There is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.
we're going to start off with a water-soluble contrast enema. What is the radiologist looking for? Is the lowest segment of the intestine, the rectum, is that narrower? And then it dilates up above that. That's a sign that we have concern for Hirschsprung's disease.
We tend to be very quick to offer minimally invasive approaches because it really is a 20 minute intervention under sedation in our place with no activity restriction and no narcotic requirement.
We use this term dilation, like we're stretching something that can be stretched up to a certain size, except that's not true. Like when they start out like a pinhole, it's a controlled tear.
I can't tell you how many people said, well, they told me I couldn't bathe and I'm so confused because if you don't wash, then you're probably not going to heal anything.
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 66 · 0:10
quotewe're the only thing standing between you and lunch↗
▶Ep 66 · 0:50
quotethere isn't a ton of earth shattering stuff that's occurred in the literature in the past couple of years that is really game changing↗
▶Ep 66 · 4:16
quoteI guess I'm old school on this. Like, I like to, you know, I'm fine maintaining patency.↗
▶Ep 66 · 4:21
quoteif you're gonna just try to keep it open, you just have to keep it open enough for like little soft, mustardy poop to be able to make it through there↗
▶Ep 66 · 4:33
quoteI like to do this operation like when I can, it doesn't have to be the next day, the day after, you know, you can uh get it done, but I like to get it done on the neonatal uh admission↗
▶Ep 66 · 8:41
quoteWe use this term dilation, like we're stretching something that can be stretched up to a certain size, except that's not true. Like when they start out like a pinhole, it's a controlled tear.↗
▶Ep 66 · 8:41
clinicalPreoperative fistula dilation is a controlled tear when the fistula starts as a pinhole, not true stretching; dilate only as big as needed and then leave it alone until definitive repair.↗
▶Ep 66 · 11:04
quotethis is basically like the same thing one would do in a bulbbar fistula but applied to a vestibular fistula↗
▶Ep 66 · 11:04
clinicalPerineal body-preserving PSARP is basically the same technique one would use for a bulbar fistula but applied to a vestibular fistula.↗
▶Ep 66 · 11:32
clinicalFor perineal body-preserving PSARP, the key is to really clean up the lateral planes before coming around the front, mobilizing the sides and staying on the bowel wall before deciding to come through the common plane.↗
▶Ep 66 · 11:32
quotewhen you're a PAP surgeon, that's what you do when you're used to the concepts of working, uh, you know, really religiously about cleaning up the lateral planes before you come around the front↗
▶Ep 66 · 11:45
clinicalWhen starting perineal body-preserving PSARP, it is acceptable to go a little bit into the perineal body on the front and a little bit behind it in the back to make the working incision not the tightest pinhole, while still keeping the perineal body largely intact.↗
▶Ep 66 · 29:29
quoteevery little flick of the bovie, like that's a blood vessel, that's a nerve, and that's another week in the bowel management clinic↗
Nelson's statements about Colorectal / ARM & Hirschsprung73 statements
clinicalHirschsprung disease is a congenital condition affecting the lower most aspect of the intestine (rectum or sigmoid), characterized by missing ganglion cells in the submucosal and myenteric plexus that allow the intestine to relax.↗
▶Ep 106 · 1:05
quoteHirschsprung's disease is a congenital issue. It is a condition that children are born with. It usually affects the lower most aspect of the intestine. A.K.A. the rectum or the sigmoid.↗
▶Ep 106 · 1:05
clinicalHirschsprung disease is a congenital condition affecting the lower most aspect of the intestine (rectum or sigmoid), characterized by missing ganglion cells in the submucosal and myenteric plexus that allow the intestine to relax.↗
▶Ep 106 · 1:05
quoteHirschsprung's disease is a congenital issue. It is a condition that children are born with. It usually affects the lower most aspect of the intestine. A.K.A. the rectum or the sigmoid.↗
▶Ep 106 · 1:25
quotethe GI system is like a big tube, right? It's like a big tube that goes from your mouth to your anus. But it's not just a pipe. It's also a pump.↗
▶Ep 106 · 1:25
quotethe GI system is like a big tube, right? It's like a big tube that goes from your mouth to your anus. But it's not just a pipe. It's also a pump.↗
▶Ep 106 · 1:50
quotein Hirschsprung's disease, we are missing the system of nerves that allows that to relax.↗
▶Ep 106 · 1:50
quotein Hirschsprung's disease, we are missing the system of nerves that allows that to relax.↗
▶Ep 106 · 2:00
clinicalIn Hirschsprung disease, the rectum and lowest part of the colon are always affected, with the aganglionosis always ending right above the anus.↗
▶Ep 106 · 2:00
clinicalIn Hirschsprung disease, the rectum and lowest part of the colon are always affected, with the aganglionosis always ending right above the anus.↗
▶Ep 106 · 2:15
quotewith Hirschsprung's, we know that it always ends right above the anus. But where does it begin? That's where the variability is.↗
▶Ep 106 · 2:15
quotewith Hirschsprung's, we know that it always ends right above the anus. But where does it begin? That's where the variability is.↗
▶Ep 106 · 2:25
epidemiologicalAbout 85% of Hirschsprung cases begin in the very end part of the sigmoid colon or the beginning of the rectum.↗
▶Ep 106 · 2:25
epidemiologicalAbout 85% of Hirschsprung cases begin in the very end part of the sigmoid colon or the beginning of the rectum.↗
▶Ep 106 · 2:35
epidemiologicalIn about 10% of Hirschsprung cases, the entire colon is affected.↗
▶Ep 106 · 2:35
epidemiologicalIn about 10% of Hirschsprung cases, the entire colon is affected.↗
▶Ep 106 · 3:30
clinicalIn newborns with suspected Hirschsprung disease, the initial workup includes a water-soluble contrast enema looking for a narrower distal segment (rectum) with dilation above.↗
▶Ep 106 · 3:30
clinicalIn newborns with suspected Hirschsprung disease, the initial workup includes a water-soluble contrast enema looking for a narrower distal segment (rectum) with dilation above.↗
▶Ep 106 · 3:40
quotewe're going to start off with a water-soluble contrast enema. What is the radiologist looking for? Is the lowest segment of the intestine, the rectum, is that narrower? And then it dilates up above that. That's a sign that we have concern for Hirschsprung's disease.↗
▶Ep 106 · 3:40
quotewe're going to start off with a water-soluble contrast enema. What is the radiologist looking for? Is the lowest segment of the intestine, the rectum, is that narrower? And then it dilates up above that. That's a sign that we have concern for Hirschsprung's disease.↗
▶Ep 106 · 4:05
clinicalIf contrast enema raises concern for Hirschsprung disease, a suction rectal biopsy is performed to examine tissue for the presence of ganglion cells.↗
▶Ep 106 · 4:05
clinicalIf contrast enema raises concern for Hirschsprung disease, a suction rectal biopsy is performed to examine tissue for the presence of ganglion cells.↗
▶Ep 106 · 4:46
quoteIn older children, Hirschsprungs can be missed. Those situations usually establish themselves. Children with Hirschsprungs very rarely thrive and develop normally. Because they're often small for their age group.↗
▶Ep 106 · 4:46
clinicalIn older children, Hirschsprung disease can be missed and typically presents with failure to thrive (small for age) and significant constipation.↗
▶Ep 106 · 4:46
quoteIn older children, Hirschsprungs can be missed. Those situations usually establish themselves. Children with Hirschsprungs very rarely thrive and develop normally. Because they're often small for their age group.↗
▶Ep 106 · 4:46
clinicalIn older children, Hirschsprung disease can be missed and typically presents with failure to thrive (small for age) and significant constipation.↗
▶Ep 106 · 5:00
clinicalChildren with Hirschsprung disease very rarely thrive and develop normally.↗
▶Ep 106 · 5:00
clinicalChildren with Hirschsprung disease very rarely thrive and develop normally.↗
▶Ep 106 · 5:20
clinicalIn older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess degree of constipation, followed by contrast rectal enema, and then biopsy depending on findings.↗
▶Ep 106 · 5:20
clinicalIn older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess degree of constipation, followed by contrast rectal enema, and then biopsy depending on findings.↗
▶Ep 106 · 5:45
clinicalIn older children with low-risk presentations (normal early years, then worsening constipation), biopsy should usually be done only after routine constipation management measures are tried and fail.↗
▶Ep 106 · 5:45
clinicalIn older children with low-risk presentations (normal early years, then worsening constipation), biopsy should usually be done only after routine constipation management measures are tried and fail.↗
▶Ep 106 · 6:25
clinicalAnorectal manometry uses a balloon catheter to measure pressures in the anus and rectum, specifically looking for the rectoanal inhibitory reflex.↗
▶Ep 106 · 6:25
clinicalAnorectal manometry uses a balloon catheter to measure pressures in the anus and rectum, specifically looking for the rectoanal inhibitory reflex.↗
▶Ep 106 · 7:05
quoteThere is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.↗
▶Ep 106 · 7:05
quoteThere is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.↗
▶Ep 106 · 7:05
clinicalThe normal rectoanal inhibitory reflex causes the anal sphincter to relax when a balloon is inflated in the rectum, but this reflex is absent in Hirschsprung disease.↗
▶Ep 106 · 7:05
clinicalThe normal rectoanal inhibitory reflex causes the anal sphincter to relax when a balloon is inflated in the rectum, but this reflex is absent in Hirschsprung disease.↗
▶Ep 106 · 7:33
quoteIt's not very sensitive. In other words, if you have a normal manometry, it doesn't completely rule out Hirschsprungs disease.↗
▶Ep 106 · 7:33
clinicalAnorectal manometry is not sufficiently sensitive to rule out Hirschsprung disease; a normal manometry does not completely exclude the diagnosis.↗
▶Ep 106 · 7:33
quoteIt's not very sensitive. In other words, if you have a normal manometry, it doesn't completely rule out Hirschsprungs disease.↗
▶Ep 106 · 7:33
clinicalAnorectal manometry is not sufficiently sensitive to rule out Hirschsprung disease; a normal manometry does not completely exclude the diagnosis.↗
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 180 · 0:10
quotewe're the only thing standing between you and lunch↗
▶Ep 180 · 0:10
quotewe're the only thing standing between you and lunch↗
▶Ep 180 · 0:50
quotethere isn't a ton of earth shattering stuff that's occurred in the literature in the past couple of years that is really game changing↗
▶Ep 180 · 0:50
quotethere isn't a ton of earth shattering stuff that's occurred in the literature in the past couple of years that is really game changing↗
▶Ep 180 · 4:16
quoteI guess I'm old school on this. Like, I like to, you know, I'm fine maintaining patency.↗
▶Ep 180 · 4:16
quoteI guess I'm old school on this. Like, I like to, you know, I'm fine maintaining patency.↗
▶Ep 180 · 4:21
quoteif you're gonna just try to keep it open, you just have to keep it open enough for like little soft, mustardy poop to be able to make it through there↗
▶Ep 180 · 4:21
quoteif you're gonna just try to keep it open, you just have to keep it open enough for like little soft, mustardy poop to be able to make it through there↗
▶Ep 180 · 4:33
quoteI like to do this operation like when I can, it doesn't have to be the next day, the day after, you know, you can uh get it done, but I like to get it done on the neonatal uh admission↗
▶Ep 180 · 4:33
quoteI like to do this operation like when I can, it doesn't have to be the next day, the day after, you know, you can uh get it done, but I like to get it done on the neonatal uh admission↗
▶Ep 180 · 8:41
quoteWe use this term dilation, like we're stretching something that can be stretched up to a certain size, except that's not true. Like when they start out like a pinhole, it's a controlled tear.↗
▶Ep 180 · 8:41
clinicalPreoperative fistula dilation is a controlled tear when the fistula starts as a pinhole, not true stretching; dilate only as big as needed and then leave it alone until definitive repair.↗
▶Ep 180 · 8:41
clinicalPreoperative fistula dilation is a controlled tear when the fistula starts as a pinhole, not true stretching; dilate only as big as needed and then leave it alone until definitive repair.↗
▶Ep 180 · 8:41
quoteWe use this term dilation, like we're stretching something that can be stretched up to a certain size, except that's not true. Like when they start out like a pinhole, it's a controlled tear.↗
▶Ep 180 · 11:04
quotethis is basically like the same thing one would do in a bulbbar fistula but applied to a vestibular fistula↗
▶Ep 180 · 11:04
clinicalPerineal body-preserving PSARP is basically the same technique one would use for a bulbar fistula but applied to a vestibular fistula.↗
▶Ep 180 · 11:04
clinicalPerineal body-preserving PSARP is basically the same technique one would use for a bulbar fistula but applied to a vestibular fistula.↗
▶Ep 180 · 11:04
quotethis is basically like the same thing one would do in a bulbbar fistula but applied to a vestibular fistula↗
▶Ep 180 · 11:32
quotewhen you're a PAP surgeon, that's what you do when you're used to the concepts of working, uh, you know, really religiously about cleaning up the lateral planes before you come around the front↗
▶Ep 180 · 11:32
clinicalFor perineal body-preserving PSARP, the key is to really clean up the lateral planes before coming around the front, mobilizing the sides and staying on the bowel wall before deciding to come through the common plane.↗
▶Ep 180 · 11:32
quotewhen you're a PAP surgeon, that's what you do when you're used to the concepts of working, uh, you know, really religiously about cleaning up the lateral planes before you come around the front↗
▶Ep 180 · 11:32
clinicalFor perineal body-preserving PSARP, the key is to really clean up the lateral planes before coming around the front, mobilizing the sides and staying on the bowel wall before deciding to come through the common plane.↗
▶Ep 180 · 11:45
clinicalWhen starting perineal body-preserving PSARP, it is acceptable to go a little bit into the perineal body on the front and a little bit behind it in the back to make the working incision not the tightest pinhole, while still keeping the perineal body largely intact.↗
▶Ep 180 · 11:45
clinicalWhen starting perineal body-preserving PSARP, it is acceptable to go a little bit into the perineal body on the front and a little bit behind it in the back to make the working incision not the tightest pinhole, while still keeping the perineal body largely intact.↗
▶Ep 180 · 20:28
clinical2021 PCPLC retrospective study of Hirschsprung pull-through showed no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days).↗
▶Ep 180 · 23:40
epidemiologicalMulti-center retrospective study published in 2022 showed 24% of Hirschsprung patients received at least one Botox injection.↗
▶Ep 180 · 23:58
clinicalCincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients who received Botox (30% vs 50%).↗
▶Ep 180 · 24:23
clinicalCincinnati Children's prospective study found patients who received Botox at time of pull-through had higher risk of diaper rash (60%).↗
▶Ep 180 · 24:58
clinicalEarly work from Sam Nurko's group in Boston used weight-based Botox dosing up to a maximum of 100 units for Hirschsprung patients.↗
▶Ep 180 · 29:29
quoteevery little flick of the bovie, like that's a blood vessel, that's a nerve, and that's another week in the bowel management clinic↗
▶Ep 180 · 29:29
quoteevery little flick of the bovie, like that's a blood vessel, that's a nerve, and that's another week in the bowel management clinic↗
Nelson's statements about Hirschsprung disease73 statements
clinicalHirschsprung disease is a congenital condition affecting the lower most aspect of the intestine (rectum or sigmoid), characterized by missing ganglion cells in the submucosal and myenteric plexus that allow the intestine to relax.↗
▶Ep 43 · 1:05
quoteHirschsprung's disease is a congenital issue. It is a condition that children are born with. It usually affects the lower most aspect of the intestine. A.K.A. the rectum or the sigmoid.↗
▶Ep 43 · 1:05
clinicalHirschsprung disease is a congenital condition affecting the lower most aspect of the intestine (rectum or sigmoid), characterized by missing ganglion cells in the submucosal and myenteric plexus that allow the intestine to relax.↗
▶Ep 43 · 1:05
quoteHirschsprung's disease is a congenital issue. It is a condition that children are born with. It usually affects the lower most aspect of the intestine. A.K.A. the rectum or the sigmoid.↗
▶Ep 43 · 1:25
quotethe GI system is like a big tube, right? It's like a big tube that goes from your mouth to your anus. But it's not just a pipe. It's also a pump.↗
▶Ep 43 · 1:25
quotethe GI system is like a big tube, right? It's like a big tube that goes from your mouth to your anus. But it's not just a pipe. It's also a pump.↗
▶Ep 43 · 1:50
quotein Hirschsprung's disease, we are missing the system of nerves that allows that to relax.↗
▶Ep 43 · 1:50
quotein Hirschsprung's disease, we are missing the system of nerves that allows that to relax.↗
▶Ep 43 · 2:00
clinicalIn Hirschsprung disease, the rectum and lowest part of the colon are always affected, with the aganglionosis always ending right above the anus.↗
▶Ep 43 · 2:00
clinicalIn Hirschsprung disease, the rectum and lowest part of the colon are always affected, with the aganglionosis always ending right above the anus.↗
▶Ep 43 · 2:15
quotewith Hirschsprung's, we know that it always ends right above the anus. But where does it begin? That's where the variability is.↗
▶Ep 43 · 2:15
quotewith Hirschsprung's, we know that it always ends right above the anus. But where does it begin? That's where the variability is.↗
▶Ep 43 · 2:25
epidemiologicalAbout 85% of Hirschsprung cases begin in the very end part of the sigmoid colon or the beginning of the rectum.↗
▶Ep 43 · 2:25
epidemiologicalAbout 85% of Hirschsprung cases begin in the very end part of the sigmoid colon or the beginning of the rectum.↗
▶Ep 43 · 2:35
epidemiologicalIn about 10% of Hirschsprung cases, the entire colon is affected.↗
▶Ep 43 · 2:35
epidemiologicalIn about 10% of Hirschsprung cases, the entire colon is affected.↗
▶Ep 43 · 3:30
clinicalIn newborns with suspected Hirschsprung disease, the initial workup includes a water-soluble contrast enema looking for a narrower distal segment (rectum) with dilation above.↗
▶Ep 43 · 3:30
clinicalIn newborns with suspected Hirschsprung disease, the initial workup includes a water-soluble contrast enema looking for a narrower distal segment (rectum) with dilation above.↗
▶Ep 43 · 3:40
quotewe're going to start off with a water-soluble contrast enema. What is the radiologist looking for? Is the lowest segment of the intestine, the rectum, is that narrower? And then it dilates up above that. That's a sign that we have concern for Hirschsprung's disease.↗
▶Ep 43 · 3:40
quotewe're going to start off with a water-soluble contrast enema. What is the radiologist looking for? Is the lowest segment of the intestine, the rectum, is that narrower? And then it dilates up above that. That's a sign that we have concern for Hirschsprung's disease.↗
▶Ep 43 · 4:05
clinicalIf contrast enema raises concern for Hirschsprung disease, a suction rectal biopsy is performed to examine tissue for the presence of ganglion cells.↗
▶Ep 43 · 4:05
clinicalIf contrast enema raises concern for Hirschsprung disease, a suction rectal biopsy is performed to examine tissue for the presence of ganglion cells.↗
▶Ep 43 · 4:46
quoteIn older children, Hirschsprungs can be missed. Those situations usually establish themselves. Children with Hirschsprungs very rarely thrive and develop normally. Because they're often small for their age group.↗
▶Ep 43 · 4:46
quoteIn older children, Hirschsprungs can be missed. Those situations usually establish themselves. Children with Hirschsprungs very rarely thrive and develop normally. Because they're often small for their age group.↗
▶Ep 43 · 4:46
clinicalIn older children, Hirschsprung disease can be missed and typically presents with failure to thrive (small for age) and significant constipation.↗
▶Ep 43 · 4:46
clinicalIn older children, Hirschsprung disease can be missed and typically presents with failure to thrive (small for age) and significant constipation.↗
▶Ep 43 · 5:00
clinicalChildren with Hirschsprung disease very rarely thrive and develop normally.↗
▶Ep 43 · 5:00
clinicalChildren with Hirschsprung disease very rarely thrive and develop normally.↗
▶Ep 43 · 5:20
clinicalIn older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess degree of constipation, followed by contrast rectal enema, and then biopsy depending on findings.↗
▶Ep 43 · 5:20
clinicalIn older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess degree of constipation, followed by contrast rectal enema, and then biopsy depending on findings.↗
▶Ep 43 · 5:45
clinicalIn older children with low-risk presentations (normal early years, then worsening constipation), biopsy should usually be done only after routine constipation management measures are tried and fail.↗
▶Ep 43 · 5:45
clinicalIn older children with low-risk presentations (normal early years, then worsening constipation), biopsy should usually be done only after routine constipation management measures are tried and fail.↗
▶Ep 43 · 6:25
clinicalAnorectal manometry uses a balloon catheter to measure pressures in the anus and rectum, specifically looking for the rectoanal inhibitory reflex.↗
▶Ep 43 · 6:25
clinicalAnorectal manometry uses a balloon catheter to measure pressures in the anus and rectum, specifically looking for the rectoanal inhibitory reflex.↗
▶Ep 43 · 7:05
quoteThere is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.↗
▶Ep 43 · 7:05
quoteThere is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.↗
▶Ep 43 · 7:05
clinicalThe normal rectoanal inhibitory reflex causes the anal sphincter to relax when a balloon is inflated in the rectum, but this reflex is absent in Hirschsprung disease.↗
▶Ep 43 · 7:05
clinicalThe normal rectoanal inhibitory reflex causes the anal sphincter to relax when a balloon is inflated in the rectum, but this reflex is absent in Hirschsprung disease.↗
▶Ep 43 · 7:33
quoteIt's not very sensitive. In other words, if you have a normal manometry, it doesn't completely rule out Hirschsprungs disease.↗
▶Ep 43 · 7:33
clinicalAnorectal manometry is not sufficiently sensitive to rule out Hirschsprung disease; a normal manometry does not completely exclude the diagnosis.↗
▶Ep 43 · 7:33
clinicalAnorectal manometry is not sufficiently sensitive to rule out Hirschsprung disease; a normal manometry does not completely exclude the diagnosis.↗
▶Ep 43 · 7:33
quoteIt's not very sensitive. In other words, if you have a normal manometry, it doesn't completely rule out Hirschsprungs disease.↗
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 78 · 0:10
quotewe're the only thing standing between you and lunch↗
▶Ep 78 · 0:10
quotewe're the only thing standing between you and lunch↗
▶Ep 78 · 0:50
quotethere isn't a ton of earth shattering stuff that's occurred in the literature in the past couple of years that is really game changing↗
▶Ep 78 · 0:50
quotethere isn't a ton of earth shattering stuff that's occurred in the literature in the past couple of years that is really game changing↗
▶Ep 78 · 4:16
quoteI guess I'm old school on this. Like, I like to, you know, I'm fine maintaining patency.↗
▶Ep 78 · 4:16
quoteI guess I'm old school on this. Like, I like to, you know, I'm fine maintaining patency.↗
▶Ep 78 · 4:21
quoteif you're gonna just try to keep it open, you just have to keep it open enough for like little soft, mustardy poop to be able to make it through there↗
▶Ep 78 · 4:21
quoteif you're gonna just try to keep it open, you just have to keep it open enough for like little soft, mustardy poop to be able to make it through there↗
▶Ep 78 · 4:33
quoteI like to do this operation like when I can, it doesn't have to be the next day, the day after, you know, you can uh get it done, but I like to get it done on the neonatal uh admission↗
▶Ep 78 · 4:33
quoteI like to do this operation like when I can, it doesn't have to be the next day, the day after, you know, you can uh get it done, but I like to get it done on the neonatal uh admission↗
▶Ep 78 · 8:41
quoteWe use this term dilation, like we're stretching something that can be stretched up to a certain size, except that's not true. Like when they start out like a pinhole, it's a controlled tear.↗
▶Ep 78 · 8:41
quoteWe use this term dilation, like we're stretching something that can be stretched up to a certain size, except that's not true. Like when they start out like a pinhole, it's a controlled tear.↗
▶Ep 78 · 8:41
clinicalPreoperative fistula dilation is a controlled tear when the fistula starts as a pinhole, not true stretching; dilate only as big as needed and then leave it alone until definitive repair.↗
▶Ep 78 · 8:41
clinicalPreoperative fistula dilation is a controlled tear when the fistula starts as a pinhole, not true stretching; dilate only as big as needed and then leave it alone until definitive repair.↗
▶Ep 78 · 11:04
quotethis is basically like the same thing one would do in a bulbbar fistula but applied to a vestibular fistula↗
▶Ep 78 · 11:04
clinicalPerineal body-preserving PSARP is basically the same technique one would use for a bulbar fistula but applied to a vestibular fistula.↗
▶Ep 78 · 11:04
clinicalPerineal body-preserving PSARP is basically the same technique one would use for a bulbar fistula but applied to a vestibular fistula.↗
▶Ep 78 · 11:04
quotethis is basically like the same thing one would do in a bulbbar fistula but applied to a vestibular fistula↗
▶Ep 78 · 11:32
clinicalFor perineal body-preserving PSARP, the key is to really clean up the lateral planes before coming around the front, mobilizing the sides and staying on the bowel wall before deciding to come through the common plane.↗
▶Ep 78 · 11:32
clinicalFor perineal body-preserving PSARP, the key is to really clean up the lateral planes before coming around the front, mobilizing the sides and staying on the bowel wall before deciding to come through the common plane.↗
▶Ep 78 · 11:32
quotewhen you're a PAP surgeon, that's what you do when you're used to the concepts of working, uh, you know, really religiously about cleaning up the lateral planes before you come around the front↗
▶Ep 78 · 11:32
quotewhen you're a PAP surgeon, that's what you do when you're used to the concepts of working, uh, you know, really religiously about cleaning up the lateral planes before you come around the front↗
▶Ep 78 · 11:45
clinicalWhen starting perineal body-preserving PSARP, it is acceptable to go a little bit into the perineal body on the front and a little bit behind it in the back to make the working incision not the tightest pinhole, while still keeping the perineal body largely intact.↗
▶Ep 78 · 11:45
clinicalWhen starting perineal body-preserving PSARP, it is acceptable to go a little bit into the perineal body on the front and a little bit behind it in the back to make the working incision not the tightest pinhole, while still keeping the perineal body largely intact.↗
▶Ep 78 · 20:28
clinical2021 PCPLC retrospective study of Hirschsprung pull-through showed no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days).↗
▶Ep 78 · 23:40
epidemiologicalMulti-center retrospective study published in 2022 showed 24% of Hirschsprung patients received at least one Botox injection.↗
▶Ep 78 · 23:58
clinicalCincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients who received Botox (30% vs 50%).↗
▶Ep 78 · 24:23
clinicalCincinnati Children's prospective study found patients who received Botox at time of pull-through had higher risk of diaper rash (60%).↗
▶Ep 78 · 24:58
clinicalEarly work from Sam Nurko's group in Boston used weight-based Botox dosing up to a maximum of 100 units for Hirschsprung patients.↗
▶Ep 78 · 29:29
quoteevery little flick of the bovie, like that's a blood vessel, that's a nerve, and that's another week in the bowel management clinic↗
▶Ep 78 · 29:29
quoteevery little flick of the bovie, like that's a blood vessel, that's a nerve, and that's another week in the bowel management clinic↗
Nelson's statements about Hirschsprung Disease21 statements
clinicalHirschsprung disease is a congenital condition affecting the lower most aspect of the intestine (rectum or sigmoid), characterized by missing ganglion cells in the submucosal and myenteric plexus that allow the intestine to relax.↗
▶Ep 14 · 1:05
quoteHirschsprung's disease is a congenital issue. It is a condition that children are born with. It usually affects the lower most aspect of the intestine. A.K.A. the rectum or the sigmoid.↗
▶Ep 14 · 1:25
quotethe GI system is like a big tube, right? It's like a big tube that goes from your mouth to your anus. But it's not just a pipe. It's also a pump.↗
▶Ep 14 · 1:50
quotein Hirschsprung's disease, we are missing the system of nerves that allows that to relax.↗
▶Ep 14 · 2:00
clinicalIn Hirschsprung disease, the rectum and lowest part of the colon are always affected, with the aganglionosis always ending right above the anus.↗
▶Ep 14 · 2:15
quotewith Hirschsprung's, we know that it always ends right above the anus. But where does it begin? That's where the variability is.↗
▶Ep 14 · 2:25
epidemiologicalAbout 85% of Hirschsprung cases begin in the very end part of the sigmoid colon or the beginning of the rectum.↗
▶Ep 14 · 2:35
epidemiologicalIn about 10% of Hirschsprung cases, the entire colon is affected.↗
▶Ep 14 · 3:30
clinicalIn newborns with suspected Hirschsprung disease, the initial workup includes a water-soluble contrast enema looking for a narrower distal segment (rectum) with dilation above.↗
▶Ep 14 · 3:40
quotewe're going to start off with a water-soluble contrast enema. What is the radiologist looking for? Is the lowest segment of the intestine, the rectum, is that narrower? And then it dilates up above that. That's a sign that we have concern for Hirschsprung's disease.↗
▶Ep 14 · 4:05
clinicalIf contrast enema raises concern for Hirschsprung disease, a suction rectal biopsy is performed to examine tissue for the presence of ganglion cells.↗
▶Ep 14 · 4:46
quoteIn older children, Hirschsprungs can be missed. Those situations usually establish themselves. Children with Hirschsprungs very rarely thrive and develop normally. Because they're often small for their age group.↗
▶Ep 14 · 4:46
clinicalIn older children, Hirschsprung disease can be missed and typically presents with failure to thrive (small for age) and significant constipation.↗
▶Ep 14 · 5:00
clinicalChildren with Hirschsprung disease very rarely thrive and develop normally.↗
▶Ep 14 · 5:20
clinicalIn older children with suspected Hirschsprung disease, the diagnostic pathway includes plain films to assess degree of constipation, followed by contrast rectal enema, and then biopsy depending on findings.↗
▶Ep 14 · 5:45
clinicalIn older children with low-risk presentations (normal early years, then worsening constipation), biopsy should usually be done only after routine constipation management measures are tried and fail.↗
▶Ep 14 · 6:25
clinicalAnorectal manometry uses a balloon catheter to measure pressures in the anus and rectum, specifically looking for the rectoanal inhibitory reflex.↗
▶Ep 14 · 7:05
quoteThere is a reflux called the recto anal inhibitory reflex. That when you blow a balloon up in the rectum and stretch the rectum, the sphincter should relax. That is a normal recto anal inhibitory reflex. But if the patient has Hirschsprung disease, that reflex, it's gone.↗
▶Ep 14 · 7:05
clinicalThe normal rectoanal inhibitory reflex causes the anal sphincter to relax when a balloon is inflated in the rectum, but this reflex is absent in Hirschsprung disease.↗
▶Ep 14 · 7:33
quoteIt's not very sensitive. In other words, if you have a normal manometry, it doesn't completely rule out Hirschsprungs disease.↗
▶Ep 14 · 7:33
clinicalAnorectal manometry is not sufficiently sensitive to rule out Hirschsprung disease; a normal manometry does not completely exclude the diagnosis.↗
Nelson's statements about Pectus Carinatum6 statements
quotemy big, beautiful surgery ripped completely open, and I was faced with a very frustrated young man begging me to do something for him↗
▶Ep 11 · 29:10
clinicalPilonidal disease almost always presents in patients who have started puberty; presentation much younger than puberty age is exceedingly rare.↗
▶Ep 11 · 31:20
clinicalFor acute pilonidal abscesses, packing wounds with strips does not help drainage, increases pain, and creates home care challenges; tucking a corner of gauze into the opening is sufficient for hemostasis.↗
▶Ep 11 · 32:00
clinicalPilonidal patients with acute infections should be placed on broad-spectrum antibiotics (Augmentin, Clindamycin, or Cipro/Flagyl for recurrent/significant infections) for 5-7 days.↗
▶Ep 11 · 33:00
clinicalThe GIPS procedure for pilonidal disease uses skin biopsy punches to remove pits, curettes to scrape the cavity and remove hair, and leaves holes open to heal; about 75% of patients are cured.↗
▶Ep 11 · 35:00
clinicalThe cleft lift procedure for pilonidal disease has an over 95% success rate.↗
Nelson's statements about Pilonidal Disease32 statements
clinical60 to 70% of pilonidal cases respond successfully to non-surgical management↗
▶Ep 8 · 2:54
opinionTreatment decisions should be tailored to patient context, such as a 16-year-old baseball player who is miserable may proceed directly to operating room↗
▶Ep 8 · 3:29
opinionIf you're not pushing hair removal and meticulous hygiene to do the best that you can, you're probably going to end up operating on some people that might not need an operation↗
▶Ep 8 · 3:29
quoteI think if you're not pushing hair removal and meticulous hygiene to do the best that you can, you're probably going to end up operating on some people that might not need an operation.↗
▶Ep 8 · 4:20
clinicalMany patients have come from multiple hospitals full of hair with nobody clipping them in the office or mentioning hair removal↗
▶Ep 8 · 4:20
quoteI can't tell you how many people have come to me from hospital and hospital and hospital and they're full of hair and nobody clipped them in the office.↗
▶Ep 8 · 4:46
guidelineHaving someone clip the area once a week is recommended↗
▶Ep 8 · 5:11
guidelineFor college students living alone without caregivers, depilatory agents (Nair) are recommended as an alternative to clipping↗
▶Ep 8 · 6:03
quoteI can't tell you how many people said, well, they told me I couldn't bathe and I'm so confused because if you don't wash, then you're probably not going to heal anything.↗
▶Ep 8 · 6:03
guidelineProper showering with a hand shower to actually put water in the affected area is important for healing↗
▶Ep 8 · 6:03
clinicalMany patients report being told they couldn't bathe, which is problematic because without washing, healing is unlikely↗
Update Course Rewind: Surgical Management of Pilonidal Disease 2024
▶Ep 9 · 1:40
clinicalAntibiotics are not used unless patients are coming in with an active infection.↗
▶Ep 9 · 1:40
clinicalSome patients with minimal external manifestation don't drain very effectively and experience severe pain with large, bulging abscesses, while others present with multiple draining abscesses but typically don't report pain or require antibiotics.↗
▶Ep 9 · 1:40
clinicalWide excision and packing is probably the most common operation that happens worldwide for pilonidal disease, with most pilonidal work not done by people doing advanced pilonidal work.↗
▶Ep 9 · 1:40
quoteI don't put people on antibiotics unless they're coming in with an active infection.↗
▶Ep 9 · 1:40
quoteI suspect worldwide, uh wide excision and packing is probably the most common operation that happens.↗
▶Ep 9 · 2:52
clinicalSome institutions use laser tract ablation, phenol to sclerose the tracts, or fibrin glue, but none have been proven superior.↗
▶Ep 9 · 2:52
clinicalLord and Millard described a minimally invasive approach in 1965 that is almost the same operation Dr. Gibbs described in 2008.↗
▶Ep 9 · 2:52
epidemiologicalCurrent success rates are closer to 70-75% where one minimally invasive operation gets you to full healing and lasting recurrence-free healing.↗
▶Ep 9 · 2:52
quoteIt's been out there for a while, just people haven't adopted it.↗
▶Ep 9 · 2:52
quoteOur numbers are a lot closer to the 70, 75% range where one minimally invasive operation gets you to full healing and a lasting recurrence free healing.↗
▶Ep 9 · 4:02
quoteWe tend to be very quick to offer minimally invasive approaches because it really is a 20 minute intervention under sedation in our place with no activity restriction and no narcotic requirement.↗
▶Ep 9 · 4:02
clinicalMinimally invasive approaches are offered quickly because it is a 20-minute intervention under sedation with no activity restriction and no narcotic requirement.↗
▶Ep 9 · 4:53
clinicalIn the Gibbs procedure, all pits are excised using circular punches, then the internal cavity is scraped out to remove inflammation, hair, and necrotic fat, leaving the wounds open to heal.↗
▶Ep 9 · 4:53
quoteAnd that's the art of doing the Gibbs procedure. Maximizing the preservation of skin bridges and avoiding the creation of a large wound.↗
▶Ep 9 · 5:42
clinicalIn the hybrid Gibbs approach, an eight French cystoscope is put into the openings after cleaning to make sure all hair is removed, and this has been done for the past five years with satisfaction.↗
▶Ep 9 · 6:48
clinicalPatients need to be attentive to hair removal (waxing or laser) throughout adolescence and into adulthood, with the longer they can sustain it, the better.↗
▶Ep 9 · 6:48
opinionAll patients should get laser hair removal once they're healed.↗
▶Ep 9 · 6:48
quoteI think that we should be getting all our patients to laser once they're healed.↗
▶Ep 9 · 6:48
quoteInto adulthood, definitely. The longer they can sustain it, the better.↗
Nelson's statements about Recto-vestibular Fistula18 statements
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 3 · 0:10
quotewe're the only thing standing between you and lunch↗
▶Ep 3 · 0:50
quotethere isn't a ton of earth shattering stuff that's occurred in the literature in the past couple of years that is really game changing↗
▶Ep 3 · 4:16
quoteI guess I'm old school on this. Like, I like to, you know, I'm fine maintaining patency.↗
▶Ep 3 · 4:21
quoteif you're gonna just try to keep it open, you just have to keep it open enough for like little soft, mustardy poop to be able to make it through there↗
▶Ep 3 · 4:33
quoteI like to do this operation like when I can, it doesn't have to be the next day, the day after, you know, you can uh get it done, but I like to get it done on the neonatal uh admission↗
▶Ep 3 · 8:41
quoteWe use this term dilation, like we're stretching something that can be stretched up to a certain size, except that's not true. Like when they start out like a pinhole, it's a controlled tear.↗
▶Ep 3 · 8:41
clinicalPreoperative fistula dilation is a controlled tear when the fistula starts as a pinhole, not true stretching; dilate only as big as needed and then leave it alone until definitive repair.↗
▶Ep 3 · 11:04
quotethis is basically like the same thing one would do in a bulbbar fistula but applied to a vestibular fistula↗
▶Ep 3 · 11:04
clinicalPerineal body-preserving PSARP is basically the same technique one would use for a bulbar fistula but applied to a vestibular fistula.↗
▶Ep 3 · 11:32
clinicalFor perineal body-preserving PSARP, the key is to really clean up the lateral planes before coming around the front, mobilizing the sides and staying on the bowel wall before deciding to come through the common plane.↗
▶Ep 3 · 11:32
quotewhen you're a PAP surgeon, that's what you do when you're used to the concepts of working, uh, you know, really religiously about cleaning up the lateral planes before you come around the front↗
▶Ep 3 · 11:45
clinicalWhen starting perineal body-preserving PSARP, it is acceptable to go a little bit into the perineal body on the front and a little bit behind it in the back to make the working incision not the tightest pinhole, while still keeping the perineal body largely intact.↗
▶Ep 3 · 20:28
clinical2021 PCPLC retrospective study of Hirschsprung pull-through showed no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days).↗
▶Ep 3 · 23:40
epidemiologicalMulti-center retrospective study published in 2022 showed 24% of Hirschsprung patients received at least one Botox injection.↗
▶Ep 3 · 23:58
clinicalCincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients who received Botox (30% vs 50%).↗
▶Ep 3 · 24:23
clinicalCincinnati Children's prospective study found patients who received Botox at time of pull-through had higher risk of diaper rash (60%).↗
▶Ep 3 · 24:58
clinicalEarly work from Sam Nurko's group in Boston used weight-based Botox dosing up to a maximum of 100 units for Hirschsprung patients.↗
▶Ep 3 · 29:29
quoteevery little flick of the bovie, like that's a blood vessel, that's a nerve, and that's another week in the bowel management clinic↗
Summaries Nelson gave as host
· 16 summaries
Recaps of other experts' statements, not Nelson's own clinical position.
Summaries Nelson gave as host · Anorectal Malformation5 summaries
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 66 · 20:28
host summaryNelson Rosen summarizing the discussion: 2021 PCPLC retrospective study of Hirschsprung pull-through showed no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days).↗
▶Ep 66 · 23:40
host summaryNelson Rosen summarizing the discussion: Multi-center retrospective study published in 2022 showed 24% of Hirschsprung patients received at least one Botox injection.↗
▶Ep 66 · 23:58
host summaryNelson Rosen summarizing the discussion: Cincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients who received Botox (30% vs 50%).↗
▶Ep 66 · 24:23
host summaryNelson Rosen summarizing the discussion: Cincinnati Children's prospective study found patients who received Botox at time of pull-through had higher risk of diaper rash (60%).↗
▶Ep 66 · 24:58
host summaryNelson Rosen summarizing the discussion: Early work from Sam Nurko's group in Boston used weight-based Botox dosing up to a maximum of 100 units for Hirschsprung patients.↗
Summaries Nelson gave as host · Colorectal / ARM & Hirschsprung5 summaries
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 180 · 20:28
host summaryNelson Rosen summarizing the discussion: 2021 PCPLC retrospective study of Hirschsprung pull-through showed no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days).↗
▶Ep 180 · 23:40
host summaryNelson Rosen summarizing the discussion: Multi-center retrospective study published in 2022 showed 24% of Hirschsprung patients received at least one Botox injection.↗
▶Ep 180 · 23:58
host summaryNelson Rosen summarizing the discussion: Cincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients who received Botox (30% vs 50%).↗
▶Ep 180 · 24:23
host summaryNelson Rosen summarizing the discussion: Cincinnati Children's prospective study found patients who received Botox at time of pull-through had higher risk of diaper rash (60%).↗
▶Ep 180 · 24:58
host summaryNelson Rosen summarizing the discussion: Early work from Sam Nurko's group in Boston used weight-based Botox dosing up to a maximum of 100 units for Hirschsprung patients.↗
Summaries Nelson gave as host · Hirschsprung disease5 summaries
2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma
▶Ep 78 · 20:28
host summaryNelson Rosen summarizing the discussion: 2021 PCPLC retrospective study of Hirschsprung pull-through showed no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days).↗
▶Ep 78 · 23:40
host summaryNelson Rosen summarizing the discussion: Multi-center retrospective study published in 2022 showed 24% of Hirschsprung patients received at least one Botox injection.↗
▶Ep 78 · 23:58
host summaryNelson Rosen summarizing the discussion: Cincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients who received Botox (30% vs 50%).↗
▶Ep 78 · 24:23
host summaryNelson Rosen summarizing the discussion: Cincinnati Children's prospective study found patients who received Botox at time of pull-through had higher risk of diaper rash (60%).↗
▶Ep 78 · 24:58
host summaryNelson Rosen summarizing the discussion: Early work from Sam Nurko's group in Boston used weight-based Botox dosing up to a maximum of 100 units for Hirschsprung patients.↗
Summaries Nelson gave as host · Pilonidal Disease1 summary
