We send the families home with the equipment to irrigate. That's a must, right? And also we teach how to irrigate before we do our pull through so that they are, and make the parents practice whether the child has enterocolitis or not pre-op so that they know how to do it. Because I don't love that catheter going through the anastomosis post-up day five when they're ready to go home or, and having issues. So I think you're dead on. Education is so key and preparing the families for this is life-saving.
Then the group in Cincinnati with Dr. Helmrath and Dr. Frischer have altered the protocol to apply Botox at the anal sphincter at the time of restoring intestinal continuity. So we've been doing that. I don't have data to share that of an outcome. I will say, I know we have a few patients that definitely got enteroclitis that were in the protocol. So it's definitely not 100% full proof. And we definitely have increased diaper rash issues. So we know we're putting it in the right place.
if you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit
Moreover, too, if you think about just the way that we close a sutured repair, you mobilize flaps from the skin and flaps from the fascia. So there's always, you know, redness around the incision, bruising around the incision. And so, you know, even that tissue manipulation is going to put you at higher risk for a potential infection or calling it erythema infection.
We typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be.
It goes without saying, and one of our, I think one of our big teaching points is you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum.
Gastroschisis and sutureless abdominal wall closure
▶Ep 22 · 7:20
opinionDue to the heterogeneity of gastroschisis, patients able to undergo primary repair probably had more favorable bowel and theoretically would have less hospital stay and feed faster.↗
▶Ep 22 · 7:20
quoteI think it was probably what we were expecting, I think, for a couple of reasons. One, due to the heterogeneity of this disease, you know, especially with gastroschisis, a lot of the patients that were able to undergo, you know, especially a primary repair, they probably had more favorable bowel. And then those patients, you know, theoretically would have less hospital stay and theoretically feed faster and things like that.↗
▶Ep 22 · 7:20
opinionMany patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions.↗
▶Ep 22 · 8:05
quoteMoreover, too, if you think about just the way that we close a sutured repair, you mobilize flaps from the skin and flaps from the fascia. So there's always, you know, redness around the incision, bruising around the incision. And so, you know, even that tissue manipulation is going to put you at higher risk for a potential infection or calling it erythema infection.↗
▶Ep 22 · 8:05
opinionThe finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation.↗
▶Ep 22 · 8:05
clinicalIn sutured repair, mobilizing flaps from the skin and fascia causes redness and bruising around the incision, which puts patients at higher risk for potential infection.↗
▶Ep 22 · 8:50
clinicalThe consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up.↗
▶Ep 22 · 8:50
clinicalThe next phase of the study is examining the same patients over several years of follow-up to assess growth and umbilical hernia repair rates.↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 29 · 3:10
quotewe start feeding essentially you have to put the dressing on uh as long as the baby's not sick not having horrible output not puking or anything like that↗
▶Ep 29 · 3:10
clinicalJason Fraser's institution starts feeding immediately after dressing placement as long as the baby is not sick, not having horrible output, and not vomiting.↗
▶Ep 29 · 3:54
quotewe don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it↗
▶Ep 29 · 3:54
clinicalFraser's institution does not intubate gastroschisis babies for reduction.↗
▶Ep 29 · 5:13
clinicalAwake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching.↗
▶Ep 29 · 5:13
quoteif you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit↗
▶Ep 29 · 6:19
quoteit's really just based upon patient tolerance and it's kind of based upon some of the data that's out there from the rest of the world where they don't have tpn and so they just you have to feed the kid if the kid does okay then they keep going↗
▶Ep 29 · 6:19
clinicalCincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory.↗
▶Ep 29 · 10:30
opinionThe reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself.↗
▶Ep 29 · 10:30
quotea lot of the inconclusivity from the the study showed that you know most likely due to the fact that there was lots of different feeding protocols that were used uh across our member institutions↗
▶Ep 29 · 10:30
epidemiologicalThe multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions.↗
▶Ep 29 · 10:50
quotethe ssi thing was probably just because patients that were fed via protocol were cared for via protocol and so that they actually had less variability and less uh less changes uh in the way that these these patients are not you know look for↗
▶Ep 29 · 11:20
quoteour length of stay for gastroschisis and cincinnati was astronomically higher than like any other nick micu in the cooperative network that we worked with so we sat down we're like what is going on here so our average length of stay was 49 days↗
▶Ep 29 · 11:20
epidemiologicalCincinnati Children's average gastroschisis length of stay was 49 days before protocol implementation, which was astronomically higher than comparable NICUs in their cooperative network.↗
▶Ep 29 · 12:10
epidemiologicalCincinnati Children's has seen a decrease in time from first feed to full feeds but has not yet reduced the time from admission to first feed (except in 2020).↗
▶Ep 29 · 12:10
epidemiologicalAfter implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years.↗
▶Ep 29 · 12:10
quotewe instituted this uh a feeding protocol we spent a lot of time trying to get people to follow it and and making some adjustments and over two years we dropped the length of stay by 10 days and the mix of patients is not different↗
▶Ep 29 · 14:20
clinicalCincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization.↗
▶Ep 29 · 16:00
quotethe most important thing that kind of keeps showing up is the fact that we really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go is the most important thing↗
▶Ep 29 · 16:00
opinionThe most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition.↗
▶Ep 29 · 16:40
quoteyes you can have a protocol yes you know you need to follow it but the most really you really need to continually evaluate the patient as they continue to go to make sure that you know yes your protocol is working but also to the patient does okay throughout↗
▶Ep 29 · 16:40
clinicalFor significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based.↗
▶Ep 29 · 17:22
epidemiologicalCincinnati Children's current average gastroschisis length of stay is 30 to 34 days.↗
▶Ep 29 · 17:22
clinicalOne recent Cincinnati Children's gastroschisis patient who was primarily reduced on day of life zero was discharged at approximately two weeks and remained well at two-week follow-up, though this is an outlier on the faster end.↗
▶Ep 29 · 18:14
epidemiologicalCincinnati Children's has not seen any aspirations with their early aggressive feeding approach, though they acknowledge they are still early in implementation and continue to monitor data.↗
▶Ep 29 · 18:56
clinicalAt Cincinnati Children's, approximately two-thirds of gastroschisis cases cannot be reduced immediately and are placed in a silo for gradual reduction followed by sutureless closure, with feeds started after closure.↗
Jason's statements about Anorectal Malformation186 statements
The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula
▶Ep 35 · 4:11
quoteI always worry about a missed presacral mass.↗
▶Ep 35 · 5:08
clinicalCross-table lateral X-ray should be obtained at approximately 24 hours of life to assess the air column position relative to the perineal skin, with the baby positioned prone to allow air to rise to the buttocks.↗
▶Ep 35 · 6:28
clinicalThe cross-table lateral film should include a marker at the expected anal location to allow measurement of the distance between the air column and the perineal skin.↗
▶Ep 35 · 7:47
clinicalWell-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together predict good prognosis for continence.↗
▶Ep 35 · 8:25
quoteWell, I have two answers for you, Mark. I think if I was sitting in a hotel room, being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here.↗
▶Ep 35 · 9:58
quoteIt goes without saying and, and one of our, I think one of our big teaching points is you should never try to go in blind.↗
▶Ep 35 · 9:58
clinicalThe surgeon should never attempt posterior sagittal approach blind; imaging must confirm that the first structure encountered will be the air pocket of the distal rectum.↗
▶Ep 35 · 11:37
quoteWe both agree that probably in real life, we would have done a primary posterior sagittal approach on this patient, and we would have found the rectum, and we could have made that rectum reach the perineum and done our anoplasty. How do we handle this? Because I didn't know that there was a fistula there. This is troublesome.↗
▶Ep 35 · 12:34
quoteYou can see this fistula is very close to the rectum. And if you're going to dissect that free, and along the urethra, um, it's important to make sure that you know that those two structures are not very far apart, and getting that into that proper plane is very important.↗
▶Ep 35 · 12:55
clinicalA bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature based on the urethral location.↗
▶Ep 35 · 13:00
quoteThe reason why Doctor Levitt or Mark is saying that. It's a bulbar fistula, it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the uh the nomenclature we like to use is an anatomic pure anatomic nomenclature saying that it's a bulbar fistula.↗
Colorectal Quiz Episode 2: When to redo a PSARP
▶Ep 36 · 0:00
opinionFor anorectoplasty, if you don't get it perfect, you might not have the best outcomes, which separates it from other surgical procedures.↗
▶Ep 36 · 1:20
quoteHow many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? That's the real frustrating one. Right? A lot.↗
▶Ep 36 · 5:50
quoteI can tell you, the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work. And is the child going to be clean and in normal underwear and just like all the other kids?↗
▶Ep 36 · 5:50
opinionThe family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work and is the child going to be clean and in normal underwear.↗
▶Ep 36 · 6:25
clinicalThe higher the malformation, the worse the prognosis.↗
▶Ep 36 · 6:35
clinicalA sacrum ratio of 0.7 or greater usually means normal or close to normal sphincters and good muscle tone, indicating that spine innervation of that area is probably good.↗
▶Ep 36 · 6:40
clinicalPatients can come with associated spinal anomaly, most commonly tethered cord, but the worst is a myelomeningocele, and those patients have much more trouble with continence.↗
▶Ep 36 · 7:44
clinicalIt's amazingly common to have a mislocated anus, either because the surgeon misses where the center is during laparoscopic pull-through or opens the PSARP incision first.↗
▶Ep 36 · 8:05
clinicalA key pitfall is opening the PSARP incision first; instead, mark the sphincters first, then open the PSARP so you don't get confused when placing the anoplasty in the correct location.↗
▶Ep 36 · 8:05
quoteA key pitfall is not do that. Mark the sphincters first, then open the PSARP because then you don't get confused at the end when you're trying to place the anoplasty in the correct location.↗
▶Ep 36 · 10:19
clinicalIn higher malformations such as a bladder neck fistula in a boy, the sphincter complex isn't always where you think it's going to be and is sometimes more anterior than anticipated.↗
▶Ep 36 · 15:19
opinionAn alternative approach for borderline cases is to let the child take their car out for a ride first and see how it works—if it drives well, stay with that anatomy; if not, then consider the redo.↗
Colorectal Quiz Episode 13: Newborn ARM Part 2
▶Ep 39 · 4:45
clinicalPerineal groove with mucosal lining will keratinize and look like normal perineal body over time↗
▶Ep 39 · 4:45
quoteMy conversation with the family often involves that this will keratinize and look like a normal peroneal body over time.↗
▶Ep 39 · 5:00
clinicalSurgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers↗
▶Ep 39 · 9:35
clinicalVestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter↗
▶Ep 39 · 10:22
clinicalPatients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair↗
▶Ep 39 · 10:22
clinicalPurpose of diversion in ARM repair is to avoid perineal body dehiscence↗
▶Ep 39 · 10:22
clinicalFor vestibular fistula diagnosed in newborn period, options are primary repair if baby is well, or allow stooling through fistula for couple months then elective repair without stoma↗
▶Ep 39 · 14:11
clinicalTo evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra↗
Colorectal Quiz Episode 14: ARM Newborn Part 3
▶Ep 40 · 1:49
clinicalCross-table lateral films can be obtained early and then around 24 hours later in cases where there is no evidence of fistula on exam.↗
▶Ep 40 · 2:06
clinicalIf the air column stops at about the 4th sacral vertebral body with a large distance between the air column and the sphincter marker, the patient should be considered for diversion and distal colostogram to delineate anatomy.↗
▶Ep 40 · 2:06
quoteif you look at the film on the left, the air column stops at about the 4th sacral vertebral body, give or take a little bit. And so, what, and you could see where the marker is or the BB is, uh, where the, where the sphincter complex appears to be located. There's a large distance between those.↗
▶Ep 40 · 2:49
quotethe air column is very close to where the anticipated anal opening should be located. And this is a case where you could take your barley bush, potentially, and make a nick, uh, a scratch, and, and do your anoplasty.↗
▶Ep 40 · 2:49
clinicalWhen the air column is very close to where the anticipated anal opening should be located, primary anoplasty may be performed.↗
▶Ep 40 · 6:13
opinionWhether to perform primary anoplasty in cases with close air column depends on individual surgeon comfort and the level of post-operative care available at the institution.↗
▶Ep 40 · 7:16
clinicalThe common wall between the rectum and the urethra is closer and longer than some people anticipate.↗
▶Ep 40 · 7:16
quotethat common wall or, or that wall between the rectum and the urethra is a lot closer and a lot longer. Of a common wall, then I think some people anticipate.↗
▶Ep 40 · 7:41
clinicalA patient at 24 hours with no obvious fistula and cross-table lateral showing air column not very distal needs a colostomy.↗
The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...
▶Ep 41 · 2:44
quoteCan I scare you for a moment? Can we talk scientifically for one minute? I know this is crazy.↗
▶Ep 41 · 3:08
clinicalThe dentate (or pectinate) line is the transition from squamous epithelium to columnar epithelium, located about 2/3 of the way up the anal canal.↗
▶Ep 41 · 3:25
clinicalBlood supply changes occur at the dentate line (splanchnic versus systemic), and there is also innervation in that area.↗
▶Ep 41 · 3:54
clinicalThe nerves located at the dentate line region tell you gas, liquid, solid; how hard, how long, and how tight to squeeze.↗
▶Ep 41 · 3:54
quoteI talk about that dentate line in the area where the nerves are located that tell you gas, liquid, solid. How hard do I need to squeeze, how long do I have to squeeze for, how tight do I have to squeeze?↗
▶Ep 41 · 4:15
clinicalPreserving the dentate line region is key because injury to that region affects a patient's ability to be continent.↗
▶Ep 41 · 6:11
clinicalIn children with anorectal malformation, Hirschsprung disease, spinal conditions, or combinations thereof, the ability to sense stool in the rectum or neorectum region is critical to success; the right consistency and bulk of stool is very important.↗
▶Ep 41 · 6:45
clinicalIf clinicians make stool too soft or too loose with medications, they put a child on the edge of having control or not and throw them over that edge, preventing success.↗
▶Ep 41 · 6:59
quoteAnd if we make it too soft or too loose, we're putting a child or a person who is on the teeter of having control or not, and you throw them over that edge, and, and you just won't be successful.↗
▶Ep 41 · 11:16
quoteI mean, it makes sense that they should if the muscle is intact, right, because this is no different than an anorectal malformation, anastomosis. That's right. But it's, it's, it's rectum or colon mucosa to skin.↗
▶Ep 41 · 11:16
clinicalA Hirschsprung patient with missing dentate line and intact muscle should be able to achieve continence, similar to an anorectal malformation anastomosis (rectum or colon mucosa to skin).↗
▶Ep 41 · 12:08
clinicalPatients with no dentate line and patulous sphincters who are soiling develop severe skin irritation from sitting in pull-ups or diapers.↗
▶Ep 41 · 12:08
quoteThat is a patient with no dentate line and pattula sphincters, and you clearly see with the skin changes around that, that this patient has really struggled and has been soiling and, and, and sitting in, in pull-ups or a diaper, really causing severe skin irritation.↗
▶Ep 41 · 18:17
quoteThis, this is, these are the harder patients to take care of, and the trick that I use is you have to constipate them. And then if they're able to empty with continence on their own, then great. If they're not, then you have to mechanically help them empty.↗
▶Ep 41 · 18:17
clinicalFor hypermotile patients (stooling 7-8 times a day), the approach is to constipate them first, then figure out how to empty them in a time-controlled fashion.↗
▶Ep 41 · 18:35
clinicalWhether hypermotile patients can empty on their own versus needing mechanical emptying to maintain social continence depends on their sphincter function.↗
▶Ep 41 · 18:35
quoteBut it, it's, it's like, it sounds counterintuitive, but at least the way I treat these patients, I constipate them, and then I empty them.↗
▶Ep 41 · 18:58
quoteBut that's how I sort of explain it to the families. It sounds weird, but we're gonna constipate you, and then we have to figure out how to empty you in a time-controlled fashion.↗
▶Ep 41 · 22:42
clinicalSome Hirschsprung patients who have a good operation have super strong sphincters that just need a little relaxation to allow passage of stool until they learn proper sphincter coordination for evacuation.↗
▶Ep 41 · 23:10
clinicalBotox helps train sphincters in Hirschsprung patients; anorectal manometry can provide objective data showing resting pressures are usually on the higher end of normal, and some patients need extra relaxation to allow them to go.↗
▶Ep 41 · 23:31
clinicalNutrition in Hirschsprung patients is very important; some patients are very sensitive to certain foods, particularly lactose.↗
▶Ep 41 · 23:50
clinicalPaying attention to diet (whether breastfed infants or older children) is important because lactose is particularly problematic in some Hirschsprung patients.↗
▶Ep 41 · 24:26
quoteNone. We have to get it right the first time.↗
▶Ep 41 · 24:29
quoteAnd if you don't get it right, you gotta use these techniques and this algorithm to figure out what's wrong, cause we could get every patient doing well. They might need help, and they might need mechanical evacuations, Botox, etc. but we could, we all should be able to get these patients on the right track.↗
▶Ep 41 · 24:29
opinionEvery Hirschsprung patient should be able to do well; they might need help and might need mechanical evacuations or Botox, but all should be able to get on the right track.↗
Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula
▶Ep 42 · 15:22
quotewhen you do find neurologic anomalies. That leads to more likely gynecological anomalies as well, especially on the same side.↗
▶Ep 42 · 15:22
clinicalWhen neurologic anomalies are found in anorectal malformation patients, gynecological anomalies are more likely, especially on the same side.↗
Colorectal Quiz Episode 29: Female ARM-Post Op Management
▶Ep 43 · 7:17
clinicalDr. Fisher's protocol for perineal body primary repair (no stoma) is 5-7 days NPO on D10 via midline catheter (not PICC line) until the repair is confirmed healed.↗
▶Ep 43 · 8:03
quoteJust because it's published doesn't mean it works.↗
▶Ep 43 · 13:51
quoteMy only concern is what's the continence rate of your patients?↗
▶Ep 43 · 15:01
quoteI guess my question is somewhere around 20% required a redo either local or total operation. Most just like local, but what did a functional out in the end of the game, all the parents want is their kid pooping in the potty. And we don't know that answer.↗
▶Ep 43 · 15:24
quoteThat's a very valid point. So what you're saying, wait, wait, Mark agreed with me.↗
▶Ep 43 · 19:00
quoteAnd when I was working with Mark here, I know, especially in the older patients that we were doing redos on, used to teach me to make the anoplasty maybe a little larger.↗
Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery
▶Ep 55 · 3:59
clinicalMRI with specific protocols and endorectal ultrasound can help determine whether the anoplasty is within the muscle complex.↗
▶Ep 55 · 14:05
opinionThe transition model includes joint clinic visits and collaborative operating, which is key to successful handoff.↗
▶Ep 55 · 14:54
opinionFreestanding children's hospitals face greater challenges than integrated hospitals because they are completely separate entities both physically and financially.↗
▶Ep 55 · 15:14
clinicalIn Cincinnati, ARM patients still come to the colorectal center at the children's hospital whether they are 12 or 40 years old, partnering with an adult colorectal surgeon; collaborative operating occurs at the University of Cincinnati with adult colorectal surgeons, adult neurologists for urology, and pediatric urologists who have privileges at the university.↗
▶Ep 55 · 18:58
opinionAdult hospitals are much more adept and skilled at managing perioperative complications like pulmonary embolism or myocardial infarction; such events in a children's hospital lead to many meetings and potential for poor outcomes.↗
▶Ep 55 · 19:33
clinicalPhysicians and surgeons are making progress on transition, but the greater struggle is providing intensive bowel management training for 35-year-old patients; pediatric centers are adept at bowel management for patients of any age, but currently adult patients requiring intensive outpatient bowel management are still being seen at children's hospitals.↗
quoteI always worry about a missed presacral mass.↗
▶Ep 83 · 5:08
quoteWe typically get at about the 24 hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like.↗
▶Ep 83 · 5:08
clinicalCross-table lateral X-ray should be obtained at approximately 24 hours of life (give or take a few hours) to assess gas column location, with the baby positioned prone to allow air to rise to the buttocks.↗
▶Ep 83 · 6:29
clinicalMarking the expected anal location on cross-table lateral X-ray allows measurement of the distance between the air column and perineal skin to guide surgical planning.↗
▶Ep 83 · 7:46
clinicalWell-formed buttocks with visible sphincter mechanism location, combined with well-developed sacrum, indicate likely good prognosis for continence.↗
▶Ep 83 · 8:27
quoteI think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do in on a Tuesday afternoon? I think. This air column is, if you're going to get this X-ray and base your decision making on where the air column is and what's going on. I'm pretty apt to say I might perform a primary posterior sagittal inter ectoplasty with this type of imaging in front of me.↗
▶Ep 83 · 9:58
quoteIt goes without saying and, and one of our, I think one of our big teaching points is you should never try to go in blind.↗
▶Ep 83 · 9:58
clinicalNever attempt posterior sagittal approach blind—only proceed when confident the first structure encountered will be the air pocket of the distal rectum.↗
▶Ep 83 · 12:34
clinicalWhen a fistula is very close to the rectum, proper plane dissection along the urethra is critical because the two structures are not far apart.↗
▶Ep 83 · 12:55
clinicalA bulbar fistula is defined by its anatomic location at the elbow of the urethra, using pure anatomic nomenclature.↗
Colorectal Quiz: Episode 47
▶Ep 77 · 6:29
clinicalThere are many ways to tell if the anus is in the proper position, such as electrical stimulation and rectal ultrasound or MRI.↗
▶Ep 77 · 6:29
guidelineAnorectal manometry is not part of the standard initial workup for anorectal malformation patients; it is saved for circumstances that are difficult to figure out.↗
▶Ep 77 · 6:29
quoteWe don't typically do anorectal manometry in our anorectal malformation patients as part of the standard initial workup. I never say never and I never say always, but it's not part of our standard evaluation.↗
▶Ep 77 · 9:40
quoteThis is one of those things I always wonder, cause we all have a few patients that have this anatomy like chicken or the egg. Like what came first?↗
▶Ep 77 · 16:49
clinicalA patient with sacral ratio 0.45 is likely to be a bowel management candidate and will probably never achieve successful bowel control given the quality of their pelvis and amount of caudal regression.↗
▶Ep 77 · 16:49
quoteI think this patient is going to be a bowel management candidate. And I doubt they will ever achieve successful bowel control anyway, given the quality of their pelvis, the amount of quadruple regression that they have.↗
▶Ep 77 · 16:49
clinicalA sacral ratio of 0.45 indicates the sacrum is not great and the perineal musculature is probably not great.↗
Colorectal Quiz: Episode 43
▶Ep 79 · 5:37
epidemiologicalAbout 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work.↗
▶Ep 79 · 7:37
clinicalThe longer the appendix, the less likely it will leak based on Poiseuille's law (flow through a tube based on radius to fourth power and length).↗
▶Ep 79 · 8:35
quoteSo we plicate them all. And I haven't had a leakage in a long, long time, several years. So I think it's a very effective strategy.↗
▶Ep 79 · 8:35
clinicalDr. Frischer and Levitt did 10 Malones in a row without plicating and five leaked, so they decided to plicate them all and have not had a leakage in several years.↗
▶Ep 79 · 9:03
clinicalIf appendix is 5 to 7 centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone.↗
▶Ep 79 · 9:03
clinicalIf appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.↗
▶Ep 79 · 9:03
clinicalIf appendix is 7 centimeters or greater it can be split, requiring minimum 2 centimeters for the Malone and 5 centimeters minimum for the Mitrofanoff.↗
▶Ep 79 · 16:13
clinicalUsing a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate.↗
▶Ep 79 · 16:54
clinicalLeaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa.↗
▶Ep 79 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanovs because they catheterize every four hours; applying this to Malones by cathing twice daily has reduced stenosis rate.↗
▶Ep 79 · 20:00
clinicalFor lost Malone access, blow up a balloon on a Foley catheter to occlude the umbilicus and inject dye under pressure to find any micro hole tract.↗
Colorectal Quiz: Episode 43
▶Ep 78 · 5:37
epidemiologicalAbout 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff; about 40% of the time you cannot make it work.↗
▶Ep 78 · 7:37
clinicalFlow of fluid through a tube is based on Poiseuille's law: radius to the fourth power and length. A longer appendix or narrower appendix affects flow probability.↗
▶Ep 78 · 8:35
clinicalThe longer the appendix, the less likely it will leak and you should not need to plicate.↗
▶Ep 78 · 8:35
clinicalPlicating all malones is a very effective strategy; no leakage has occurred in several years using this approach.↗
▶Ep 78 · 8:35
epidemiologicalIn a study of 10 malones done in a row without plicating, five leaked, leading to the decision to plicate all malones.↗
▶Ep 78 · 9:03
clinicalIf appendix is seven centimeters or greater it can be split, requiring minimum two centimeters for Malone and five centimeters minimum for Mitrofanoff.↗
▶Ep 78 · 9:03
clinicalIf appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.↗
▶Ep 78 · 9:03
clinicalIf appendix is five to seven centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone.↗
▶Ep 78 · 10:00
clinicalFor patients with appendix 4-7 centimeters, 90% of appendix can be given to urologist with extension of appendiceal stump into cecum using non-cutting endo-TA stapler or hand-sewn non-absorbable braided suture.↗
▶Ep 78 · 12:08
clinicalPay attention to ileocecal valve location when creating Malone and plication to avoid obstruction at the ileocecal valve.↗
▶Ep 78 · 16:13
clinicalUsing a 10 French tube instead of 8, leaving it in for a month, and cathing twice a day has reduced the incidence of stenosis.↗
▶Ep 78 · 16:54
clinicalProlonged stenting increases prolapse rate due to pressure on the appendiceal base pushing up mucosa.↗
▶Ep 78 · 16:54
clinicalLeaving tubes in prevents stenosis but increases the chance of leakage because the valve is no longer as pertinent with a stent across it.↗
▶Ep 78 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanoff because they cath every four hours; cathing the Malone twice a day has reduced stenosis rate.↗
▶Ep 78 · 18:20
clinicalFor recurrent leakage after two wraps, consider whether appendix length is a problem and whether channel needs lengthening.↗
▶Ep 78 · 20:00
clinicalBlowing up a balloon on Foley catheter to occlude umbilicus and injecting dye creates pressurized system that will find any micro-hole tract still present.↗
Colorectal Quiz: Episode 40
▶Ep 90 · 11:35
clinicalOptions for vaginal reconstruction when native vagina cannot reach include: dilating the existing introitus, opening the area and laying in a buccal graft, or waiting for tissue engineering options expected within 20 years or less.↗
▶Ep 90 · 12:14
quoteI think it's going to be, there are people right now taking a few vaginal cells and growing them and hopeful, just like you said, Mark, we're going to have some great tissue engineering that will assist us and make this a easier and better procedure for our patients.↗
▶Ep 90 · 13:09
opinionIf a neovagina bridge is functioning well without problems, there may be no reason to remove it later.↗
Colorectal Quiz: Episode 40
▶Ep 80 · 5:32
quoteWait, is this Meyer-Rotakansky-Kuster-Hauser syndrome?↗
▶Ep 80 · 11:35
opinionThe introitus in this case is potentially dilatable in the future to create a functional vagina.↗
▶Ep 80 · 12:14
quoteThere are people right now taking a few vaginal cells and growing them.↗
▶Ep 80 · 12:14
opinionTissue engineering options for vaginal reconstruction are expected to be available within 20 years or perhaps even shorter, with researchers currently growing vaginal cells.↗
▶Ep 80 · 13:09
opinionIf a neovagina functions well and causes no problems, there is no reason to remove it later even if it is bowel or another graft material.↗
▶Ep 80 · 13:09
quoteI think you need it when there's a problem. If there's no problem, why go in and remove tissue, whether it be bowel or whatever you have as your graft?↗
▶Ep 80 · 14:50
quoteI applaud you, Chris, and your partners for going in thinking you're going to do this big reconstruction, encounter something that you weren't expecting and doing the safe thing.↗
▶Ep 80 · 15:57
quoteFred Reichman used to say, you are judged by what you are willing to stop for.↗
▶Ep 80 · 15:57
guidelineIf a surgeon is uncertain about vascular anatomy during an operation, they should stop, gather more information, and reconfront the situation rather than proceeding blindly.↗
▶Ep 80 · 15:57
opinionFred Reichman used to say that surgeons are judged by what they are willing to stop for.↗
▶Ep 80 · 15:57
quoteAs surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through.↗
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
▶Ep 91 · 4:36
quoteDo you automatically get an echo on every one of your anorectal malformation babies?↗
▶Ep 91 · 7:24
opinionFor perineal fistula or vestibular fistula in a female, one can consider just dilating with good evacuation and letting the cardiac situation play itself out.↗
▶Ep 91 · 7:24
clinicalIn a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they're evacuating okay.↗
▶Ep 91 · 7:48
clinicalIn a blue baby with significant cardiac lesion requiring early surgery where patient isn't oxygenating well, there is concern about healing of an ARM repair.↗
▶Ep 91 · 7:48
quoteMy concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair↗
▶Ep 91 · 11:08
quoteDissecting in with a mosquito, making sure you're in, not touching any vessel before you insufflate, and also clear the line of air↗
▶Ep 91 · 11:08
clinicalFor umbilical access in laparoscopy, dissect in with a mosquito, ensure you're in the peritoneum without touching any vessel before insufflation, and clear the line of air.↗
▶Ep 91 · 13:56
clinicalThe white beads along the raphe should be scraped off during repair, as they can persist into teenage years and young adulthood if left alone.↗
▶Ep 91 · 13:56
quoteI've seen teenagers and young adults with those beads that never went away. So, yeah, you've got to scrape that off↗
▶Ep 91 · 14:23
clinicalFor a 50-50 perineal fistula (half within muscle complex, half anterior), leave the anterior wall as it's the danger zone, mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction.↗
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
▶Ep 82 · 4:36
quoteDo you automatically get an echo on every one of your anorectal malformation babies?↗
▶Ep 82 · 7:24
clinicalIn a cardiac patient with an external ARM opening, the typical approach is to dilate as long as they're evacuating okay, allowing the cardiac situation to play itself out.↗
▶Ep 82 · 7:48
clinicalThe concern with early ARM repair in a blue baby with significant cardiac lesion requiring early surgery is the healing of that repair when the patient isn't oxygenating well.↗
▶Ep 82 · 7:48
quoteMy concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair.↗
▶Ep 82 · 11:21
quoteIt is important to irrigate as much as you can↗
Colorectal Quiz Episode 29: Female ARM
▶Ep 92 · 7:17
clinicalDr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO.↗
▶Ep 92 · 15:02
clinicalApproximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures.↗
Colorectal Quiz Episode 29: Female ARM
▶Ep 84 · 7:17
clinicalFrischer uses midline catheter (not PICC line) with D10 for 5-7 days NPO after primary perineal body repair.↗
▶Ep 84 · 14:04
quoteMy only concern is what's the continence rate of your patients? You have a percent of looking at, right? You're somewhere in the order of 15 to 20, 22% got redo operations, mostly local.↗
▶Ep 84 · 15:23
clinicalLong-term continence outcomes are unknown for patients who developed strictures and underwent revision in the non-dilation group.↗
▶Ep 84 · 16:30
clinicalFull continence can be restored with redo surgery for stricture, based on available data for longer strictures requiring full redo.↗
clinicalIn higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated↗
▶Ep 94 · 15:20
opinionAlternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo↗
Colorectal Quiz: Episode 2
▶Ep 86 · 10:19
clinicalIn higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated.↗
▶Ep 86 · 10:19
quotePatients like patients who have a higher malformation, such as a bladder neck, sometimes those sphincter complexes are sort of more anterior than you think that you're anticipating it might be.↗
▶Ep 86 · 15:20
opinionAn alternative approach for borderline anatomy is to be more conservative and let the child take their car out for a ride first to see how it works before considering redo.↗
The Colorectal Quiz: Episode 1
▶Ep 95 · 4:15
quoteif it's an anal stenosis or a rectal atresia defect, then you need to be very worried about finding a pre-sacral mass. And almost half the time, you'll find one. And those patients will end up getting an MRI.↗
▶Ep 95 · 4:15
epidemiologicalPre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI↗
▶Ep 95 · 5:05
guidelineCross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning↗
▶Ep 95 · 5:05
quoteWe typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be.↗
▶Ep 95 · 7:36
clinicalWell-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis↗
▶Ep 95 · 8:25
quoteI have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.↗
▶Ep 95 · 8:25
opinionWith air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging↗
▶Ep 95 · 9:57
guidelineShould never try to go in blind—must know what structure will be encountered before making posterior sagittal incision↗
▶Ep 95 · 9:57
quoteyou should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum.↗
▶Ep 95 · 12:34
quoteThe reason why Dr. Levitt or Mark is saying that it's a bulbar fistula is it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the nomenclature we like to use is an anatomic, pure anatomic nomenclature saying that it's a bulbar fistula.↗
▶Ep 95 · 12:34
quoteyou can see this fistula is very close to the rectum. And if you're going to dissect that free and along the urethra, it's important to make sure that you know that those two structures are not very far apart. And getting that into that proper plane is very important.↗
▶Ep 95 · 12:34
clinicalBulbar fistula nomenclature refers to anatomic location at the elbow of the urethra↗
▶Ep 95 · 12:34
clinicalFistula can be very close to rectum, making proper plane dissection along urethra important↗
The Colorectal Quiz: Episode 1
▶Ep 88 · 4:15
epidemiologicalPre-sacral mass is rare in typical imperforate anus but occurs in almost half of anal stenosis or rectal atresia cases↗
▶Ep 88 · 4:15
clinicalPatients with anal stenosis or rectal atresia and pre-sacral mass will need MRI evaluation↗
▶Ep 88 · 5:05
quoteWe typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be.↗
▶Ep 88 · 5:05
clinicalCross-table lateral x-ray is typically obtained at about 24 hours of life, give or take a few hours, to visualize the gas column position↗
▶Ep 88 · 7:36
clinicalWell-formed buttocks, good muscle mass, and identifiable sphincter mechanism location on physical exam contribute to favorable prognosis in anorectal malformation↗
▶Ep 88 · 8:25
quoteI have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.↗
▶Ep 88 · 9:57
quoteIt goes without saying, and one of our, I think one of our big teaching points is you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum.↗
▶Ep 88 · 12:34
clinicalA bulbar fistula is named for its location at the elbow of the urethra, using pure anatomic nomenclature↗
Jason's statements about Anorectal Malformations42 statements
The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula
▶Ep 9 · 4:11
quoteI always worry about a missed presacral mass.↗
▶Ep 9 · 5:08
clinicalCross-table lateral X-ray should be obtained at approximately 24 hours of life to assess the air column position relative to the perineal skin, with the baby positioned prone to allow air to rise to the buttocks.↗
▶Ep 9 · 6:28
clinicalThe cross-table lateral film should include a marker at the expected anal location to allow measurement of the distance between the air column and the perineal skin.↗
▶Ep 9 · 7:47
clinicalWell-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together predict good prognosis for continence.↗
▶Ep 9 · 8:25
quoteWell, I have two answers for you, Mark. I think if I was sitting in a hotel room, being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here.↗
▶Ep 9 · 9:58
quoteIt goes without saying and, and one of our, I think one of our big teaching points is you should never try to go in blind.↗
▶Ep 9 · 9:58
clinicalThe surgeon should never attempt posterior sagittal approach blind; imaging must confirm that the first structure encountered will be the air pocket of the distal rectum.↗
▶Ep 9 · 11:37
quoteWe both agree that probably in real life, we would have done a primary posterior sagittal approach on this patient, and we would have found the rectum, and we could have made that rectum reach the perineum and done our anoplasty. How do we handle this? Because I didn't know that there was a fistula there. This is troublesome.↗
▶Ep 9 · 12:34
quoteYou can see this fistula is very close to the rectum. And if you're going to dissect that free, and along the urethra, um, it's important to make sure that you know that those two structures are not very far apart, and getting that into that proper plane is very important.↗
▶Ep 9 · 12:55
clinicalA bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature based on the urethral location.↗
▶Ep 9 · 13:00
quoteThe reason why Doctor Levitt or Mark is saying that. It's a bulbar fistula, it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the uh the nomenclature we like to use is an anatomic pure anatomic nomenclature saying that it's a bulbar fistula.↗
Colorectal Quiz Episode 2: When to redo a PSARP
▶Ep 10 · 0:00
opinionFor anorectoplasty, if you don't get it perfect, you might not have the best outcomes, which separates it from other surgical procedures.↗
▶Ep 10 · 1:20
quoteHow many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? That's the real frustrating one. Right? A lot.↗
▶Ep 10 · 5:50
quoteI can tell you, the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work. And is the child going to be clean and in normal underwear and just like all the other kids?↗
▶Ep 10 · 5:50
opinionThe family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work and is the child going to be clean and in normal underwear.↗
▶Ep 10 · 6:25
clinicalThe higher the malformation, the worse the prognosis.↗
▶Ep 10 · 6:35
clinicalA sacrum ratio of 0.7 or greater usually means normal or close to normal sphincters and good muscle tone, indicating that spine innervation of that area is probably good.↗
▶Ep 10 · 6:40
clinicalPatients can come with associated spinal anomaly, most commonly tethered cord, but the worst is a myelomeningocele, and those patients have much more trouble with continence.↗
▶Ep 10 · 7:44
clinicalIt's amazingly common to have a mislocated anus, either because the surgeon misses where the center is during laparoscopic pull-through or opens the PSARP incision first.↗
▶Ep 10 · 8:05
quoteA key pitfall is not do that. Mark the sphincters first, then open the PSARP because then you don't get confused at the end when you're trying to place the anoplasty in the correct location.↗
▶Ep 10 · 8:05
clinicalA key pitfall is opening the PSARP incision first; instead, mark the sphincters first, then open the PSARP so you don't get confused when placing the anoplasty in the correct location.↗
▶Ep 10 · 10:19
clinicalIn higher malformations such as a bladder neck fistula in a boy, the sphincter complex isn't always where you think it's going to be and is sometimes more anterior than anticipated.↗
▶Ep 10 · 15:19
opinionAn alternative approach for borderline cases is to let the child take their car out for a ride first and see how it works—if it drives well, stay with that anatomy; if not, then consider the redo.↗
Colorectal Quiz Episode 14: ARM Newborn Part 3
▶Ep 12 · 1:49
clinicalCross-table lateral films can be obtained early and then around 24 hours later in cases where there is no evidence of fistula on exam.↗
▶Ep 12 · 2:06
clinicalIf the air column stops at about the 4th sacral vertebral body with a large distance between the air column and the sphincter marker, the patient should be considered for diversion and distal colostogram to delineate anatomy.↗
▶Ep 12 · 2:06
quoteif you look at the film on the left, the air column stops at about the 4th sacral vertebral body, give or take a little bit. And so, what, and you could see where the marker is or the BB is, uh, where the, where the sphincter complex appears to be located. There's a large distance between those.↗
▶Ep 12 · 2:49
quotethe air column is very close to where the anticipated anal opening should be located. And this is a case where you could take your barley bush, potentially, and make a nick, uh, a scratch, and, and do your anoplasty.↗
▶Ep 12 · 2:49
clinicalWhen the air column is very close to where the anticipated anal opening should be located, primary anoplasty may be performed.↗
▶Ep 12 · 6:13
opinionWhether to perform primary anoplasty in cases with close air column depends on individual surgeon comfort and the level of post-operative care available at the institution.↗
▶Ep 12 · 7:16
quotethat common wall or, or that wall between the rectum and the urethra is a lot closer and a lot longer. Of a common wall, then I think some people anticipate.↗
▶Ep 12 · 7:16
clinicalThe common wall between the rectum and the urethra is closer and longer than some people anticipate.↗
▶Ep 12 · 7:41
clinicalA patient at 24 hours with no obvious fistula and cross-table lateral showing air column not very distal needs a colostomy.↗
Colorectal Quiz Episode 17: Cloaca Part 1
▶Ep 13 · 11:30
quoteThis is huge. This is why, this is real time, and we all know a book chapter takes five years to, three to five years to get published.↗
Colorectal Quiz Episode 18: Cloaca Part 2
▶Ep 14 · 4:50
clinicalDuring cystoscopy it is important to look for cervices to understand Müllerian development (one vagina vs. two, presence of uterus) and to identify ureteral orifices, which in complex malformations may attach anomalously low to the bladder or bladder neck.↗
Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula
▶Ep 15 · 15:22
clinicalWhen neurologic anomalies are found in anorectal malformation patients, gynecological anomalies are more likely, especially on the same side.↗
▶Ep 15 · 15:22
quotewhen you do find neurologic anomalies. That leads to more likely gynecological anomalies as well, especially on the same side.↗
Colorectal Quiz Episode 29: Female ARM-Post Op Management
▶Ep 16 · 7:17
clinicalDr. Fisher's protocol for perineal body primary repair (no stoma) is 5-7 days NPO on D10 via midline catheter (not PICC line) until the repair is confirmed healed.↗
▶Ep 16 · 8:03
quoteJust because it's published doesn't mean it works.↗
▶Ep 16 · 13:51
quoteMy only concern is what's the continence rate of your patients?↗
▶Ep 16 · 15:01
quoteI guess my question is somewhere around 20% required a redo either local or total operation. Most just like local, but what did a functional out in the end of the game, all the parents want is their kid pooping in the potty. And we don't know that answer.↗
▶Ep 16 · 15:24
quoteThat's a very valid point. So what you're saying, wait, wait, Mark agreed with me.↗
▶Ep 16 · 19:00
quoteAnd when I was working with Mark here, I know, especially in the older patients that we were doing redos on, used to teach me to make the anoplasty maybe a little larger.↗
Jason's statements about Anorectal Malformations & Cloacal Reconstruction41 statements
quoteI always worry about a missed presacral mass.↗
▶Ep 14 · 5:08
quoteWe typically get at about the 24 hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like.↗
▶Ep 14 · 5:08
clinicalCross-table lateral X-ray should be obtained at approximately 24 hours of life (give or take a few hours) to assess gas column location, with the baby positioned prone to allow air to rise to the buttocks.↗
▶Ep 14 · 6:29
clinicalMarking the expected anal location on cross-table lateral X-ray allows measurement of the distance between the air column and perineal skin to guide surgical planning.↗
▶Ep 14 · 7:46
clinicalWell-formed buttocks with visible sphincter mechanism location, combined with well-developed sacrum, indicate likely good prognosis for continence.↗
▶Ep 14 · 8:27
quoteI think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do in on a Tuesday afternoon? I think. This air column is, if you're going to get this X-ray and base your decision making on where the air column is and what's going on. I'm pretty apt to say I might perform a primary posterior sagittal inter ectoplasty with this type of imaging in front of me.↗
▶Ep 14 · 9:58
clinicalNever attempt posterior sagittal approach blind—only proceed when confident the first structure encountered will be the air pocket of the distal rectum.↗
▶Ep 14 · 9:58
quoteIt goes without saying and, and one of our, I think one of our big teaching points is you should never try to go in blind.↗
▶Ep 14 · 12:34
clinicalWhen a fistula is very close to the rectum, proper plane dissection along the urethra is critical because the two structures are not far apart.↗
▶Ep 14 · 12:55
clinicalA bulbar fistula is defined by its anatomic location at the elbow of the urethra, using pure anatomic nomenclature.↗
Colorectal Quiz: Episode 40
▶Ep 16 · 11:35
clinicalOptions for vaginal reconstruction when native vagina cannot reach include: dilating the existing introitus, opening the area and laying in a buccal graft, or waiting for tissue engineering options expected within 20 years or less.↗
▶Ep 16 · 12:14
quoteI think it's going to be, there are people right now taking a few vaginal cells and growing them and hopeful, just like you said, Mark, we're going to have some great tissue engineering that will assist us and make this a easier and better procedure for our patients.↗
▶Ep 16 · 13:09
opinionIf a neovagina bridge is functioning well without problems, there may be no reason to remove it later.↗
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
▶Ep 17 · 4:36
quoteDo you automatically get an echo on every one of your anorectal malformation babies?↗
▶Ep 17 · 7:24
clinicalIn a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they're evacuating okay.↗
▶Ep 17 · 7:24
opinionFor perineal fistula or vestibular fistula in a female, one can consider just dilating with good evacuation and letting the cardiac situation play itself out.↗
▶Ep 17 · 7:48
clinicalIn a blue baby with significant cardiac lesion requiring early surgery where patient isn't oxygenating well, there is concern about healing of an ARM repair.↗
▶Ep 17 · 7:48
quoteMy concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair↗
▶Ep 17 · 11:08
quoteDissecting in with a mosquito, making sure you're in, not touching any vessel before you insufflate, and also clear the line of air↗
▶Ep 17 · 11:08
clinicalFor umbilical access in laparoscopy, dissect in with a mosquito, ensure you're in the peritoneum without touching any vessel before insufflation, and clear the line of air.↗
▶Ep 17 · 13:56
quoteI've seen teenagers and young adults with those beads that never went away. So, yeah, you've got to scrape that off↗
▶Ep 17 · 13:56
clinicalThe white beads along the raphe should be scraped off during repair, as they can persist into teenage years and young adulthood if left alone.↗
▶Ep 17 · 14:23
clinicalFor a 50-50 perineal fistula (half within muscle complex, half anterior), leave the anterior wall as it's the danger zone, mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction.↗
Colorectal Quiz Episode 29: Female ARM
▶Ep 18 · 7:17
clinicalDr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO.↗
▶Ep 18 · 15:02
clinicalApproximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures.↗
clinicalIn higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated↗
▶Ep 21 · 15:20
opinionAlternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo↗
The Colorectal Quiz: Episode 1
▶Ep 22 · 4:15
epidemiologicalPre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI↗
▶Ep 22 · 4:15
quoteif it's an anal stenosis or a rectal atresia defect, then you need to be very worried about finding a pre-sacral mass. And almost half the time, you'll find one. And those patients will end up getting an MRI.↗
▶Ep 22 · 5:05
quoteWe typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be.↗
▶Ep 22 · 5:05
guidelineCross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning↗
▶Ep 22 · 7:36
clinicalWell-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis↗
▶Ep 22 · 8:25
opinionWith air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging↗
▶Ep 22 · 8:25
quoteI have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.↗
▶Ep 22 · 9:57
quoteyou should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum.↗
▶Ep 22 · 9:57
guidelineShould never try to go in blind—must know what structure will be encountered before making posterior sagittal incision↗
▶Ep 22 · 12:34
clinicalBulbar fistula nomenclature refers to anatomic location at the elbow of the urethra↗
▶Ep 22 · 12:34
clinicalFistula can be very close to rectum, making proper plane dissection along urethra important↗
▶Ep 22 · 12:34
quoteyou can see this fistula is very close to the rectum. And if you're going to dissect that free and along the urethra, it's important to make sure that you know that those two structures are not very far apart. And getting that into that proper plane is very important.↗
▶Ep 22 · 12:34
quoteThe reason why Dr. Levitt or Mark is saying that it's a bulbar fistula is it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the nomenclature we like to use is an anatomic, pure anatomic nomenclature saying that it's a bulbar fistula.↗
quoteThis is huge. This is why, this is real time, and we all know a book chapter takes five years to, three to five years to get published.↗
Colorectal Quiz Episode 18: Cloaca Part 2
▶Ep 19 · 4:50
clinicalDuring cystoscopy it is important to look for cervices to understand Müllerian development (one vagina vs. two, presence of uterus) and to identify ureteral orifices, which in complex malformations may attach anomalously low to the bladder or bladder neck.↗
Colorectal Quiz: Episode 47
▶Ep 20 · 6:29
guidelineAnorectal manometry is not part of the standard initial workup for anorectal malformation patients; it is saved for circumstances that are difficult to figure out.↗
▶Ep 20 · 6:29
quoteWe don't typically do anorectal manometry in our anorectal malformation patients as part of the standard initial workup. I never say never and I never say always, but it's not part of our standard evaluation.↗
▶Ep 20 · 6:29
clinicalThere are many ways to tell if the anus is in the proper position, such as electrical stimulation and rectal ultrasound or MRI.↗
▶Ep 20 · 9:40
quoteThis is one of those things I always wonder, cause we all have a few patients that have this anatomy like chicken or the egg. Like what came first?↗
▶Ep 20 · 16:49
quoteI think this patient is going to be a bowel management candidate. And I doubt they will ever achieve successful bowel control anyway, given the quality of their pelvis, the amount of quadruple regression that they have.↗
▶Ep 20 · 16:49
clinicalA patient with sacral ratio 0.45 is likely to be a bowel management candidate and will probably never achieve successful bowel control given the quality of their pelvis and amount of caudal regression.↗
▶Ep 20 · 16:49
clinicalA sacral ratio of 0.45 indicates the sacrum is not great and the perineal musculature is probably not great.↗
Colorectal Quiz: Episode 40
▶Ep 30 · 11:35
clinicalOptions for vaginal reconstruction when native vagina cannot reach include: dilating the existing introitus, opening the area and laying in a buccal graft, or waiting for tissue engineering options expected within 20 years or less.↗
▶Ep 30 · 12:14
quoteI think it's going to be, there are people right now taking a few vaginal cells and growing them and hopeful, just like you said, Mark, we're going to have some great tissue engineering that will assist us and make this a easier and better procedure for our patients.↗
▶Ep 30 · 13:09
opinionIf a neovagina bridge is functioning well without problems, there may be no reason to remove it later.↗
Colorectal Quiz: Episode 40
▶Ep 22 · 5:32
quoteWait, is this Meyer-Rotakansky-Kuster-Hauser syndrome?↗
▶Ep 22 · 11:35
opinionThe introitus in this case is potentially dilatable in the future to create a functional vagina.↗
▶Ep 22 · 12:14
opinionTissue engineering options for vaginal reconstruction are expected to be available within 20 years or perhaps even shorter, with researchers currently growing vaginal cells.↗
▶Ep 22 · 12:14
quoteThere are people right now taking a few vaginal cells and growing them.↗
▶Ep 22 · 13:09
opinionIf a neovagina functions well and causes no problems, there is no reason to remove it later even if it is bowel or another graft material.↗
▶Ep 22 · 13:09
quoteI think you need it when there's a problem. If there's no problem, why go in and remove tissue, whether it be bowel or whatever you have as your graft?↗
▶Ep 22 · 14:50
quoteI applaud you, Chris, and your partners for going in thinking you're going to do this big reconstruction, encounter something that you weren't expecting and doing the safe thing.↗
▶Ep 22 · 15:57
quoteFred Reichman used to say, you are judged by what you are willing to stop for.↗
▶Ep 22 · 15:57
opinionFred Reichman used to say that surgeons are judged by what they are willing to stop for.↗
▶Ep 22 · 15:57
guidelineIf a surgeon is uncertain about vascular anatomy during an operation, they should stop, gather more information, and reconfront the situation rather than proceeding blindly.↗
▶Ep 22 · 15:57
quoteAs surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through.↗
Jason's statements about Colorectal / ARM & Hirschsprung594 statements
quoteI, I don't believe that a pure trans anal is necessarily less invasive. In other words, I believe that putting 3 incisions on the abdomen is actually less invasive in my hands, in my hands, certainly not in your guys' hands, but in my hands, I'm gonna be torquing in that anal canal much more than if I had done it laparoscopically and freed everything up from the abdominal approach.↗
▶Ep 14 · 4:22
opinionA pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions.↗
▶Ep 14 · 4:22
quoteI, I don't believe that a pure trans anal is necessarily less invasive. In other words, I believe that putting 3 incisions on the abdomen is actually less invasive in my hands, in my hands, certainly not in your guys' hands, but in my hands, I'm gonna be torquing in that anal canal much more than if I had done it laparoscopically and freed everything up from the abdominal approach.↗
▶Ep 14 · 4:22
opinionA pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions.↗
▶Ep 14 · 5:46
clinicalFor standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study.↗
▶Ep 14 · 5:46
clinicalFor standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study.↗
▶Ep 14 · 6:12
clinicalPost-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).↗
▶Ep 14 · 6:12
clinicalPost-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).↗
▶Ep 14 · 7:25
clinicalWorkup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; if no anatomic cause is found, perform biopsy.↗
▶Ep 14 · 7:25
clinicalWorkup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; if no anatomic cause is found, perform biopsy.↗
▶Ep 14 · 9:04
clinicalFor Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns).↗
▶Ep 14 · 9:04
clinicalGoing only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation.↗
▶Ep 14 · 9:04
clinicalFor Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns).↗
▶Ep 14 · 9:04
clinicalGoing only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation.↗
▶Ep 14 · 9:43
quoteI want to ensure, because, and maybe we have a biased population in what we see, that I do not injure the dentate line because the patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients.↗
▶Ep 14 · 9:43
opinionInjury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line.↗
▶Ep 14 · 9:43
quoteI want to ensure, because, and maybe we have a biased population in what we see, that I do not injure the dentate line because the patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients.↗
▶Ep 14 · 9:43
opinionInjury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line.↗
▶Ep 14 · 10:39
clinicalIn ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region.↗
▶Ep 14 · 10:39
clinicalIn ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region.↗
▶Ep 14 · 11:39
clinicalThe dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line.↗
▶Ep 14 · 11:39
clinicalThe dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line.↗
▶Ep 14 · 17:17
clinicalThe traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates.↗
▶Ep 14 · 17:17
clinicalThe traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates.↗
▶Ep 14 · 17:27
clinicalConservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding.↗
▶Ep 14 · 17:27
clinicalConservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding.↗
▶Ep 14 · 17:50
quoteI know there are a number of pediatric surgeons that will repair an anorectal malformation at whatever age with dirty stool and feed the child the day 1 or 2 days post-op when they recover from the anesthesia, and I'm sure that incidence of complication is probably similar.↗
▶Ep 14 · 17:50
quoteI know there are a number of pediatric surgeons that will repair an anorectal malformation at whatever age with dirty stool and feed the child the day 1 or 2 days post-op when they recover from the anesthesia, and I'm sure that incidence of complication is probably similar.↗
▶Ep 14 · 18:54
clinicalWhen vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through.↗
▶Ep 14 · 18:54
clinicalWhen vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through.↗
▶Ep 14 · 20:09
clinicalRectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.↗
▶Ep 14 · 20:09
clinicalRectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.↗
▶Ep 14 · 20:49
clinicalTesting for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed.↗
▶Ep 14 · 20:49
clinicalTesting for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed.↗
▶Ep 14 · 21:19
clinicalInitial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management.↗
▶Ep 14 · 21:19
clinicalInitial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management.↗
▶Ep 14 · 22:45
quoteI can tell you when it recurs to re-operate on those patients is not going to matter at all.↗
▶Ep 14 · 22:45
clinicalSclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.↗
▶Ep 14 · 22:45
clinicalSclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.↗
▶Ep 14 · 22:45
quoteI can tell you when it recurs to re-operate on those patients is not going to matter at all.↗
▶Ep 14 · 23:02
epidemiologicalTransabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure).↗
▶Ep 14 · 23:36
clinicalResection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.↗
▶Ep 14 · 23:56
clinicalLaparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.↗
▶Ep 14 · 24:10
clinicalMesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs.↗
▶Ep 14 · 24:10
clinicalVentral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory.↗
▶Ep 14 · 24:10
clinicalVentral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory.↗
▶Ep 14 · 24:10
clinicalMesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs.↗
▶Ep 14 · 24:55
clinicalVentral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age.↗
▶Ep 14 · 24:55
clinicalVentral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age.↗
Hirschsprung Disease: Update Course 2015
▶Ep 35 · 0:22
quoteI recall having a full day of uh Hirschprung's webcast, and now I get 5 minutes.↗
▶Ep 35 · 3:06
opinionThe safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through.↗
▶Ep 35 · 3:06
quoteI, every time that I do a primary trans anal, I get. I tighten up a little bit to make sure that I'm confident that I can do, and I have an exit strategy in mind if I get in trouble↗
▶Ep 35 · 3:46
opinionLeveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable.↗
▶Ep 35 · 4:03
clinicalLeveling colostomy represents a three-stage procedure for Hirschsprung disease management.↗
▶Ep 35 · 5:07
opinionProlonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching.↗
▶Ep 35 · 5:07
quoteBelinda and I talk about this a lot, and it's about a comfort level and how fit, I take, I watch the clock how long I'm doing a trans anal dissection because I do not want to be stretching on those sphincters for 4 hours trying to dig up in a dark hole when I could put a scope in.↗
▶Ep 35 · 5:30
clinicalLaparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases.↗
▶Ep 35 · 5:46
clinicalStandard rectosigmoid Hirschsprung disease (6-10 centimeters proximal) can be completed transanally in approximately 2 hours when the level is known from a good contrast study.↗
▶Ep 35 · 6:12
clinicalComplications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues.↗
▶Ep 35 · 6:31
clinicalSoiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence.↗
▶Ep 35 · 6:45
clinicalObstructive symptoms after Hirschsprung surgery require differentiation between anatomic problems and pathologic problems.↗
▶Ep 35 · 6:52
clinicalTrue fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line.↗
▶Ep 35 · 7:04
clinicalPseudo-incontinence after Hirschsprung surgery may be caused by underlying constipation.↗
▶Ep 35 · 7:25
clinicalWorkup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia evaluating dentate line position, stricture, stretched sphincter, and anatomic twists.↗
Hirschsprung's Disease
▶Ep 73 · 0:35
quoteMore than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 73 · 0:35
clinicalSome infants with Hirschsprung's disease do pass meconium.↗
▶Ep 73 · 0:35
clinicalMore than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 73 · 0:35
clinicalMore than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 73 · 0:35
quoteMore than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 73 · 0:35
clinicalSome infants with Hirschsprung's disease do pass meconium.↗
▶Ep 73 · 1:57
quoteThe second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.↗
▶Ep 73 · 1:57
clinicalSuction biopsy technique is typically used for patients less than six months of age.↗
▶Ep 73 · 1:57
clinicalFull thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.↗
▶Ep 73 · 1:57
epidemiologicalApproximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.↗
▶Ep 73 · 1:57
clinicalThe classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.↗
▶Ep 73 · 1:57
clinicalA rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease, meaning the aganglionic bowel is contracted and narrow compared to the dilated ganglionated bowel more proximal.↗
▶Ep 73 · 1:57
clinicalIn total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.↗
▶Ep 73 · 1:57
quoteThe three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.↗
▶Ep 73 · 1:57
epidemiologicalApproximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.↗
▶Ep 73 · 1:57
clinicalRectal biopsy is the true definitive diagnosis for Hirschsprung disease.↗
▶Ep 73 · 1:57
clinicalTypical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining.↗
▶Ep 73 · 1:57
clinicalTo be considered an adequate biopsy, it must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers.↗
▶Ep 73 · 1:57
quoteThe three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.↗
▶Ep 73 · 1:57
clinicalTypical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining.↗
▶Ep 73 · 1:57
clinicalRectal biopsy is the true definitive diagnosis for Hirschsprung disease.↗
▶Ep 73 · 1:57
clinicalIn total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.↗
▶Ep 73 · 1:57
clinicalA rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease, meaning the aganglionic bowel is contracted and narrow compared to the dilated ganglionated bowel more proximal.↗
▶Ep 73 · 1:57
clinicalThe classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.↗
▶Ep 73 · 1:57
quoteThe second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.↗
▶Ep 73 · 1:57
clinicalFull thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.↗
▶Ep 73 · 1:57
clinicalSuction biopsy technique is typically used for patients less than six months of age.↗
▶Ep 73 · 1:57
clinicalTo be considered an adequate biopsy, it must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers.↗
▶Ep 73 · 4:23
clinicalIn Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).↗
▶Ep 73 · 4:23
clinicalThe rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.↗
▶Ep 73 · 4:23
guidelineAny patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.↗
▶Ep 73 · 4:23
clinicalIn Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).↗
▶Ep 73 · 4:23
guidelineAny patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.↗
▶Ep 73 · 4:23
clinicalThe rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.↗
▶Ep 73 · 6:42
quoteThere are three goals to the surgical management of Hirschsprung's disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity.↗
▶Ep 73 · 6:42
clinicalThe three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.↗
▶Ep 73 · 6:42
clinicalThe three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.↗
▶Ep 73 · 6:42
quoteThere are three goals to the surgical management of Hirschsprung's disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity.↗
▶Ep 73 · 7:36
clinicalThe Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.↗
▶Ep 73 · 7:36
clinicalA con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.↗
▶Ep 73 · 7:36
opinionThe Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.↗
▶Ep 73 · 7:36
clinicalIn the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.↗
▶Ep 73 · 7:36
clinicalIn the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.↗
▶Ep 73 · 7:36
clinicalIn the Swenson procedure, you pull down the aganglionic bowel and perform a full thickness anastomosis one to two centimeters above the dentate line, leaving the most minimal amount of aganglionic bowel possible.↗
▶Ep 73 · 7:36
opinionThe Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.↗
▶Ep 73 · 7:36
clinicalIn the Swenson procedure, you pull down the aganglionic bowel and perform a full thickness anastomosis one to two centimeters above the dentate line, leaving the most minimal amount of aganglionic bowel possible.↗
▶Ep 73 · 7:36
clinicalIn the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.↗
▶Ep 73 · 7:36
clinicalThe Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.↗
▶Ep 73 · 7:36
clinicalIn the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.↗
▶Ep 73 · 7:36
clinicalA con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.↗
▶Ep 73 · 12:34
clinicalTreatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.↗
▶Ep 73 · 12:34
quoteHirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 73 · 12:34
clinicalA child with enterocolitis presents with abdominal distension, vomiting, fever, and change in bowel habits that could be either diarrhea or not passing stool at all.↗
▶Ep 73 · 12:34
clinicalHirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 73 · 12:34
clinicalFor enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.↗
▶Ep 73 · 12:34
quoteWhen we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.↗
▶Ep 73 · 12:34
clinicalHirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 73 · 12:34
quoteHirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 73 · 12:34
clinicalTreatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.↗
▶Ep 73 · 12:34
clinicalA child with enterocolitis presents with abdominal distension, vomiting, fever, and change in bowel habits that could be either diarrhea or not passing stool at all.↗
▶Ep 73 · 12:34
quoteWhen we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.↗
▶Ep 73 · 12:34
clinicalFor enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.↗
▶Ep 73 · 14:51
clinicalFor patients not doing well after pull-through, if there is a stricture at the anastomosis, it needs to be addressed either through dilations or revising the pull through procedure.↗
▶Ep 73 · 14:51
clinicalFor patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.↗
▶Ep 73 · 14:51
clinicalFor patients with anatomic problems after pull-through, you typically have to revise the pull through.↗
▶Ep 73 · 14:51
clinicalAnatomic problems after pull-through can include a twist in the pull through, an obstructing cuff, a non-functioning Duhamel pouch, or a transition zone or continued aganglionic segment.↗
▶Ep 73 · 14:51
clinicalFor patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.↗
▶Ep 73 · 14:51
clinicalFor patients not doing well after pull-through, if there is a stricture at the anastomosis, it needs to be addressed either through dilations or revising the pull through procedure.↗
▶Ep 73 · 14:51
clinicalAnatomic problems after pull-through can include a twist in the pull through, an obstructing cuff, a non-functioning Duhamel pouch, or a transition zone or continued aganglionic segment.↗
▶Ep 73 · 14:51
clinicalFor patients with anatomic problems after pull-through, you typically have to revise the pull through.↗
The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula
▶Ep 84 · 4:11
quoteI always worry about a missed presacral mass.↗
▶Ep 84 · 5:08
clinicalCross-table lateral X-ray should be obtained at approximately 24 hours of life to assess the air column position relative to the perineal skin, with the baby positioned prone to allow air to rise to the buttocks.↗
▶Ep 84 · 6:28
clinicalThe cross-table lateral film should include a marker at the expected anal location to allow measurement of the distance between the air column and the perineal skin.↗
▶Ep 84 · 7:47
clinicalWell-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together predict good prognosis for continence.↗
▶Ep 84 · 8:25
quoteWell, I have two answers for you, Mark. I think if I was sitting in a hotel room, being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here.↗
▶Ep 84 · 9:58
quoteIt goes without saying and, and one of our, I think one of our big teaching points is you should never try to go in blind.↗
▶Ep 84 · 9:58
clinicalThe surgeon should never attempt posterior sagittal approach blind; imaging must confirm that the first structure encountered will be the air pocket of the distal rectum.↗
▶Ep 84 · 11:37
quoteWe both agree that probably in real life, we would have done a primary posterior sagittal approach on this patient, and we would have found the rectum, and we could have made that rectum reach the perineum and done our anoplasty. How do we handle this? Because I didn't know that there was a fistula there. This is troublesome.↗
▶Ep 84 · 12:34
quoteYou can see this fistula is very close to the rectum. And if you're going to dissect that free, and along the urethra, um, it's important to make sure that you know that those two structures are not very far apart, and getting that into that proper plane is very important.↗
▶Ep 84 · 12:55
clinicalA bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature based on the urethral location.↗
▶Ep 84 · 13:00
quoteThe reason why Doctor Levitt or Mark is saying that. It's a bulbar fistula, it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the uh the nomenclature we like to use is an anatomic pure anatomic nomenclature saying that it's a bulbar fistula.↗
Colorectal Quiz Episode 2: When to redo a PSARP
▶Ep 85 · 0:00
opinionFor anorectoplasty, if you don't get it perfect, you might not have the best outcomes, which separates it from other surgical procedures.↗
▶Ep 85 · 0:40
opinionA lot of surgeons agree that oftentimes your first shot might be your only shot to give this patient a good outcome and the right anatomy.↗
▶Ep 85 · 1:20
quoteHow many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? That's the real frustrating one. Right? A lot.↗
▶Ep 85 · 5:50
quoteI can tell you, the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work. And is the child going to be clean and in normal underwear and just like all the other kids?↗
▶Ep 85 · 5:50
opinionThe family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work and is the child going to be clean and in normal underwear.↗
▶Ep 85 · 6:25
clinicalThe higher the malformation, the worse the prognosis.↗
▶Ep 85 · 6:35
clinicalA sacrum ratio of 0.7 or greater usually means normal or close to normal sphincters and good muscle tone, indicating that spine innervation of that area is probably good.↗
▶Ep 85 · 6:40
clinicalPatients can come with associated spinal anomaly, most commonly tethered cord, but the worst is a myelomeningocele, and those patients have much more trouble with continence.↗
▶Ep 85 · 7:44
clinicalIt's amazingly common to have a mislocated anus, either because the surgeon misses where the center is during laparoscopic pull-through or opens the PSARP incision first.↗
▶Ep 85 · 8:05
clinicalA key pitfall is opening the PSARP incision first; instead, mark the sphincters first, then open the PSARP so you don't get confused when placing the anoplasty in the correct location.↗
▶Ep 85 · 8:05
quoteA key pitfall is not do that. Mark the sphincters first, then open the PSARP because then you don't get confused at the end when you're trying to place the anoplasty in the correct location.↗
▶Ep 85 · 10:19
clinicalIn higher malformations such as a bladder neck fistula in a boy, the sphincter complex isn't always where you think it's going to be and is sometimes more anterior than anticipated.↗
▶Ep 85 · 15:19
opinionAn alternative approach for borderline cases is to let the child take their car out for a ride first and see how it works—if it drives well, stay with that anatomy; if not, then consider the redo.↗
Colorectal Quiz Episode 3: Hirschsprung Disease
▶Ep 86 · 9:52
clinicalIn Hirschsprung disease, the aganglionic rectum appears narrow due to spasm and inability to relax, while the ganglionated proximal bowel is dilated, creating the recto-sigmoid ratio↗
▶Ep 86 · 13:03
clinicalThree good biopsy specimens should be obtained for pathologic evaluation↗
▶Ep 86 · 13:03
clinicalQuick diff staining highlights ganglion cells better than standard H&E staining↗
▶Ep 86 · 16:45
clinicalThe crypts are located above the dentate line, so optimal biopsy location is at least 1-2 cm above the dentate line↗
The Colorectal Quiz Episode 3.5: Proximal Hirschsprung Disease
quoteYeah. And I think you could make guesses about this. But like you said, it's hard on a newborn film to really discern small and large bowel. And you can get fooled.↗
▶Ep 87 · 3:48
clinicalIt is hard on a newborn film to really discern small and large bowel, and you can get fooled.↗
▶Ep 87 · 4:43
clinicalA limited upper GI was performed and ruled out malrotation in this child.↗
▶Ep 87 · 5:20
clinicalPatients with proximal Hirschsprung disease are at risk of perforation, usually in the cecum.↗
▶Ep 87 · 5:20
clinicalTo get a perforation, you need distension, and if you have a transition zone at the hepatic flexure, then all the pressure is in the right colon.↗
▶Ep 87 · 5:20
quoteSo they were quick to point out that we're lucky this patient didn't show up with a perforation. And usually they perforate in the cecum.↗
▶Ep 87 · 5:41
clinicalA baby that doesn't have a competent ileosecal valve might be saved from perforation because pressure can decompress into the small bowel.↗
▶Ep 87 · 5:57
clinicalYou are obligated at some point, maybe after resuscitation, to get a rectal biopsy in a patient with suspected Hirschsprung disease.↗
▶Ep 87 · 5:57
quoteYou're obligated at some point, maybe after resuscitation, to get a rectal biopsy.↗
▶Ep 87 · 7:14
clinicalProximal Hirschsprung disease and distal Hirschsprung disease require two different operative approaches.↗
▶Ep 87 · 7:14
quoteTwo different operative approaches for the same disease because one is more proximal and more complicated and the other is more distal.↗
quotePreviously, we used to do this transanally, it would take a few hours. Now, the transanal dissection should be usually way under 1 hour, especially in a primary pull-through point.↗
▶Ep 88 · 6:37
quotePreviously, we used to do this transanally, it would take a few hours. Now, the transanal dissection should be usually way under 1 hour, especially in a primary pull-through point.↗
▶Ep 88 · 6:37
clinicalWith proper laparoscopic dissection, the transanal portion of a primary Hirschsprung pull-through should take well under one hour.↗
▶Ep 88 · 6:37
clinicalWith proper laparoscopic dissection, the transanal portion of a primary Hirschsprung pull-through should take well under one hour.↗
▶Ep 88 · 12:26
clinicalFor distal Hirschsprung disease, only distal branches of the IMA need to be taken, but for left colon involvement, the IMA itself may need to be taken to achieve adequate reach.↗
▶Ep 88 · 12:26
clinicalFor distal Hirschsprung disease, only distal branches of the IMA need to be taken, but for left colon involvement, the IMA itself may need to be taken to achieve adequate reach.↗
The Colorectal Quiz Episode 8: Motility Disorders Part 1
▶Ep 91 · 6:29
quoteIt's saying that this is not a Monet, that is for certain.↗
▶Ep 91 · 7:12
clinicalContrast studies are not great predictors of how patients will respond to medical or surgical management; normal-looking colons may not respond while abnormal-appearing colons may respond well↗
▶Ep 91 · 8:06
clinicalWater-soluble contrast (not barium) is used for contrast enemas because it helps empty the colon and acts as a cleanout for patients starting new medical therapy↗
▶Ep 91 · 10:51
opinionIn the past, surgeons did not understand the major role the sphincter played in many patients↗
▶Ep 91 · 10:51
quoteI think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played.↗
The Colorectal Quiz Episode 10: Total Colonic Hirschsprung Disease Part 1
▶Ep 94 · 7:26
quoteMy cutoff is around 6 months when I switch from suction rectal biopsy to full thickness biopsy.↗
▶Ep 94 · 7:26
clinicalThe age cutoff for switching from suction rectal biopsy to full-thickness biopsy is around 6 months↗
▶Ep 94 · 8:38
quoteIf the patient is doing well and able to be managed with irrigations, would love to have my final diagnosis of Hirschprung's disease through the rectal biopsy before entering the abdomen.↗
▶Ep 94 · 8:38
clinicalIf the patient is doing well and can be managed with irrigations, it is preferable to have final pathology diagnosis of Hirschsprung disease from rectal biopsy before entering the abdomen↗
▶Ep 94 · 9:13
clinicalStandard biopsy locations during operative mapping include rectosigmoid, proximal sigmoid around the left colon, splenic flexure/transverse colon, and right colon or hepatic flexure area↗
The Colorectal Quiz Episode 11: Total Colonic Hirschsprung's Part 2
clinicalDr. Fisher waits until the child has good growth and more solid stool on table food diet, sometimes adding thickeners to achieve thicker stool consistency.↗
▶Ep 95 · 3:38
quoteSo how do you get them to the point where they're having more solid stool, you know, when they're on more of a solid diet and table food diet, and maybe we even add some thickeners to their diet so that their stool becomes more thick.↗
▶Ep 95 · 4:12
clinicalDr. Fisher uses a skin training technique where families take stool from the ostomy bag and place it in the diaper for 15-20 minutes to expose virgin buttock skin to stool before pull-through.↗
▶Ep 95 · 4:27
quoteThe skin, the buttock skin, has not really seen or been exposed to stool.↗
▶Ep 95 · 4:32
quoteAnd so I have the families put some stool in the diaper and expose that skin to stool for a little.↗
▶Ep 95 · 5:19
quoteBut the one thing that I learned checking a urine sodium, the total body sodium and not just the blood sodium, is a key component for these patients, which is obviously important in growth.↗
▶Ep 95 · 5:19
clinicalFor patients with long-standing ileostomies and high output who are not growing well, checking urine sodium (which reflects total body sodium, not just blood sodium) is a key component for growth assessment.↗
▶Ep 95 · 5:34
clinicalDr. Fisher checks urine sodium a few weeks after ileostomy creation prior to discharge and again a month or two later.↗
▶Ep 95 · 5:49
clinicalLow total body sodium can be treated with salt tablets or salt addition.↗
▶Ep 95 · 8:00
quoteFor this case, I typically do an ileoanal anastomosis, a straight pull through, but there are a few other options.↗
▶Ep 95 · 8:00
clinicalDr. Fisher typically performs an ileoanal anastomosis (straight pull-through) for total colonic Hirschsprung disease.↗
▶Ep 95 · 9:57
clinicalDr. Fisher makes a game-time decision on whether to divert after ileoanal anastomosis based on anastomotic appearance, blood supply, tension, and nutritional optimization; if any concerns exist, he diverts and returns 6-8 weeks later to close the ileostomy.↗
▶Ep 95 · 9:57
quoteI talk to the families and I, I say it's a game time decision.↗
▶Ep 95 · 10:57
clinicalFamily comfort with rectal irrigations is an important consideration when planning surgery.↗
▶Ep 95 · 11:26
clinicalDr. Fisher's first-line medication treatment is loperamide.↗
▶Ep 95 · 12:07
clinicalLomotil (diphenoxylate-atropine) is a controlled substance in the United States.↗
▶Ep 95 · 12:24
quoteI give the Botox immediately, um, when we have intestinal continuity, and I see the child at 2 weeks post-op just for a routine check.↗
▶Ep 95 · 12:24
clinicalDr. Fisher gives Botox immediately when intestinal continuity is established.↗
▶Ep 95 · 12:34
clinicalDr. Fisher sees the child at 2 weeks post-op for routine check (eating, growth, rash assessment) and does not check the anastomosis until 4 weeks.↗
▶Ep 95 · 12:38
quoteI don't check the anastomosis until 4 weeks.↗
▶Ep 95 · 12:41
clinicalAt 4 weeks in clinic, Dr. Fisher performs an anastomosis check using Hagar dilators to size to the appropriate size for the child's age.↗
▶Ep 95 · 13:05
clinicalDr. Fisher starts with a 7 or 8 Hagar dilator in clinic and gently sizes up to resistance, not to stretch but to check size; for a child who had pull-through at around 10 months, the proper size should be 13 or 14 Hagar dilator.↗
clinicalPerineal groove with mucosal lining will keratinize and look like normal perineal body over time↗
▶Ep 98 · 4:45
clinicalPerineal groove with mucosal lining will keratinize and look like normal perineal body over time↗
▶Ep 98 · 4:45
quoteMy conversation with the family often involves that this will keratinize and look like a normal peroneal body over time.↗
▶Ep 98 · 4:45
quoteMy conversation with the family often involves that this will keratinize and look like a normal peroneal body over time.↗
▶Ep 98 · 5:00
clinicalSurgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers↗
▶Ep 98 · 5:00
clinicalSurgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers↗
▶Ep 98 · 9:35
clinicalVestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter↗
▶Ep 98 · 9:35
clinicalVestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter↗
▶Ep 98 · 10:22
clinicalPurpose of diversion in ARM repair is to avoid perineal body dehiscence↗
▶Ep 98 · 10:22
clinicalPatients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair↗
▶Ep 98 · 10:22
clinicalPurpose of diversion in ARM repair is to avoid perineal body dehiscence↗
▶Ep 98 · 10:22
clinicalPatients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair↗
▶Ep 98 · 10:22
clinicalFor vestibular fistula diagnosed in newborn period, options are primary repair if baby is well, or allow stooling through fistula for couple months then elective repair without stoma↗
▶Ep 98 · 10:22
clinicalFor vestibular fistula diagnosed in newborn period, options are primary repair if baby is well, or allow stooling through fistula for couple months then elective repair without stoma↗
▶Ep 98 · 14:11
clinicalTo evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra↗
▶Ep 98 · 14:11
clinicalTo evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra↗
Colorectal Quiz Episode 14: ARM Newborn Part 3
▶Ep 99 · 1:49
clinicalCross-table lateral films can be obtained early and then around 24 hours later in cases where there is no evidence of fistula on exam.↗
▶Ep 99 · 2:06
clinicalIf the air column stops at about the 4th sacral vertebral body with a large distance between the air column and the sphincter marker, the patient should be considered for diversion and distal colostogram to delineate anatomy.↗
▶Ep 99 · 2:06
quoteif you look at the film on the left, the air column stops at about the 4th sacral vertebral body, give or take a little bit. And so, what, and you could see where the marker is or the BB is, uh, where the, where the sphincter complex appears to be located. There's a large distance between those.↗
▶Ep 99 · 2:49
quotethe air column is very close to where the anticipated anal opening should be located. And this is a case where you could take your barley bush, potentially, and make a nick, uh, a scratch, and, and do your anoplasty.↗
▶Ep 99 · 2:49
clinicalWhen the air column is very close to where the anticipated anal opening should be located, primary anoplasty may be performed.↗
▶Ep 99 · 6:13
opinionWhether to perform primary anoplasty in cases with close air column depends on individual surgeon comfort and the level of post-operative care available at the institution.↗
▶Ep 99 · 7:16
clinicalThe common wall between the rectum and the urethra is closer and longer than some people anticipate.↗
▶Ep 99 · 7:16
quotethat common wall or, or that wall between the rectum and the urethra is a lot closer and a lot longer. Of a common wall, then I think some people anticipate.↗
▶Ep 99 · 7:41
clinicalA patient at 24 hours with no obvious fistula and cross-table lateral showing air column not very distal needs a colostomy.↗
Colorectal Quiz Episode 15: Bowel Management in Spinal Patients - Need for a UrologistPart 1
▶Ep 100 · 5:30
quoteit's almost like a chemical burn. The cause they're blistered usually.↗
▶Ep 100 · 5:30
clinicalSenna-induced perineal rash is thought to be a chemical burn rather than a true allergy, presenting with blistering.↗
▶Ep 100 · 5:38
clinicalSenna rash is treated with silver sulfadiazine and resolves with time; some patients tolerate senna upon reintroduction.↗
▶Ep 100 · 5:38
quoteWe treat it with silver sulfadiazine, and they've all gotten better with time.↗
▶Ep 100 · 5:47
clinicalTiming senna doses in the early morning so that bowel movements occur during the day (when diapers are changed promptly) reduces the risk of senna rash.↗
▶Ep 100 · 5:53
quotewhat we've done is we timed the dose of Senna in these patients, usually in the early morning, so that they're pooping during the day. And their diapers changed rather quickly versus potentially being in a diaper over a long period of time at night.↗
▶Ep 100 · 8:31
clinicalBisacodyl can be administered as an enema or suppository in infants.↗
▶Ep 100 · 10:11
quoteIf there's one take-home message from this podcast, you just said it↗
▶Ep 100 · 10:31
quotethat care coordination, collaboration with the urologist might be the most beneficial thing we could do for our patients.↗
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
▶Ep 101 · 1:17
clinicalWhen a 7 cm appendix is shared between urology and colorectal surgery, the urologist typically takes 6.25 cm leaving only 0.75 cm for colorectal use↗
▶Ep 101 · 1:17
quoteWhen you get that really short stumpy appendix, whether it be from splitting it, and the urologist, if I have a 7 centimeter appendix, the urologist takes 6.25 centimeters and I get 0.75.↗
▶Ep 101 · 1:55
clinicalThe colorectal team benefits from using the appendix portion closer to the cecum which has a stronger blood supply↗
▶Ep 101 · 2:05
clinicalA short appendiceal stump can be extended by suturing or using a laparoscopic non-cutting linear stapler along the cecal wall to add 2-3 cm of length↗
▶Ep 101 · 2:34
clinicalOne of the problems with Malone appendicostomy is leakage↗
▶Ep 101 · 2:47
clinicalThe longer the Malone channel, the less likely it is to leak↗
▶Ep 101 · 2:52
quoteThe longer the channel, the less likely that Malone's going to leak.↗
▶Ep 101 · 2:55
clinicalExtending the Malone channel by 2-3 cm using suturing or stapling can be extremely helpful in preventing leakage↗
▶Ep 101 · 3:43
clinicalRectal irrigation using pressurized water systems made for patients with hand difficulties is an alternative to Malone and Mitrofanoff procedures↗
▶Ep 101 · 4:25
clinicalColoplast makes a rectal irrigation device for self-administration of enemas↗
▶Ep 101 · 9:43
clinicalAt Cincinnati Children's, 99% of Malones are placed in the umbilicus and almost all Mitrofanoffs are in the right lower quadrant with a tunnel channel through the rectus to prevent leakage↗
▶Ep 101 · 10:21
clinicalThe primary determinant of orifice location is where the appendix reaches and its blood supply↗
▶Ep 101 · 11:09
clinicalLaxity of the pelvic floor and anal canal is a huge issue in spinal patients, especially when doing retrograde enemas↗
Colorectal Quiz Episode 17: Cloaca Part 1
▶Ep 102 · 11:30
quoteThis is huge. This is why, this is real time, and we all know a book chapter takes five years to, three to five years to get published.↗
Colorectal Quiz Episode 18: Cloaca Part 2
▶Ep 103 · 4:50
clinicalDuring cystoscopy it is important to look for cervices to understand Müllerian development (one vagina vs. two, presence of uterus) and to identify ureteral orifices, which in complex malformations may attach anomalously low to the bladder or bladder neck.↗
opinionThe management approach at Cincinnati Children's is to maximize medical therapy and understand anatomic and functional issues before resorting to surgical intervention and potential resection.↗
▶Ep 104 · 10:31
quoteBut I think our management style now here at Cincinnati Children's has been to try to maximize medical therapy, understand the anatomic and functional issues, and then if we can't overcome those issues with medical management, resort to surgical intervention and potential resection.↗
▶Ep 104 · 11:04
quoteI want to stress that we shouldn't resort to resection right away just because we have one abnormal finding.↗
▶Ep 104 · 11:04
opinionResection should not be performed immediately based on one abnormal finding; multiple factors must be considered.↗
clinicalThe first step in evaluating a patient with suspected motility disorder is to ensure normal anatomy, which can be assessed with contrast studies.↗
Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1
▶Ep 105 · 4:51
quoteI think one key thing to talk about with all our listeners is when you do that exam, make sure you step to the side. A little bit funny, but a little bit, you don't wanna be in the way of what could be coming out.↗
▶Ep 105 · 4:51
clinicalWhen performing initial rectal exam on a distended child with suspected enterocolitis, step to the side because there may be an explosive release of stool and gas.↗
▶Ep 105 · 12:06
quoteIf you have a patient that comes in with a diagnosis of Hirschprung's in the past and comes with, comes in sick, you have to assume it's Hirschprung's associated enterocolitis.↗
▶Ep 105 · 12:06
clinicalFor a patient with prior Hirschsprung diagnosis presenting sick, assume Hirschsprung-associated enterocolitis; treatment with rectal irrigations, IV fluids, and antibiotics will not cause harm even if the diagnosis is different (e.g., Crohn's disease, E. coli enterocolitis).↗
▶Ep 105 · 14:58
guidelineFamilies should not undergo Hirschsprung pull-through surgery until they can demonstrate ability to perform rectal irrigations, and they should be discharged with supplies to perform irrigations at home.↗
▶Ep 105 · 18:19
clinicalIn a logical workup, obtain the contrast study before going to the OR for rectal exam under anesthesia, as it may reveal findings that guide the surgical approach.↗
▶Ep 105 · 18:33
quoteI think we all agree we get the contrast study before going to the operating room for a rectal exam↗
▶Ep 105 · 19:43
clinicalA lateral view on contrast enema is important because it provides significant information about the presacral space and distal rectum anatomy.↗
The Colorectal Quiz Episode 20: Hirschsprung Disease Obstruction Part 2
▶Ep 107 · 4:26
clinicalBotox is being studied to prevent enterocolitis with the theory of chemo-denervating nerves in the area instead of permanent stretch or anatomic destruction from surgery↗
▶Ep 107 · 11:11
quoteIs now, let's say 3 centimeters, or 4, or 5. Well, is that the problem that this kid did well until that cuff got to a length, that's a ganglionic, and now it's causing obstructive problems.↗
▶Ep 107 · 17:23
guidelineInitial treatment for obstructed Hirschsprung's patient must include rectal irrigation, done early↗
▶Ep 107 · 17:28
guidelineEvery institution should have a protocol for obstructed Hirschsprung's patients to ensure quick and efficient response↗
▶Ep 107 · 17:41
guidelineSystematic workup for obstructed Hirschsprung's includes: resuscitation, imaging studies, and comprehensive rectal exam under anesthesia↗
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
▶Ep 108 · 10:08
clinicalDoctor Martin developed the Martin procedure, an extended Duhamel procedure that leaves a longer aganglionic segment of rectum for long-segment Hirschsprung disease.↗
▶Ep 108 · 10:40
clinicalIn 1977, Doctor Martin was the first to apply the endorectal pull-through technique used in Hirschsprung disease to the surgical treatment of ulcerative colitis, performing total proctocolectomy with ileoanal anastomosis.↗
▶Ep 108 · 11:19
clinicalDoctor Martin's ulcerative colitis technique predated the J-pouch, which later modified his approach.↗
The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1
▶Ep 109 · 5:07
clinicalPathology can change over time; cases exist where ganglion cells were present at pull-through but absent with hypertrophic nerves 7 years later when problems developed.↗
▶Ep 109 · 9:58
clinicalSphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function.↗
▶Ep 109 · 16:07
clinicalDuring normal bowel movements, sphincters relax and the anus opens with some mucosal descent, but as soon as sphincters tighten, the mucosa retracts back in; prolapse at rest indicates damaged muscles and/or mucosa brought too low at anastomosis.↗
clinicalIf terminal ileum cannot be intubated, gastroenterologists may treat presumptively and re-scope after a few months of treatment when inflammation has decreased.↗
▶Ep 115 · 6:52
clinicalThe highest risk factors for lymphoma with biologic therapy are male gender, teenage age, and combination therapy with methotrexate.↗
▶Ep 115 · 9:00
epidemiologicalMale gender over the age of 10, and presence of a fistula are risk factors with much higher incidence of Crohn's disease being diagnosed in patients presenting with perianal lesions to the emergency room.↗
▶Ep 115 · 9:29
clinicalIn pediatric patients, unlike adult patients, the first presenting factor for Crohn's disease can often be perianal disease.↗
▶Ep 115 · 12:25
quoteI don't like to make holes when there aren't holes there.↗
▶Ep 115 · 12:31
clinicalThe mucosa heals first compared to skin in perianal disease, so leaving a mucosal opening without a seton risks recurrent abscess when biologics heal the mucosa.↗
▶Ep 115 · 12:31
quoteThe thing that's going to heal first is the mucosa.↗
▶Ep 115 · 13:12
clinicalMaking a large cruciate incision and packing a perianal abscess in a child with undiagnosed Crohn's disease may result in non-healing and potentially require colostomy or ileostomy.↗
▶Ep 115 · 13:20
quoteYou may have bought that kid a colostomy or ileostomy.↗
▶Ep 115 · 14:15
clinicalHydrogen peroxide is preferred over methylene blue for identifying fistula tracts because it is neater; 3% hydrogen peroxide in a syringe with 16-20 gauge angiocath is used with a speculum in the anus.↗
▶Ep 115 · 14:54
clinicalWhen a fistula opening cannot be found despite hydrogen peroxide testing, a seton should not be placed at that time to avoid creating a hole where there isn't one.↗
▶Ep 115 · 17:17
clinicalSource control of infection must be achieved before starting immunosuppressive therapy including steroids and biologics.↗
▶Ep 115 · 17:17
clinicalIf an abscess is not adequately drained, reimaging should be performed before giving biologics or steroids.↗
▶Ep 115 · 19:23
clinicalBefore removing a seton, the bottom must look better, drainage must be better, the patient must be symptom-free, and they must have reached steady state of biologic (loading dose plus at least 3 more doses, typically 2-3 months from start).↗
▶Ep 115 · 19:55
clinicalInflammatory markers including fecal calprotectin, ESR, and CRP should be checked before removing a seton to ensure systemic disease is under control.↗
▶Ep 115 · 20:49
clinicalThe initial Remicade paper from 1998 or 1999 in the New England Journal of Medicine was on perianal disease and demonstrated improved healing time and improved length of time between recurrence when combination of seton and infliximab is used versus either separately.↗
Hirschsprung Disease in Brief
▶Ep 116 · 0:33
clinicalHirschsprung disease is a congenital anomaly of the GI tract that results in a functional bowel obstruction.↗
▶Ep 116 · 1:11
quoteMore than 95% of neonates pass meconium within the first 48 hours of life. And failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 116 · 1:11
clinicalMore than 95% of neonates pass meconium within the first 48 hours of life.↗
▶Ep 116 · 1:11
clinicalFailure to pass meconium within the first 48 hours of life is typical of Hirschsprung's disease.↗
▶Ep 116 · 1:43
clinicalThe RET gene is a predisposing genetic condition associated with Hirschsprung disease.↗
▶Ep 116 · 1:43
epidemiologicalUp to 10% of children with Hirschsprung's disease will have trisomy 21.↗
▶Ep 116 · 1:43
clinicalHirschsprung disease is associated with Wordenberg syndrome and congenital central hyperventilation (Andine's curse).↗
▶Ep 116 · 1:43
epidemiologicalOnly 1 to 2% of patients with trisomy 21 have Hirschsprung's disease.↗
▶Ep 116 · 1:43
epidemiologicalAbout 10% of children with Hirschsprung disease will have a positive family history.↗
▶Ep 116 · 2:25
guidelineThe three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.↗
▶Ep 116 · 2:42
clinicalThe classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.↗
▶Ep 116 · 2:42
quoteThe classic finding is a transition zone in the rectosigmoid, but that transition zone really can be located anywhere within the bowel.↗
▶Ep 116 · 3:14
clinicalA rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease.↗
▶Ep 116 · 3:49
quoteThe second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.↗
▶Ep 116 · 3:49
guidelineRectal biopsy is the true definitive diagnosis for Hirschsprung disease.↗
▶Ep 116 · 4:04
quoteTypical features on the biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of colon esterase staining, and an absence of calretinine staining.↗
▶Ep 116 · 4:04
guidelineTo be considered an adequate rectal biopsy, it must be taken from the rectum at least 1 cm above the dentate line and must include both mucosa and submucosal layers.↗
▶Ep 116 · 4:04
clinicalTypical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of colon esterase staining, and an absence of calretinine staining.↗
▶Ep 116 · 4:29
guidelineFull thickness rectal biopsy technique should be considered for patients older than 6 months or when a suction biopsy is inadequate.↗
▶Ep 116 · 4:29
guidelineSuction rectal biopsy technique is typically used for patients less than 6 months of age.↗
▶Ep 116 · 5:42
guidelineAny patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.↗
▶Ep 116 · 7:29
quoteThere are three goals to the surgical management of Hirschsprung disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity.↗
▶Ep 116 · 7:29
guidelineThe three goals of surgical management of Hirschsprung disease are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.↗
▶Ep 116 · 7:59
clinicalThe three procedures for Hirschsprung disease (Swensen, Suave, Duamel) all involve a transanal approach of removing the aganglionic colon and pulling down healthy colon and sewing it to the anus.↗
▶Ep 116 · 7:59
clinicalThe Duamel procedure involves performing a pouch with an anastomosis of aganglionic and ganglionated bowel.↗
▶Ep 116 · 7:59
clinicalThe Suave procedure is a mucosectomy where you leave a cuff of aganglionic bowel and bring the ganglionated bowel through that cuff of rectum and perform the anastomosis.↗
▶Ep 116 · 7:59
clinicalThe Swensen technique is a full thickness dissection and anastomosis.↗
▶Ep 116 · 9:15
guidelineEnterocolitis must be recognized as potential enterocolitis and treated urgently.↗
▶Ep 116 · 9:15
clinicalA child with enterocolitis presents with abdominal distention, vomiting, fever, and change in bowel habits.↗
▶Ep 116 · 9:15
quoteHirschsprung's associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 116 · 9:15
guidelineDepending on the severity of enterocolitis, broad-spectrum antibiotics are sometimes added, and patients are usually started on metronidazole.↗
▶Ep 116 · 9:15
clinicalHirschsprung's associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 116 · 9:15
guidelineTreatment for enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.↗
The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...
▶Ep 118 · 2:44
quoteCan I scare you for a moment? Can we talk scientifically for one minute? I know this is crazy.↗
▶Ep 118 · 3:08
clinicalThe dentate (or pectinate) line is the transition from squamous epithelium to columnar epithelium, located about 2/3 of the way up the anal canal.↗
▶Ep 118 · 3:25
clinicalBlood supply changes occur at the dentate line (splanchnic versus systemic), and there is also innervation in that area.↗
▶Ep 118 · 3:54
clinicalThe nerves located at the dentate line region tell you gas, liquid, solid; how hard, how long, and how tight to squeeze.↗
▶Ep 118 · 3:54
quoteI talk about that dentate line in the area where the nerves are located that tell you gas, liquid, solid. How hard do I need to squeeze, how long do I have to squeeze for, how tight do I have to squeeze?↗
▶Ep 118 · 4:15
clinicalPreserving the dentate line region is key because injury to that region affects a patient's ability to be continent.↗
▶Ep 118 · 6:11
clinicalIn children with anorectal malformation, Hirschsprung disease, spinal conditions, or combinations thereof, the ability to sense stool in the rectum or neorectum region is critical to success; the right consistency and bulk of stool is very important.↗
▶Ep 118 · 6:45
clinicalIf clinicians make stool too soft or too loose with medications, they put a child on the edge of having control or not and throw them over that edge, preventing success.↗
▶Ep 118 · 6:59
quoteAnd if we make it too soft or too loose, we're putting a child or a person who is on the teeter of having control or not, and you throw them over that edge, and, and you just won't be successful.↗
▶Ep 118 · 11:16
quoteI mean, it makes sense that they should if the muscle is intact, right, because this is no different than an anorectal malformation, anastomosis. That's right. But it's, it's, it's rectum or colon mucosa to skin.↗
▶Ep 118 · 11:16
clinicalA Hirschsprung patient with missing dentate line and intact muscle should be able to achieve continence, similar to an anorectal malformation anastomosis (rectum or colon mucosa to skin).↗
▶Ep 118 · 12:08
clinicalPatients with no dentate line and patulous sphincters who are soiling develop severe skin irritation from sitting in pull-ups or diapers.↗
▶Ep 118 · 12:08
quoteThat is a patient with no dentate line and pattula sphincters, and you clearly see with the skin changes around that, that this patient has really struggled and has been soiling and, and, and sitting in, in pull-ups or a diaper, really causing severe skin irritation.↗
▶Ep 118 · 18:17
quoteThis, this is, these are the harder patients to take care of, and the trick that I use is you have to constipate them. And then if they're able to empty with continence on their own, then great. If they're not, then you have to mechanically help them empty.↗
▶Ep 118 · 18:17
clinicalFor hypermotile patients (stooling 7-8 times a day), the approach is to constipate them first, then figure out how to empty them in a time-controlled fashion.↗
▶Ep 118 · 18:35
clinicalWhether hypermotile patients can empty on their own versus needing mechanical emptying to maintain social continence depends on their sphincter function.↗
▶Ep 118 · 18:35
quoteBut it, it's, it's like, it sounds counterintuitive, but at least the way I treat these patients, I constipate them, and then I empty them.↗
▶Ep 118 · 18:58
quoteBut that's how I sort of explain it to the families. It sounds weird, but we're gonna constipate you, and then we have to figure out how to empty you in a time-controlled fashion.↗
▶Ep 118 · 22:42
clinicalSome Hirschsprung patients who have a good operation have super strong sphincters that just need a little relaxation to allow passage of stool until they learn proper sphincter coordination for evacuation.↗
▶Ep 118 · 23:10
clinicalBotox helps train sphincters in Hirschsprung patients; anorectal manometry can provide objective data showing resting pressures are usually on the higher end of normal, and some patients need extra relaxation to allow them to go.↗
▶Ep 118 · 23:31
clinicalNutrition in Hirschsprung patients is very important; some patients are very sensitive to certain foods, particularly lactose.↗
▶Ep 118 · 23:50
clinicalPaying attention to diet (whether breastfed infants or older children) is important because lactose is particularly problematic in some Hirschsprung patients.↗
▶Ep 118 · 24:26
quoteNone. We have to get it right the first time.↗
▶Ep 118 · 24:29
quoteAnd if you don't get it right, you gotta use these techniques and this algorithm to figure out what's wrong, cause we could get every patient doing well. They might need help, and they might need mechanical evacuations, Botox, etc. but we could, we all should be able to get these patients on the right track.↗
▶Ep 118 · 24:29
opinionEvery Hirschsprung patient should be able to do well; they might need help and might need mechanical evacuations or Botox, but all should be able to get on the right track.↗
Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula
▶Ep 119 · 15:22
quotewhen you do find neurologic anomalies. That leads to more likely gynecological anomalies as well, especially on the same side.↗
▶Ep 119 · 15:22
clinicalWhen neurologic anomalies are found in anorectal malformation patients, gynecological anomalies are more likely, especially on the same side.↗
Colorectal Quiz Episode 29: Female ARM-Post Op Management
▶Ep 120 · 7:17
clinicalDr. Fisher's protocol for perineal body primary repair (no stoma) is 5-7 days NPO on D10 via midline catheter (not PICC line) until the repair is confirmed healed.↗
▶Ep 120 · 8:03
quoteJust because it's published doesn't mean it works.↗
▶Ep 120 · 13:51
quoteMy only concern is what's the continence rate of your patients?↗
▶Ep 120 · 15:01
quoteI guess my question is somewhere around 20% required a redo either local or total operation. Most just like local, but what did a functional out in the end of the game, all the parents want is their kid pooping in the potty. And we don't know that answer.↗
▶Ep 120 · 15:24
quoteThat's a very valid point. So what you're saying, wait, wait, Mark agreed with me.↗
▶Ep 120 · 19:00
quoteAnd when I was working with Mark here, I know, especially in the older patients that we were doing redos on, used to teach me to make the anoplasty maybe a little larger.↗
Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease
▶Ep 136 · 12:26
clinicalDr. Newman brought Dr. Yancey's story to the attention of the Hirschsprung interest group at APSA.↗
▶Ep 136 · 15:06
quoteI was reading the operative note from one of my fellows who provided the history of the patient. I had to do a reoperation on the patient. And the history read that this five-year-old child is status post a Yancey Suave procedure in such and such date and had an asthmatic stricture.↗
▶Ep 136 · 15:06
clinicalA fellow at Children's National wrote an operative note describing a patient as status post a 'Yancey-Suave procedure,' indicating the terminology has become part of standard practice.↗
Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery
▶Ep 158 · 3:59
clinicalMRI with specific protocols and endorectal ultrasound can help determine whether the anoplasty is within the muscle complex.↗
▶Ep 158 · 14:05
opinionThe transition model includes joint clinic visits and collaborative operating, which is key to successful handoff.↗
▶Ep 158 · 14:54
opinionFreestanding children's hospitals face greater challenges than integrated hospitals because they are completely separate entities both physically and financially.↗
▶Ep 158 · 15:14
clinicalIn Cincinnati, ARM patients still come to the colorectal center at the children's hospital whether they are 12 or 40 years old, partnering with an adult colorectal surgeon; collaborative operating occurs at the University of Cincinnati with adult colorectal surgeons, adult neurologists for urology, and pediatric urologists who have privileges at the university.↗
▶Ep 158 · 18:58
opinionAdult hospitals are much more adept and skilled at managing perioperative complications like pulmonary embolism or myocardial infarction; such events in a children's hospital lead to many meetings and potential for poor outcomes.↗
▶Ep 158 · 19:33
clinicalPhysicians and surgeons are making progress on transition, but the greater struggle is providing intensive bowel management training for 35-year-old patients; pediatric centers are adept at bowel management for patients of any age, but currently adult patients requiring intensive outpatient bowel management are still being seen at children's hospitals.↗
guidelineAnorectal manometry is not part of the standard initial workup for anorectal malformation patients; it is saved for circumstances that are difficult to figure out.↗
▶Ep 224 · 6:29
quoteWe don't typically do anorectal manometry in our anorectal malformation patients as part of the standard initial workup. I never say never and I never say always, but it's not part of our standard evaluation.↗
▶Ep 224 · 6:29
clinicalThere are many ways to tell if the anus is in the proper position, such as electrical stimulation and rectal ultrasound or MRI.↗
▶Ep 224 · 6:29
quoteWe don't typically do anorectal manometry in our anorectal malformation patients as part of the standard initial workup. I never say never and I never say always, but it's not part of our standard evaluation.↗
▶Ep 224 · 6:29
guidelineAnorectal manometry is not part of the standard initial workup for anorectal malformation patients; it is saved for circumstances that are difficult to figure out.↗
▶Ep 224 · 6:29
clinicalThere are many ways to tell if the anus is in the proper position, such as electrical stimulation and rectal ultrasound or MRI.↗
▶Ep 224 · 9:40
quoteThis is one of those things I always wonder, cause we all have a few patients that have this anatomy like chicken or the egg. Like what came first?↗
▶Ep 224 · 9:40
quoteThis is one of those things I always wonder, cause we all have a few patients that have this anatomy like chicken or the egg. Like what came first?↗
▶Ep 224 · 16:49
clinicalA patient with sacral ratio 0.45 is likely to be a bowel management candidate and will probably never achieve successful bowel control given the quality of their pelvis and amount of caudal regression.↗
▶Ep 224 · 16:49
clinicalA patient with sacral ratio 0.45 is likely to be a bowel management candidate and will probably never achieve successful bowel control given the quality of their pelvis and amount of caudal regression.↗
▶Ep 224 · 16:49
clinicalA sacral ratio of 0.45 indicates the sacrum is not great and the perineal musculature is probably not great.↗
▶Ep 224 · 16:49
quoteI think this patient is going to be a bowel management candidate. And I doubt they will ever achieve successful bowel control anyway, given the quality of their pelvis, the amount of quadruple regression that they have.↗
▶Ep 224 · 16:49
quoteI think this patient is going to be a bowel management candidate. And I doubt they will ever achieve successful bowel control anyway, given the quality of their pelvis, the amount of quadruple regression that they have.↗
▶Ep 224 · 16:49
clinicalA sacral ratio of 0.45 indicates the sacrum is not great and the perineal musculature is probably not great.↗
▶Ep 224 · 17:18
clinicalDr. Levitt has had some patients with good success with continence where the sigmoid is able to feel some distension after resection and sigmoid pull-through, but it is not the expectation.↗
Colorectal Quiz: Episode 46
▶Ep 221 · 6:27
clinicalIn anorectal malformation patients with perforation, the sigmoid colon typically perforates with a linear, longitudinal tear along the taenia.↗
▶Ep 221 · 7:34
quoteYou need to break the cycle of the physiologic obstruction. They are obstructed both at the sphincter level and in the aganglionic segment. And you have to break that cycle by getting a tube across it and then a lumen of that tube then to allow for egress of that stool because it's the stasis that's the problem. It's the stasis, the bacterial overgrowth. That overgrowth leads to translocation and that's where the sepsis comes in.↗
▶Ep 221 · 7:34
clinicalThe pathophysiology of Hirschsprung enterocolitis involves physiologic obstruction at both the sphincter level and in the aganglionic segment, leading to stasis, bacterial overgrowth, translocation, and sepsis.↗
▶Ep 221 · 8:41
clinicalCold saline used for irrigations in small children can significantly change the child's body temperature, so warm saline should be used.↗
▶Ep 221 · 10:55
clinicalSawtoothing in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease, particularly when associated with enterocolitis.↗
▶Ep 221 · 13:33
quoteIf it was a reliable family and irrigations were going well, I probably would have sent them home for a couple, a month or two, and then brought them back for their definitive operation.↗
▶Ep 221 · 13:33
opinionIf a patient has recovered from enterocolitis and irrigations are going well with reliable family, it is reasonable to send them home for 1-2 months before definitive operation rather than operating at 2 weeks.↗
▶Ep 221 · 14:29
quoteI agree with Mark. I would wait minimum four weeks from getting healthy after treating enterocolitis, maybe even longer before doing this. And I think there's good literature out there from the PCPLC and Michael Rollins on outcomes of Hirschsprung's disease and delayed treatment and delayed mepeter, wrong term. But just doing the definitive surgery, they looked at about three months out and had similar outcomes.↗
▶Ep 221 · 14:29
clinicalLiterature from the PCPLC and Michael Rollins shows that delayed definitive surgery for Hirschsprung disease (around 3 months out) has similar outcomes, so it is okay to wait as long as patient receives good irrigations and is growing and healthy.↗
▶Ep 221 · 17:23
clinicalIf mapping the colon without frozen section available, the entire colon should be mapped (left colon, transverse colon, and hepatic flexure/right colon) to avoid missing ganglionic segments.↗
▶Ep 221 · 22:52
clinicalIn settings where patients can be kept well hydrated with easy healthcare access, ileostomy is preferred over colostomy for diversion because colostomy mesentery becomes shortened and inflamed after division, making subsequent pull-through technically difficult with inadequate reach.↗
▶Ep 221 · 22:52
quoteI'm a fan of doing ileostomies in these cases where we need to divert and we have time and we're in a place where we're able to keep the patients hydrated well.↗
▶Ep 221 · 23:41
clinicalWhen performing ileostomy for Hirschsprung diversion, frozen section should be done on the ileostomy to ensure it will function.↗
▶Ep 221 · 26:54
clinicalCincinnati group is conducting a non-randomized study of Botox injection at the anal sphincter at time of ileostomy closure, with retrospective baseline comparison and prospective data collection currently in mid-30s patients; some patients in the protocol have still developed enterocolitis, so it is not 100% effective.↗
▶Ep 221 · 28:04
clinicalFamilies should be sent home with equipment to irrigate and taught how to irrigate before the pull-through so they can practice, ensuring they know the technique before discharge and avoiding catheter passage through fresh anastomosis post-op day 5.↗
▶Ep 221 · 28:04
quoteWe send the families home with the equipment to irrigate. That's a must, right? And also we teach how to irrigate before we do our pull through so that they are, and make the parents practice whether the child has enterocolitis or not pre-op so that they know how to do it.↗
Colorectal Quiz: Episode 46
▶Ep 226 · 4:52
quoteFree air, irrigation, you could irrigate, but I don't, the time it takes to irrigate, you're not getting to OR that fast for anything.↗
▶Ep 226 · 6:27
clinicalIn anorectal malformation patients with perforation, the sigmoid colon perforates as a linear longitudinal tear along the tenia.↗
▶Ep 226 · 6:34
quoteYeah, so that typically is the sigmoid colon, right? And it's a very, it's a linear, like a longitudinal tear along the tinea. I've seen it a couple of times in patients who had delayed diagnosis of imperforate anus.↗
▶Ep 226 · 6:53
clinicalWhen a baby goes to OR with free air and a perforation is found in the cecum, this strongly suggests Hirschsprung disease and should prompt rectal biopsy; most such patients would receive an ileostomy.↗
▶Ep 226 · 6:53
quoteI think, Mark, I think I've seen perfs in transverse colon, too, but when I go in and you take a baby to your OR with free air and you find a perf in the cecum, that to me sort of cries rectal biopsy.↗
▶Ep 226 · 7:34
quoteIt's very important. You need to break the cycle of the physiologic obstruction. They are obstructed both at the sphincter level and in the aganglionic segment. And you have to break that cycle by getting a tube across it and then a lumen of that tube then to allow for egress of that stool because it's the stasis that's the problem. It's the stasis, the bacterial overgrowth. That overgrowth leads to translocation and that's where the sepsis comes in.↗
▶Ep 226 · 7:34
clinicalProper irrigation technique requires breaking the cycle of physiologic obstruction at both the sphincter level and in the aganglionic segment by getting a tube across and allowing egress of stool, because stasis leads to bacterial overgrowth, translocation, and sepsis.↗
▶Ep 226 · 8:41
clinicalCold saline should not be used for irrigations in small children because it can significantly change the child's temperature.↗
▶Ep 226 · 8:41
quoteSome people have different methods. We typically say until about clear. Just make sure you're using warm saline because in a small child, cold saline can really change the temperature of the child.↗
▶Ep 226 · 10:55
clinicalSawtoothing visible in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease, particularly when associated with enterocolitis.↗
▶Ep 226 · 10:55
quoteWell, I would even add that there's hyperperistalsis. You can actually see the enero colitis more in the left colon. And the sawtoothing is the rectum is hyperperistaltic. That's very classic for Hirschsprung's disease.↗
▶Ep 226 · 13:33
opinionIn a patient who has recovered from enterocolitis with successful irrigations and is being fed, the appropriate approach is to send them home on irrigations and return for definitive operation in 1-2 months.↗
▶Ep 226 · 13:33
quoteYeah, I, um, that contrast study I would have read as a little bit of enterocolitis still happening, even though the patient was clinically well. If it was a reliable family and irrigations were going well, I probably would have sent them home for a couple, a month or two, and then brought them back for their definitive operation.↗
▶Ep 226 · 14:07
clinicalLiterature from the PCPLC and Michael Rollins shows that delayed definitive surgery for Hirschsprung disease (approximately 3 months out) has similar outcomes to earlier surgery, supporting that it is safe to wait as long as irrigations are successful and the patient is growing and healthy.↗
▶Ep 226 · 14:07
opinionThe minimum wait time after treating enterocolitis before performing definitive Hirschsprung surgery should be 4 weeks, possibly even longer.↗
▶Ep 226 · 14:29
quoteI agree with Mark. I would wait minimum four weeks from getting healthy after treating enterocolitis, maybe even longer before doing this. And I think there's good literature out there from the PCPLC and Michael Rollins on outcomes of Hirschsprung's disease and delayed treatment and delayed mepeter, wrong term. But just doing the definitive surgery, they looked at about three months out and had similar outcomes.↗
▶Ep 226 · 16:33
quoteI have seen patients, I don't know if you've seen this scenario, Jason, where someone has done this mapping, but they never sampled the right colon. And then the patient has an ileostomy and the sigmoid and left colon are no good. And they have concluded that the patient has total colonic. Maybe they sent the appendix, which is a complete mistake.↗
▶Ep 226 · 17:14
clinicalIf mapping the colon without frozen section available, the entire colon should be mapped (left colon, transverse colon, and hepatic flexure/right colon), because incomplete mapping can lead to incorrect conclusions about the extent of disease.↗
▶Ep 226 · 17:23
opinionPull-through should not extend past the hepatic flexure into distal ascending colon because Soave pull-throughs do not succeed very well with that anatomy.↗
▶Ep 226 · 17:23
quoteSo I think there's two scenarios, whether you have frozen section or not. If you have frozen section available and you get ganglion cells, then I don't think you need to do further mapping. If you don't have areas we go and operate or areas that don't have frozen section, I think you need to map the whole colon.↗
▶Ep 226 · 22:52
quoteI'm a fan of doing ileostomies in these cases where we need to divert and we have time and we're in a place where we're able to keep the patients hydrated well.↗
▶Ep 226 · 23:41
clinicalWhen performing ileostomy for Hirschsprung diversion, frozen section should be done on the ileostomy to ensure it will function.↗
▶Ep 226 · 23:41
quoteI agree exactly. And I would do exactly the same thing. I would map and then do an ileostomy. I would do a frozen section on the ileostomy just to make absolutely certain that it's going to function.↗
▶Ep 226 · 26:54
clinicalThe Cincinnati protocol now applies Botox at the anal sphincter at the time of restoring intestinal continuity; prospective data collection is ongoing with patients in the mid-30s, though some patients in the protocol have definitely developed enterocolitis, so it is not 100% foolproof.↗
▶Ep 226 · 26:54
quoteThen the group in Cincinnati with Dr. Helmrath and Dr. Frischer have altered the protocol to apply Botox at the anal sphincter at the time of restoring intestinal continuity. So we've been doing that. I don't have data to share that of an outcome. I will say, I know we have a few patients that definitely got enteroclitis that were in the protocol. So it's definitely not 100% full proof. And we definitely have increased diaper rash issues. So we know we're putting it in the right place.↗
▶Ep 226 · 28:04
quoteWe send the families home with the equipment to irrigate. That's a must, right? And also we teach how to irrigate before we do our pull through so that they are, and make the parents practice whether the child has enterocolitis or not pre-op so that they know how to do it. Because I don't love that catheter going through the anastomosis post-up day five when they're ready to go home or, and having issues. So I think you're dead on. Education is so key and preparing the families for this is life-saving.↗
▶Ep 226 · 28:04
clinicalFamilies should be sent home with irrigation equipment and taught how to irrigate before the pull-through surgery, with parents practicing the technique so they know how to do it, because having a catheter go through the anastomosis post-op day 5 when ready for discharge can cause issues.↗
Colorectal Quiz: Episode 43
▶Ep 222 · 5:37
epidemiologicalAbout 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work.↗
▶Ep 222 · 7:37
clinicalThe longer the appendix, the less likely it will leak based on Poiseuille's law (flow through a tube based on radius to fourth power and length).↗
▶Ep 222 · 8:35
quoteSo we plicate them all. And I haven't had a leakage in a long, long time, several years. So I think it's a very effective strategy.↗
▶Ep 222 · 8:35
clinicalDr. Frischer and Levitt did 10 Malones in a row without plicating and five leaked, so they decided to plicate them all and have not had a leakage in several years.↗
▶Ep 222 · 9:03
clinicalIf appendix is 7 centimeters or greater it can be split, requiring minimum 2 centimeters for the Malone and 5 centimeters minimum for the Mitrofanoff.↗
▶Ep 222 · 9:03
clinicalIf appendix is 5 to 7 centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone.↗
▶Ep 222 · 9:03
clinicalIf appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.↗
▶Ep 222 · 16:13
clinicalUsing a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate.↗
▶Ep 222 · 16:54
clinicalLeaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa.↗
▶Ep 222 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanovs because they catheterize every four hours; applying this to Malones by cathing twice daily has reduced stenosis rate.↗
▶Ep 222 · 20:00
clinicalFor lost Malone access, blow up a balloon on a Foley catheter to occlude the umbilicus and inject dye under pressure to find any micro hole tract.↗
Colorectal Quiz: Episode 43
▶Ep 228 · 5:37
epidemiologicalAbout 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff; about 40% of the time you cannot make it work.↗
▶Ep 228 · 5:37
epidemiologicalAbout 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff; about 40% of the time you cannot make it work.↗
▶Ep 228 · 7:37
clinicalFlow of fluid through a tube is based on Poiseuille's law: radius to the fourth power and length. A longer appendix or narrower appendix affects flow probability.↗
▶Ep 228 · 7:37
clinicalFlow of fluid through a tube is based on Poiseuille's law: radius to the fourth power and length. A longer appendix or narrower appendix affects flow probability.↗
▶Ep 228 · 8:35
epidemiologicalIn a study of 10 malones done in a row without plicating, five leaked, leading to the decision to plicate all malones.↗
▶Ep 228 · 8:35
epidemiologicalIn a study of 10 malones done in a row without plicating, five leaked, leading to the decision to plicate all malones.↗
▶Ep 228 · 8:35
clinicalThe longer the appendix, the less likely it will leak and you should not need to plicate.↗
▶Ep 228 · 8:35
clinicalThe longer the appendix, the less likely it will leak and you should not need to plicate.↗
▶Ep 228 · 8:35
clinicalPlicating all malones is a very effective strategy; no leakage has occurred in several years using this approach.↗
▶Ep 228 · 8:35
clinicalPlicating all malones is a very effective strategy; no leakage has occurred in several years using this approach.↗
▶Ep 228 · 9:03
clinicalIf appendix is five to seven centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone.↗
▶Ep 228 · 9:03
clinicalIf appendix is five to seven centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone.↗
▶Ep 228 · 9:03
clinicalIf appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.↗
▶Ep 228 · 9:03
clinicalIf appendix is seven centimeters or greater it can be split, requiring minimum two centimeters for Malone and five centimeters minimum for Mitrofanoff.↗
▶Ep 228 · 9:03
clinicalIf appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.↗
▶Ep 228 · 9:03
clinicalIf appendix is seven centimeters or greater it can be split, requiring minimum two centimeters for Malone and five centimeters minimum for Mitrofanoff.↗
▶Ep 228 · 10:00
clinicalFor patients with appendix 4-7 centimeters, 90% of appendix can be given to urologist with extension of appendiceal stump into cecum using non-cutting endo-TA stapler or hand-sewn non-absorbable braided suture.↗
▶Ep 228 · 10:00
clinicalFor patients with appendix 4-7 centimeters, 90% of appendix can be given to urologist with extension of appendiceal stump into cecum using non-cutting endo-TA stapler or hand-sewn non-absorbable braided suture.↗
▶Ep 228 · 12:08
clinicalPay attention to ileocecal valve location when creating Malone and plication to avoid obstruction at the ileocecal valve.↗
▶Ep 228 · 12:08
clinicalPay attention to ileocecal valve location when creating Malone and plication to avoid obstruction at the ileocecal valve.↗
▶Ep 228 · 16:13
clinicalUsing a 10 French tube instead of 8, leaving it in for a month, and cathing twice a day has reduced the incidence of stenosis.↗
▶Ep 228 · 16:13
clinicalUsing a 10 French tube instead of 8, leaving it in for a month, and cathing twice a day has reduced the incidence of stenosis.↗
▶Ep 228 · 16:54
clinicalProlonged stenting increases prolapse rate due to pressure on the appendiceal base pushing up mucosa.↗
▶Ep 228 · 16:54
clinicalLeaving tubes in prevents stenosis but increases the chance of leakage because the valve is no longer as pertinent with a stent across it.↗
▶Ep 228 · 16:54
clinicalLeaving tubes in prevents stenosis but increases the chance of leakage because the valve is no longer as pertinent with a stent across it.↗
▶Ep 228 · 16:54
clinicalProlonged stenting increases prolapse rate due to pressure on the appendiceal base pushing up mucosa.↗
▶Ep 228 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanoff because they cath every four hours; cathing the Malone twice a day has reduced stenosis rate.↗
▶Ep 228 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanoff because they cath every four hours; cathing the Malone twice a day has reduced stenosis rate.↗
▶Ep 228 · 18:20
clinicalFor recurrent leakage after two wraps, consider whether appendix length is a problem and whether channel needs lengthening.↗
▶Ep 228 · 18:20
clinicalFor recurrent leakage after two wraps, consider whether appendix length is a problem and whether channel needs lengthening.↗
▶Ep 228 · 20:00
clinicalBlowing up a balloon on Foley catheter to occlude umbilicus and injecting dye creates pressurized system that will find any micro-hole tract still present.↗
▶Ep 228 · 20:00
clinicalBlowing up a balloon on Foley catheter to occlude umbilicus and injecting dye creates pressurized system that will find any micro-hole tract still present.↗
Colorectal Quiz: Episode 40
▶Ep 223 · 11:35
clinicalOptions for vaginal reconstruction when native vagina cannot reach include: dilating the existing introitus, opening the area and laying in a buccal graft, or waiting for tissue engineering options expected within 20 years or less.↗
▶Ep 223 · 12:14
quoteI think it's going to be, there are people right now taking a few vaginal cells and growing them and hopeful, just like you said, Mark, we're going to have some great tissue engineering that will assist us and make this a easier and better procedure for our patients.↗
▶Ep 223 · 13:09
opinionIf a neovagina bridge is functioning well without problems, there may be no reason to remove it later.↗
Colorectal Quiz: Episode 40
▶Ep 230 · 5:32
quoteWait, is this Meyer-Rotakansky-Kuster-Hauser syndrome?↗
▶Ep 230 · 5:32
quoteWait, is this Meyer-Rotakansky-Kuster-Hauser syndrome?↗
▶Ep 230 · 11:35
opinionThe introitus in this case is potentially dilatable in the future to create a functional vagina.↗
▶Ep 230 · 11:35
opinionThe introitus in this case is potentially dilatable in the future to create a functional vagina.↗
▶Ep 230 · 12:14
quoteThere are people right now taking a few vaginal cells and growing them.↗
▶Ep 230 · 12:14
quoteThere are people right now taking a few vaginal cells and growing them.↗
▶Ep 230 · 12:14
opinionTissue engineering options for vaginal reconstruction are expected to be available within 20 years or perhaps even shorter, with researchers currently growing vaginal cells.↗
▶Ep 230 · 12:14
opinionTissue engineering options for vaginal reconstruction are expected to be available within 20 years or perhaps even shorter, with researchers currently growing vaginal cells.↗
▶Ep 230 · 13:09
quoteI think you need it when there's a problem. If there's no problem, why go in and remove tissue, whether it be bowel or whatever you have as your graft?↗
▶Ep 230 · 13:09
opinionIf a neovagina functions well and causes no problems, there is no reason to remove it later even if it is bowel or another graft material.↗
▶Ep 230 · 13:09
quoteI think you need it when there's a problem. If there's no problem, why go in and remove tissue, whether it be bowel or whatever you have as your graft?↗
▶Ep 230 · 13:09
opinionIf a neovagina functions well and causes no problems, there is no reason to remove it later even if it is bowel or another graft material.↗
▶Ep 230 · 14:50
quoteI applaud you, Chris, and your partners for going in thinking you're going to do this big reconstruction, encounter something that you weren't expecting and doing the safe thing.↗
▶Ep 230 · 14:50
quoteI applaud you, Chris, and your partners for going in thinking you're going to do this big reconstruction, encounter something that you weren't expecting and doing the safe thing.↗
▶Ep 230 · 15:57
opinionFred Reichman used to say that surgeons are judged by what they are willing to stop for.↗
▶Ep 230 · 15:57
opinionFred Reichman used to say that surgeons are judged by what they are willing to stop for.↗
▶Ep 230 · 15:57
quoteAs surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through.↗
▶Ep 230 · 15:57
guidelineIf a surgeon is uncertain about vascular anatomy during an operation, they should stop, gather more information, and reconfront the situation rather than proceeding blindly.↗
▶Ep 230 · 15:57
quoteAs surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through.↗
▶Ep 230 · 15:57
quoteFred Reichman used to say, you are judged by what you are willing to stop for.↗
▶Ep 230 · 15:57
quoteFred Reichman used to say, you are judged by what you are willing to stop for.↗
▶Ep 230 · 15:57
guidelineIf a surgeon is uncertain about vascular anatomy during an operation, they should stop, gather more information, and reconfront the situation rather than proceeding blindly.↗
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
▶Ep 224 · 4:36
quoteDo you automatically get an echo on every one of your anorectal malformation babies?↗
▶Ep 224 · 7:24
clinicalIn a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they're evacuating okay.↗
▶Ep 224 · 7:24
opinionFor perineal fistula or vestibular fistula in a female, one can consider just dilating with good evacuation and letting the cardiac situation play itself out.↗
▶Ep 224 · 7:48
clinicalIn a blue baby with significant cardiac lesion requiring early surgery where patient isn't oxygenating well, there is concern about healing of an ARM repair.↗
▶Ep 224 · 7:48
quoteMy concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair↗
▶Ep 224 · 11:08
quoteDissecting in with a mosquito, making sure you're in, not touching any vessel before you insufflate, and also clear the line of air↗
▶Ep 224 · 11:08
clinicalFor umbilical access in laparoscopy, dissect in with a mosquito, ensure you're in the peritoneum without touching any vessel before insufflation, and clear the line of air.↗
▶Ep 224 · 13:56
clinicalThe white beads along the raphe should be scraped off during repair, as they can persist into teenage years and young adulthood if left alone.↗
▶Ep 224 · 13:56
quoteI've seen teenagers and young adults with those beads that never went away. So, yeah, you've got to scrape that off↗
▶Ep 224 · 14:23
clinicalFor a 50-50 perineal fistula (half within muscle complex, half anterior), leave the anterior wall as it's the danger zone, mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction.↗
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
▶Ep 232 · 4:36
quoteDo you automatically get an echo on every one of your anorectal malformation babies?↗
▶Ep 232 · 4:36
quoteDo you automatically get an echo on every one of your anorectal malformation babies?↗
▶Ep 232 · 7:24
clinicalIn a cardiac patient with an external ARM opening, the typical approach is to dilate as long as they're evacuating okay, allowing the cardiac situation to play itself out.↗
▶Ep 232 · 7:24
clinicalIn a cardiac patient with an external ARM opening, the typical approach is to dilate as long as they're evacuating okay, allowing the cardiac situation to play itself out.↗
▶Ep 232 · 7:48
quoteMy concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair.↗
▶Ep 232 · 7:48
clinicalThe concern with early ARM repair in a blue baby with significant cardiac lesion requiring early surgery is the healing of that repair when the patient isn't oxygenating well.↗
▶Ep 232 · 7:48
quoteMy concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair.↗
▶Ep 232 · 7:48
clinicalThe concern with early ARM repair in a blue baby with significant cardiac lesion requiring early surgery is the healing of that repair when the patient isn't oxygenating well.↗
▶Ep 232 · 11:21
quoteIt is important to irrigate as much as you can↗
▶Ep 232 · 11:21
quoteIt is important to irrigate as much as you can↗
▶Ep 232 · 11:21
clinicalDr. Levitt's technique for distal irrigation involves having someone look laparoscopically while he passes the tube into the distal segment and does the irrigation under direct visualization.↗
Colorectal Quiz Episode 29: Female ARM
▶Ep 225 · 7:17
clinicalDr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO.↗
▶Ep 225 · 15:02
clinicalApproximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures.↗
Colorectal Quiz Episode 29: Female ARM
▶Ep 234 · 7:17
clinicalFrischer uses midline catheter (not PICC line) with D10 for 5-7 days NPO after primary perineal body repair.↗
▶Ep 234 · 7:17
clinicalFrischer uses midline catheter (not PICC line) with D10 for 5-7 days NPO after primary perineal body repair.↗
▶Ep 234 · 14:04
quoteMy only concern is what's the continence rate of your patients? You have a percent of looking at, right? You're somewhere in the order of 15 to 20, 22% got redo operations, mostly local.↗
▶Ep 234 · 14:04
quoteMy only concern is what's the continence rate of your patients? You have a percent of looking at, right? You're somewhere in the order of 15 to 20, 22% got redo operations, mostly local.↗
▶Ep 234 · 15:02
clinicalApproximately 20% of patients in the dilation RCT required redo operations (either local or total), with most requiring only local revision.↗
▶Ep 234 · 15:23
clinicalLong-term continence outcomes are unknown for patients who developed strictures and underwent revision in the non-dilation group.↗
▶Ep 234 · 15:23
clinicalLong-term continence outcomes are unknown for patients who developed strictures and underwent revision in the non-dilation group.↗
▶Ep 234 · 16:30
clinicalFull continence can be restored with redo surgery for stricture, based on available data for longer strictures requiring full redo.↗
▶Ep 234 · 16:30
clinicalFull continence can be restored with redo surgery for stricture, based on available data for longer strictures requiring full redo.↗
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
▶Ep 226 · 5:05
quoteHe united us. Yeah. In a way. And he doesn't even know it.↗
▶Ep 226 · 9:40
clinicalDr. Martin developed the Martin procedure, an expansion of the Duhamel for long-segment Hirschsprung disease, leaving a longer aganglionated segment of rectum and pulling through ganglionated bowel.↗
clinicalDr. Martin was the first surgeon-in-chief and pediatric surgeon at Cincinnati Children's Hospital.↗
▶Ep 226 · 14:13
quoteI think that's the who's who of Hirschsprung's right there.↗
▶Ep 226 · 14:47
quoteI have a feeling we're going to have way more discussions about Hirschsprung disease because just because, because I think it's a fascinating disease that there are so many intricacies. You just mentioned dentorocolitis. We could talk forever about that.↗
The Colorectal Quiz Episode 4
▶Ep 229 · 10:19
clinicalFrozen section biopsy must include submucosa to avoid missing hypertrophic nerves in submucosal layer while finding ganglion cells in seromuscular layer↗
▶Ep 229 · 10:19
quotethey must see submucosa. And if you send them a biopsy without submucosa, our pathologist will say, hey, where's the submucosa? Because you want to make sure, again, that you don't find ganglion cells in the seromuscular layer and hypertrophic nerves in the submucosal layer.↗
▶Ep 229 · 11:00
clinicalMesenteric dissection should stay close to bowel wall, not deep in mesentery, to reduce bleeding↗
▶Ep 229 · 12:26
quoteYou need to be very careful of preserving that arcade along the left colon and sigmoid colon so you could get enough distance to reach the pelvis.↗
▶Ep 229 · 12:26
clinicalMust preserve arcade along left colon and sigmoid to get enough length to reach pelvis↗
▶Ep 229 · 16:06
clinicalResection margin should be approximately five centimeters above biopsy site where bowel looks good↗
clinicalIn higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated↗
▶Ep 230 · 15:20
opinionAlternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo↗
The Colorectal Quiz Episode 4
▶Ep 241 · 6:33
clinicalThe transanal dissection should usually take way under an hour, especially in a primary pull-through.↗
▶Ep 241 · 6:33
quotethe transanal dissection should be usually way under an hour, especially in a primary pull-through point.↗
▶Ep 241 · 6:33
clinicalThe transanal dissection should usually take way under an hour, especially in a primary pull-through.↗
▶Ep 241 · 6:33
quotethe transanal dissection should be usually way under an hour, especially in a primary pull-through point.↗
▶Ep 241 · 12:35
clinicalFor distal disease, only distal branches of the IMA need to be taken, but for left colon or splenic flexure involvement, the IMA itself might need to be taken.↗
▶Ep 241 · 12:35
clinicalFor distal disease, only distal branches of the IMA need to be taken, but for left colon or splenic flexure involvement, the IMA itself might need to be taken.↗
Colorectal Quiz: Episode 2
▶Ep 242 · 10:19
clinicalIn higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated.↗
▶Ep 242 · 10:19
quotePatients like patients who have a higher malformation, such as a bladder neck, sometimes those sphincter complexes are sort of more anterior than you think that you're anticipating it might be.↗
▶Ep 242 · 10:19
clinicalIn higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated.↗
▶Ep 242 · 10:19
quotePatients like patients who have a higher malformation, such as a bladder neck, sometimes those sphincter complexes are sort of more anterior than you think that you're anticipating it might be.↗
▶Ep 242 · 15:20
opinionAn alternative approach for borderline anatomy is to be more conservative and let the child take their car out for a ride first to see how it works before considering redo.↗
▶Ep 242 · 15:20
opinionAn alternative approach for borderline anatomy is to be more conservative and let the child take their car out for a ride first to see how it works before considering redo.↗
The Colorectal Quiz: Episode 1
▶Ep 231 · 4:15
epidemiologicalPre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI↗
▶Ep 231 · 4:15
quoteif it's an anal stenosis or a rectal atresia defect, then you need to be very worried about finding a pre-sacral mass. And almost half the time, you'll find one. And those patients will end up getting an MRI.↗
▶Ep 231 · 5:05
guidelineCross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning↗
▶Ep 231 · 5:05
quoteWe typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be.↗
▶Ep 231 · 7:36
clinicalWell-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis↗
▶Ep 231 · 8:25
quoteI have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.↗
▶Ep 231 · 8:25
opinionWith air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging↗
▶Ep 231 · 9:57
quoteyou should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum.↗
▶Ep 231 · 9:57
guidelineShould never try to go in blind—must know what structure will be encountered before making posterior sagittal incision↗
▶Ep 231 · 12:34
clinicalFistula can be very close to rectum, making proper plane dissection along urethra important↗
▶Ep 231 · 12:34
clinicalBulbar fistula nomenclature refers to anatomic location at the elbow of the urethra↗
▶Ep 231 · 12:34
quoteThe reason why Dr. Levitt or Mark is saying that it's a bulbar fistula is it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the nomenclature we like to use is an anatomic, pure anatomic nomenclature saying that it's a bulbar fistula.↗
▶Ep 231 · 12:34
quoteyou can see this fistula is very close to the rectum. And if you're going to dissect that free and along the urethra, it's important to make sure that you know that those two structures are not very far apart. And getting that into that proper plane is very important.↗
The Colorectal Quiz: Episode 1
▶Ep 244 · 4:15
epidemiologicalPre-sacral mass is rare in typical imperforate anus but occurs in almost half of anal stenosis or rectal atresia cases↗
▶Ep 244 · 4:15
clinicalPatients with anal stenosis or rectal atresia and pre-sacral mass will need MRI evaluation↗
▶Ep 244 · 4:15
clinicalPatients with anal stenosis or rectal atresia and pre-sacral mass will need MRI evaluation↗
▶Ep 244 · 4:15
epidemiologicalPre-sacral mass is rare in typical imperforate anus but occurs in almost half of anal stenosis or rectal atresia cases↗
▶Ep 244 · 5:05
quoteWe typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be.↗
▶Ep 244 · 5:05
clinicalCross-table lateral x-ray is typically obtained at about 24 hours of life, give or take a few hours, to visualize the gas column position↗
▶Ep 244 · 5:05
quoteWe typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be.↗
▶Ep 244 · 5:05
clinicalCross-table lateral x-ray is typically obtained at about 24 hours of life, give or take a few hours, to visualize the gas column position↗
▶Ep 244 · 7:36
clinicalWell-formed buttocks, good muscle mass, and identifiable sphincter mechanism location on physical exam contribute to favorable prognosis in anorectal malformation↗
▶Ep 244 · 7:36
clinicalWell-formed buttocks, good muscle mass, and identifiable sphincter mechanism location on physical exam contribute to favorable prognosis in anorectal malformation↗
▶Ep 244 · 8:25
quoteI have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.↗
▶Ep 244 · 8:25
quoteI have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.↗
▶Ep 244 · 9:57
quoteIt goes without saying, and one of our, I think one of our big teaching points is you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum.↗
▶Ep 244 · 9:57
quoteIt goes without saying, and one of our, I think one of our big teaching points is you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum.↗
▶Ep 244 · 12:34
clinicalA bulbar fistula is named for its location at the elbow of the urethra, using pure anatomic nomenclature↗
▶Ep 244 · 12:34
clinicalA bulbar fistula is named for its location at the elbow of the urethra, using pure anatomic nomenclature↗
Jason's statements about Congenital Diaphragmatic Hernia21 statements
quoteI've seen it associated with congenital diaphragmatic hernias a few times, and I think that's when we have a high suspicion for it.↗
▶Ep 12 · 1:33
epidemiological60% of gastric volvulus cases in the pediatric population happen in the first year of life, with about 21% in the first month.↗
▶Ep 12 · 1:33
quote60% happen in the first year of life in the pediatric population, and so about 21% in the first month and over a third in the first year of life.↗
▶Ep 12 · 1:58
quoteIf the child's like 4 months old, is it more likely, are you're more likely to have an acute problem or a chronic problem? So they're acute.↗
▶Ep 12 · 1:58
clinicalIn a 4-month-old child with gastric volvulus, acute presentation is more likely than chronic.↗
▶Ep 12 · 2:45
quoteThat's the big one, I think, right there. I think a little bit of bloody aspirate from the. Logo can't advance it. Funny looking stomach bubble on the X-ray.↗
▶Ep 12 · 2:47
clinicalA little bit of bloody aspirate from the NG tube and a funny looking stomach bubble on X-ray are key findings in gastric volvulus.↗
▶Ep 12 · 3:10
clinicalChronic gastric volvulus is more related to laxity of the gastric ligaments including gastrophrenic, gastrosplenic, gastrocolic, and gastrohepatic ligaments.↗
▶Ep 12 · 3:10
quoteThose are more to do with the laxity of the gastric ligaments, and the stomach has ligamentous attachments basically surrounding the entire stomach from gastrophrenic, gastrosplenic, gastrocolic. And of course. Gastropatic ligament.↗
▶Ep 12 · 3:43
quoteThe first one, the first and most common is organoaxial volvulus.↗
▶Ep 12 · 3:43
clinicalOrganoaxial volvulus is the first and most common type of gastric volvulus.↗
▶Ep 12 · 3:55
quoteThey describe a line that's drawn on this diagram between the GE junction and the pylorus, and it's spinning around that axis. The greater curvature then sort of flips up and over and becomes more superior than the lesser curvature.↗
▶Ep 12 · 3:55
clinicalIn organoaxial volvulus, the stomach spins around an axis drawn between the GE junction and the pylorus, with the greater curvature flipping up and over to become more superior than the lesser curvature.↗
▶Ep 12 · 4:18
clinicalIn mesenteroaxial volvulus, rotation occurs around a line through the middle of the stomach from lesser to greater curvature, with the stomach flipping behind and back over.↗
▶Ep 12 · 4:34
quoteThen, and flip the stomach up and over that way, so it's going sort of behind. The stomach and back over it.↗
▶Ep 12 · 4:46
clinicalIn gastric volvulus, when filled with contrast, the pylorus appears right next to or near the GE junction and above the body of the stomach.↗
▶Ep 12 · 4:46
quoteWhen the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach.↗
▶Ep 12 · 6:08
clinicalIn mesenteroaxial volvulus, the duodenum may fill above or superior to the GE junction because the pylorus has flipped up and over or behind and over the top of the stomach.↗
▶Ep 12 · 6:22
quoteMesentero axial favulus. Again, this is the sort of pylorus flipping up and over or behind and over the top of the stomach, and then therefore, your pylorus is located all the way up here.↗
▶Ep 12 · 8:40
quoteAlso, you always want to check the viability of the stomach. So, right, if this is chronically volvulized or been volvulized for a couple of days, uh, at least looking at the cirrhosa and looking at the blood flow.↗
▶Ep 12 · 8:40
clinicalWhen managing gastric volvulus found during CDH repair, viability of the stomach must always be checked, especially if chronically volvulized or volvulized for a couple of days, by looking at the serosa and blood flow.↗
Jason's statements about Congenital Diaphragmatic Hernia21 statements
quoteI've seen it associated with congenital diaphragmatic hernias a few times, and I think that's when we have a high suspicion for it.↗
▶Ep 15 · 1:33
quote60% happen in the first year of life in the pediatric population, and so about 21% in the first month and over a third in the first year of life.↗
▶Ep 15 · 1:33
epidemiological60% of gastric volvulus cases in the pediatric population happen in the first year of life, with about 21% in the first month.↗
▶Ep 15 · 1:58
clinicalIn a 4-month-old child with gastric volvulus, acute presentation is more likely than chronic.↗
▶Ep 15 · 1:58
quoteIf the child's like 4 months old, is it more likely, are you're more likely to have an acute problem or a chronic problem? So they're acute.↗
▶Ep 15 · 2:45
quoteThat's the big one, I think, right there. I think a little bit of bloody aspirate from the. Logo can't advance it. Funny looking stomach bubble on the X-ray.↗
▶Ep 15 · 2:47
clinicalA little bit of bloody aspirate from the NG tube and a funny looking stomach bubble on X-ray are key findings in gastric volvulus.↗
▶Ep 15 · 3:10
clinicalChronic gastric volvulus is more related to laxity of the gastric ligaments including gastrophrenic, gastrosplenic, gastrocolic, and gastrohepatic ligaments.↗
▶Ep 15 · 3:10
quoteThose are more to do with the laxity of the gastric ligaments, and the stomach has ligamentous attachments basically surrounding the entire stomach from gastrophrenic, gastrosplenic, gastrocolic. And of course. Gastropatic ligament.↗
▶Ep 15 · 3:43
clinicalOrganoaxial volvulus is the first and most common type of gastric volvulus.↗
▶Ep 15 · 3:43
quoteThe first one, the first and most common is organoaxial volvulus.↗
▶Ep 15 · 3:55
quoteThey describe a line that's drawn on this diagram between the GE junction and the pylorus, and it's spinning around that axis. The greater curvature then sort of flips up and over and becomes more superior than the lesser curvature.↗
▶Ep 15 · 3:55
clinicalIn organoaxial volvulus, the stomach spins around an axis drawn between the GE junction and the pylorus, with the greater curvature flipping up and over to become more superior than the lesser curvature.↗
▶Ep 15 · 4:18
clinicalIn mesenteroaxial volvulus, rotation occurs around a line through the middle of the stomach from lesser to greater curvature, with the stomach flipping behind and back over.↗
▶Ep 15 · 4:34
quoteThen, and flip the stomach up and over that way, so it's going sort of behind. The stomach and back over it.↗
▶Ep 15 · 4:46
quoteWhen the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach.↗
▶Ep 15 · 4:46
clinicalIn gastric volvulus, when filled with contrast, the pylorus appears right next to or near the GE junction and above the body of the stomach.↗
▶Ep 15 · 6:08
clinicalIn mesenteroaxial volvulus, the duodenum may fill above or superior to the GE junction because the pylorus has flipped up and over or behind and over the top of the stomach.↗
▶Ep 15 · 6:22
quoteMesentero axial favulus. Again, this is the sort of pylorus flipping up and over or behind and over the top of the stomach, and then therefore, your pylorus is located all the way up here.↗
▶Ep 15 · 8:40
clinicalWhen managing gastric volvulus found during CDH repair, viability of the stomach must always be checked, especially if chronically volvulized or volvulized for a couple of days, by looking at the serosa and blood flow.↗
▶Ep 15 · 8:40
quoteAlso, you always want to check the viability of the stomach. So, right, if this is chronically volvulized or been volvulized for a couple of days, uh, at least looking at the cirrhosa and looking at the blood flow.↗
Jason's statements about Congenital Lung Lesions (CPAM)15 statements
clinicalIn asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU↗
▶Ep 22 · 4:45
clinicalCT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients↗
▶Ep 22 · 4:45
clinicalCT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients↗
▶Ep 22 · 17:23
clinicalWhen using energy devices for vessel control, leave enough remnant tissue so the vessel doesn't retract if seal fails, allowing purchase for clip or suture↗
▶Ep 22 · 17:23
clinicalWhen using energy devices for vessel control, leave enough remnant tissue so the vessel doesn't retract if seal fails, allowing purchase for clip or suture↗
▶Ep 22 · 17:47
clinicalObtain proximal control or partially cut across vessel with energy device to detect failure before complete division↗
▶Ep 22 · 17:47
clinicalObtain proximal control or partially cut across vessel with energy device to detect failure before complete division↗
▶Ep 22 · 17:56
clinicalWhen using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation↗
▶Ep 22 · 17:56
clinicalWhen using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation↗
▶Ep 22 · 46:59
clinicalNewborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF↗
▶Ep 22 · 46:59
clinicalNewborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF↗
▶Ep 22 · 48:23
clinicalEcho findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies↗
▶Ep 22 · 48:23
clinicalEcho findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies↗
▶Ep 22 · 1:04:12
epidemiologicalEsophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea↗
▶Ep 22 · 1:04:12
epidemiologicalEsophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea↗
Jason's statements about Congenital Pulmonary Airway Malformation7 statements
clinicalCT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients↗
▶Ep 19 · 17:23
clinicalWhen using energy devices for vessel control, leave enough remnant tissue so the vessel doesn't retract if seal fails, allowing purchase for clip or suture↗
▶Ep 19 · 17:47
clinicalObtain proximal control or partially cut across vessel with energy device to detect failure before complete division↗
▶Ep 19 · 17:56
clinicalWhen using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation↗
▶Ep 19 · 46:59
clinicalNewborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF↗
▶Ep 19 · 48:23
clinicalEcho findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies↗
▶Ep 19 · 1:04:12
epidemiologicalEsophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea↗
Jason's statements about Congenital Pulmonary Airway Malformation7 statements
clinicalCT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients↗
▶Ep 19 · 17:23
clinicalWhen using energy devices for vessel control, leave enough remnant tissue so the vessel doesn't retract if seal fails, allowing purchase for clip or suture↗
▶Ep 19 · 17:47
clinicalObtain proximal control or partially cut across vessel with energy device to detect failure before complete division↗
▶Ep 19 · 17:56
clinicalWhen using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation↗
▶Ep 19 · 46:59
clinicalNewborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF↗
▶Ep 19 · 48:23
clinicalEcho findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies↗
▶Ep 19 · 1:04:12
epidemiologicalEsophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea↗
Jason's statements about Constipation18 statements
The Colorectal Quiz Episode 8: Motility Disorders Part 1
▶Ep 7 · 6:29
quoteIt's saying that this is not a Monet, that is for certain.↗
▶Ep 7 · 7:12
clinicalContrast studies are not great predictors of how patients will respond to medical or surgical management; normal-looking colons may not respond while abnormal-appearing colons may respond well↗
▶Ep 7 · 8:06
clinicalWater-soluble contrast (not barium) is used for contrast enemas because it helps empty the colon and acts as a cleanout for patients starting new medical therapy↗
▶Ep 7 · 10:51
opinionIn the past, surgeons did not understand the major role the sphincter played in many patients↗
▶Ep 7 · 10:51
quoteI think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played.↗
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
▶Ep 8 · 1:17
clinicalWhen a 7 cm appendix is shared between urology and colorectal surgery, the urologist typically takes 6.25 cm leaving only 0.75 cm for colorectal use↗
▶Ep 8 · 1:17
quoteWhen you get that really short stumpy appendix, whether it be from splitting it, and the urologist, if I have a 7 centimeter appendix, the urologist takes 6.25 centimeters and I get 0.75.↗
▶Ep 8 · 1:55
clinicalThe colorectal team benefits from using the appendix portion closer to the cecum which has a stronger blood supply↗
▶Ep 8 · 2:05
clinicalA short appendiceal stump can be extended by suturing or using a laparoscopic non-cutting linear stapler along the cecal wall to add 2-3 cm of length↗
▶Ep 8 · 2:34
clinicalOne of the problems with Malone appendicostomy is leakage↗
▶Ep 8 · 2:47
clinicalThe longer the Malone channel, the less likely it is to leak↗
▶Ep 8 · 2:52
quoteThe longer the channel, the less likely that Malone's going to leak.↗
▶Ep 8 · 2:55
clinicalExtending the Malone channel by 2-3 cm using suturing or stapling can be extremely helpful in preventing leakage↗
▶Ep 8 · 3:43
clinicalRectal irrigation using pressurized water systems made for patients with hand difficulties is an alternative to Malone and Mitrofanoff procedures↗
▶Ep 8 · 4:25
clinicalColoplast makes a rectal irrigation device for self-administration of enemas↗
▶Ep 8 · 9:43
clinicalAt Cincinnati Children's, 99% of Malones are placed in the umbilicus and almost all Mitrofanoffs are in the right lower quadrant with a tunnel channel through the rectus to prevent leakage↗
▶Ep 8 · 10:21
clinicalThe primary determinant of orifice location is where the appendix reaches and its blood supply↗
▶Ep 8 · 11:09
clinicalLaxity of the pelvic floor and anal canal is a huge issue in spinal patients, especially when doing retrograde enemas↗
Jason's statements about Crohn's Disease70 statements
Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1
▶Ep 1 · 4:51
quoteI think one key thing to talk about with all our listeners is when you do that exam, make sure you step to the side. A little bit funny, but a little bit, you don't wanna be in the way of what could be coming out.↗
▶Ep 1 · 4:51
clinicalWhen performing initial rectal exam on a distended child with suspected enterocolitis, step to the side because there may be an explosive release of stool and gas.↗
▶Ep 1 · 4:51
quoteI think one key thing to talk about with all our listeners is when you do that exam, make sure you step to the side. A little bit funny, but a little bit, you don't wanna be in the way of what could be coming out.↗
▶Ep 1 · 4:51
clinicalWhen performing initial rectal exam on a distended child with suspected enterocolitis, step to the side because there may be an explosive release of stool and gas.↗
▶Ep 1 · 12:06
clinicalFor a patient with prior Hirschsprung diagnosis presenting sick, assume Hirschsprung-associated enterocolitis; treatment with rectal irrigations, IV fluids, and antibiotics will not cause harm even if the diagnosis is different (e.g., Crohn's disease, E. coli enterocolitis).↗
▶Ep 1 · 12:06
quoteIf you have a patient that comes in with a diagnosis of Hirschprung's in the past and comes with, comes in sick, you have to assume it's Hirschprung's associated enterocolitis.↗
▶Ep 1 · 12:06
clinicalFor a patient with prior Hirschsprung diagnosis presenting sick, assume Hirschsprung-associated enterocolitis; treatment with rectal irrigations, IV fluids, and antibiotics will not cause harm even if the diagnosis is different (e.g., Crohn's disease, E. coli enterocolitis).↗
▶Ep 1 · 12:06
quoteIf you have a patient that comes in with a diagnosis of Hirschprung's in the past and comes with, comes in sick, you have to assume it's Hirschprung's associated enterocolitis.↗
▶Ep 1 · 14:58
guidelineFamilies should not undergo Hirschsprung pull-through surgery until they can demonstrate ability to perform rectal irrigations, and they should be discharged with supplies to perform irrigations at home.↗
▶Ep 1 · 14:58
guidelineFamilies should not undergo Hirschsprung pull-through surgery until they can demonstrate ability to perform rectal irrigations, and they should be discharged with supplies to perform irrigations at home.↗
▶Ep 1 · 18:19
clinicalIn a logical workup, obtain the contrast study before going to the OR for rectal exam under anesthesia, as it may reveal findings that guide the surgical approach.↗
▶Ep 1 · 18:19
clinicalIn a logical workup, obtain the contrast study before going to the OR for rectal exam under anesthesia, as it may reveal findings that guide the surgical approach.↗
▶Ep 1 · 18:33
quoteI think we all agree we get the contrast study before going to the operating room for a rectal exam↗
▶Ep 1 · 18:33
quoteI think we all agree we get the contrast study before going to the operating room for a rectal exam↗
▶Ep 1 · 19:43
clinicalA lateral view on contrast enema is important because it provides significant information about the presacral space and distal rectum anatomy.↗
▶Ep 1 · 19:43
clinicalA lateral view on contrast enema is important because it provides significant information about the presacral space and distal rectum anatomy.↗
clinicalIf terminal ileum cannot be intubated, gastroenterologists may treat presumptively and re-scope after a few months of treatment when inflammation has decreased.↗
▶Ep 8 · 6:52
clinicalThe highest risk factors for lymphoma with biologic therapy are male gender, teenage age, and combination therapy with methotrexate.↗
▶Ep 8 · 9:00
epidemiologicalMale gender over the age of 10, and presence of a fistula are risk factors with much higher incidence of Crohn's disease being diagnosed in patients presenting with perianal lesions to the emergency room.↗
▶Ep 8 · 9:29
clinicalIn pediatric patients, unlike adult patients, the first presenting factor for Crohn's disease can often be perianal disease.↗
▶Ep 8 · 12:25
quoteI don't like to make holes when there aren't holes there.↗
▶Ep 8 · 12:31
clinicalThe mucosa heals first compared to skin in perianal disease, so leaving a mucosal opening without a seton risks recurrent abscess when biologics heal the mucosa.↗
▶Ep 8 · 12:31
quoteThe thing that's going to heal first is the mucosa.↗
▶Ep 8 · 13:12
clinicalMaking a large cruciate incision and packing a perianal abscess in a child with undiagnosed Crohn's disease may result in non-healing and potentially require colostomy or ileostomy.↗
▶Ep 8 · 13:20
quoteYou may have bought that kid a colostomy or ileostomy.↗
▶Ep 8 · 14:15
clinicalHydrogen peroxide is preferred over methylene blue for identifying fistula tracts because it is neater; 3% hydrogen peroxide in a syringe with 16-20 gauge angiocath is used with a speculum in the anus.↗
▶Ep 8 · 14:54
clinicalWhen a fistula opening cannot be found despite hydrogen peroxide testing, a seton should not be placed at that time to avoid creating a hole where there isn't one.↗
▶Ep 8 · 17:17
clinicalIf an abscess is not adequately drained, reimaging should be performed before giving biologics or steroids.↗
▶Ep 8 · 17:17
clinicalSource control of infection must be achieved before starting immunosuppressive therapy including steroids and biologics.↗
▶Ep 8 · 19:23
clinicalBefore removing a seton, the bottom must look better, drainage must be better, the patient must be symptom-free, and they must have reached steady state of biologic (loading dose plus at least 3 more doses, typically 2-3 months from start).↗
▶Ep 8 · 19:55
clinicalInflammatory markers including fecal calprotectin, ESR, and CRP should be checked before removing a seton to ensure systemic disease is under control.↗
▶Ep 8 · 20:49
clinicalThe initial Remicade paper from 1998 or 1999 in the New England Journal of Medicine was on perianal disease and demonstrated improved healing time and improved length of time between recurrence when combination of seton and infliximab is used versus either separately.↗
Colorectal Quiz: Episode 43
▶Ep 6 · 5:37
epidemiologicalAbout 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work.↗
▶Ep 6 · 5:37
epidemiologicalAbout 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work.↗
▶Ep 6 · 7:37
clinicalThe longer the appendix, the less likely it will leak based on Poiseuille's law (flow through a tube based on radius to fourth power and length).↗
▶Ep 6 · 7:37
clinicalThe longer the appendix, the less likely it will leak based on Poiseuille's law (flow through a tube based on radius to fourth power and length).↗
▶Ep 6 · 8:35
clinicalDr. Frischer and Levitt did 10 Malones in a row without plicating and five leaked, so they decided to plicate them all and have not had a leakage in several years.↗
▶Ep 6 · 8:35
quoteSo we plicate them all. And I haven't had a leakage in a long, long time, several years. So I think it's a very effective strategy.↗
▶Ep 6 · 8:35
quoteSo we plicate them all. And I haven't had a leakage in a long, long time, several years. So I think it's a very effective strategy.↗
▶Ep 6 · 8:35
clinicalDr. Frischer and Levitt did 10 Malones in a row without plicating and five leaked, so they decided to plicate them all and have not had a leakage in several years.↗
▶Ep 6 · 9:03
clinicalIf appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.↗
▶Ep 6 · 9:03
clinicalIf appendix is 5 to 7 centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone.↗
▶Ep 6 · 9:03
clinicalIf appendix is 7 centimeters or greater it can be split, requiring minimum 2 centimeters for the Malone and 5 centimeters minimum for the Mitrofanoff.↗
▶Ep 6 · 9:03
clinicalIf appendix is 5 to 7 centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone.↗
▶Ep 6 · 9:03
clinicalIf appendix is 7 centimeters or greater it can be split, requiring minimum 2 centimeters for the Malone and 5 centimeters minimum for the Mitrofanoff.↗
▶Ep 6 · 9:03
clinicalIf appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.↗
▶Ep 6 · 16:13
clinicalUsing a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate.↗
▶Ep 6 · 16:13
clinicalUsing a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate.↗
▶Ep 6 · 16:54
clinicalLeaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa.↗
▶Ep 6 · 16:54
clinicalLeaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa.↗
▶Ep 6 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanovs because they catheterize every four hours; applying this to Malones by cathing twice daily has reduced stenosis rate.↗
▶Ep 6 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanovs because they catheterize every four hours; applying this to Malones by cathing twice daily has reduced stenosis rate.↗
▶Ep 6 · 20:00
clinicalFor lost Malone access, blow up a balloon on a Foley catheter to occlude the umbilicus and inject dye under pressure to find any micro hole tract.↗
▶Ep 6 · 20:00
clinicalFor lost Malone access, blow up a balloon on a Foley catheter to occlude the umbilicus and inject dye under pressure to find any micro hole tract.↗
Colorectal Quiz: Episode 43
▶Ep 7 · 5:37
epidemiologicalAbout 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff; about 40% of the time you cannot make it work.↗
▶Ep 7 · 7:37
clinicalFlow of fluid through a tube is based on Poiseuille's law: radius to the fourth power and length. A longer appendix or narrower appendix affects flow probability.↗
▶Ep 7 · 8:35
clinicalThe longer the appendix, the less likely it will leak and you should not need to plicate.↗
▶Ep 7 · 8:35
epidemiologicalIn a study of 10 malones done in a row without plicating, five leaked, leading to the decision to plicate all malones.↗
▶Ep 7 · 8:35
clinicalPlicating all malones is a very effective strategy; no leakage has occurred in several years using this approach.↗
▶Ep 7 · 9:03
clinicalIf appendix is seven centimeters or greater it can be split, requiring minimum two centimeters for Malone and five centimeters minimum for Mitrofanoff.↗
▶Ep 7 · 9:03
clinicalIf appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.↗
▶Ep 7 · 9:03
clinicalIf appendix is five to seven centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone.↗
▶Ep 7 · 10:00
clinicalFor patients with appendix 4-7 centimeters, 90% of appendix can be given to urologist with extension of appendiceal stump into cecum using non-cutting endo-TA stapler or hand-sewn non-absorbable braided suture.↗
▶Ep 7 · 12:08
clinicalPay attention to ileocecal valve location when creating Malone and plication to avoid obstruction at the ileocecal valve.↗
▶Ep 7 · 16:13
clinicalUsing a 10 French tube instead of 8, leaving it in for a month, and cathing twice a day has reduced the incidence of stenosis.↗
▶Ep 7 · 16:54
clinicalProlonged stenting increases prolapse rate due to pressure on the appendiceal base pushing up mucosa.↗
▶Ep 7 · 16:54
clinicalLeaving tubes in prevents stenosis but increases the chance of leakage because the valve is no longer as pertinent with a stent across it.↗
▶Ep 7 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanoff because they cath every four hours; cathing the Malone twice a day has reduced stenosis rate.↗
▶Ep 7 · 18:20
clinicalFor recurrent leakage after two wraps, consider whether appendix length is a problem and whether channel needs lengthening.↗
▶Ep 7 · 20:00
clinicalBlowing up a balloon on Foley catheter to occlude umbilicus and injecting dye creates pressurized system that will find any micro-hole tract still present.↗
Jason's statements about Enterocolitis80 statements
quoteI, I don't believe that a pure trans anal is necessarily less invasive. In other words, I believe that putting 3 incisions on the abdomen is actually less invasive in my hands, in my hands, certainly not in your guys' hands, but in my hands, I'm gonna be torquing in that anal canal much more than if I had done it laparoscopically and freed everything up from the abdominal approach.↗
▶Ep 3 · 4:22
opinionA pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions.↗
▶Ep 3 · 5:46
clinicalFor standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study.↗
▶Ep 3 · 6:12
clinicalPost-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).↗
▶Ep 3 · 7:25
clinicalWorkup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; if no anatomic cause is found, perform biopsy.↗
▶Ep 3 · 9:04
clinicalFor Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns).↗
▶Ep 3 · 9:04
clinicalGoing only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation.↗
▶Ep 3 · 9:43
quoteI want to ensure, because, and maybe we have a biased population in what we see, that I do not injure the dentate line because the patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients.↗
▶Ep 3 · 9:43
opinionInjury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line.↗
▶Ep 3 · 10:39
clinicalIn ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region.↗
▶Ep 3 · 11:39
clinicalThe dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line.↗
▶Ep 3 · 17:17
clinicalThe traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates.↗
▶Ep 3 · 17:27
clinicalConservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding.↗
▶Ep 3 · 17:50
quoteI know there are a number of pediatric surgeons that will repair an anorectal malformation at whatever age with dirty stool and feed the child the day 1 or 2 days post-op when they recover from the anesthesia, and I'm sure that incidence of complication is probably similar.↗
▶Ep 3 · 18:54
clinicalWhen vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through.↗
▶Ep 3 · 20:09
clinicalRectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.↗
▶Ep 3 · 20:49
clinicalTesting for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed.↗
▶Ep 3 · 21:19
clinicalInitial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management.↗
▶Ep 3 · 22:45
quoteI can tell you when it recurs to re-operate on those patients is not going to matter at all.↗
▶Ep 3 · 22:45
clinicalSclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.↗
▶Ep 3 · 24:10
clinicalMesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs.↗
▶Ep 3 · 24:10
clinicalVentral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory.↗
▶Ep 3 · 24:55
clinicalVentral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age.↗
Hirschsprung Disease: Update Course 2015
▶Ep 7 · 0:22
quoteI recall having a full day of uh Hirschprung's webcast, and now I get 5 minutes.↗
▶Ep 7 · 3:06
quoteI, every time that I do a primary trans anal, I get. I tighten up a little bit to make sure that I'm confident that I can do, and I have an exit strategy in mind if I get in trouble↗
▶Ep 7 · 3:06
opinionThe safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through.↗
▶Ep 7 · 3:46
opinionLeveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable.↗
▶Ep 7 · 4:03
clinicalLeveling colostomy represents a three-stage procedure for Hirschsprung disease management.↗
▶Ep 7 · 5:07
quoteBelinda and I talk about this a lot, and it's about a comfort level and how fit, I take, I watch the clock how long I'm doing a trans anal dissection because I do not want to be stretching on those sphincters for 4 hours trying to dig up in a dark hole when I could put a scope in.↗
▶Ep 7 · 5:07
opinionProlonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching.↗
▶Ep 7 · 5:30
clinicalLaparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases.↗
▶Ep 7 · 5:46
clinicalStandard rectosigmoid Hirschsprung disease (6-10 centimeters proximal) can be completed transanally in approximately 2 hours when the level is known from a good contrast study.↗
▶Ep 7 · 6:12
clinicalComplications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues.↗
▶Ep 7 · 6:31
clinicalSoiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence.↗
▶Ep 7 · 6:45
clinicalObstructive symptoms after Hirschsprung surgery require differentiation between anatomic problems and pathologic problems.↗
▶Ep 7 · 6:52
clinicalTrue fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line.↗
▶Ep 7 · 7:04
clinicalPseudo-incontinence after Hirschsprung surgery may be caused by underlying constipation.↗
▶Ep 7 · 7:25
clinicalWorkup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia evaluating dentate line position, stricture, stretched sphincter, and anatomic twists.↗
Hirschsprung's Disease
▶Ep 13 · 0:35
clinicalSome infants with Hirschsprung's disease do pass meconium.↗
▶Ep 13 · 0:35
clinicalMore than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 13 · 0:35
quoteMore than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 13 · 1:57
clinicalSuction biopsy technique is typically used for patients less than six months of age.↗
▶Ep 13 · 1:57
quoteThe three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.↗
▶Ep 13 · 1:57
quoteThe second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.↗
▶Ep 13 · 1:57
clinicalTypical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining.↗
▶Ep 13 · 1:57
clinicalTo be considered an adequate biopsy, it must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers.↗
▶Ep 13 · 1:57
clinicalFull thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.↗
▶Ep 13 · 1:57
clinicalRectal biopsy is the true definitive diagnosis for Hirschsprung disease.↗
▶Ep 13 · 1:57
epidemiologicalApproximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.↗
▶Ep 13 · 1:57
clinicalIn total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.↗
▶Ep 13 · 1:57
clinicalA rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease, meaning the aganglionic bowel is contracted and narrow compared to the dilated ganglionated bowel more proximal.↗
▶Ep 13 · 1:57
clinicalThe classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.↗
▶Ep 13 · 4:23
clinicalThe rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.↗
▶Ep 13 · 4:23
clinicalIn Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).↗
▶Ep 13 · 4:23
guidelineAny patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.↗
▶Ep 13 · 6:42
quoteThere are three goals to the surgical management of Hirschsprung's disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity.↗
▶Ep 13 · 6:42
clinicalThe three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.↗
▶Ep 13 · 7:36
clinicalIn the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.↗
▶Ep 13 · 7:36
clinicalA con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.↗
▶Ep 13 · 7:36
clinicalIn the Swenson procedure, you pull down the aganglionic bowel and perform a full thickness anastomosis one to two centimeters above the dentate line, leaving the most minimal amount of aganglionic bowel possible.↗
▶Ep 13 · 7:36
clinicalIn the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.↗
▶Ep 13 · 7:36
clinicalThe Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.↗
▶Ep 13 · 7:36
opinionThe Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.↗
▶Ep 13 · 12:34
clinicalA child with enterocolitis presents with abdominal distension, vomiting, fever, and change in bowel habits that could be either diarrhea or not passing stool at all.↗
▶Ep 13 · 12:34
clinicalTreatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.↗
▶Ep 13 · 12:34
clinicalFor enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.↗
▶Ep 13 · 12:34
clinicalHirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 13 · 12:34
quoteHirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 13 · 12:34
quoteWhen we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.↗
▶Ep 13 · 14:51
clinicalFor patients with anatomic problems after pull-through, you typically have to revise the pull through.↗
▶Ep 13 · 14:51
clinicalFor patients not doing well after pull-through, if there is a stricture at the anastomosis, it needs to be addressed either through dilations or revising the pull through procedure.↗
▶Ep 13 · 14:51
clinicalAnatomic problems after pull-through can include a twist in the pull through, an obstructing cuff, a non-functioning Duhamel pouch, or a transition zone or continued aganglionic segment.↗
▶Ep 13 · 14:51
clinicalFor patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.↗
Colorectal Quiz Episode 3: Hirschsprung Disease
▶Ep 16 · 9:52
clinicalIn Hirschsprung disease, the aganglionic rectum appears narrow due to spasm and inability to relax, while the ganglionated proximal bowel is dilated, creating the recto-sigmoid ratio↗
▶Ep 16 · 13:03
clinicalThree good biopsy specimens should be obtained for pathologic evaluation↗
▶Ep 16 · 13:03
clinicalQuick diff staining highlights ganglion cells better than standard H&E staining↗
▶Ep 16 · 16:45
clinicalThe crypts are located above the dentate line, so optimal biopsy location is at least 1-2 cm above the dentate line↗
The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1
▶Ep 18 · 5:07
clinicalPathology can change over time; cases exist where ganglion cells were present at pull-through but absent with hypertrophic nerves 7 years later when problems developed.↗
▶Ep 18 · 9:58
clinicalSphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function.↗
▶Ep 18 · 16:07
clinicalDuring normal bowel movements, sphincters relax and the anus opens with some mucosal descent, but as soon as sphincters tighten, the mucosa retracts back in; prolapse at rest indicates damaged muscles and/or mucosa brought too low at anastomosis.↗
Jason's statements about Enterocolitis80 statements
opinionA pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions.↗
▶Ep 3 · 4:22
quoteI, I don't believe that a pure trans anal is necessarily less invasive. In other words, I believe that putting 3 incisions on the abdomen is actually less invasive in my hands, in my hands, certainly not in your guys' hands, but in my hands, I'm gonna be torquing in that anal canal much more than if I had done it laparoscopically and freed everything up from the abdominal approach.↗
▶Ep 3 · 5:46
clinicalFor standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study.↗
▶Ep 3 · 6:12
clinicalPost-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).↗
▶Ep 3 · 7:25
clinicalWorkup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; if no anatomic cause is found, perform biopsy.↗
▶Ep 3 · 9:04
clinicalFor Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns).↗
▶Ep 3 · 9:04
clinicalGoing only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation.↗
▶Ep 3 · 9:43
quoteI want to ensure, because, and maybe we have a biased population in what we see, that I do not injure the dentate line because the patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients.↗
▶Ep 3 · 9:43
opinionInjury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line.↗
▶Ep 3 · 10:39
clinicalIn ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region.↗
▶Ep 3 · 11:39
clinicalThe dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line.↗
▶Ep 3 · 17:17
clinicalThe traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates.↗
▶Ep 3 · 17:27
clinicalConservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding.↗
▶Ep 3 · 17:50
quoteI know there are a number of pediatric surgeons that will repair an anorectal malformation at whatever age with dirty stool and feed the child the day 1 or 2 days post-op when they recover from the anesthesia, and I'm sure that incidence of complication is probably similar.↗
▶Ep 3 · 18:54
clinicalWhen vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through.↗
▶Ep 3 · 20:09
clinicalRectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.↗
▶Ep 3 · 20:49
clinicalTesting for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed.↗
▶Ep 3 · 21:19
clinicalInitial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management.↗
▶Ep 3 · 22:45
quoteI can tell you when it recurs to re-operate on those patients is not going to matter at all.↗
▶Ep 3 · 22:45
clinicalSclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.↗
▶Ep 3 · 24:10
clinicalMesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs.↗
▶Ep 3 · 24:10
clinicalVentral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory.↗
▶Ep 3 · 24:55
clinicalVentral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age.↗
Hirschsprung Disease: Update Course 2015
▶Ep 7 · 0:22
quoteI recall having a full day of uh Hirschprung's webcast, and now I get 5 minutes.↗
▶Ep 7 · 3:06
quoteI, every time that I do a primary trans anal, I get. I tighten up a little bit to make sure that I'm confident that I can do, and I have an exit strategy in mind if I get in trouble↗
▶Ep 7 · 3:06
opinionThe safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through.↗
▶Ep 7 · 3:46
opinionLeveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable.↗
▶Ep 7 · 4:03
clinicalLeveling colostomy represents a three-stage procedure for Hirschsprung disease management.↗
▶Ep 7 · 5:07
quoteBelinda and I talk about this a lot, and it's about a comfort level and how fit, I take, I watch the clock how long I'm doing a trans anal dissection because I do not want to be stretching on those sphincters for 4 hours trying to dig up in a dark hole when I could put a scope in.↗
▶Ep 7 · 5:07
opinionProlonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching.↗
▶Ep 7 · 5:30
clinicalLaparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases.↗
▶Ep 7 · 5:46
clinicalStandard rectosigmoid Hirschsprung disease (6-10 centimeters proximal) can be completed transanally in approximately 2 hours when the level is known from a good contrast study.↗
▶Ep 7 · 6:12
clinicalComplications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues.↗
▶Ep 7 · 6:31
clinicalSoiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence.↗
▶Ep 7 · 6:45
clinicalObstructive symptoms after Hirschsprung surgery require differentiation between anatomic problems and pathologic problems.↗
▶Ep 7 · 6:52
clinicalTrue fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line.↗
▶Ep 7 · 7:04
clinicalPseudo-incontinence after Hirschsprung surgery may be caused by underlying constipation.↗
▶Ep 7 · 7:25
clinicalWorkup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia evaluating dentate line position, stricture, stretched sphincter, and anatomic twists.↗
Hirschsprung's Disease
▶Ep 13 · 0:35
quoteMore than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 13 · 0:35
clinicalMore than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease.↗
▶Ep 13 · 0:35
clinicalSome infants with Hirschsprung's disease do pass meconium.↗
▶Ep 13 · 1:57
quoteThe second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.↗
▶Ep 13 · 1:57
quoteThe three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.↗
▶Ep 13 · 1:57
clinicalA rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease, meaning the aganglionic bowel is contracted and narrow compared to the dilated ganglionated bowel more proximal.↗
▶Ep 13 · 1:57
clinicalSuction biopsy technique is typically used for patients less than six months of age.↗
▶Ep 13 · 1:57
clinicalFull thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.↗
▶Ep 13 · 1:57
clinicalThe classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.↗
▶Ep 13 · 1:57
clinicalIn total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.↗
▶Ep 13 · 1:57
clinicalTypical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining.↗
▶Ep 13 · 1:57
epidemiologicalApproximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.↗
▶Ep 13 · 1:57
clinicalRectal biopsy is the true definitive diagnosis for Hirschsprung disease.↗
▶Ep 13 · 1:57
clinicalTo be considered an adequate biopsy, it must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers.↗
▶Ep 13 · 4:23
guidelineAny patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.↗
▶Ep 13 · 4:23
clinicalThe rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.↗
▶Ep 13 · 4:23
clinicalIn Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).↗
▶Ep 13 · 6:42
clinicalThe three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.↗
▶Ep 13 · 6:42
quoteThere are three goals to the surgical management of Hirschsprung's disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity.↗
▶Ep 13 · 7:36
clinicalIn the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.↗
▶Ep 13 · 7:36
clinicalA con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.↗
▶Ep 13 · 7:36
clinicalIn the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.↗
▶Ep 13 · 7:36
clinicalIn the Swenson procedure, you pull down the aganglionic bowel and perform a full thickness anastomosis one to two centimeters above the dentate line, leaving the most minimal amount of aganglionic bowel possible.↗
▶Ep 13 · 7:36
opinionThe Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.↗
▶Ep 13 · 7:36
clinicalThe Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.↗
▶Ep 13 · 12:34
clinicalA child with enterocolitis presents with abdominal distension, vomiting, fever, and change in bowel habits that could be either diarrhea or not passing stool at all.↗
▶Ep 13 · 12:34
quoteHirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 13 · 12:34
quoteWhen we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.↗
▶Ep 13 · 12:34
clinicalHirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.↗
▶Ep 13 · 12:34
clinicalFor enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.↗
▶Ep 13 · 12:34
clinicalTreatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.↗
▶Ep 13 · 14:51
clinicalFor patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.↗
▶Ep 13 · 14:51
clinicalFor patients with anatomic problems after pull-through, you typically have to revise the pull through.↗
▶Ep 13 · 14:51
clinicalAnatomic problems after pull-through can include a twist in the pull through, an obstructing cuff, a non-functioning Duhamel pouch, or a transition zone or continued aganglionic segment.↗
▶Ep 13 · 14:51
clinicalFor patients not doing well after pull-through, if there is a stricture at the anastomosis, it needs to be addressed either through dilations or revising the pull through procedure.↗
Colorectal Quiz Episode 3: Hirschsprung Disease
▶Ep 16 · 9:52
clinicalIn Hirschsprung disease, the aganglionic rectum appears narrow due to spasm and inability to relax, while the ganglionated proximal bowel is dilated, creating the recto-sigmoid ratio↗
▶Ep 16 · 13:03
clinicalQuick diff staining highlights ganglion cells better than standard H&E staining↗
▶Ep 16 · 13:03
clinicalThree good biopsy specimens should be obtained for pathologic evaluation↗
▶Ep 16 · 16:45
clinicalThe crypts are located above the dentate line, so optimal biopsy location is at least 1-2 cm above the dentate line↗
The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1
▶Ep 18 · 5:07
clinicalPathology can change over time; cases exist where ganglion cells were present at pull-through but absent with hypertrophic nerves 7 years later when problems developed.↗
▶Ep 18 · 9:58
clinicalSphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function.↗
▶Ep 18 · 16:07
clinicalDuring normal bowel movements, sphincters relax and the anus opens with some mucosal descent, but as soon as sphincters tighten, the mucosa retracts back in; prolapse at rest indicates damaged muscles and/or mucosa brought too low at anastomosis.↗
Jason's statements about Esophageal Atresia8 statements
clinicalIn asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU↗
▶Ep 2 · 4:45
clinicalCT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients↗
▶Ep 2 · 17:23
clinicalWhen using energy devices for vessel control, leave enough remnant tissue so the vessel doesn't retract if seal fails, allowing purchase for clip or suture↗
▶Ep 2 · 17:47
clinicalObtain proximal control or partially cut across vessel with energy device to detect failure before complete division↗
▶Ep 2 · 17:56
clinicalWhen using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation↗
▶Ep 2 · 46:59
clinicalNewborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF↗
▶Ep 2 · 48:23
clinicalEcho findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies↗
▶Ep 2 · 1:04:12
epidemiologicalEsophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea↗
Jason's statements about Etiologies (Gastroschisis/NEC/Atresia/Volvulus)55 statements
Gastroschisis and sutureless abdominal wall closure
▶Ep 31 · 7:20
opinionMany patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions.↗
▶Ep 31 · 7:20
opinionDue to the heterogeneity of gastroschisis, patients able to undergo primary repair probably had more favorable bowel and theoretically would have less hospital stay and feed faster.↗
▶Ep 31 · 7:20
quoteI think it was probably what we were expecting, I think, for a couple of reasons. One, due to the heterogeneity of this disease, you know, especially with gastroschisis, a lot of the patients that were able to undergo, you know, especially a primary repair, they probably had more favorable bowel. And then those patients, you know, theoretically would have less hospital stay and theoretically feed faster and things like that.↗
▶Ep 31 · 8:05
quoteMoreover, too, if you think about just the way that we close a sutured repair, you mobilize flaps from the skin and flaps from the fascia. So there's always, you know, redness around the incision, bruising around the incision. And so, you know, even that tissue manipulation is going to put you at higher risk for a potential infection or calling it erythema infection.↗
▶Ep 31 · 8:05
clinicalIn sutured repair, mobilizing flaps from the skin and fascia causes redness and bruising around the incision, which puts patients at higher risk for potential infection.↗
▶Ep 31 · 8:05
opinionThe finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation.↗
▶Ep 31 · 8:50
clinicalThe next phase of the study is examining the same patients over several years of follow-up to assess growth and umbilical hernia repair rates.↗
▶Ep 31 · 8:50
clinicalThe consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up.↗
Neonatal Gastric Volvulus with Dr. Jason Frischer
▶Ep 43 · 1:10
quoteI've seen it associated with congenital diaphragmatic hernias a few times, and I think that's when we have a high suspicion for it.↗
▶Ep 43 · 1:33
epidemiological60% of gastric volvulus cases in the pediatric population happen in the first year of life, with about 21% in the first month.↗
▶Ep 43 · 1:33
quote60% happen in the first year of life in the pediatric population, and so about 21% in the first month and over a third in the first year of life.↗
▶Ep 43 · 1:58
quoteIf the child's like 4 months old, is it more likely, are you're more likely to have an acute problem or a chronic problem? So they're acute.↗
▶Ep 43 · 1:58
clinicalIn a 4-month-old child with gastric volvulus, acute presentation is more likely than chronic.↗
▶Ep 43 · 2:45
quoteThat's the big one, I think, right there. I think a little bit of bloody aspirate from the. Logo can't advance it. Funny looking stomach bubble on the X-ray.↗
▶Ep 43 · 2:47
clinicalA little bit of bloody aspirate from the NG tube and a funny looking stomach bubble on X-ray are key findings in gastric volvulus.↗
▶Ep 43 · 3:10
clinicalChronic gastric volvulus is more related to laxity of the gastric ligaments including gastrophrenic, gastrosplenic, gastrocolic, and gastrohepatic ligaments.↗
▶Ep 43 · 3:10
quoteThose are more to do with the laxity of the gastric ligaments, and the stomach has ligamentous attachments basically surrounding the entire stomach from gastrophrenic, gastrosplenic, gastrocolic. And of course. Gastropatic ligament.↗
▶Ep 43 · 3:43
clinicalOrganoaxial volvulus is the first and most common type of gastric volvulus.↗
▶Ep 43 · 3:43
quoteThe first one, the first and most common is organoaxial volvulus.↗
▶Ep 43 · 3:55
quoteThey describe a line that's drawn on this diagram between the GE junction and the pylorus, and it's spinning around that axis. The greater curvature then sort of flips up and over and becomes more superior than the lesser curvature.↗
▶Ep 43 · 3:55
clinicalIn organoaxial volvulus, the stomach spins around an axis drawn between the GE junction and the pylorus, with the greater curvature flipping up and over to become more superior than the lesser curvature.↗
▶Ep 43 · 4:18
clinicalIn mesenteroaxial volvulus, rotation occurs around a line through the middle of the stomach from lesser to greater curvature, with the stomach flipping behind and back over.↗
▶Ep 43 · 4:34
quoteThen, and flip the stomach up and over that way, so it's going sort of behind. The stomach and back over it.↗
▶Ep 43 · 4:46
clinicalIn gastric volvulus, when filled with contrast, the pylorus appears right next to or near the GE junction and above the body of the stomach.↗
▶Ep 43 · 4:46
quoteWhen the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach.↗
▶Ep 43 · 6:08
clinicalIn mesenteroaxial volvulus, the duodenum may fill above or superior to the GE junction because the pylorus has flipped up and over or behind and over the top of the stomach.↗
▶Ep 43 · 6:22
quoteMesentero axial favulus. Again, this is the sort of pylorus flipping up and over or behind and over the top of the stomach, and then therefore, your pylorus is located all the way up here.↗
▶Ep 43 · 8:40
clinicalWhen managing gastric volvulus found during CDH repair, viability of the stomach must always be checked, especially if chronically volvulized or volvulized for a couple of days, by looking at the serosa and blood flow.↗
▶Ep 43 · 8:40
quoteAlso, you always want to check the viability of the stomach. So, right, if this is chronically volvulized or been volvulized for a couple of days, uh, at least looking at the cirrhosa and looking at the blood flow.↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 46 · 3:10
clinicalJason Fraser's institution starts feeding immediately after dressing placement as long as the baby is not sick, not having horrible output, and not vomiting.↗
▶Ep 46 · 3:10
quotewe start feeding essentially you have to put the dressing on uh as long as the baby's not sick not having horrible output not puking or anything like that↗
▶Ep 46 · 3:54
clinicalFraser's institution does not intubate gastroschisis babies for reduction.↗
▶Ep 46 · 3:54
quotewe don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it↗
▶Ep 46 · 5:13
quoteif you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit↗
▶Ep 46 · 5:13
clinicalAwake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching.↗
▶Ep 46 · 6:19
clinicalCincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory.↗
▶Ep 46 · 6:19
quoteit's really just based upon patient tolerance and it's kind of based upon some of the data that's out there from the rest of the world where they don't have tpn and so they just you have to feed the kid if the kid does okay then they keep going↗
▶Ep 46 · 10:30
epidemiologicalThe multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions.↗
▶Ep 46 · 10:30
opinionThe reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself.↗
▶Ep 46 · 10:30
quotea lot of the inconclusivity from the the study showed that you know most likely due to the fact that there was lots of different feeding protocols that were used uh across our member institutions↗
▶Ep 46 · 10:50
quotethe ssi thing was probably just because patients that were fed via protocol were cared for via protocol and so that they actually had less variability and less uh less changes uh in the way that these these patients are not you know look for↗
▶Ep 46 · 11:20
epidemiologicalCincinnati Children's average gastroschisis length of stay was 49 days before protocol implementation, which was astronomically higher than comparable NICUs in their cooperative network.↗
▶Ep 46 · 11:20
quoteour length of stay for gastroschisis and cincinnati was astronomically higher than like any other nick micu in the cooperative network that we worked with so we sat down we're like what is going on here so our average length of stay was 49 days↗
▶Ep 46 · 12:10
epidemiologicalCincinnati Children's has seen a decrease in time from first feed to full feeds but has not yet reduced the time from admission to first feed (except in 2020).↗
▶Ep 46 · 12:10
epidemiologicalAfter implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years.↗
▶Ep 46 · 12:10
quotewe instituted this uh a feeding protocol we spent a lot of time trying to get people to follow it and and making some adjustments and over two years we dropped the length of stay by 10 days and the mix of patients is not different↗
▶Ep 46 · 14:20
clinicalCincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization.↗
▶Ep 46 · 16:00
opinionThe most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition.↗
▶Ep 46 · 16:00
quotethe most important thing that kind of keeps showing up is the fact that we really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go is the most important thing↗
▶Ep 46 · 16:40
quoteyes you can have a protocol yes you know you need to follow it but the most really you really need to continually evaluate the patient as they continue to go to make sure that you know yes your protocol is working but also to the patient does okay throughout↗
▶Ep 46 · 16:40
clinicalFor significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based.↗
▶Ep 46 · 17:22
clinicalOne recent Cincinnati Children's gastroschisis patient who was primarily reduced on day of life zero was discharged at approximately two weeks and remained well at two-week follow-up, though this is an outlier on the faster end.↗
▶Ep 46 · 17:22
epidemiologicalCincinnati Children's current average gastroschisis length of stay is 30 to 34 days.↗
▶Ep 46 · 18:14
epidemiologicalCincinnati Children's has not seen any aspirations with their early aggressive feeding approach, though they acknowledge they are still early in implementation and continue to monitor data.↗
▶Ep 46 · 18:56
clinicalAt Cincinnati Children's, approximately two-thirds of gastroschisis cases cannot be reduced immediately and are placed in a silo for gradual reduction followed by sutureless closure, with feeds started after closure.↗
Jason's statements about Fecal Incontinence9 statements
Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease
▶Ep 8 · 12:26
clinicalDr. Newman brought Dr. Yancey's story to the attention of the Hirschsprung interest group at APSA.↗
▶Ep 8 · 15:06
clinicalA fellow at Children's National wrote an operative note describing a patient as status post a 'Yancey-Suave procedure,' indicating the terminology has become part of standard practice.↗
▶Ep 8 · 15:06
quoteI was reading the operative note from one of my fellows who provided the history of the patient. I had to do a reoperation on the patient. And the history read that this five-year-old child is status post a Yancey Suave procedure in such and such date and had an asthmatic stricture.↗
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
▶Ep 6 · 5:05
quoteHe united us. Yeah. In a way. And he doesn't even know it.↗
▶Ep 6 · 9:40
clinicalDr. Martin developed the Martin procedure, an expansion of the Duhamel for long-segment Hirschsprung disease, leaving a longer aganglionated segment of rectum and pulling through ganglionated bowel.↗
▶Ep 6 · 9:40
clinicalDr. Martin was the first surgeon-in-chief and pediatric surgeon at Cincinnati Children's Hospital.↗
quoteI think that's the who's who of Hirschsprung's right there.↗
▶Ep 6 · 14:47
quoteI have a feeling we're going to have way more discussions about Hirschsprung disease because just because, because I think it's a fascinating disease that there are so many intricacies. You just mentioned dentorocolitis. We could talk forever about that.↗
Jason's statements about Functional Colorectal Disorders & Bowel Management11 statements
epidemiologicalAbout 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work.↗
▶Ep 33 · 7:37
clinicalThe longer the appendix, the less likely it will leak based on Poiseuille's law (flow through a tube based on radius to fourth power and length).↗
▶Ep 33 · 8:35
clinicalDr. Frischer and Levitt did 10 Malones in a row without plicating and five leaked, so they decided to plicate them all and have not had a leakage in several years.↗
▶Ep 33 · 8:35
quoteSo we plicate them all. And I haven't had a leakage in a long, long time, several years. So I think it's a very effective strategy.↗
▶Ep 33 · 9:03
clinicalIf appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.↗
▶Ep 33 · 9:03
clinicalIf appendix is 5 to 7 centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone.↗
▶Ep 33 · 9:03
clinicalIf appendix is 7 centimeters or greater it can be split, requiring minimum 2 centimeters for the Malone and 5 centimeters minimum for the Mitrofanoff.↗
▶Ep 33 · 16:13
clinicalUsing a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate.↗
▶Ep 33 · 16:54
clinicalLeaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa.↗
▶Ep 33 · 17:45
clinicalUrologists almost never get stenosis of Mitrofanovs because they catheterize every four hours; applying this to Malones by cathing twice daily has reduced stenosis rate.↗
▶Ep 33 · 20:00
clinicalFor lost Malone access, blow up a balloon on a Foley catheter to occlude the umbilicus and inject dye under pressure to find any micro hole tract.↗
Jason's statements about Gastroschisis34 statements
Gastroschisis and sutureless abdominal wall closure
▶Ep 13 · 7:20
quoteI think it was probably what we were expecting, I think, for a couple of reasons. One, due to the heterogeneity of this disease, you know, especially with gastroschisis, a lot of the patients that were able to undergo, you know, especially a primary repair, they probably had more favorable bowel. And then those patients, you know, theoretically would have less hospital stay and theoretically feed faster and things like that.↗
▶Ep 13 · 7:20
opinionMany patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions.↗
▶Ep 13 · 7:20
opinionDue to the heterogeneity of gastroschisis, patients able to undergo primary repair probably had more favorable bowel and theoretically would have less hospital stay and feed faster.↗
▶Ep 13 · 8:05
clinicalIn sutured repair, mobilizing flaps from the skin and fascia causes redness and bruising around the incision, which puts patients at higher risk for potential infection.↗
▶Ep 13 · 8:05
quoteMoreover, too, if you think about just the way that we close a sutured repair, you mobilize flaps from the skin and flaps from the fascia. So there's always, you know, redness around the incision, bruising around the incision. And so, you know, even that tissue manipulation is going to put you at higher risk for a potential infection or calling it erythema infection.↗
▶Ep 13 · 8:05
opinionThe finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation.↗
▶Ep 13 · 8:50
clinicalThe next phase of the study is examining the same patients over several years of follow-up to assess growth and umbilical hernia repair rates.↗
▶Ep 13 · 8:50
clinicalThe consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up.↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 17 · 3:10
clinicalJason Fraser's institution starts feeding immediately after dressing placement as long as the baby is not sick, not having horrible output, and not vomiting.↗
▶Ep 17 · 3:10
quotewe start feeding essentially you have to put the dressing on uh as long as the baby's not sick not having horrible output not puking or anything like that↗
▶Ep 17 · 3:54
quotewe don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it↗
▶Ep 17 · 3:54
clinicalFraser's institution does not intubate gastroschisis babies for reduction.↗
▶Ep 17 · 5:13
clinicalAwake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching.↗
▶Ep 17 · 5:13
quoteif you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit↗
▶Ep 17 · 6:19
quoteit's really just based upon patient tolerance and it's kind of based upon some of the data that's out there from the rest of the world where they don't have tpn and so they just you have to feed the kid if the kid does okay then they keep going↗
▶Ep 17 · 6:19
clinicalCincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory.↗
▶Ep 17 · 10:30
opinionThe reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself.↗
▶Ep 17 · 10:30
epidemiologicalThe multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions.↗
▶Ep 17 · 10:30
quotea lot of the inconclusivity from the the study showed that you know most likely due to the fact that there was lots of different feeding protocols that were used uh across our member institutions↗
▶Ep 17 · 10:50
quotethe ssi thing was probably just because patients that were fed via protocol were cared for via protocol and so that they actually had less variability and less uh less changes uh in the way that these these patients are not you know look for↗
▶Ep 17 · 11:20
epidemiologicalCincinnati Children's average gastroschisis length of stay was 49 days before protocol implementation, which was astronomically higher than comparable NICUs in their cooperative network.↗
▶Ep 17 · 11:20
quoteour length of stay for gastroschisis and cincinnati was astronomically higher than like any other nick micu in the cooperative network that we worked with so we sat down we're like what is going on here so our average length of stay was 49 days↗
▶Ep 17 · 12:10
quotewe instituted this uh a feeding protocol we spent a lot of time trying to get people to follow it and and making some adjustments and over two years we dropped the length of stay by 10 days and the mix of patients is not different↗
▶Ep 17 · 12:10
epidemiologicalCincinnati Children's has seen a decrease in time from first feed to full feeds but has not yet reduced the time from admission to first feed (except in 2020).↗
▶Ep 17 · 12:10
epidemiologicalAfter implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years.↗
▶Ep 17 · 14:20
clinicalCincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization.↗
▶Ep 17 · 16:00
quotethe most important thing that kind of keeps showing up is the fact that we really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go is the most important thing↗
▶Ep 17 · 16:00
opinionThe most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition.↗
▶Ep 17 · 16:40
quoteyes you can have a protocol yes you know you need to follow it but the most really you really need to continually evaluate the patient as they continue to go to make sure that you know yes your protocol is working but also to the patient does okay throughout↗
▶Ep 17 · 16:40
clinicalFor significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based.↗
▶Ep 17 · 17:22
epidemiologicalCincinnati Children's current average gastroschisis length of stay is 30 to 34 days.↗
▶Ep 17 · 17:22
clinicalOne recent Cincinnati Children's gastroschisis patient who was primarily reduced on day of life zero was discharged at approximately two weeks and remained well at two-week follow-up, though this is an outlier on the faster end.↗
▶Ep 17 · 18:14
epidemiologicalCincinnati Children's has not seen any aspirations with their early aggressive feeding approach, though they acknowledge they are still early in implementation and continue to monitor data.↗
▶Ep 17 · 18:56
clinicalAt Cincinnati Children's, approximately two-thirds of gastroschisis cases cannot be reduced immediately and are placed in a silo for gradual reduction followed by sutureless closure, with feeds started after closure.↗
Jason's statements about Gastroschisis34 statements
Gastroschisis and sutureless abdominal wall closure
▶Ep 14 · 7:20
quoteI think it was probably what we were expecting, I think, for a couple of reasons. One, due to the heterogeneity of this disease, you know, especially with gastroschisis, a lot of the patients that were able to undergo, you know, especially a primary repair, they probably had more favorable bowel. And then those patients, you know, theoretically would have less hospital stay and theoretically feed faster and things like that.↗
▶Ep 14 · 7:20
opinionMany patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions.↗
▶Ep 14 · 7:20
opinionDue to the heterogeneity of gastroschisis, patients able to undergo primary repair probably had more favorable bowel and theoretically would have less hospital stay and feed faster.↗
▶Ep 14 · 8:05
clinicalIn sutured repair, mobilizing flaps from the skin and fascia causes redness and bruising around the incision, which puts patients at higher risk for potential infection.↗
▶Ep 14 · 8:05
opinionThe finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation.↗
▶Ep 14 · 8:05
quoteMoreover, too, if you think about just the way that we close a sutured repair, you mobilize flaps from the skin and flaps from the fascia. So there's always, you know, redness around the incision, bruising around the incision. And so, you know, even that tissue manipulation is going to put you at higher risk for a potential infection or calling it erythema infection.↗
▶Ep 14 · 8:50
clinicalThe next phase of the study is examining the same patients over several years of follow-up to assess growth and umbilical hernia repair rates.↗
▶Ep 14 · 8:50
clinicalThe consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up.↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 18 · 3:10
clinicalJason Fraser's institution starts feeding immediately after dressing placement as long as the baby is not sick, not having horrible output, and not vomiting.↗
▶Ep 18 · 3:10
quotewe start feeding essentially you have to put the dressing on uh as long as the baby's not sick not having horrible output not puking or anything like that↗
▶Ep 18 · 3:54
quotewe don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it↗
▶Ep 18 · 3:54
clinicalFraser's institution does not intubate gastroschisis babies for reduction.↗
▶Ep 18 · 5:13
clinicalAwake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching.↗
▶Ep 18 · 5:13
quoteif you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit↗
▶Ep 18 · 6:19
clinicalCincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory.↗
▶Ep 18 · 6:19
quoteit's really just based upon patient tolerance and it's kind of based upon some of the data that's out there from the rest of the world where they don't have tpn and so they just you have to feed the kid if the kid does okay then they keep going↗
▶Ep 18 · 10:30
opinionThe reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself.↗
▶Ep 18 · 10:30
quotea lot of the inconclusivity from the the study showed that you know most likely due to the fact that there was lots of different feeding protocols that were used uh across our member institutions↗
▶Ep 18 · 10:30
epidemiologicalThe multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions.↗
▶Ep 18 · 10:50
quotethe ssi thing was probably just because patients that were fed via protocol were cared for via protocol and so that they actually had less variability and less uh less changes uh in the way that these these patients are not you know look for↗
▶Ep 18 · 11:20
quoteour length of stay for gastroschisis and cincinnati was astronomically higher than like any other nick micu in the cooperative network that we worked with so we sat down we're like what is going on here so our average length of stay was 49 days↗
▶Ep 18 · 11:20
epidemiologicalCincinnati Children's average gastroschisis length of stay was 49 days before protocol implementation, which was astronomically higher than comparable NICUs in their cooperative network.↗
▶Ep 18 · 12:10
quotewe instituted this uh a feeding protocol we spent a lot of time trying to get people to follow it and and making some adjustments and over two years we dropped the length of stay by 10 days and the mix of patients is not different↗
▶Ep 18 · 12:10
epidemiologicalCincinnati Children's has seen a decrease in time from first feed to full feeds but has not yet reduced the time from admission to first feed (except in 2020).↗
▶Ep 18 · 12:10
epidemiologicalAfter implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years.↗
▶Ep 18 · 14:20
clinicalCincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization.↗
▶Ep 18 · 16:00
quotethe most important thing that kind of keeps showing up is the fact that we really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go is the most important thing↗
▶Ep 18 · 16:00
opinionThe most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition.↗
▶Ep 18 · 16:40
quoteyes you can have a protocol yes you know you need to follow it but the most really you really need to continually evaluate the patient as they continue to go to make sure that you know yes your protocol is working but also to the patient does okay throughout↗
▶Ep 18 · 16:40
clinicalFor significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based.↗
▶Ep 18 · 17:22
clinicalOne recent Cincinnati Children's gastroschisis patient who was primarily reduced on day of life zero was discharged at approximately two weeks and remained well at two-week follow-up, though this is an outlier on the faster end.↗
▶Ep 18 · 17:22
epidemiologicalCincinnati Children's current average gastroschisis length of stay is 30 to 34 days.↗
▶Ep 18 · 18:14
epidemiologicalCincinnati Children's has not seen any aspirations with their early aggressive feeding approach, though they acknowledge they are still early in implementation and continue to monitor data.↗
▶Ep 18 · 18:56
clinicalAt Cincinnati Children's, approximately two-thirds of gastroschisis cases cannot be reduced immediately and are placed in a silo for gradual reduction followed by sutureless closure, with feeds started after closure.↗
Jason's statements about Hirschsprung disease60 statements
opinionA pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions.↗
▶Ep 5 · 4:22
quoteI, I don't believe that a pure trans anal is necessarily less invasive. In other words, I believe that putting 3 incisions on the abdomen is actually less invasive in my hands, in my hands, certainly not in your guys' hands, but in my hands, I'm gonna be torquing in that anal canal much more than if I had done it laparoscopically and freed everything up from the abdominal approach.↗
▶Ep 5 · 4:22
quoteI, I don't believe that a pure trans anal is necessarily less invasive. In other words, I believe that putting 3 incisions on the abdomen is actually less invasive in my hands, in my hands, certainly not in your guys' hands, but in my hands, I'm gonna be torquing in that anal canal much more than if I had done it laparoscopically and freed everything up from the abdominal approach.↗
▶Ep 5 · 4:22
opinionA pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions.↗
▶Ep 5 · 5:46
clinicalFor standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study.↗
▶Ep 5 · 5:46
clinicalFor standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study.↗
▶Ep 5 · 6:12
clinicalPost-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).↗
▶Ep 5 · 6:12
clinicalPost-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).↗
▶Ep 5 · 7:25
clinicalWorkup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; if no anatomic cause is found, perform biopsy.↗
▶Ep 5 · 7:25
clinicalWorkup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; if no anatomic cause is found, perform biopsy.↗
▶Ep 5 · 9:04
clinicalGoing only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation.↗
▶Ep 5 · 9:04
clinicalFor Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns).↗
▶Ep 5 · 9:04
clinicalFor Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns).↗
▶Ep 5 · 9:04
clinicalGoing only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation.↗
▶Ep 5 · 9:43
opinionInjury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line.↗
▶Ep 5 · 9:43
quoteI want to ensure, because, and maybe we have a biased population in what we see, that I do not injure the dentate line because the patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients.↗
▶Ep 5 · 9:43
opinionInjury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line.↗
▶Ep 5 · 9:43
quoteI want to ensure, because, and maybe we have a biased population in what we see, that I do not injure the dentate line because the patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients.↗
▶Ep 5 · 10:39
clinicalIn ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region.↗
▶Ep 5 · 10:39
clinicalIn ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region.↗
▶Ep 5 · 11:39
clinicalThe dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line.↗
▶Ep 5 · 11:39
clinicalThe dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line.↗
▶Ep 5 · 17:17
clinicalThe traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates.↗
▶Ep 5 · 17:17
clinicalThe traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates.↗
▶Ep 5 · 17:27
clinicalConservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding.↗
▶Ep 5 · 17:27
clinicalConservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding.↗
▶Ep 5 · 17:50
quoteI know there are a number of pediatric surgeons that will repair an anorectal malformation at whatever age with dirty stool and feed the child the day 1 or 2 days post-op when they recover from the anesthesia, and I'm sure that incidence of complication is probably similar.↗
▶Ep 5 · 17:50
quoteI know there are a number of pediatric surgeons that will repair an anorectal malformation at whatever age with dirty stool and feed the child the day 1 or 2 days post-op when they recover from the anesthesia, and I'm sure that incidence of complication is probably similar.↗
▶Ep 5 · 18:54
clinicalWhen vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through.↗
▶Ep 5 · 18:54
clinicalWhen vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through.↗
▶Ep 5 · 20:09
clinicalRectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.↗
▶Ep 5 · 20:09
clinicalRectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.↗
▶Ep 5 · 20:49
clinicalTesting for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed.↗
▶Ep 5 · 20:49
clinicalTesting for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed.↗
▶Ep 5 · 21:19
clinicalInitial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management.↗
▶Ep 5 · 21:19
clinicalInitial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management.↗
▶Ep 5 · 22:45
clinicalSclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.↗
▶Ep 5 · 22:45
quoteI can tell you when it recurs to re-operate on those patients is not going to matter at all.↗
▶Ep 5 · 22:45
clinicalSclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.↗
▶Ep 5 · 22:45
quoteI can tell you when it recurs to re-operate on those patients is not going to matter at all.↗
▶Ep 5 · 23:02
epidemiologicalTransabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure).↗
▶Ep 5 · 23:36
clinicalResection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.↗
▶Ep 5 · 23:56
clinicalLaparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.↗
▶Ep 5 · 24:10
clinicalVentral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory.↗
▶Ep 5 · 24:10
clinicalMesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs.↗
▶Ep 5 · 24:10
clinicalVentral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory.↗
▶Ep 5 · 24:10
clinicalMesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs.↗
▶Ep 5 · 24:55
clinicalVentral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age.↗
▶Ep 5 · 24:55
clinicalVentral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age.↗
Hirschsprung Disease: Update Course 2015
▶Ep 16 · 0:22
quoteI recall having a full day of uh Hirschprung's webcast, and now I get 5 minutes.↗
▶Ep 16 · 3:06
quoteI, every time that I do a primary trans anal, I get. I tighten up a little bit to make sure that I'm confident that I can do, and I have an exit strategy in mind if I get in trouble↗
▶Ep 16 · 3:06
opinionThe safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through.↗
▶Ep 16 · 3:46
opinionLeveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable.↗
▶Ep 16 · 4:03
clinicalLeveling colostomy represents a three-stage procedure for Hirschsprung disease management.↗
▶Ep 16 · 5:07
opinionProlonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching.↗
▶Ep 16 · 5:07
quoteBelinda and I talk about this a lot, and it's about a comfort level and how fit, I take, I watch the clock how long I'm doing a trans anal dissection because I do not want to be stretching on those sphincters for 4 hours trying to dig up in a dark hole when I could put a scope in.↗
▶Ep 16 · 5:30
clinicalLaparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases.↗
▶Ep 16 · 5:46
clinicalStandard rectosigmoid Hirschsprung disease (6-10 centimeters proximal) can be completed transanally in approximately 2 hours when the level is known from a good contrast study.↗
▶Ep 16 · 6:12
clinicalComplications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues.↗
▶Ep 16 · 6:31
clinicalSoiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence.↗
Summaries Jason gave as host
· 50 summaries
Recaps of other experts' statements, not Jason's own clinical position.
Summaries Jason gave as host · Abdominal Wall Defects2 summaries
Gastroschisis and sutureless abdominal wall closure
▶Ep 22 · 8:50
host summaryJason Frischer summarizes what Dr. Jason Fraser said: Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate.↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 29 · 15:17
host summaryJason Frischer summarizing the discussion: Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement.↗
Summaries Jason gave as host · Anorectal Malformation7 summaries
host summaryJason Frischer summarizes what Dr. Marc Levitt said: A lot of surgeons agree that oftentimes your first shot might be your only shot to give this patient a good outcome and the right anatomy.↗
Colorectal Quiz Episode 29: Female ARM-Post Op Management
▶Ep 43 · 14:20
host summaryJason Frischer summarizing the discussion: In the dilation trial, 4 patients required redo operations for stricture: 2 in the dilation arm (who didn't actually dilate) and 2 in the non-dilation arm. Additional patients required Heineke-Mikulicz procedures (3 in one group, 47 total procedures mentioned).↗
Colorectal Quiz: Episode 47
▶Ep 77 · 17:18
host summaryJason Frischer summarizing the discussion: Dr. Levitt has had some patients with good success with continence where the sigmoid is able to feel some distension after resection and sigmoid pull-through, but it is not the expectation.↗
Colorectal Quiz: Episode 40
▶Ep 90 · 15:57
host summaryJason Frischer summarizing the discussion: Fred Reichman used to say 'you are judged by what you are willing to stop for'—surgeons must be willing to stop when uncertain, get more information or help, rather than plowing through.↗
▶Ep 90 · 15:57
host summaryJason Frischer summarizing the discussion: Fred Reichman used to say, you are judged by what you are willing to stop for. And as surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through.↗
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
▶Ep 82 · 11:21
host summaryJason Frischer summarizes what Dr. Marc Levitt said: Dr. Levitt's technique for distal irrigation involves having someone look laparoscopically while he passes the tube into the distal segment and does the irrigation under direct visualization.↗
Colorectal Quiz Episode 29: Female ARM
▶Ep 84 · 15:02
host summaryJason Frischer summarizing the discussion: Approximately 20% of patients in the dilation RCT required redo operations (either local or total), with most requiring only local revision.↗
Summaries Jason gave as host · Anorectal Malformations2 summaries
host summaryJason Frischer summarizes what Dr. Marc Levitt said: A lot of surgeons agree that oftentimes your first shot might be your only shot to give this patient a good outcome and the right anatomy.↗
Colorectal Quiz Episode 29: Female ARM-Post Op Management
▶Ep 16 · 14:20
host summaryJason Frischer summarizing the discussion: In the dilation trial, 4 patients required redo operations for stricture: 2 in the dilation arm (who didn't actually dilate) and 2 in the non-dilation arm. Additional patients required Heineke-Mikulicz procedures (3 in one group, 47 total procedures mentioned).↗
Summaries Jason gave as host · Anorectal Malformations & Cloacal Reconstruction2 summaries
host summaryJason Frischer summarizing the discussion: Fred Reichman used to say, you are judged by what you are willing to stop for. And as surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through.↗
▶Ep 16 · 15:57
host summaryJason Frischer summarizing the discussion: Fred Reichman used to say 'you are judged by what you are willing to stop for'—surgeons must be willing to stop when uncertain, get more information or help, rather than plowing through.↗
host summaryJason Frischer summarizing the discussion: Dr. Levitt has had some patients with good success with continence where the sigmoid is able to feel some distension after resection and sigmoid pull-through, but it is not the expectation.↗
Colorectal Quiz: Episode 40
▶Ep 30 · 15:57
host summaryJason Frischer summarizing the discussion: Fred Reichman used to say 'you are judged by what you are willing to stop for'—surgeons must be willing to stop when uncertain, get more information or help, rather than plowing through.↗
▶Ep 30 · 15:57
host summaryJason Frischer summarizing the discussion: Fred Reichman used to say, you are judged by what you are willing to stop for. And as surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through.↗
Summaries Jason gave as host · Colorectal / ARM & Hirschsprung12 summaries
host summaryJason Frischer summarizing the discussion: Transabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure).↗
▶Ep 14 · 23:36
host summaryJason Frischer summarizing the discussion: Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.↗
▶Ep 14 · 23:56
host summaryJason Frischer summarizing the discussion: Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.↗
Hirschsprung Disease: Update Course 2015
▶Ep 35 · 7:08
host summaryJason Frischer summarizing the discussion: Jack Langer published an algorithm for working up patients with problems after Hirschsprung disease.↗
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
▶Ep 101 · 8:39
host summaryJason Frischer summarizing the discussion: Fecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux↗
▶Ep 101 · 10:51
host summaryJason Frischer summarizing the discussion: The last steps of combined procedures should be maturing the Mitrofanoff, maturing the Malone, then closing the abdomen↗
Colorectal Quiz Episode 29: Female ARM-Post Op Management
▶Ep 120 · 14:20
host summaryJason Frischer summarizing the discussion: In the dilation trial, 4 patients required redo operations for stricture: 2 in the dilation arm (who didn't actually dilate) and 2 in the non-dilation arm. Additional patients required Heineke-Mikulicz procedures (3 in one group, 47 total procedures mentioned).↗
Colorectal Quiz: Episode 47
▶Ep 224 · 17:18
host summaryJason Frischer summarizing the discussion: Dr. Levitt has had some patients with good success with continence where the sigmoid is able to feel some distension after resection and sigmoid pull-through, but it is not the expectation.↗
Colorectal Quiz: Episode 40
▶Ep 223 · 15:57
host summaryJason Frischer summarizing the discussion: Fred Reichman used to say, you are judged by what you are willing to stop for. And as surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through.↗
▶Ep 223 · 15:57
host summaryJason Frischer summarizing the discussion: Fred Reichman used to say 'you are judged by what you are willing to stop for'—surgeons must be willing to stop when uncertain, get more information or help, rather than plowing through.↗
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
▶Ep 232 · 11:21
host summaryJason Frischer summarizes what Dr. Marc Levitt said: Dr. Levitt's technique for distal irrigation involves having someone look laparoscopically while he passes the tube into the distal segment and does the irrigation under direct visualization.↗
Colorectal Quiz Episode 29: Female ARM
▶Ep 234 · 15:02
host summaryJason Frischer summarizing the discussion: Approximately 20% of patients in the dilation RCT required redo operations (either local or total), with most requiring only local revision.↗
Summaries Jason gave as host · Congenital Lung Lesions (CPAM)1 summary
host summaryJason Frischer summarizing the discussion: In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU↗
Summaries Jason gave as host · Congenital Pulmonary Airway Malformation1 summary
host summaryJason Frischer summarizing the discussion: In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU↗
Summaries Jason gave as host · Congenital Pulmonary Airway Malformation1 summary
host summaryJason Frischer summarizing the discussion: In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU↗
Summaries Jason gave as host · Constipation2 summaries
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
▶Ep 8 · 8:39
host summaryJason Frischer summarizing the discussion: Fecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux↗
▶Ep 8 · 10:51
host summaryJason Frischer summarizing the discussion: The last steps of combined procedures should be maturing the Mitrofanoff, maturing the Malone, then closing the abdomen↗
Summaries Jason gave as host · Enterocolitis4 summaries
host summaryJason Frischer summarizing the discussion: Transabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure).↗
▶Ep 3 · 23:36
host summaryJason Frischer summarizing the discussion: Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.↗
▶Ep 3 · 23:56
host summaryJason Frischer summarizing the discussion: Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.↗
Hirschsprung Disease: Update Course 2015
▶Ep 7 · 7:08
host summaryJason Frischer summarizing the discussion: Jack Langer published an algorithm for working up patients with problems after Hirschsprung disease.↗
Summaries Jason gave as host · Enterocolitis4 summaries
host summaryJason Frischer summarizing the discussion: Transabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure).↗
▶Ep 3 · 23:36
host summaryJason Frischer summarizing the discussion: Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.↗
▶Ep 3 · 23:56
host summaryJason Frischer summarizing the discussion: Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.↗
Hirschsprung Disease: Update Course 2015
▶Ep 7 · 7:08
host summaryJason Frischer summarizing the discussion: Jack Langer published an algorithm for working up patients with problems after Hirschsprung disease.↗
Summaries Jason gave as host · Etiologies (Gastroschisis/NEC/Atresia/Volvulus)2 summaries
Gastroschisis and sutureless abdominal wall closure
▶Ep 31 · 8:50
host summaryJason Frischer summarizes what Dr. Jason Fraser said: Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate.↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 46 · 15:17
host summaryJason Frischer summarizing the discussion: Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement.↗
Summaries Jason gave as host · Gastroschisis2 summaries
Gastroschisis and sutureless abdominal wall closure
▶Ep 13 · 8:50
host summaryJason Frischer summarizes what Dr. Jason Fraser said: Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate.↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 17 · 15:17
host summaryJason Frischer summarizing the discussion: Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement.↗
Summaries Jason gave as host · Gastroschisis2 summaries
Gastroschisis and sutureless abdominal wall closure
▶Ep 14 · 8:50
host summaryJason Frischer summarizes what Dr. Jason Fraser said: Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate.↗
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
▶Ep 18 · 15:17
host summaryJason Frischer summarizing the discussion: Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement.↗
Summaries Jason gave as host · Hirschsprung disease3 summaries
host summaryJason Frischer summarizing the discussion: Transabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure).↗
▶Ep 5 · 23:36
host summaryJason Frischer summarizing the discussion: Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.↗
▶Ep 5 · 23:56
host summaryJason Frischer summarizing the discussion: Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.↗
