If you excise all the pits, they tend to lead to a cavity. And I think that's the key is with the multiple pit excisions, even though they're small, you can access that cavity and really clean that out.
You can operate after 8 hours of putting them on Bival, as long as your levels are stable, which happens really soon. And it's a much easier surgical repair. There's very little edema.
Update Course Rewind: When & How to Operate CDH Patients on ECMO 2024
▶Ep 36 · 1:33
clinicalThe majority of centers still do VA ECMO primarily for CDH babies.↗
▶Ep 36 · 1:33
quoteAnd I would be the old school person that still does VA because I'm not bold enough to go VV.↗
▶Ep 36 · 1:33
clinicalThere are lots of benefits to VV and lots of benefits to VA ECMO.↗
▶Ep 36 · 1:33
opinionBoth VA and VV ECMO answers are totally reasonable for severe CDH.↗
Update Course Rewind: When & How to Operate CDH Patients on ECMO 2024 Part 2
▶Ep 37 · 1:02
quoteBival is pretty much a no-brainer and we use predominantly as the sole anticoagulant drip for most.↗
▶Ep 37 · 1:02
quoteI think most places still use heparin, but I think this is one of those times when the needle is like really moving quickly because everything is better about it and I think people once you try it will switch pretty quickly.↗
▶Ep 37 · 1:02
clinicalBivalirudin is used predominantly as the sole anticoagulant drip for most ECMO cases at the speaker's institution.↗
▶Ep 37 · 1:02
opinionMost places still use heparin for ECMO anticoagulation, but the practice is shifting quickly toward bivalirudin.↗
▶Ep 37 · 2:42
clinicalBuilding team buy-in for early repair requires showing data and assembling a dedicated team including anesthesiologists and neonatologists willing to operate in the OR and on weekends.↗
▶Ep 37 · 2:42
clinicalWith bivalirudin, surgical repair can be performed as early as 8 hours after ECMO initiation once levels are stable, which happens quickly.↗
▶Ep 37 · 2:42
clinicalEarly repair on ECMO results in much less tissue edema, making it very similar to performing repair off ECMO.↗
▶Ep 37 · 2:42
quoteYou can operate after 8 hours of putting them on Bival, as long as your levels are stable, which happens really soon. And it's a much easier surgical repair. There's very little edema.↗
Steven's statements about Pilonidal Disease18 statements
clinicalThe patient presented with two previous abscess drainages (I&Ds) in the emergency department within the past 6 months↗
▶Ep 3 · 2:45
clinicalAt UCLA, the institution was transitioning from unroofing and marsupialization to minimal pit excision for pilonidal disease management as of 2019↗
▶Ep 3 · 3:54
clinicalGIPS procedures can be done in the clinic or on an outpatient basis↗
▶Ep 3 · 3:54
quoteYou can often do them in the clinic or as an outpatient basis.↗
▶Ep 3 · 4:34
quoteClearly improved outcomes with respect to healing times, recovery times, and most importantly, they've really decreased the, the need for additional operations and recurrence rates.↗
▶Ep 3 · 6:30
clinicalThe key principle is that excising all pits allows access to the cavity for thorough cleaning; leaving material behind leads to recurrence↗
▶Ep 3 · 6:30
quoteIf you excise all the pits, they tend to lead to a cavity. And I think that's the key is with the multiple pit excisions, even though they're small, you can access that cavity and really clean that out.↗
▶Ep 3 · 7:07
clinicalDoctor Lee occasionally uses hydrogen peroxide to help clean out the tract but does not use sclerosing agents↗
▶Ep 3 · 7:46
clinicalAggressive scraping of granulation tissue using Cottes and gauze is performed after hair removal↗
▶Ep 3 · 7:46
quoteWe use, we use Cottes to scrape it out, and we're very aggressive. We'll also use the gauze to, to rub it and, and so forth.↗
▶Ep 3 · 8:17
clinicalIf incisions close too early, silver nitrate can be used in clinic to keep the incisions open↗
▶Ep 3 · 8:17
clinicalTraditional unroofing and marsupialization required roughly 4 to 6 weeks for complete healing↗
▶Ep 3 · 8:17
clinicalWeekly hair shaving is recommended during healing with one-week follow-up visits↗
▶Ep 3 · 10:05
clinicalNo perioperative antibiotics are needed for GIPS procedures↗
▶Ep 3 · 10:05
clinicalDoctor Lee does not use antibiotics for GIPS procedures unless there is an abscess, because wounds are left open to drain↗
▶Ep 3 · 10:05
quotePersonally, um, unless there's an abscess, uh, but for the, for this, I don't use them because you're leaving the, the wounds open and they should drain. So there's no need for even perioperative antibiotics for this.↗
▶Ep 3 · 11:09
clinicalFor emergency department drainage with significant inflammation and infection, adequate clean-out often cannot be achieved, so simple abscess drainage is recommended↗
▶Ep 3 · 11:09
clinicalDoctor Lee advocates draining abscesses off midline so that when the tract forms, it will be off midline↗
Steven's statements about Recto-vestibular Fistula7 statements
host summarySteven Lee summarizing the discussion: Doctor Lee sometimes performs GIPS procedures in his office↗
▶Ep 3 · 4:34
host summarySteven Lee summarizing the discussion: GIPS procedure shows improved outcomes with respect to healing times, recovery times, and decreased need for additional operations and recurrence rates compared to traditional open excisions↗
▶Ep 3 · 6:30
host summarySteven Lee summarizing the discussion: For recurrences, minimally invasive tactics can be repeated, including pit picking technique where hairs are plucked out↗
