic injuries extending to the pharynx by sewing the colon to the pharynx and down to the stomach, which is tough to do with a gastric pull-up.↗
▶Ep 3 · 9:56
quoteAnd yet there's very good physiologic data that tension is a growth promoter, not necessarily in the esophagus, but in other organs. So I think that it's an area ripe for a little more basic science.↗
▶Ep 3 · 9:56
opinionVon Allman states we don't know whether esophageal elongation is growth or stretch and should do studies to understand that, but notes that tension is a very good physiologic growth promoter in other organs, making this an area ripe for more basic science.↗
▶Ep 3 · 9:56
quoteI don't think we know we should do the studies to understand that. But I would say that this gets back to David van der Zee's comment about, go have a cup of coffee and come back and it'll be fine. Clearly, that's not growth, that's stretch.↗
Daniel's statements about Long Gap Esophageal Atresia23 statements
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
▶Ep 3 · 0:46
quoteOur method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap.↗
▶Ep 3 · 0:46
clinicalAt Cincinnati Children's, if a child has no gas in the abdomen, they place a G-tube and may put something up the distal esophagus for a fluoro shot, then wait a couple of weeks for a protocol gap measurement in interventional radiology.↗
▶Ep 3 · 2:10
quoteThe physiology, which I believe in intensely, is that stretch is a very strong promoter of growth. And then if you put things on tension, they will actually grow over time. That's how the cardiovascular system develops in utero.↗
▶Ep 3 · 2:10
clinicalStretch is a very strong promoter of growth, and if you put things on tension they will actually grow over time, which is how the cardiovascular system develops in utero.↗
▶Ep 3 · 2:10
clinicalThe philosophy of traction-based elongation is that with traction, you can get the two ends of the esophagus to grow, and if you can get them to grow far enough, you can put them together.↗
▶Ep 3 · 2:10
quoteBut the philosophy here is that with traction, you can get the two ends of the esophagus to grow. And if you can get them to grow far enough, you can put them together.↗
▶Ep 3 · 4:36
quoteYou can actually use the colon as an interposition as well. I personally was trained to do colon interpositions.↗
▶Ep 3 · 4:36
clinicalThe colon can be used as an interposition for esophageal replacement.↗
▶Ep 3 · 8:00
quoteCommon problems with this are that they dilate and they can become tortuous. It's not uncommon to get kind of a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 3 · 8:00
clinicalCommon problems with colonic interposition are that the colon can dilate and become tortuous, and it's not uncommon to get a sigmoid sink drain deformity just above the diaphragm.↗
▶Ep 3 · 8:17
quoteI was taught initially that you can't fix that and that it's too dangerous and that you'll risk the blood supply to the colon interposition. But I found that actually that's not really true.↗
▶Ep 3 · 8:17
opinionVon Allman was initially taught that sigmoid redundancy in colonic interposition can't be fixed and that it's too dangerous because it will risk the blood supply, but he found that this is not really true.↗
▶Ep 3 · 8:17
clinicalVon Allman passes the colonic interposition posterior to the stomach, which leaves the vascular pedicle along the spine, allowing mobilization of the colon by dividing the gastric duodenotomy and colon attachment to the stomach, then mobilizing the sigmoid redundancy transhiatally and reanastomosing the colon to the stomach.↗
▶Ep 3 · 8:17
opinionColonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 3 · 8:17
quoteSo I wouldn't pretend to say that these don't need to be revised sometimes, but it is not impossible to revise them and the kids tend to do pretty well.↗
▶Ep 3 · 8:17
quoteI pass the interposition posterior to the stomach, which leaves the vascular pedicle along the spine. And you can mobilize the colon. You can divide the gastric dual aporotomy, divide the colon attachment to the stomach, and then mobilize that sigmoid redundancy transhiatally, and then reinestimose the colon to the stomach.↗
▶Ep 3 · 9:03
quoteYou can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up.↗
▶Ep 3 · 9:03
clinicalYou can get extraordinary length with colonic interposition, allowing treatment of cases with caustic injuries extending to the pharynx by sewing the colon to the pharynx and down to the stomach, which is tough to do with a gastric pull-up.↗
▶Ep 3 · 9:56
opinionVon Allman states we don't know whether esophageal elongation is growth or stretch and should do studies to understand that, but notes that tension is a very good physiologic growth promoter in other organs, making this an area ripe for more basic science.↗
▶Ep 3 · 9:56
quoteAnd yet there's very good physiologic data that tension is a growth promoter, not necessarily in the esophagus, but in other organs. So I think that it's an area ripe for a little more basic science.↗
▶Ep 3 · 9:56
quoteI don't think we know we should do the studies to understand that. But I would say that this gets back to David van der Zee's comment about, go have a cup of coffee and come back and it'll be fine. Clearly, that's not growth, that's stretch.↗
Update Course 2021: MAGNET THERAPY FOR ESOPHAGEAL ATRESIA
▶Ep 4 · 0:50
quotewe're going to finish up once again with a completely non controversial topic for which the therapy is very straightforward and that is long gap esophagial atresia.↗
▶Ep 4 · 21:07
clinicalDr. Von Allmen's single magnet case worked but resulted in dense stricture requiring lots of dilation and G-tube feeds for long time, though avoided reoperation.↗
Daniel's statements about Metastatic Disease37 statements
clinicalWhen neuroblastoma patients have metastatic disease, they may present with either bony pain or potentially neurologic symptoms from cord compression.↗
▶Ep 1 · 0:41
clinicalIn younger patients, neuroblastoma is often picked up either prenatally on ultrasound, or in younger kids (two-year-old or three-year-old) as a solid abdominal mass.↗
▶Ep 1 · 0:41
quoteSo in the younger patients, they're oftentimes picked up either prenatally on ultrasound, or in younger kids, say two-year-old or three-year-old, it might be picked up as a solid abdominal mass.↗
▶Ep 1 · 1:07
clinicalWhen considering neuroblastoma as part of the differential diagnosis, it is important to get catecholamines (either urine or serum) as one of the most diagnostic laboratory tests for this tumor.↗
▶Ep 1 · 1:39
clinicalMost children with suspected neuroblastoma would get a cross-sectional imaging study, either a CT scan or an MRI.↗
▶Ep 1 · 1:39
clinicalIf imaging suggests neuroblastoma (central abdominal mass or adrenal mass rather than kidney mass), the next test would be a nuclear medicine study, typically an MIBG study.↗
▶Ep 1 · 1:39
clinicalThe MIBG study is helpful for confirming the diagnosis of neuroblastoma and can also demonstrate metastatic disease.↗
▶Ep 1 · 2:20
clinicalSome centers, including Cincinnati Children's Hospital, would get a PET scan looking for tumor uptake as well as potential metastatic disease.↗
▶Ep 1 · 2:20
clinicalAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 1 · 2:20
quoteAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 1 · 2:45
guidelineThere is a special category MS for children less than 18 months of age who have metastases to either the bone marrow or the skin.↗
▶Ep 1 · 2:45
guidelineBased on the most recent iteration of the neuroblastoma staging system (INRGSS), it is possible to assign a stage before any invasive procedure is performed.↗
▶Ep 1 · 2:45
guidelineIn the INRGSS system, tumors that are localized are categorized as L1; if localized but have image-defined risk factors (encasing nerves or vessels), they are L2; if they have metastatic disease, they are M.↗
▶Ep 1 · 3:36
guidelineThe INRGSS pre-biopsy staging system was specifically created to allow studies from different centers in different countries to be compared based on the pre-surgical staging of the patient.↗
▶Ep 1 · 3:36
guidelineThe prior neuroblastoma staging system required tissue diagnosis before assigning a stage.↗
▶Ep 1 · 4:06
clinicalA child with an adrenal mass on the right side and a positive MIBG scan but no evidence of metastases could potentially be treated with a primary resection of the mass via laparotomy.↗
▶Ep 1 · 4:06
opinionSome surgeons would approach resection of a localized neuroblastoma with laparoscopy depending on the size of the tumor.↗
▶Ep 1 · 4:44
clinicalFor very large masses that encase the aorta, cava, or other major vasculature, all you really want is tissue for diagnosis, which can be obtained through open biopsy, laparoscopic biopsy, or core needle biopsies done by an interventional radiologist.↗
▶Ep 1 · 5:14
clinicalIn addition to NMIC status, you want to look for 1P and 11Q deletions and Shimada histology in neuroblastoma biopsy tissue.↗
▶Ep 1 · 5:14
clinicalThe most important biologic risk determinant to obtain from neuroblastoma biopsy tissue is the NMIC status.↗
▶Ep 1 · 5:45
clinicalBiologic risk determinants from biopsy will tell you what risk category the patient falls into: very low risk, low risk, intermediate risk, or high risk.↗
▶Ep 1 · 5:45
epidemiologicalNeuroblastoma risk is divided about 50-50 between the low risk categories and the high risk category, with a smaller percentage being intermediate risk.↗
▶Ep 1 · 6:11
quoteNMIC and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 1 · 6:11
clinicalPatients with high risk neuroblastoma receive aggressive chemotherapy including peripheral stem cell transplant times 2, aggressive surgery with the goal of greater than 90% resection of the tumor, followed by radiation, immunotherapy after chemotherapy, and potentially retinoic acid therapy.↗
▶Ep 1 · 6:11
clinicalNMIC amplification and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 1 · 6:51
clinicalIntermediate risk neuroblastoma tumors get varying cycles of chemotherapy based on the biologic risk factors they have.↗
▶Ep 1 · 6:51
clinicalFor intermediate risk neuroblastoma, the goal at the time of debulking or resecting the primary tumor is to achieve at least a 50% response from the initial volume of the primary tumor through the combination of neoadjuvant chemotherapy and surgical resection.↗
▶Ep 1 · 7:22
clinicalThe low risk neuroblastoma group, depending on the actual age of the patient and how it is diagnosed, could potentially be followed simply with observation.↗
▶Ep 1 · 7:22
clinicalJed Nocturne led a study through the Children's Oncology Group looking at patients less than six months of age with either a prenatally diagnosed or shortly postnatally diagnosed localized mass, showing these patients can be observed with the expectation that the vast majority will avoid any type of surgical procedure.↗
▶Ep 1 · 7:55
clinicalIf the metastatic disease is progressing on neoadjuvant chemotherapy, then surgery is not indicated.↗
▶Ep 1 · 7:55
quoteMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow, specifically not bone, not cortical bone, and is less than 18 months of age.↗
▶Ep 1 · 7:55
clinicalIf the tumor and metastatic disease are responding to neoadjuvant chemotherapy, one would attack the primary tumor site with a resection, with many advocating for attempting a greater than 90% resection.↗
▶Ep 1 · 7:55
clinicalPatients with metastatic neuroblastoma typically receive four or five cycles of neoadjuvant chemotherapy and then are reassessed.↗
▶Ep 1 · 7:55
clinicalMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow (specifically not bone, not cortical bone) and is less than 18 months of age.↗
▶Ep 1 · 7:55
clinicalIn patients with MS disease, simple observation can be the treatment path.↗
▶Ep 1 · 7:55
clinicalIf MS disease patients progress or develop respiratory issues because of an enlarging liver mass, treatment might be elected because of the complication of the size of the tumor, but the tumor itself usually does not have to be treated.↗
▶Ep 1 · 8:55
clinicalYou can biopsy the skin lesions in MS disease and that will give you the diagnosis.↗
Daniel's statements about Neuroblastoma102 statements
quoteI think that the, the main controversy, at least from my perspective, that still persists is what to do with the high-risk patients.↗
▶Ep 2 · 0:34
quoteI think that the, the main controversy, at least from my perspective, that still persists is what to do with the high-risk patients.↗
▶Ep 2 · 0:42
epidemiologicalSurvival rate for high-risk neuroblastoma patients is in the 38 to 40% range↗
▶Ep 2 · 0:42
epidemiologicalSurvival rate for high-risk neuroblastoma patients is in the 38 to 40% range↗
▶Ep 2 · 6:31
quoteThe difference between what a surgeon says they did in the operating room and and what the postoperative imaging says they did in the operating room, and those are not necessarily the same.↗
▶Ep 2 · 6:31
quoteThe difference between what a surgeon says they did in the operating room and and what the postoperative imaging says they did in the operating room, and those are not necessarily the same.↗
▶Ep 2 · 6:52
clinicalSurgeon-reported degree of resection showed only 66% concordance with radiologist assessment of postoperative imaging in tandem transplant pilot study↗
▶Ep 2 · 6:52
clinicalSurgeon-reported degree of resection showed only 66% concordance with radiologist assessment of postoperative imaging in tandem transplant pilot study↗
▶Ep 2 · 7:33
clinicalRepeat study in recent COG high-risk trial showed same 66% concordance rate between surgeon op notes and postoperative imaging, with surgeons underestimating and radiologists overcalling resection completeness↗
▶Ep 2 · 7:33
clinicalRepeat study in recent COG high-risk trial showed same 66% concordance rate between surgeon op notes and postoperative imaging, with surgeons underestimating and radiologists overcalling resection completeness↗
▶Ep 2 · 8:16
quoteWe don't have a very good definition of what is a greater than 90% resection.↗
▶Ep 2 · 8:16
quoteWe don't have a very good definition of what is a greater than 90% resection.↗
▶Ep 2 · 10:00
clinicalMemorial Sloan Kettering data suggests biggest volume response of neuroblastoma tumor occurs with first two cycles of chemotherapy, with very little response after that↗
▶Ep 2 · 10:17
quoteThe more chemotherapy you give or other agents, and now things like MIBG, which is local radiation, um. Uh, that you actually make the tumor more fibrotic, and it makes that technique of getting down on the vessels and splitting it off much more difficult.↗
▶Ep 2 · 10:17
opinionMore chemotherapy or other agents like MIBG may make tumor more fibrotic and make subadventitial dissection more difficult↗
▶Ep 2 · 10:17
quoteThe more chemotherapy you give or other agents, and now things like MIBG, which is local radiation, um. Uh, that you actually make the tumor more fibrotic, and it makes that technique of getting down on the vessels and splitting it off much more difficult.↗
▶Ep 2 · 10:17
opinionMore chemotherapy or other agents like MIBG may make tumor more fibrotic and make subadventitial dissection more difficult↗
▶Ep 2 · 13:07
epidemiologicalComplication rate for aggressive neuroblastoma resection is approximately 30% morbidity with mortality less than 1%↗
▶Ep 2 · 13:07
epidemiologicalComplication rate for aggressive neuroblastoma resection is approximately 30% morbidity with mortality less than 1%↗
▶Ep 2 · 15:10
clinicalHigh-risk neuroblastoma treatment includes tandem peripheral blood stem cell transplants, with second transplant given as soon as patient recovers from first, followed by immunotherapy and Retin-A↗
▶Ep 2 · 15:10
clinicalHigh-risk neuroblastoma treatment includes tandem peripheral blood stem cell transplants, with second transplant given as soon as patient recovers from first, followed by immunotherapy and Retin-A↗
▶Ep 2 · 16:48
clinicalGerman study of 278 stage 4 high-risk neuroblastoma patients achieved complete resection in almost half and >90% resection in another quarter (75% total with >90% resection)↗
▶Ep 2 · 17:13
epidemiologicalGerman study showed overall survival 45%, event-free survival 33%, and local progression-free survival 58% in stage 4 neuroblastoma↗
▶Ep 2 · 17:32
clinicalGerman study showed no difference in overall survival, event-free survival, or local progression-free survival based on completeness of resection in stage 4 neuroblastoma↗
▶Ep 2 · 17:51
guidelineGerman study concluded aggressive surgery is not justified in stage 4 neuroblastoma, that limited operations decrease complications, and there is limited impact on patient outcome↗
▶Ep 2 · 18:14
clinicalEuropean study included 1,324 high-risk neuroblastoma patients (stages 2, 3, and 4) and achieved 76% with >95% resection↗
▶Ep 2 · 19:02
epidemiologicalEuropean neuroblastoma study showed 0.5% mortality and 10% morbidity (30% including lesser complications)↗
▶Ep 2 · 19:17
clinicalEuropean study showed significant improvement in event-free survival and overall survival with aggressive resection in high-risk neuroblastoma - first study to show overall survival benefit↗
▶Ep 2 · 19:37
quoteThis is very important to support the aggressive approach that everybody in this room has suggested that they would, uh, that they would pursue. There actually now is some data to support that.↗
▶Ep 2 · 19:37
quoteThis is very important to support the aggressive approach that everybody in this room has suggested that they would, uh, that they would pursue. There actually now is some data to support that.↗
▶Ep 2 · 20:17
clinicalEuropean study concluded >95% resection results in improvement in event-free survival in high-risk neuroblastoma↗
▶Ep 2 · 21:24
clinicalCOG 3973 study of approximately 230 high-risk neuroblastoma patients showed significant improvement in local relapse-free survival and event-free survival but not overall survival↗
▶Ep 2 · 21:56
opinionCOG 3973 study's inability to demonstrate overall survival benefit may be type 2 error due to smaller sample size (230 vs 1,300 patients in European study)↗
▶Ep 2 · 21:56
opinionCOG 3973 study's inability to demonstrate overall survival benefit may be type 2 error due to smaller sample size (230 vs 1,300 patients in European study)↗
▶Ep 2 · 23:30
quoteIf you're not comfortable taking care of them, you should send them to somebody that is.↗
▶Ep 2 · 23:30
quoteIf you're not comfortable taking care of them, you should send them to somebody that is.↗
▶Ep 2 · 23:33
clinicalEuropean neuroblastoma procedures are performed in more than 200 hospitals yet still demonstrated survival improvements↗
▶Ep 2 · 24:03
clinicalOlder data shows worse survival in neuroblastoma when kidney is removed, likely because single kidney limits chemotherapy dosing↗
clinicalImmunotherapy is effective in neuroblastoma in the setting of minimal residual disease↗
▶Ep 2 · 25:38
clinicalImmunotherapy is effective in neuroblastoma in the setting of minimal residual disease↗
Neuroblastoma
▶Ep 3 · 2:11
clinicalOther differential diagnoses for suprarenal mass include neuroblastoma, pulmonary sequestration below the diaphragm, and misdiagnosed renal anomaly↗
▶Ep 3 · 2:11
clinicalAdrenal hemorrhage is the most common differential diagnosis for prenatal suprarenal mass, more common with history of fetal stress↗
▶Ep 3 · 6:02
opinionRadiologists are quite good at identifying adrenal hemorrhage on ultrasound↗
▶Ep 3 · 6:02
guidelineMIBG scan is the next step if catecholamines are elevated↗
▶Ep 3 · 8:14
clinicalIn perinatal phase, most common metastatic sites are liver, bone, skin, and lymph nodes↗
▶Ep 3 · 8:44
guidelineNocktern study data supports observation of prenatal neuroblastoma with careful ultrasound surveillance↗
▶Ep 3 · 12:27
quoteThe only caution I would raise is that we had a case of a child who presented with exactly this scenario, was observed, the adrenal mass went away and age at age three she presented with widely metastatic high risk neuroblastoma.↗
▶Ep 3 · 12:27
clinicalCase report: child with observed prenatal adrenal mass that resolved presented at age 3 with widely metastatic high-risk neuroblastoma↗
▶Ep 3 · 16:36
clinicalLymph node status in neuroblastoma is not as important for therapy changes as in Wilms tumor↗
▶Ep 3 · 17:58
clinicalPrimary concern in stage MS with liver involvement is mass effect causing respiratory compromise↗
▶Ep 3 · 17:58
quoteThe most common thing that we worry about is is the mass, is the mass effect of the tumor in the liver, which can be really dramatic and causes respiratory compromise.↗
▶Ep 3 · 19:06
opinionClassic findings of stage MS (high catecholamines, blue blebs on skin, liver metastasis, adrenal mass) may not require biopsy↗
▶Ep 3 · 25:06
epidemiological10% of neuroblastomas are not MIBG avid↗
▶Ep 3 · 25:06
clinicalPET scan may detect metastases in MIBG-negative neuroblastomas↗
Topics in 10: Neuroblastoma
▶Ep 5 · 0:41
clinicalIn younger patients, neuroblastoma is often picked up either prenatally on ultrasound, or in younger kids (two-year-old or three-year-old) as a solid abdominal mass.↗
▶Ep 5 · 0:41
quoteSo in the younger patients, they're oftentimes picked up either prenatally on ultrasound, or in younger kids, say two-year-old or three-year-old, it might be picked up as a solid abdominal mass.↗
▶Ep 5 · 0:41
clinicalWhen neuroblastoma patients have metastatic disease, they may present with either bony pain or potentially neurologic symptoms from cord compression.↗
▶Ep 5 · 1:07
clinicalWhen considering neuroblastoma as part of the differential diagnosis, it is important to get catecholamines (either urine or serum) as one of the most diagnostic laboratory tests for this tumor.↗
▶Ep 5 · 1:39
clinicalIf imaging suggests neuroblastoma (central abdominal mass or adrenal mass rather than kidney mass), the next test would be a nuclear medicine study, typically an MIBG study.↗
▶Ep 5 · 1:39
clinicalMost children with suspected neuroblastoma would get a cross-sectional imaging study, either a CT scan or an MRI.↗
▶Ep 5 · 1:39
clinicalThe MIBG study is helpful for confirming the diagnosis of neuroblastoma and can also demonstrate metastatic disease.↗
▶Ep 5 · 2:20
clinicalAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 5 · 2:20
quoteAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 5 · 2:20
clinicalSome centers, including Cincinnati Children's Hospital, would get a PET scan looking for tumor uptake as well as potential metastatic disease.↗
▶Ep 5 · 2:45
guidelineBased on the most recent iteration of the neuroblastoma staging system (INRGSS), it is possible to assign a stage before any invasive procedure is performed.↗
▶Ep 5 · 2:45
guidelineIn the INRGSS system, tumors that are localized are categorized as L1; if localized but have image-defined risk factors (encasing nerves or vessels), they are L2; if they have metastatic disease, they are M.↗
▶Ep 5 · 2:45
guidelineThere is a special category MS for children less than 18 months of age who have metastases to either the bone marrow or the skin.↗
▶Ep 5 · 3:36
guidelineThe prior neuroblastoma staging system required tissue diagnosis before assigning a stage.↗
▶Ep 5 · 3:36
guidelineThe INRGSS pre-biopsy staging system was specifically created to allow studies from different centers in different countries to be compared based on the pre-surgical staging of the patient.↗
▶Ep 5 · 4:06
clinicalA child with an adrenal mass on the right side and a positive MIBG scan but no evidence of metastases could potentially be treated with a primary resection of the mass via laparotomy.↗
▶Ep 5 · 4:06
opinionSome surgeons would approach resection of a localized neuroblastoma with laparoscopy depending on the size of the tumor.↗
▶Ep 5 · 4:44
clinicalFor very large masses that encase the aorta, cava, or other major vasculature, all you really want is tissue for diagnosis, which can be obtained through open biopsy, laparoscopic biopsy, or core needle biopsies done by an interventional radiologist.↗
▶Ep 5 · 5:14
clinicalThe most important biologic risk determinant to obtain from neuroblastoma biopsy tissue is the NMIC status.↗
▶Ep 5 · 5:14
clinicalIn addition to NMIC status, you want to look for 1P and 11Q deletions and Shimada histology in neuroblastoma biopsy tissue.↗
▶Ep 5 · 5:45
clinicalBiologic risk determinants from biopsy will tell you what risk category the patient falls into: very low risk, low risk, intermediate risk, or high risk.↗
▶Ep 5 · 5:45
epidemiologicalNeuroblastoma risk is divided about 50-50 between the low risk categories and the high risk category, with a smaller percentage being intermediate risk.↗
▶Ep 5 · 6:11
clinicalPatients with high risk neuroblastoma receive aggressive chemotherapy including peripheral stem cell transplant times 2, aggressive surgery with the goal of greater than 90% resection of the tumor, followed by radiation, immunotherapy after chemotherapy, and potentially retinoic acid therapy.↗
▶Ep 5 · 6:11
clinicalNMIC amplification and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 5 · 6:11
quoteNMIC and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 5 · 6:51
clinicalIntermediate risk neuroblastoma tumors get varying cycles of chemotherapy based on the biologic risk factors they have.↗
▶Ep 5 · 6:51
clinicalFor intermediate risk neuroblastoma, the goal at the time of debulking or resecting the primary tumor is to achieve at least a 50% response from the initial volume of the primary tumor through the combination of neoadjuvant chemotherapy and surgical resection.↗
▶Ep 5 · 7:22
clinicalJed Nocturne led a study through the Children's Oncology Group looking at patients less than six months of age with either a prenatally diagnosed or shortly postnatally diagnosed localized mass, showing these patients can be observed with the expectation that the vast majority will avoid any type of surgical procedure.↗
▶Ep 5 · 7:22
clinicalThe low risk neuroblastoma group, depending on the actual age of the patient and how it is diagnosed, could potentially be followed simply with observation.↗
▶Ep 5 · 7:55
clinicalPatients with metastatic neuroblastoma typically receive four or five cycles of neoadjuvant chemotherapy and then are reassessed.↗
▶Ep 5 · 7:55
quoteMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow, specifically not bone, not cortical bone, and is less than 18 months of age.↗
▶Ep 5 · 7:55
clinicalIf the tumor and metastatic disease are responding to neoadjuvant chemotherapy, one would attack the primary tumor site with a resection, with many advocating for attempting a greater than 90% resection.↗
▶Ep 5 · 7:55
clinicalIn patients with MS disease, simple observation can be the treatment path.↗
▶Ep 5 · 7:55
clinicalMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow (specifically not bone, not cortical bone) and is less than 18 months of age.↗
▶Ep 5 · 7:55
clinicalIf the metastatic disease is progressing on neoadjuvant chemotherapy, then surgery is not indicated.↗
▶Ep 5 · 7:55
clinicalIf MS disease patients progress or develop respiratory issues because of an enlarging liver mass, treatment might be elected because of the complication of the size of the tumor, but the tumor itself usually does not have to be treated.↗
▶Ep 5 · 8:55
clinicalYou can biopsy the skin lesions in MS disease and that will give you the diagnosis.↗
Neuroblastoma
▶Ep 6 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 6 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 6 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 6 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 6 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 6 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 6 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 6 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 6 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 6 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
Daniel's statements about Neuroblastoma62 statements
clinicalAdrenal hemorrhage is the most common differential diagnosis for prenatal suprarenal mass, more common with history of fetal stress↗
▶Ep 1 · 2:11
clinicalOther differential diagnoses for suprarenal mass include neuroblastoma, pulmonary sequestration below the diaphragm, and misdiagnosed renal anomaly↗
▶Ep 1 · 6:02
guidelineMIBG scan is the next step if catecholamines are elevated↗
▶Ep 1 · 6:02
opinionRadiologists are quite good at identifying adrenal hemorrhage on ultrasound↗
▶Ep 1 · 8:14
clinicalIn perinatal phase, most common metastatic sites are liver, bone, skin, and lymph nodes↗
▶Ep 1 · 8:44
guidelineNocktern study data supports observation of prenatal neuroblastoma with careful ultrasound surveillance↗
▶Ep 1 · 12:27
clinicalCase report: child with observed prenatal adrenal mass that resolved presented at age 3 with widely metastatic high-risk neuroblastoma↗
▶Ep 1 · 12:27
quoteThe only caution I would raise is that we had a case of a child who presented with exactly this scenario, was observed, the adrenal mass went away and age at age three she presented with widely metastatic high risk neuroblastoma.↗
▶Ep 1 · 16:36
clinicalLymph node status in neuroblastoma is not as important for therapy changes as in Wilms tumor↗
▶Ep 1 · 17:58
clinicalPrimary concern in stage MS with liver involvement is mass effect causing respiratory compromise↗
▶Ep 1 · 17:58
quoteThe most common thing that we worry about is is the mass, is the mass effect of the tumor in the liver, which can be really dramatic and causes respiratory compromise.↗
▶Ep 1 · 19:06
opinionClassic findings of stage MS (high catecholamines, blue blebs on skin, liver metastasis, adrenal mass) may not require biopsy↗
▶Ep 1 · 25:06
epidemiological10% of neuroblastomas are not MIBG avid↗
▶Ep 1 · 25:06
clinicalPET scan may detect metastases in MIBG-negative neuroblastomas↗
Topics in 10: Neuroblastoma
▶Ep 2 · 0:41
quoteSo in the younger patients, they're oftentimes picked up either prenatally on ultrasound, or in younger kids, say two-year-old or three-year-old, it might be picked up as a solid abdominal mass.↗
▶Ep 2 · 0:41
clinicalIn younger patients, neuroblastoma is often picked up either prenatally on ultrasound, or in younger kids (two-year-old or three-year-old) as a solid abdominal mass.↗
▶Ep 2 · 0:41
clinicalWhen neuroblastoma patients have metastatic disease, they may present with either bony pain or potentially neurologic symptoms from cord compression.↗
▶Ep 2 · 1:07
clinicalWhen considering neuroblastoma as part of the differential diagnosis, it is important to get catecholamines (either urine or serum) as one of the most diagnostic laboratory tests for this tumor.↗
▶Ep 2 · 1:39
clinicalThe MIBG study is helpful for confirming the diagnosis of neuroblastoma and can also demonstrate metastatic disease.↗
▶Ep 2 · 1:39
clinicalMost children with suspected neuroblastoma would get a cross-sectional imaging study, either a CT scan or an MRI.↗
▶Ep 2 · 1:39
clinicalIf imaging suggests neuroblastoma (central abdominal mass or adrenal mass rather than kidney mass), the next test would be a nuclear medicine study, typically an MIBG study.↗
▶Ep 2 · 2:20
clinicalSome centers, including Cincinnati Children's Hospital, would get a PET scan looking for tumor uptake as well as potential metastatic disease.↗
▶Ep 2 · 2:20
quoteAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 2 · 2:20
clinicalAbout 10% of neuroblastomas are MIBG negative.↗
▶Ep 2 · 2:45
guidelineThere is a special category MS for children less than 18 months of age who have metastases to either the bone marrow or the skin.↗
▶Ep 2 · 2:45
guidelineIn the INRGSS system, tumors that are localized are categorized as L1; if localized but have image-defined risk factors (encasing nerves or vessels), they are L2; if they have metastatic disease, they are M.↗
▶Ep 2 · 2:45
guidelineBased on the most recent iteration of the neuroblastoma staging system (INRGSS), it is possible to assign a stage before any invasive procedure is performed.↗
▶Ep 2 · 3:36
guidelineThe prior neuroblastoma staging system required tissue diagnosis before assigning a stage.↗
▶Ep 2 · 3:36
guidelineThe INRGSS pre-biopsy staging system was specifically created to allow studies from different centers in different countries to be compared based on the pre-surgical staging of the patient.↗
▶Ep 2 · 4:06
clinicalA child with an adrenal mass on the right side and a positive MIBG scan but no evidence of metastases could potentially be treated with a primary resection of the mass via laparotomy.↗
▶Ep 2 · 4:06
opinionSome surgeons would approach resection of a localized neuroblastoma with laparoscopy depending on the size of the tumor.↗
▶Ep 2 · 4:44
clinicalFor very large masses that encase the aorta, cava, or other major vasculature, all you really want is tissue for diagnosis, which can be obtained through open biopsy, laparoscopic biopsy, or core needle biopsies done by an interventional radiologist.↗
▶Ep 2 · 5:14
clinicalThe most important biologic risk determinant to obtain from neuroblastoma biopsy tissue is the NMIC status.↗
▶Ep 2 · 5:14
clinicalIn addition to NMIC status, you want to look for 1P and 11Q deletions and Shimada histology in neuroblastoma biopsy tissue.↗
▶Ep 2 · 5:45
epidemiologicalNeuroblastoma risk is divided about 50-50 between the low risk categories and the high risk category, with a smaller percentage being intermediate risk.↗
▶Ep 2 · 5:45
clinicalBiologic risk determinants from biopsy will tell you what risk category the patient falls into: very low risk, low risk, intermediate risk, or high risk.↗
▶Ep 2 · 6:11
clinicalNMIC amplification and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 2 · 6:11
clinicalPatients with high risk neuroblastoma receive aggressive chemotherapy including peripheral stem cell transplant times 2, aggressive surgery with the goal of greater than 90% resection of the tumor, followed by radiation, immunotherapy after chemotherapy, and potentially retinoic acid therapy.↗
▶Ep 2 · 6:11
quoteNMIC and age greater than 18 months are the most important prognostic determinants for neuroblastoma.↗
▶Ep 2 · 6:51
clinicalFor intermediate risk neuroblastoma, the goal at the time of debulking or resecting the primary tumor is to achieve at least a 50% response from the initial volume of the primary tumor through the combination of neoadjuvant chemotherapy and surgical resection.↗
▶Ep 2 · 6:51
clinicalIntermediate risk neuroblastoma tumors get varying cycles of chemotherapy based on the biologic risk factors they have.↗
▶Ep 2 · 7:22
clinicalJed Nocturne led a study through the Children's Oncology Group looking at patients less than six months of age with either a prenatally diagnosed or shortly postnatally diagnosed localized mass, showing these patients can be observed with the expectation that the vast majority will avoid any type of surgical procedure.↗
▶Ep 2 · 7:22
clinicalThe low risk neuroblastoma group, depending on the actual age of the patient and how it is diagnosed, could potentially be followed simply with observation.↗
▶Ep 2 · 7:55
clinicalMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow (specifically not bone, not cortical bone) and is less than 18 months of age.↗
▶Ep 2 · 7:55
clinicalIn patients with MS disease, simple observation can be the treatment path.↗
▶Ep 2 · 7:55
clinicalIf MS disease patients progress or develop respiratory issues because of an enlarging liver mass, treatment might be elected because of the complication of the size of the tumor, but the tumor itself usually does not have to be treated.↗
▶Ep 2 · 7:55
clinicalPatients with metastatic neuroblastoma typically receive four or five cycles of neoadjuvant chemotherapy and then are reassessed.↗
▶Ep 2 · 7:55
quoteMS disease is specifically for patients who have a primary site with metastatic disease to the liver, the skin, or the bone marrow, specifically not bone, not cortical bone, and is less than 18 months of age.↗
▶Ep 2 · 7:55
clinicalIf the tumor and metastatic disease are responding to neoadjuvant chemotherapy, one would attack the primary tumor site with a resection, with many advocating for attempting a greater than 90% resection.↗
▶Ep 2 · 7:55
clinicalIf the metastatic disease is progressing on neoadjuvant chemotherapy, then surgery is not indicated.↗
▶Ep 2 · 8:55
clinicalYou can biopsy the skin lesions in MS disease and that will give you the diagnosis.↗
Neuroblastoma
▶Ep 3 · 2:00
clinicalAdrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress↗
▶Ep 3 · 7:24
clinicalThe GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery↗
▶Ep 3 · 14:21
clinicalLymph node status in neuroblastoma does not change therapy, unlike Wilms tumor↗
▶Ep 3 · 22:12
clinicalApproximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful↗
▶Ep 3 · 43:17
clinicalTumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies↗
▶Ep 3 · 44:04
clinicalCOG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients)↗
▶Ep 3 · 45:28
clinicalEuropean neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival↗
▶Ep 3 · 46:10
epidemiologicalApproximately 70% of high-risk neuroblastoma patients can achieve >90% resection↗
▶Ep 3 · 50:54
clinicalNeuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed↗
▶Ep 3 · 51:30
clinicalThere is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings↗
▶Ep 3 · 51:30
quoteThere is zero correlation, zero. There is absolutely no correlation between the findings on post-op imaging and the findings that are reported in the op note.↗
Summaries Daniel gave as host
· 161 summaries
Recaps of other experts' statements, not Daniel's own clinical position.
Summaries Daniel gave as host · Appendicitis14 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 4 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 4 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 4 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 4 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 4 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 4 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 7 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 7 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 7 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 7 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 7 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 7 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 7 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
Summaries Daniel gave as host · Appendicitis14 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 5 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 5 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 5 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 5 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 5 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 5 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 5 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 10 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 10 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 10 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 10 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 10 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 10 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 10 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
Summaries Daniel gave as host · Biliary Atresia14 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 6 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 6 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 6 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 6 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 6 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 6 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 6 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 10 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 10 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 10 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 10 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 10 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 10 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 10 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
Summaries Daniel gave as host · Colorectal / ARM & Hirschsprung7 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 76 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 76 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 76 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 76 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 76 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 76 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 76 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
Summaries Daniel gave as host · Enterocolitis1 summary
Tracheoesophageal Fistula with Dr. Daniel von Allmen
▶Ep 2 · 31:37
host summaryDaniel von Allmen summarizing a resource: Atlanta group uses stay stitch between two ends brought out of chest to hold anastomosis up for subsequent stitches, similar to duodenal atresia technique↗
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
▶Ep 5 · 3:15
host summaryDaniel von Allmen summarizing a resource: In the Boston Group 2015 study, the primary group had a median ICU stay of 70 days with a couple of weeks being paralyzed, and the secondary group had a median ICU stay of 110 days with a month of being paralyzed.↗
▶Ep 5 · 3:15
host summaryDaniel von Allmen summarizing a resource: In the Boston Group 2015 study, the primary group (de novo cases) achieved an intact esophagus in 96% of patients, while the secondary group (patients with previous operations) achieved this in about two thirds of patients.↗
▶Ep 5 · 3:15
host summaryDaniel von Allmen summarizing a resource: In the Boston Group 2015 study, about two thirds of patients with primary repair were able to get full oral nutrition and about 10% of patients who had secondary repair achieved full oral nutrition.↗
▶Ep 5 · 3:15
host summaryDaniel von Allmen summarizing a resource: But these procedures are not without some morbidity. And you look at the ICU stay is a median of 70 days with a couple of weeks being paralyzed for the primary group and 110 days for the secondary group with a month of being paralyzed.↗
▶Ep 5 · 3:15
host summaryDaniel von Allmen summarizing a resource: About two thirds of patients with the primary repair were able to get the full oral nutrition and about 10% of the patients who had the secondary repair.↗
▶Ep 5 · 3:15
host summaryDaniel von Allmen summarizing a resource: Obviously, you look at the result of getting the esophagus together and intact esophagus in 96% of patients in the primary group, about two thirds of patients in the secondary group.↗
▶Ep 5 · 3:15
host summaryDaniel von Allmen summarizing a resource: There was a great article published by the Boston Group 2015. Divides the cases into two groups, a primary group and a secondary group. Secondary being patients who had had operations previously in the primary group, being cases that they saw de novo.↗
▶Ep 5 · 4:36
host summaryDaniel von Allmen summarizing a resource: You divide the esophageal stump at the esophageal hiatus and mobilize the fundus and pull the fundus up and you can pull it up either in the anterior or posterior mediastinum.↗
▶Ep 5 · 4:36
host summaryDaniel von Allmen summarizing a resource: The surgical group from INOEA recommends gastric pull up as the first option for esophageal replacement, dividing the esophageal stump at the esophageal hiatus and mobilizing the fundus to pull it up in either the anterior or posterior mediastinum.↗
▶Ep 5 · 4:36
host summaryDaniel von Allmen summarizing a resource: You could use the stomach. That would be called a gastric transposition. The surgical group from the INOEA, their recommendation, the recommendation for the first option is a gastric pull up.↗
Summaries Daniel gave as host · Esophageal Atresia1 summary
Tracheoesophageal Fistula with Dr. Daniel von Allmen
▶Ep 26 · 31:37
host summaryDaniel von Allmen summarizing a resource: Atlanta group uses stay stitch between two ends brought out of chest to hold anastomosis up for subsequent stitches, similar to duodenal atresia technique↗
Summaries Daniel gave as host · Esophageal Atresia1 summary
Tracheoesophageal Fistula with Dr. Daniel von Allmen
▶Ep 21 · 31:37
host summaryDaniel von Allmen summarizing a resource: Atlanta group uses stay stitch between two ends brought out of chest to hold anastomosis up for subsequent stitches, similar to duodenal atresia technique↗
Summaries Daniel gave as host · Etiologies (Gastroschisis/NEC/Atresia/Volvulus)7 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 26 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 26 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 26 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 26 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 26 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 26 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 26 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
Summaries Daniel gave as host · Gastroesophageal Reflux3 summaries
host summaryDaniel von Allmen summarizing the discussion: In adult literature, after about 15 years almost all fundoplications are undone↗
▶Ep 1 · 9:03
host summaryDaniel von Allmen summarizing the discussion: If you look at the adult literature for fund application, after about 15 years, almost all of them are, are, are undone. And so I don't know why we think that ours is going to be any different. We just don't follow our patients past 18.↗
▶Ep 1 · 21:20
host summaryDaniel von Allmen summarizing the discussion: Neurologically impaired patients do worse than neurologically normal patients after fundoplication according to historical data↗
Summaries Daniel gave as host · Gastroesophageal Reflux Disease3 summaries
host summaryDaniel von Allmen summarizing the discussion: In adult literature, after about 15 years almost all fundoplications are undone↗
▶Ep 5 · 9:03
host summaryDaniel von Allmen summarizing the discussion: If you look at the adult literature for fund application, after about 15 years, almost all of them are, are, are undone. And so I don't know why we think that ours is going to be any different. We just don't follow our patients past 18.↗
▶Ep 5 · 21:20
host summaryDaniel von Allmen summarizing the discussion: Neurologically impaired patients do worse than neurologically normal patients after fundoplication according to historical data↗
Summaries Daniel gave as host · Gastroesophageal Reflux Disease3 summaries
host summaryDaniel von Allmen summarizing the discussion: In adult literature, after about 15 years almost all fundoplications are undone↗
▶Ep 5 · 9:03
host summaryDaniel von Allmen summarizing the discussion: If you look at the adult literature for fund application, after about 15 years, almost all of them are, are, are undone. And so I don't know why we think that ours is going to be any different. We just don't follow our patients past 18.↗
▶Ep 5 · 21:20
host summaryDaniel von Allmen summarizing the discussion: Neurologically impaired patients do worse than neurologically normal patients after fundoplication according to historical data↗
Summaries Daniel gave as host · High-risk Neuroblastoma13 summaries
host summaryDaniel von Allmen summarizing the discussion: Memorial Sloan Kettering data suggests biggest volume response of neuroblastoma tumor occurs with first two cycles of chemotherapy, with very little response after that↗
▶Ep 2 · 16:48
host summaryDaniel von Allmen summarizing the discussion: German study of 278 stage 4 high-risk neuroblastoma patients achieved complete resection in almost half and >90% resection in another quarter (75% total with >90% resection)↗
▶Ep 2 · 17:13
host summaryDaniel von Allmen summarizing the discussion: German study showed overall survival 45%, event-free survival 33%, and local progression-free survival 58% in stage 4 neuroblastoma↗
▶Ep 2 · 17:32
host summaryDaniel von Allmen summarizing the discussion: German study showed no difference in overall survival, event-free survival, or local progression-free survival based on completeness of resection in stage 4 neuroblastoma↗
▶Ep 2 · 17:51
host summaryDaniel von Allmen summarizing the discussion: German study concluded aggressive surgery is not justified in stage 4 neuroblastoma, that limited operations decrease complications, and there is limited impact on patient outcome↗
▶Ep 2 · 18:14
host summaryDaniel von Allmen summarizing the discussion: European study included 1,324 high-risk neuroblastoma patients (stages 2, 3, and 4) and achieved 76% with >95% resection↗
▶Ep 2 · 19:02
host summaryDaniel von Allmen summarizing the discussion: European neuroblastoma study showed 0.5% mortality and 10% morbidity (30% including lesser complications)↗
▶Ep 2 · 19:17
host summaryDaniel von Allmen summarizing the discussion: European study showed significant improvement in event-free survival and overall survival with aggressive resection in high-risk neuroblastoma - first study to show overall survival benefit↗
▶Ep 2 · 20:17
host summaryDaniel von Allmen summarizing the discussion: European study concluded >95% resection results in improvement in event-free survival in high-risk neuroblastoma↗
▶Ep 2 · 21:24
host summaryDaniel von Allmen summarizing the discussion: COG 3973 study of approximately 230 high-risk neuroblastoma patients showed significant improvement in local relapse-free survival and event-free survival but not overall survival↗
▶Ep 2 · 23:33
host summaryDaniel von Allmen summarizing the discussion: European neuroblastoma procedures are performed in more than 200 hospitals yet still demonstrated survival improvements↗
▶Ep 2 · 24:03
host summaryDaniel von Allmen summarizing the discussion: Older data shows worse survival in neuroblastoma when kidney is removed, likely because single kidney limits chemotherapy dosing↗
▶Ep 2 · 24:52
host summaryDaniel von Allmen summarizing the discussion: If you can't be informed, be opinionated↗
Summaries Daniel gave as host · Intestinal Failure14 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 3 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 3 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 3 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 3 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 3 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 3 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 3 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 7 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 7 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 7 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 7 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 7 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 7 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 7 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
Summaries Daniel gave as host · Intestinal Rehab14 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 14 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 14 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 14 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 14 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 14 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 14 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
▶Ep 14 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 35 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 35 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 35 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 35 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 35 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 35 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 35 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
Summaries Daniel gave as host · Intestinal Transplant7 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 2:48
host summaryDaniel von Allmen summarizing the discussion: The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy.↗
▶Ep 4 · 3:32
host summaryDaniel von Allmen summarizing the discussion: The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference.↗
▶Ep 4 · 4:01
host summaryDaniel von Allmen summarizing the discussion: High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo.↗
▶Ep 4 · 4:39
host summaryDaniel von Allmen summarizing the discussion: Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo.↗
▶Ep 4 · 4:55
host summaryDaniel von Allmen summarizing the discussion: Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events.↗
▶Ep 4 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the paper, and I believe them, feel that anything less than a 25% difference is probably not worth the potential risk of the early complications associated with the steroids.↗
▶Ep 4 · 7:11
host summaryDaniel von Allmen summarizing the discussion: The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids.↗
Summaries Daniel gave as host · Long-gap Esophageal Atresia10 summaries
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: Obviously, you look at the result of getting the esophagus together and intact esophagus in 96% of patients in the primary group, about two thirds of patients in the secondary group.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: But these procedures are not without some morbidity. And you look at the ICU stay is a median of 70 days with a couple of weeks being paralyzed for the primary group and 110 days for the secondary group with a month of being paralyzed.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: About two thirds of patients with the primary repair were able to get the full oral nutrition and about 10% of the patients who had the secondary repair.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: There was a great article published by the Boston Group 2015. Divides the cases into two groups, a primary group and a secondary group. Secondary being patients who had had operations previously in the primary group, being cases that they saw de novo.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: In the Boston Group 2015 study, the primary group (de novo cases) achieved an intact esophagus in 96% of patients, while the secondary group (patients with previous operations) achieved this in about two thirds of patients.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: In the Boston Group 2015 study, about two thirds of patients with primary repair were able to get full oral nutrition and about 10% of patients who had secondary repair achieved full oral nutrition.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: In the Boston Group 2015 study, the primary group had a median ICU stay of 70 days with a couple of weeks being paralyzed, and the secondary group had a median ICU stay of 110 days with a month of being paralyzed.↗
▶Ep 3 · 4:36
host summaryDaniel von Allmen summarizing a resource: You could use the stomach. That would be called a gastric transposition. The surgical group from the INOEA, their recommendation, the recommendation for the first option is a gastric pull up.↗
▶Ep 3 · 4:36
host summaryDaniel von Allmen summarizing a resource: The surgical group from INOEA recommends gastric pull up as the first option for esophageal replacement, dividing the esophageal stump at the esophageal hiatus and mobilizing the fundus to pull it up in either the anterior or posterior mediastinum.↗
▶Ep 3 · 4:36
host summaryDaniel von Allmen summarizing a resource: You divide the esophageal stump at the esophageal hiatus and mobilize the fundus and pull the fundus up and you can pull it up either in the anterior or posterior mediastinum.↗
Summaries Daniel gave as host · Long Gap Esophageal Atresia10 summaries
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: There was a great article published by the Boston Group 2015. Divides the cases into two groups, a primary group and a secondary group. Secondary being patients who had had operations previously in the primary group, being cases that they saw de novo.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: In the Boston Group 2015 study, the primary group (de novo cases) achieved an intact esophagus in 96% of patients, while the secondary group (patients with previous operations) achieved this in about two thirds of patients.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: In the Boston Group 2015 study, the primary group had a median ICU stay of 70 days with a couple of weeks being paralyzed, and the secondary group had a median ICU stay of 110 days with a month of being paralyzed.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: In the Boston Group 2015 study, about two thirds of patients with primary repair were able to get full oral nutrition and about 10% of patients who had secondary repair achieved full oral nutrition.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: But these procedures are not without some morbidity. And you look at the ICU stay is a median of 70 days with a couple of weeks being paralyzed for the primary group and 110 days for the secondary group with a month of being paralyzed.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: Obviously, you look at the result of getting the esophagus together and intact esophagus in 96% of patients in the primary group, about two thirds of patients in the secondary group.↗
▶Ep 3 · 3:15
host summaryDaniel von Allmen summarizing a resource: About two thirds of patients with the primary repair were able to get the full oral nutrition and about 10% of the patients who had the secondary repair.↗
▶Ep 3 · 4:36
host summaryDaniel von Allmen summarizing a resource: You divide the esophageal stump at the esophageal hiatus and mobilize the fundus and pull the fundus up and you can pull it up either in the anterior or posterior mediastinum.↗
▶Ep 3 · 4:36
host summaryDaniel von Allmen summarizing a resource: The surgical group from INOEA recommends gastric pull up as the first option for esophageal replacement, dividing the esophageal stump at the esophageal hiatus and mobilizing the fundus to pull it up in either the anterior or posterior mediastinum.↗
▶Ep 3 · 4:36
host summaryDaniel von Allmen summarizing a resource: You could use the stomach. That would be called a gastric transposition. The surgical group from the INOEA, their recommendation, the recommendation for the first option is a gastric pull up.↗
Summaries Daniel gave as host · Neuroblastoma13 summaries
host summaryDaniel von Allmen summarizing the discussion: Memorial Sloan Kettering data suggests biggest volume response of neuroblastoma tumor occurs with first two cycles of chemotherapy, with very little response after that↗
▶Ep 2 · 16:48
host summaryDaniel von Allmen summarizing the discussion: German study of 278 stage 4 high-risk neuroblastoma patients achieved complete resection in almost half and >90% resection in another quarter (75% total with >90% resection)↗
▶Ep 2 · 17:13
host summaryDaniel von Allmen summarizing the discussion: German study showed overall survival 45%, event-free survival 33%, and local progression-free survival 58% in stage 4 neuroblastoma↗
▶Ep 2 · 17:32
host summaryDaniel von Allmen summarizing the discussion: German study showed no difference in overall survival, event-free survival, or local progression-free survival based on completeness of resection in stage 4 neuroblastoma↗
▶Ep 2 · 17:51
host summaryDaniel von Allmen summarizing the discussion: German study concluded aggressive surgery is not justified in stage 4 neuroblastoma, that limited operations decrease complications, and there is limited impact on patient outcome↗
▶Ep 2 · 18:14
host summaryDaniel von Allmen summarizing the discussion: European study included 1,324 high-risk neuroblastoma patients (stages 2, 3, and 4) and achieved 76% with >95% resection↗
▶Ep 2 · 19:02
host summaryDaniel von Allmen summarizing the discussion: European neuroblastoma study showed 0.5% mortality and 10% morbidity (30% including lesser complications)↗
▶Ep 2 · 19:17
host summaryDaniel von Allmen summarizing the discussion: European study showed significant improvement in event-free survival and overall survival with aggressive resection in high-risk neuroblastoma - first study to show overall survival benefit↗
▶Ep 2 · 20:17
host summaryDaniel von Allmen summarizing the discussion: European study concluded >95% resection results in improvement in event-free survival in high-risk neuroblastoma↗
▶Ep 2 · 21:24
host summaryDaniel von Allmen summarizing the discussion: COG 3973 study of approximately 230 high-risk neuroblastoma patients showed significant improvement in local relapse-free survival and event-free survival but not overall survival↗
▶Ep 2 · 23:33
host summaryDaniel von Allmen summarizing the discussion: European neuroblastoma procedures are performed in more than 200 hospitals yet still demonstrated survival improvements↗
▶Ep 2 · 24:03
host summaryDaniel von Allmen summarizing the discussion: Older data shows worse survival in neuroblastoma when kidney is removed, likely because single kidney limits chemotherapy dosing↗
▶Ep 2 · 24:52
host summaryDaniel von Allmen summarizing the discussion: If you can't be informed, be opinionated↗
