# Aerodigestive / ENT — GCMD Library living collection

Also covered as: esophageal atresia · tracheoesophageal fistula · aspiration · tracheomalacia · laryngeal cleft · eosinophilic esophagitis · dysphagia · CHARGE syndrome

Experts: Dr. Em Gootee, Dr. Todd Ponsky, Dr. Bob Wood, Dr. Phil Putnam

Updated: n/a · 26 episodes · 517 cited statements

## Episodes
### Fundamentals
- [QUAD #22: What is CHARGE syndrome? with Dr. Catherine Hart](https://qa.library.globalcastmd.com/watch/quad-22-what-is-charge-syndrome-with-dr-catherine-hart-9458) — video · 0:59 · [machine version](https://qa.library.globalcastmd.com/watch/quad-22-what-is-charge-syndrome-with-dr-catherine-hart-9458.md)

### Diagnosis & Workup
- [Aerodigestive & Esophageal Surgery: Dual Endoscopy Discussion](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038) — video · 2:22 · [machine version](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038.md)
- [Aerodigestive & Esophageal Surgery: Aspiration in TEFs](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039) — video · 5:28 · [machine version](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039.md)

### Acute Management
- [QUAD #7 Anesthesia for Thoracoscopic Techniques with Dr. Nathaniel Tighe](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115) — video · 7:35 · [machine version](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115.md)

### Medical Management
- [Pediatric Gastroesophageal Reflux Disease](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359) — podcast · 81:04 · [machine version](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359.md)
- [Gastroesophageal Reflux Disease](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289) — podcast · 81:04 · [machine version](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289.md)
- [QUAD #25: Medical Management of Minor Laryngeal Clefts with Dr. Greg Burg](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773) — video · 7:11 · [machine version](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773.md)

### Surgical Management
- [Pediatric Tracheostomy in a 7 year old child Dr. Tamer Ashraf Wafa](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151) — video · 2:53 · [machine version](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151.md)
- [Laryngeal Clefts](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226) — video · 14:20 · [machine version](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226.md)
- [Laryngotracheal Stenosis](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406) — video · 16:20 · [machine version](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406.md)
- [QUAD #1: Cervical Tracheopexy with Dr. Alessandro de Alarcon](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779) — video · 5:26 · [machine version](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779.md)
- [QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919) — video · 7:36 · [machine version](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919.md)
- [QUAD #4: Surgical Management of Button Battery & Caustic Ingestion with Dr. Aaron Garrison](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088) — video · 8:10 · [machine version](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088.md)
- [QUAD #6 Slide Tracheoplasty for TEF, Otolaryngology Approach with Dr. Mike Rutter](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114) — video · 7:37 · [machine version](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114.md)
- [QUAD #20: Endoscopic Repair of Minor Laryngeal Clefts with Dr. Catherine Hart](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373) — video · 6:01 · [machine version](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373.md)

### Complications
- [QUAD #5 Pharyngeal Scar Management with Dr. Doug von Allmen](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116) — video · 7:12 · [machine version](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116.md)

### Evidence & Research
- [Article of Interest: Optimal Timing of Tracheostomy in Injured Adolescents](https://qa.library.globalcastmd.com/watch/article-of-interest-optimal-timing-of-tracheostomy-in-injured-adolescents-5788) — video · 1:34 · [machine version](https://qa.library.globalcastmd.com/watch/article-of-interest-optimal-timing-of-tracheostomy-in-injured-adolescents-5788.md)
- [Quick Literature Updates Episode 8](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713) — video · [machine version](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713.md)
- [Esophageal Surveillance Practices in Esophageal Atresia Patients](https://qa.library.globalcastmd.com/watch/esophageal-surveillance-practices-in-esophageal-atresia-patients-6844) — video · [machine version](https://qa.library.globalcastmd.com/watch/esophageal-surveillance-practices-in-esophageal-atresia-patients-6844.md)
- [Tracheobronchopexy to Avoid Tracheostomy in Esophageal Atresia Patients With Severe Life-Threatening Tracheobronchomalacia](https://qa.library.globalcastmd.com/watch/tracheobronchopexy-to-avoid-tracheostomy-in-esophageal-atresia-patients-with-severe-life-threatening-tracheobronchomalacia-10435) — video · 0:50 · [machine version](https://qa.library.globalcastmd.com/watch/tracheobronchopexy-to-avoid-tracheostomy-in-esophageal-atresia-patients-with-severe-life-threatening-tracheobronchomalacia-10435.md)
- [Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2025](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786) — podcast · 16:35 · [machine version](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786.md)

### Case-Based Learning
- [Aerodigestive & Esophageal Surgery - The Unsalvageable Esophagus & Cases](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738) — video · 101:09 · [machine version](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738.md)
- [Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739) — video · 120:59 · [machine version](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739.md)
- [TEF Presentations (Extended): Aerodigestive & Esophageal Surgery](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037) — video · 108:11 · [machine version](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037.md)

### In-Depth Reviews
- [Aerodigestive Management of Pediatric Aspiration - FULL SHOW](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796) — video · 157:09 · [machine version](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796.md)
- [QUAD #27 - Multidisciplinary - How Do Teams Enhance Outcomes by the CCHMC ADEC Team](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201) — video · 10:19 · [machine version](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=0) Diagnostic Techniques for Finding TEF (Ep 4)
- [6:41](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=401) Endoscopic TEF Repair Technique and First Case (Ep 4)
- [19:16](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1156) Recurrent TEF Case with Positive Pressure Testing (Ep 4)
- [28:29](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1709) Slide Tracheoplasty for Complex TEF (Ep 4)
- [41:00](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2460) Button Battery Injuries and Their Complications (Ep 4)
- [50:05](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3005) Transtracheal Repair Approach for High TEF (Ep 4)
- [61:40](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3700) Endoscopic Suturing and Alternative Techniques (Ep 4)
- [78:00](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4680) Seven-Year-Old with Missed H-Type TEF (Ep 4)
- [89:33](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5373) Hearing Aid Mold Foreign Body and Bronchoesophageal Fistula (Ep 4)
- [102:10](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6130) Multiple Bronchoesophageal Fistulas Case (Ep 4)
- [104:24](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6264) Laryngeal Cleft Missed on Flexible Bronchoscopy (Ep 4)
- [106:44](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6404) Tracheal Pouch Marsupialization Technique (Ep 4)
- [0:00](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=0) Introduction and first long-gap case: 4-month-old with type C TEF (Ep 2)
- [3:50](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=230) Experimental approaches: endoscopic Foker and magnets (Ep 2)
- [7:44](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=464) Segmental colonic interposition for long-gap atresia (Ep 2)
- [13:22](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=802) 16-year-old with failed small bowel interposition and proximal stricture (Ep 2)
- [19:57](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1197) 2-year-old with recalcitrant anastomotic stricture after multiple Foker procedures (Ep 2)
- [25:23](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1523) Stricture management: dilation frequency, needle knife, steroids, and stents (Ep 2)
- [39:42](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2382) Timing of anti-reflux surgery in recalcitrant strictures (Ep 2)
- [51:10](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3070) Case: 16-year-old with high cervical stricture and intact distal esophagus (Ep 2)
- [66:46](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4006) Multidisciplinary evaluation protocol for complex esophageal cases (Ep 2)
- [78:10](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4690) Case: 16-year-old with multiple TEFs, non-continuous esophagus, and tracheal defects (Ep 2)
- [90:52](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5452) Alternative approach: posterior tracheopexy and pericardial patch (Ep 2)
- [99:43](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5983) Summary and closing reflections (Ep 2)
- [0:00](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=0) Introduction and case presentation: 6-month-old with vomiting and respiratory symptoms (Ep 1)
- [2:49](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=169) Initial workup: ruling out oropharyngeal dysphagia and food allergy (Ep 1)
- [8:20](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=500) Proton pump inhibitors in infants: ineffective and harmful (Ep 1)
- [12:30](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=750) Endoscopy to rule out eosinophilic esophagitis; use of macrolides (Ep 1)
- [17:11](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1031) Role of upper GI and when to suspect anatomic problems (Ep 1)
- [24:25](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1465) NICU preemie with feeding intolerance: NG vs. G-tube timing (Ep 1)
- [34:57](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2097) Diagnostic value of NJ trial and moving away from pH-impedance (Ep 1)
- [40:10](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2410) When pH-impedance is useful: Rome IV categories in older children (Ep 1)
- [44:50](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2690) Duration of PPI therapy and monitoring (Ep 1)
- [50:00](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3000) The 'perfect Nissen': minimal mobilization to prevent wrap migration (Ep 1)
- [56:40](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3400) Post-fundoplication retching: workup and management (Ep 1)
- [61:40](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3700) Neurologically impaired patients and indications for fundoplication (Ep 1)
- [70:00](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=4200) Failed fundoplication: when to redo and alternative procedures (Ep 1)
- [75:20](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=4520) Rumination syndrome: a critical masquerader (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=0) Introduction and Guest Introductions (Ep 8)
- [2:49](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=169) Initial Workup of Infant with Vomiting and Respiratory Symptoms (Ep 8)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "The bugbee cautery is useful and underutilized among general surgeons for treating recurrent tracheoesophageal fistulas." — Todd Ponsky (opinion) [Ep 4 · 0:04](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4)
- "A 70-degree endoscope is a difficult tool to use but useful for tracking down hard-to-find tracheoesophageal fistulas." (clinical) [Ep 4 · 0:37](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=37)
- "Routine bronchoscopy is now standard practice for all type C esophageal atresia cases, though this represents a change from earlier training when it was not necessarily performed." — Dan (clinical) [Ep 4 · 1:13](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=73)
- "General surgeons may underappreciate tracheomalacia or laryngomalacia, making collaboration with ENT colleagues valuable for comprehensive airway assessment." — Todd Ponsky (opinion) [Ep 4 · 1:53](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=113)
- "Pediatric surgery fellows at this institution complete a one-month attachment with ENT to perform bronchoscopies as part of their training." (clinical) [Ep 4 · 2:22](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=142)
- "Dual scoping (simultaneous bronchoscopy and esophagoscopy) is enormously valuable for complicated TEF patients, providing different information and advantages in visualization." — Dan (clinical) [Ep 4 · 6:41](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=401)
- "During dual scoping, you can see the light from one scope through the epithelium, inject material that may come through subtle holes, or observe bubbles from air insufflation, making simultaneous visualization quite valuable." — Phil (clinical) [Ep 4 · 7:33](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=453)
- "For combined bronchoscopy and esophagoscopy in small children, a 2.8 mm flexible bronchoscope is typically used alongside an infant gastroscope (5.4 or 6 mm outer diameter)." — Phil (clinical) [Ep 4 · 8:19](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=499)
- "An infant gastroscope will fit retrograde through a 16 French gastrostomy tube." — Phil (clinical) [Ep 4 · 8:36](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=516)
- "The concept of endoscopic TEF repair is to demucosalize the tract because mucosa is a non-stick surface; you want raw against raw with a tiny bit of fibrin glue to seal it while it scars off." (clinical) [Ep 4 · 11:01](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=661)
- "When using fibrin glue for TEF repair, use a very small amount (about 0.1 ml) via a Duplo double-lumen catheter to avoid forming a foreign body." (clinical) [Ep 4 · 11:36](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=696)
- "Trichloroacetic acid (TCA) can be used for TEF demucosalization, but it is difficult to control precisely and leaves white tissue everywhere, whereas the bugbee provides more precise control." — Todd Ponsky (clinical) [Ep 4 · 12:21](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=741)
- "When using bugbee cautery for TEF repair, place something in the esophagus (such as an endotracheal tube) as a spacer to avoid burning the back of the esophageal wall." (clinical) [Ep 4 · 13:36](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=816)
- "A bugbee catheter will go down an EGD scope, allowing cauterization from the esophageal side if the tract angle is favorable." (clinical) [Ep 4 · 14:29](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=869)
- "A 3 French bugbee fits through a 2.8 mm flexible bronchoscope with a 1.2 mm suction channel, providing precise control of the tip." — Bob Wood (clinical) [Ep 4 · 15:10](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=910)
- "When passing a bugbee through a rigid scope, bending the end at a slight angle before insertion allows steering by rotation." (clinical) [Ep 4 · 15:32](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=932)
- "Endoscopic TEF repair often needs to be performed more than once; the average is approximately 2 procedures, with some requiring 1 and others 3-4 attempts." (clinical) [Ep 4 · 22:37](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1357)
- "The success rate for endoscopic TEF closure is running about 80%, not 100%." (clinical) [Ep 4 · 24:18](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1458)
- "After 3 or 4 failed endoscopic TEF repair attempts, it is typically time to give up and discuss alternative approaches." (clinical) [Ep 4 · 24:27](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1467)
- "When cauterizing a TEF, you should particularly try to get the edges and sides because as they scar in, that will narrow the whole mouth, making re-intervention easier if needed." (clinical) [Ep 4 · 24:59](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1499)
- "To reduce airway fire risk during bugbee cautery, insufflated oxygen should be kept at 30% or less." (clinical) [Ep 4 · 25:51](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1551)
- "Patients can tolerate a minute or two of lower oxygen saturation during cautery procedures to maintain safe oxygen levels below 30%." — Bob Wood (clinical) [Ep 4 · 26:10](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1570)
- "Radiance voice gel (used for vocal cord injection) can be injected into the wall beside a TEF to obliterate the potential space and hold raw surfaces together; it only lasts a few weeks." (clinical) [Ep 4 · 27:05](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1625)
- "For TEF repair, all that matters is achieving raw-on-raw tissue contact for healing." — Todd Ponsky (clinical) [Ep 4 · 69:25](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4165)
- "Thoracoscopic diaphragmatic hernia repairs may have a higher recurrence rate than open repairs, possibly because they do not cause enough raw-on-raw tissue contact." — Todd Ponsky (opinion) [Ep 4 · 69:33](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4173)
- "Slide tracheoplasty is a useful technique for big complex TEF holes, using part of the trachea to repair the esophageal defect." (clinical) [Ep 4 · 30:55](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1855)
- "Sternal periosteum is an excellent interposition graft material—it is like Kevlar, bulletproof, abundant, and very strong, though almost impossible to suture." (clinical) [Ep 4 · 34:02](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2042)
- "Slide tracheoplasty appears to be a learning-curve, surgeon-dependent operation, unlike many operations where the surgeon does not matter long-term." (opinion) [Ep 4 · 57:09](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3429)
- "Button batteries are extremely dangerous and can cause ongoing tissue damage that extends beyond what is visible and beyond the expected time frame." — Dan (clinical) [Ep 4 · 43:17](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2597)
- "The institutional protocol for button battery ingestion is to remove them within 2 hours of identification, as it is considered a medical emergency." — Phil (guideline) [Ep 4 · 44:04](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2644)
- "Dead button batteries still have about 2 volts and continue to cause damage." — Todd Ponsky (host_summary) [Ep 4 · 45:31](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2731)
- "Button batteries can be distinguished from coins on AP X-ray by a visible rim, eliminating the need for a lateral view." — Todd Ponsky (host_summary) [Ep 4 · 45:37](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2737)
- "The American Society of Pediatric Otolaryngology has a task force working to introduce legislation requiring skull-and-crossbones etching on all button batteries to distinguish them from coins on X-ray." (guideline) [Ep 4 · 44:22](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2662)
- "In the series of approximately 12 slide tracheoplasties for TEF, there were two failures, both in button battery cases, and both patients were the only button battery cases in the series." (clinical) [Ep 4 · 41:00](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2460)
- "For button battery ingestions, if there was a witnessed ingestion, the patient is asymptomatic, removal occurs within a couple of hours, and the mucosa looks good, the likelihood of doing well is high." — Phil (clinical) [Ep 4 · 46:02](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2762)
- "Late deaths from aortoesophageal fistulas have occurred following unwitnessed button battery ingestions that were not terribly prolonged." — Phil (clinical) [Ep 4 · 46:18](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2778)
- "For button battery cases, CT angiography to look at the aorta may provide as much information about risk of sudden death as endoscopic evaluation, though sensitivity data is lacking." — Phil (opinion) [Ep 4 · 47:10](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2830)
- "The style of button battery matters for risk: large round flat 3-volt batteries are by far the most potentially damaging, while smaller fatter batteries pose less risk." (clinical) [Ep 4 · 48:01](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2881)
- "The protocol is to remove button batteries from the stomach because if they do not leave and sit in one spot, they create considerable injury, especially in the distal stomach/antrum where scarring or stenosis can occur." — Phil (clinical) [Ep 4 · 49:22](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2962)
- "For transtracheal TEF repair, a three-layer closure is performed: esophageal layer with knots in the esophageal lumen, interposition graft (typically sternal periosteum), and tracheal layer with knots in the tracheal lumen to reduce refistulization risk." (clinical) [Ep 4 · 54:11](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3251)
- "Transtracheal repair is a relatively two-dimensional operation where the surgeon matters less than in three-dimensional operations like slide tracheoplasty." (opinion) [Ep 4 · 56:21](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3381)
- "The primary complication of transtracheal TEF repair is refistulization, whereas slide tracheoplasty complications include dehiscence, which is a much bigger deal." (clinical) [Ep 4 · 56:03](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3363)
- "When repairing high H-type fistulas from a thoracic approach, there is a temptation to ligate the fistula on the esophageal side, which can leave a large tracheal pouch/diverticulum that causes problems if the patient needs a tracheostomy." (clinical) [Ep 4 · 64:18](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3858)
- "Endoscopic suturing in the trachea is remarkably humbling and painful, and the hardest part is tying the knot." (opinion) [Ep 4 · 68:11](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4091)
- "Nitinol clips could theoretically be used for endoscopic TEF repair, though they are permanent." — Dan (opinion) [Ep 4 · 68:33](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4113)
- "Metal clips can be used with endoscopic sutures for laryngeal cleft repairs from the esophageal side to hold sutures; the patient swallows the clip when the PDS dissolves." (clinical) [Ep 4 · 69:01](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4141)
- "Anal fistula plugs made of biologic material (surgesis) can be used for TEF repair by wrapping them with barbed VOC suture and inserting them into the fistula tract to promote scarring and collagen matrix formation." — Todd Ponsky (clinical) [Ep 4 · 97:24](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5844)
- "Long skinny TEF tracts from proximal to distal are the ideal candidates for endoscopic repair, while short, fat, wide tracts do not tend to do well with endoscopic techniques." (clinical) [Ep 4 · 63:58](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3838)
- "H-type fistulas are relatively short tracks straight from trachea to esophagus and do not do nearly as well with endoscopic repair compared to longer tracts." (clinical) [Ep 4 · 63:46](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3826)
- "Positive pressure testing for TEF involves placing an endotracheal tube with cuff in the esophagus and applying 30 cm H2O pressure of air, then observing for air blowing out of the fistula; the stomach must be suctioned afterward." (clinical) [Ep 4 · 21:36](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1296)
- "For proximal fistulas, intubation with a cuffed tube past the hole is preferred so the cuff holds the hole occluded during repair; this is not possible for fistulas on the carina." (clinical) [Ep 4 · 23:29](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1409)
- "One of the problems with endoscopic TEF cauterization is not being aggressive enough; you need to destroy the mucosa, not just give it a fright." — Bob Wood (clinical) [Ep 4 · 17:42](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1062)
- "With a flexible bronchoscope, you can insufflate through the suction channel and distend the lumen to get a better view and sweep the inside of the lumen during cauterization." — Bob Wood (clinical) [Ep 4 · 18:03](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1083)
- "Laryngeal clefts are incredibly easy to miss and must be actively looked for and probed, not just visually inspected." (clinical) [Ep 4 · 20:10](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1210)
- "A flexible bronchoscope is not a reliable tool for diagnosing laryngeal clefts; you cannot find them even when you know they are there 95% of the time due to limitations of flexible instrumentation." — Bob Wood (clinical) [Ep 4 · 103:43](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6223)
- "For anything suspected in the posterior commissure, subglottic space, or cervical trachea, a rigid scope with probing is mandatory, not just visual inspection." — Bob Wood (clinical) [Ep 4 · 104:02](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6242)
- "The retroflexed (upside-down) flexible bronchoscopy technique allows greater angulation at the scope tip in one direction than the opposite, making it useful for examining the posterior tracheal wall." — Bob Wood (clinical) [Ep 4 · 73:30](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4410)
- "Insufflating with oxygen through the suction channel at about 2 L/min during bronchoscopy spreads tissue apart, does not hurt respirations, and gives a better view." — Bob Wood (clinical) [Ep 4 · 74:15](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4455)
- "When advancing a flexible bronchoscope through the nose and glottis, it is very easy to miss pathology in the cervical trachea and subglottis; it is easier to see these areas while slowly withdrawing the scope than while advancing." — Bob Wood (clinical) [Ep 4 · 74:51](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4491)
- "High tracheoesophageal fistulas are very difficult to find from the esophageal side because they are just below the esophageal inlet where a forward-viewing gastroscope does not deflect well enough to get an en face view." — Phil (clinical) [Ep 4 · 4:43](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=283)
- "Going retrograde up the esophagus provides easier maneuvering just below the esophageal inlet for finding high fistulas." — Phil (clinical) [Ep 4 · 5:17](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=317)
- "Bronchoesophageal fistulas can be very hard to find because there are so many subsegmental bronchi." (clinical) [Ep 4 · 5:36](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=336)
- "During dual scoping for bronchoesophageal fistula, you can shake hands across the fistula if you can track it down, and seeing the other operator's scope is usually a giveaway." (clinical) [Ep 4 · 5:50](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=350)
- "During dual scoping, you can see the light from the other scope through the epithelium, inject material that may come through a hole, or see bubbles from insufflation, making simultaneous scoping quite valuable." — Phil (clinical) [Ep 4 · 7:33](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=453)
- "Operators can turn off their light during dual scoping so the other person can see their light and determine if they are in the right region." (clinical) [Ep 4 · 7:58](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=478)
- "A 2.8 mm flexible bronchoscope is typically used for combined procedures, and the GI scope for small children is an infant scope (5.4 or 6 mm outer diameter)." — Phil (clinical) [Ep 4 · 8:19](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=499)
- "An infant gastroscope will fit retrograde through a 16 French gastrostomy tube, which is why 16 French G-tubes are preferred over 14 French." — Phil (clinical) [Ep 4 · 8:36](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=516)
- "A bronchoscope can be used retrograde in the esophagus because it fits through smaller openings." — Bob Wood (clinical) [Ep 4 · 8:57](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=537)
- "For patients with Down syndrome, swallow studies are difficult to interpret due to cooperation issues." (clinical) [Ep 4 · 71:25](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4285)
- "If a patient is clinically aspirating with a history of TEF repair, maintain a high index of suspicion for recurrent fistula or laryngeal cleft even if initial studies are negative." (clinical) [Ep 4 · 71:44](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4304)
- "After TEF repair, patients may have persistent bronchiectasis from years of aspiration, requiring months of care with vibrating vest and chest physiotherapy even after successful fistula closure." (clinical) [Ep 4 · 82:40](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4960)
- "Tracheal pouches/diverticula can cause problems during tracheostomy tube changes because the tube may go into the pouch instead of the trachea, causing the patient to decompensate." (clinical) [Ep 4 · 104:45](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6285)
- "Tracheal pouches can be marsupialized using a Storz ClickLine biopsy forceps (pediatric laparoscopic instrument) with suction and cautery at about 40 watts to divide the common party wall." (clinical) [Ep 4 · 105:12](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6312)
- "Marsupializing tracheal pouches can make tracheomalacia worse symptomatically, though usually it does not and kids do well." — Bob Wood (clinical) [Ep 4 · 106:00](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6360)
- "After marsupialization of tracheal pouches, what remains tends to scar to the sides and becomes almost invisible." (clinical) [Ep 4 · 106:29](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6389)
- "Hearing aid molds are radiolucent and can be missed on chest X-ray." (clinical) [Ep 4 · 84:50](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5090)
- "Airway stents can erode and create new fistulas into the esophagus." (clinical) [Ep 4 · 87:49](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5269)
- "A Y-shaped stent placed in both bronchi and up the trachea with a trach tube into the stent can successfully bypass a bronchoesophageal fistula, allowing significant clinical improvement." (clinical) [Ep 4 · 88:07](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5287)
- "Pectus excavatum can worsen tracheobronchomalacia, and sternotomy for other procedures can make the pectus worse." (clinical) [Ep 4 · 86:40](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5200)
- "Placing a pectus bar can improve severe tracheobronchomalacia by pulling the chest wall forward." (clinical) [Ep 4 · 87:33](https://qa.library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5253)
- "For long-gap esophageal atresia, a gap of 2 vertebral bodies or approximately 2 centimeters is considered close enough to attempt primary anastomosis." — Dan (guideline) [Ep 2 · 5:44](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=344)
- "If primary anastomosis cannot be achieved at initial operation, placing the ends on tension for one week and then re-operating often allows successful closure due to stretch." — Dan (clinical) [Ep 2 · 5:51](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=351)
- "In experimental porcine models of endoscopic Foker (using olive beads and wire traction), pressure necrosis at the anastomotic site is the suspected cause of death." — Todd Ponsky (clinical) [Ep 2 · 6:32](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=392)
- "Intraluminal magnetic anastomosis is being developed as a minimally invasive approach to long-gap atresia, with the goal of reducing pressure necrosis compared to bead-based traction." — Todd Ponsky (clinical) [Ep 2 · 7:00](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=420)
- "Segmental colonic interposition (preserving distal native esophagus) reduces the risk of long-term redundancy and tortuosity compared to full-length colon interposition from cervical esophagus to stomach." — Dan (clinical) [Ep 2 · 9:00](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=540)
- "Segmental interposition preserves the native gastroesophageal junction, allowing potential future anti-reflux surgery at the normal GE junction rather than at a colonic-gastric anastomosis." — Dan (clinical) [Ep 2 · 9:22](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=562)
- "Segmental colonic interposition requires two anastomoses (one in chest, one in neck) and a thoracotomy, making it a morbid operation, but it is theoretically 'one and done.'" — Dan (clinical) [Ep 2 · 9:44](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=584)
- "Sometimes surgeons try too hard to salvage the native esophagus, and children may do better with esophageal replacement, especially when chronic aspiration from recurrent TEFs or strictures causes severe pulmonary disease." — Dan (opinion) [Ep 2 · 11:24](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=684)
- "When mobilizing a distal esophageal pouch off tension (e.g., from prevertebral fascia), the pouch retracts and becomes much shorter than it appeared pre-operatively." — Dan (clinical) [Ep 2 · 12:53](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=773)
- "Esophageal stents can compress the adjacent trachea, especially in children with tracheomalacia or when the esophagus lies directly posterior to the trachea. Always perform bronchoscopy after stent placement." — Em Gootee (clinical) [Ep 2 · 48:18](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2898)
- "On CT scan, if the dilated esophagus lies immediately posterior to the malacic trachea, any esophageal distention (food bolus, stent) will compress the trachea. If the esophagus deviates to the left, tracheal compression is less likely." — Bob (clinical) [Ep 2 · 48:58](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2938)
- "Chronic esophageal foreign bodies (e.g., coins lodged for weeks) can cause posterior tracheal bulge and present as refractory asthma or bronchiolitis, often diagnosed late because chest X-rays are not routinely obtained in asthma protocols." — Em Gootee (clinical) [Ep 2 · 50:20](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3020)
- "For recalcitrant esophageal strictures, weekly dilations (3–4 cycles) prevent fibroblasts from bridging and allow the stricture to scar open rather than closed." — Em Gootee (clinical) [Ep 2 · 36:29](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2189)
- "Needle knife incision of esophageal strictures is effective for short, well-defined, non-circumferential scar bands. It should be avoided on the anterior wall in patients with prior TEF due to proximity to the trachea." — Phil (clinical) [Ep 2 · 35:13](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2113)
- "Kenalog (steroid) injection after stricture dilation is preferred over mitomycin. Mitomycin at high concentrations (up to 5 mg/mL) causes tissue necrosis and has not shown superior outcomes compared to steroids." — Em Gootee (clinical) [Ep 2 · 33:28](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2008)
- "Patients born with tracheoesophageal fistula, especially those with esophageal atresia, are at significantly higher risk for eosinophilic esophagitis, a non-acid inflammatory condition that causes strictures if untreated." — Phil (epidemiological) [Ep 2 · 46:14](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2774)
- "Eosinophilic esophagitis in infants is effectively managed with elemental formula, which works in approximately 95% of cases." — Phil (clinical) [Ep 2 · 47:14](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2834)
- "Routine esophageal biopsies should be performed during endoscopy in TEF patients to screen for eosinophilic esophagitis, even in the absence of overt symptoms." — Phil (guideline) [Ep 2 · 46:53](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2813)
- "In patients with recalcitrant anastomotic strictures and documented reflux, treating reflux with fundoplication may allow the stricture to heal. However, this approach risks making subsequent esophageal mobilization more difficult if replacement is ultimately needed." — Dan (clinical) [Ep 2 · 43:07](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2587)
- "Medical acid suppression (PPI) reduces gastric acid but does not stop reflux itself. A mechanical barrier (fundoplication) is required to prevent reflux of bile and other irritants." — Phil (clinical) [Ep 2 · 44:13](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2653)
- "Feeding via gastrojejunal tube with gastric drainage (GJ/G) is a temporizing measure to reduce reflux into the esophagus while managing a refractory stricture." — Em Gootee (clinical) [Ep 2 · 45:47](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2747)
- "Substernal colonic interposition avoids thoracotomy and is useful when the chest is heavily scarred from prior operations. However, it requires sacrificing the entire native esophagus." — Dan (clinical) [Ep 2 · 10:27](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=627)
- "When performing segmental colonic interposition, the choice of right vs. left colon is based on intraoperative assessment of the marginal artery; the side with better vascularity is selected." — Dan (clinical) [Ep 2 · 66:15](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3975)
- "Redundant colonic interposition can be revised by shortening the conduit at the distal anastomosis, dividing small branches along the colonic wall while preserving the vascular arcade." — Dan (clinical) [Ep 2 · 72:54](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4374)
- "Covered esophageal stents (8 mm diameter) are now available for pediatric use and may be effective for temporizing strictures or leaks. They are partially covered to reduce migration and perforation risk." — Phil (clinical) [Ep 2 · 38:45](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2325)
- "In complex esophageal cases, a combined operating room evaluation with rigid bronchoscopy, flexible bronchoscopy, and EGD (often with two scopes simultaneously) provides comprehensive anatomic assessment and is safer than sequential procedures." — Dan (clinical) [Ep 2 · 78:10](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4690)
- "Contrast studies through the endoscope under fluoroscopy are routinely performed before attempting wire passage or dilation to confirm anatomy and avoid perforation." — Phil (clinical) [Ep 2 · 78:53](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4733)
- "Esophageal bypass (leaving native esophagus in situ) is a viable option when resection would create an unreconstructible tracheal defect. A fundoplication is performed to prevent reflux into the residual esophageal pouch." — Dan (clinical) [Ep 2 · 86:54](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5214)
- "When performing esophageal bypass, leaving a tracheoesophageal fistula open allows native esophageal secretions to drain into the airway, preventing mucocele formation in the residual pouch." — Bob (clinical) [Ep 2 · 87:49](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5269)
- "Children who have been unable to swallow for years may continue to spit reflexively even after successful esophageal reconstruction. It can take weeks to months for them to relearn swallowing." — Dan (clinical) [Ep 2 · 88:42](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5322)
- "Posterior tracheopexy (pexing the trachea to the anterior spine) combined with bovine pericardial patch for tracheal defects is an alternative to esophageal bypass, but pericardial patches can fail and create large tracheal defects." — Em Gootee (host_summary) [Ep 2 · 94:15](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5655)
- "Tissue-engineered tracheal homografts with pre-epithelialization are under development in multiple centers (London leading) but are not yet ready for routine clinical use." — Em Gootee (clinical) [Ep 2 · 92:06](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5526)
- "Tracheal homografts (dead trachea implants) have been performed but are associated with difficult postoperative courses lasting several months." — Em Gootee (clinical) [Ep 2 · 91:42](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5502)
- "Magnetic compression anastomosis (magnamosis) has been used successfully for gastrojejunostomy but is unproven in the esophagus. The main limitations are the distance magnets can attract across and the lack of mucosal lining in the resulting anastomosis." — Todd Ponsky (clinical) [Ep 2 · 30:25](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1825)
- "For a spit fistula to avoid recurrent TEF, the distal esophageal stump must be fully mobilized down to the diaphragm and separated from the trachea, not just divided and dropped." — Todd Ponsky (clinical) [Ep 2 · 74:05](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4445)
- "In patients with multiple prior thoracotomies and fused ribs, exposure can still be achieved by 'chipping away' at the fused ribs, though the field is narrow and the lung is at risk of injury from scarring." — Dan (clinical) [Ep 2 · 29:25](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1765)
- "Placing endoscopes from above and below during thoracoscopic stricture resection allows identification of the stricture by transillumination ('go to the light')." — Todd Ponsky (clinical) [Ep 2 · 26:28](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1588)
- "Cervical esophageal strictures at the thoracic inlet are difficult to resect via neck approach because the esophagus is fixed substernally and cannot be mobilized adequately for tension-free anastomosis." — Dan (clinical) [Ep 2 · 17:07](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1027)
- "Manubrial resection for high esophageal strictures provides less exposure than expected because the clavicles limit the width of the resection corridor." — Em Gootee (clinical) [Ep 2 · 16:38](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=998)
- "Contrast esophagrams can underestimate the true diameter of a stricture if the proximal esophagus is dysmotile and does not generate enough pressure to distend the lumen. Balloon dilation under endoscopy provides a more accurate assessment." — Phil (clinical) [Ep 2 · 18:46](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1126)
- "Serial bougie dilation (e.g., Maloney or Savary dilators) is less effective than balloon dilation for esophageal strictures. Balloon dilation applies radial force and can crack scar tissue without requiring needle knife incision." — Todd Ponsky (clinical) [Ep 2 · 41:47](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2507)
- "In long-gap atresia, some surgeons use a Hagar dilator to measure the gap, but this may not reach the true end of the distal pouch. A flexible scope is more reliable for accurate gap measurement." — Todd Ponsky (clinical) [Ep 2 · 2:21](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=141)
- "Interventional radiology can perform gap studies using a catheter with contrast injection to confirm the catheter is at the top of the pouch, then apply stretch to measure the gap under tension." — Dan (clinical) [Ep 2 · 2:35](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=155)
- "In long-gap atresia, if the distal pouch has been tacked to the prevertebral fascia at the initial operation, it will not mobilize adequately for primary repair unless the tack is surgically released." — Dan (clinical) [Ep 2 · 4:44](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=284)
- "David Vanderzee described a thoracoscopic technique for long-gap atresia: place traction sutures on both ends, externalize them on buttons without tightening, wait 3–4 days, return to OR to break adhesions and re-tension, then perform delayed anastomosis." — Dan (host_summary) [Ep 2 · 4:19](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=259)
- "Esophageal replacement options for long-gap atresia include reverse gastric tube, gastric pull-up, colon interposition, and small bowel interposition." — Dan (guideline) [Ep 2 · 5:12](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=312)
- "Long-term complications of full-length colonic interposition include progressive tortuosity and poor drainage, which can be mitigated by using shorter segmental interpositions." — Dan (clinical) [Ep 2 · 9:00](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=540)
- "Mobilizing the gastroesophageal junction to achieve length for primary esophageal anastomosis effectively creates a hiatal hernia and predisposes to reflux." — Todd Ponsky (clinical) [Ep 2 · 54:12](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3252)
- "In a patient with a high cervical stricture and intact distal esophagus, primary resection and reanastomosis is theoretically possible but may be under significant tension and at risk of leak or re-stricture." — Dan (clinical) [Ep 2 · 59:20](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3560)
- "A combined neck and abdominal approach (two surgeons working simultaneously) significantly reduces operative time for complex esophageal reconstructions, which is important given the prolonged anesthesia these cases require." — Dan (clinical) [Ep 2 · 63:40](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3820)
- "When performing colonic interposition to the cervical esophagus, the colon can be brought substernally if the chest is too scarred for thoracotomy, even if a segmental interposition is planned." — Dan (clinical) [Ep 2 · 66:59](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4019)
- "Proximal esophageal anastomoses in the neck are at higher risk of leak when the native esophagus is scarred, short, and of poor quality. Leaks typically heal with conservative management (drainage, stenting)." — Dan (clinical) [Ep 2 · 68:16](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4096)
- "Colonic interposition that appears appropriately short in the operating room may become redundant postoperatively due to the natural elasticity and lengthening of the colon over time." — Dan (clinical) [Ep 2 · 68:57](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4137)
- "Covered esophageal stents can temporize anastomotic leaks and allow healing while maintaining luminal patency. Stent removal is typically planned after several weeks." — Em Gootee (clinical) [Ep 2 · 70:42](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4242)
- "When the proximal esophagus is essentially absent (less than 1 cm), anastomosis can be performed to the hypopharynx by having the surgeon place fingers in the patient's mouth, push down to the base of the hypopharynx, and sew the conduit to the surgeon's fingers from below." — Dan (clinical) [Ep 2 · 75:31](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4531)
- "In patients with multiple tracheoesophageal fistulas and a non-continuous esophagus, attempting resection may create an unreconstructible posterior tracheal defect. Esophageal bypass is a safer alternative." — Dan (clinical) [Ep 2 · 86:54](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5214)
- "Residual esophageal secretions in a bypassed esophageal pouch are minimal and typically drain via a persistent TEF, preventing mucocele formation without requiring esophagectomy." — Dan (clinical) [Ep 2 · 87:42](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5262)
- "Long-term surveillance of bypassed esophagus includes periodic CT scans to rule out mucocele and endoscopic evaluation via the persistent TEF if needed." — Em Gootee (clinical) [Ep 2 · 93:15](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5595)
- "Patients with bypassed esophagus and colonic interposition can achieve full oral intake and normal quality of life, including eating solid foods like pizza." — Dan (clinical) [Ep 2 · 89:02](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5342)
- "Complications are nearly inevitable in complex esophageal reconstruction. The goal is not to eliminate complications but to anticipate and manage them effectively through a multidisciplinary team approach." — Em Gootee (opinion) [Ep 2 · 99:43](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5983)
- "The vast majority of kids who have vomiting, respiratory symptoms, and wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux." — Rachel Rosen (clinical) [Ep 1 · 3:23](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=203)
- "In infants fed every 2 to 3 hours, milk remains in the stomach for up to 2–3 hours; acid production only begins after 3 hours, so infants reflux non-acidic gastric content." — Rachel Rosen (clinical) [Ep 1 · 5:39](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=339)
- "Proton pump inhibitors are not beneficial in children under the age of 1 because they reflux non-acidic milk, not acid." — Rachel Rosen (clinical) [Ep 1 · 5:26](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=326)
- "Studies have shown that both H2 blockers and PPIs increase the risk of sepsis, UTIs, necrotizing enterocolitis, pneumonia, pharyngitis, upper respiratory infections, GI bugs, and C. diff in infants." — Rachel Rosen (epidemiological) [Ep 1 · 7:21](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=441)
- "Eosinophilic esophagitis is found in about 10% of kids under age 5 who are scoped for respiratory symptoms." — Rachel Rosen (epidemiological) [Ep 1 · 9:53](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=593)
- "In children under 5, the most common presentation of eosinophilic esophagitis is chronic cough; the second most common is vomiting or failure to thrive." — Rachel Rosen (clinical) [Ep 1 · 9:41](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=581)
- "In older kids, eosinophilic esophagitis presents with chest pain, food impactions, and dysphagia." — Rachel Rosen (clinical) [Ep 1 · 10:08](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=608)
- "You really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis." — Rachel Rosen (guideline) [Ep 1 · 10:54](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=654)
- "About 60 to 70% of kids with eosinophilic esophagitis are allergic to dairy." — Rachel Rosen (epidemiological) [Ep 1 · 12:02](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=722)
- "Macrolides (erythromycin) are motilin agonists that make the antrum of the stomach contract and can help with vomiting; they also have an anti-inflammatory effect on the airway and lungs." — Rachel Rosen (clinical) [Ep 1 · 16:28](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=988)
- "There are no great normal values for the number of reflux episodes in pediatric patients, so the best use of a probe is to correlate symptoms with reflux episodes." — Rachel Rosen (clinical) [Ep 1 · 17:48](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1068)
- "The majority of kids will outgrow their oropharyngeal dysphagia by 3 to 4 months of age." — Rachel Rosen (clinical) [Ep 1 · 28:21](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1701)
- "In kids with oropharyngeal dysphagia in the NICU, about 75% will get the NG tube out and not need to go on to gastrostomy." — Rachel Rosen (epidemiological) [Ep 1 · 28:42](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1722)
- "When we looked at our own data at Boston Children's, once a gastrostomy goes in in children that aspirate from oropharyngeal dysphagia, their rates of hospitalization are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures." — Rachel Rosen (epidemiological) [Ep 1 · 29:37](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1777)
- "An upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux." — Whit Holcomb (clinical) [Ep 1 · 22:32](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1352)
- "In a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients." — Whit Holcomb (epidemiological) [Ep 1 · 23:19](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=1399)
- "New GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months, then attempting to wean; if unable to wean, restart the drug, but the goal should be to try to wean ideally 2 times a year." — Rachel Rosen (guideline) [Ep 1 · 43:42](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2622)
- "If you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term." — Rachel Rosen (clinical) [Ep 1 · 45:31](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2731)
- "In Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest." — Whit Holcomb (epidemiological) [Ep 1 · 46:40](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2800)
- "By doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups." — Whit Holcomb (epidemiological) [Ep 1 · 57:32](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3452)
- "The surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration." — Whit Holcomb (clinical) [Ep 1 · 59:22](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3562)
- "You've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach." — Whit Holcomb (clinical) [Ep 1 · 60:49](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3649)
- "When you're looking at the post-fundoplication patient, if they have a G tube, you have to image them both ways: putting barium through the G tube and also giving them barium from above via a nasoesophageal tube to see if the esophagus is emptying." — Rachel Rosen (clinical) [Ep 1 · 62:02](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3722)
- "A study out of Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching." — Rachel Rosen (clinical) [Ep 1 · 63:07](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3787)
- "We use a lot of erythromycin in babies who have respiratory symptoms; macrolides are motilin agonists and also have an anti-inflammatory effect for the airway and lungs." — Rachel Rosen (clinical) [Ep 1 · 16:28](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=988)
- "Pyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching." — Rachel Rosen (clinical) [Ep 1 · 54:19](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3259)
- "Cyproheptadine (periactin) helps with gastric accommodation and can control retching in kids." — Rachel Rosen (clinical) [Ep 1 · 54:26](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3266)
- "When you look at kids that tend to do the worst after Nissen, it's the kid who had a Nissen for pulmonary reasons; if they're aspirating during swallowing, their saliva pools in the esophagus over the Nissen and they continue to aspirate, so they gag, retch, and cough all the time." — Rachel Rosen (clinical) [Ep 1 · 49:02](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2942)
- "The kids who are the most miserable post-Nissen are the kids that were retching pre-op, because they retch a lot post-op too." — Rachel Rosen (clinical) [Ep 1 · 35:28](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2128)
- "Using an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients." — Whit Holcomb (epidemiological) [Ep 1 · 63:46](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3826)
- "Patients who ruminate describe vomiting 50 to 100 times a day, typically within minutes of starting a meal or for the hour after a meal; esophageal motility study shows simultaneous contraction of the stomach with bolus movement up into the esophagus." — Rachel Rosen (clinical) [Ep 1 · 78:58](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=4738)
- "If you wrap patients who ruminate, they continue to do this even with a wrap in place, so fundoplication does not help." — Rachel Rosen (clinical) [Ep 1 · 79:31](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=4771)
- "When you look at rates of reflux post-Nissen, it's somewhere between 10 and 20 reflux episodes per 24-hour period on impedance probe, and if I see that, I'm pretty happy that the Nissen is still doing its job." — Rachel Rosen (clinical) [Ep 1 · 71:39](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=4299)
- "Being able to use blenderized food instead of formula has really changed our rates of needing to think about fundoplication, because everything we're putting through the gastrostomy tube is so heavy and migrates to the antrum away from the LES and cardia." — Rachel Rosen (clinical) [Ep 1 · 52:39](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=3159)
- "There are three Rome IV diagnostic categories for older children with chest pain or heartburn: non-erosive reflux disease (NERD, abnormal acid burden with normal scope), reflux hypersensitivity (normal acid burden but symptom correlation with reflux), and functional heartburn (normal scope, normal acid, no symptom correlation)." — Rachel Rosen (guideline) [Ep 1 · 40:54](https://qa.library.globalcastmd.com/watch/pediatric-gastroesophageal-reflux-disease-359?t=2454)
- "The vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux." — Rachel Rosen (clinical) [Ep 8 · 3:23](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=203)
- "The peak age of reflux is between 4 and 6 months of age." — Rachel Rosen (epidemiological) [Ep 8 · 4:18](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=258)
- "In children under the age of 1, proton pump inhibitors are not beneficial because these kids reflux non-acidic gastric content (milk)." — Rachel Rosen (clinical) [Ep 8 · 5:26](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=326)
- "Normal gastric emptying of infants takes 2 to 3 hours; acid production only starts after the 3 hour mark when the stomach is empty." — Rachel Rosen (clinical) [Ep 8 · 5:45](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=345)
- "Studies have shown both with H2 blockers and PPIs you can get sepsis, UTIs, necrotizing enterocolitis, pneumonias, pharyngitis, upper respiratory infections, and C. diff in young children." — Rachel Rosen (clinical) [Ep 8 · 7:21](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=441)
- "In kids under the age of 5, the most common presentation of eosinophilic esophagitis is chronic cough." — Rachel Rosen (clinical) [Ep 8 · 9:27](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=567)
- "When you scope all kids under the age of 5 who are presenting with respiratory symptoms, you'll find eosinophilic esophagitis in about 10% of kids." — Rachel Rosen (epidemiological) [Ep 8 · 9:53](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=593)
- "You really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis." — Rachel Rosen (guideline) [Ep 8 · 10:54](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=654)
- "In about 60 to 70% of kids with eosinophilic esophagitis, the most likely allergen is dairy." — Rachel Rosen (epidemiological) [Ep 8 · 11:57](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=717)
- "Macrolides like erythromycin are motilin agonists that make the antrum of the stomach contract and help with vomiting, plus they have anti-inflammatory effects for the airway and lungs." — Rachel Rosen (clinical) [Ep 8 · 16:28](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=988)
- "There are no great normal values for the number of reflux episodes in pediatric patients, making pH impedance interpretation difficult." — Rachel Rosen (clinical) [Ep 8 · 17:48](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1068)
- "Reflux in Dr. Rosen's opinion is rarely a cause of failure to thrive and respiratory symptoms in infants." — Rachel Rosen (opinion) [Ep 8 · 19:18](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1158)
- "The majority of kids with oropharyngeal dysphagia will outgrow it by 3 to 4 months of age according to a study in JPGN." — Rachel Rosen (clinical) [Ep 8 · 28:21](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1701)
- "In kids who aspirate from oropharyngeal dysphagia, rates of hospitalization after gastrostomy placement are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures." — Rachel Rosen (epidemiological) [Ep 8 · 29:37](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1777)
- "In Boston Children's data, about 75% of NICU babies with severe dysphagia managed with NG tubes will not need to go on to gastrostomy." — Rachel Rosen (epidemiological) [Ep 8 · 28:42](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1722)
- "An upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux." — Whit Holcomb (clinical) [Ep 8 · 22:38](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1358)
- "In a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients." — Whit Holcomb (epidemiological) [Ep 8 · 23:17](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1397)
- "The new GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months then attempting to wean, with goal of weaning twice yearly." — Rachel Rosen (guideline) [Ep 8 · 43:42](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2622)
- "If you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term." — Rachel Rosen (clinical) [Ep 8 · 45:31](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2731)
- "In Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique." — Whit Holcomb (clinical) [Ep 8 · 46:40](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2800)
- "The primary reason for redo fundoplication is transmigration of the wrap into the chest." — Whit Holcomb (clinical) [Ep 8 · 46:43](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2803)
- "Before adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change." — Whit Holcomb (epidemiological) [Ep 8 · 57:23](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3443)
- "The key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach." — Whit Holcomb (clinical) [Ep 8 · 60:49](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3649)
- "Kids who present with aspiration during swallowing and then get a Nissen tend to do worse because their saliva pools in their esophagus over the Nissen or they continue to aspirate their saliva." — Rachel Rosen (clinical) [Ep 8 · 49:02](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2942)
- "Blenderized feeds through gastrostomy tubes have really changed management of reflux because the food is heavier and migrates to the antrum away from the LES and cardia." — Rachel Rosen (clinical) [Ep 8 · 52:39](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3159)
- "A study from Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching." — Rachel Rosen (clinical) [Ep 8 · 63:11](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3791)
- "Pyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching." — Rachel Rosen (clinical) [Ep 8 · 54:19](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3259)
- "Cyproheptadine (Periactin) helps with gastric accommodation and can control retching in children." — Rachel Rosen (clinical) [Ep 8 · 54:26](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3266)
- "Kids who wretch preoperatively will likely wretch postoperatively, and families should be counseled about this." — Rachel Rosen (clinical) [Ep 8 · 35:28](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2128)
- "Using an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation." — Whit Holcomb (clinical) [Ep 8 · 63:42](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3822)
- "Post-fundoplication patients should have 10-20 reflux episodes per 24 hours on impedance probe, which is acceptable and indicates the Nissen is still functioning." — Rachel Rosen (clinical) [Ep 8 · 71:44](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4304)
- "Rome IV defines three categories: non-erosive reflux disease (NERD - abnormal acid burden, normal scope), reflux hypersensitivity (normal acid burden but symptoms correlate with reflux), and functional heartburn (no correlation between symptoms and reflux)." — Rachel Rosen (guideline) [Ep 8 · 40:54](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2454)
- "Patients with rumination syndrome describe vomiting 50-100 times a day, typically within minutes of starting a meal or for the hour after a meal." — Rachel Rosen (clinical) [Ep 8 · 78:40](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4720)
- "On esophageal motility study, rumination shows simultaneous contraction of the stomach with bolus movement up into the esophagus." — Rachel Rosen (clinical) [Ep 8 · 79:13](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4753)
- "If you wrap patients with rumination syndrome, they continue to ruminate even with a wrap in place." — Rachel Rosen (clinical) [Ep 8 · 79:31](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4771)
- "Gastric stimulation may work through a sensory effect rather than purely a motility effect, as some patients improve without improvements in motility." — Rachel Rosen (opinion) [Ep 8 · 68:04](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4084)
- "Botox doesn't reliably improve gastric emptying but helps significantly with retching, suggesting a sensory mechanism." — Rachel Rosen (clinical) [Ep 8 · 68:18](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4098)
- "Multiple scopes provide different information and complementary advantages in complicated aerodigestive patients." (opinion) [Ep 5 · 0:00](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=0)
- "Simultaneous dual endoscopy is easier in patients with a tracheostomy, but feasible even without one." (clinical) [Ep 5 · 0:31](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=31)
- "Typical dual-scope setup uses a flexible bronchoscope through the nose and a flexible GI scope through the mouth or retrograde via a gastrostomy tube." (clinical) [Ep 5 · 0:38](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=38)
- "Transillumination allows one operator to see the light from the other scope through the esophageal or airway wall." (clinical) [Ep 5 · 0:54](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=54)
- "Injection of saline or insufflation of air can reveal subtle perforations or fistulae by demonstrating passage of material or bubbles through the wall." (clinical) [Ep 5 · 0:54](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=54)
- "One operator can turn off their light so the other can see transillumination and confirm anatomic localization." (clinical) [Ep 5 · 1:14](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=74)
- "A 2.8 mm flexible bronchoscope is typically used for the airway component of dual endoscopy." (clinical) [Ep 5 · 1:34](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=94)
- "An infant GI scope (5.4 or 6 mm outer diameter) is used for the esophageal component and will fit retrograde through a 16 French gastrostomy tube." (clinical) [Ep 5 · 1:34](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=94)
- "A 14 French gastrostomy tube is too small for retrograde passage of an infant GI scope without dilation." (clinical) [Ep 5 · 2:01](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=121)
- "Intraoperative dilation of a gastrostomy tract with Hagar dilators allows passage of a larger scope; the tract will contract back down by the end of the case." (clinical) [Ep 5 · 2:07](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=127)
- "A bronchoscope can be used retrograde through the esophagus when a larger GI scope will not fit." (clinical) [Ep 5 · 2:13](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-dual-endoscopy-discussion-1038?t=133)
- "Most children who aspirate have a functional or neurological problem." (host_summary) [Ep 6 · 0:10](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=10)
- "Cerebral palsy and CHARGE syndrome are examples of functional/neurological causes of aspiration." (host_summary) [Ep 6 · 0:16](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=16)
- "Anatomical problems causing aspiration include tracheoesophageal fistula and laryngeal cleft." (host_summary) [Ep 6 · 0:22](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=22)
- "Bad pharyngeal scarring can cause aspiration in some children." (host_summary) [Ep 6 · 0:34](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=34)
- "Esophageal stenosis with backup and spillover can cause aspiration." (host_summary) [Ep 6 · 0:39](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=39)
- "For children who aspirate food and drink, nasogastric tube or gastrostomy tube can be considered." (host_summary) [Ep 6 · 0:53](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=53)
- "Robinul (glycopyrrolate) can be tried for saliva management but generally does not work." (host_summary) [Ep 6 · 1:13](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=73)
- "Botox injection of major salivary glands is a temporary solution and serves as a good test for how a child would cope with less saliva." (host_summary) [Ep 6 · 1:19](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=79)
- "A drool procedure involves removing the submandibular glands and ligating the parotid ducts." (host_summary) [Ep 6 · 1:30](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=90)
- "Tracheotomy allows suctioning of the airway clear of secretions." (host_summary) [Ep 6 · 1:38](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=98)
- "BiPAP can be placed on a tracheostomy so that secretions are blown up and out of the mouth." (host_summary) [Ep 6 · 1:45](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=105)
- "Laryngotracheal separation is the only guaranteed operation to stop aspiration but results in loss of ability to vocalize." (host_summary) [Ep 6 · 1:53](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=113)
- "Nissen fundoplication or any fundoplication may assist with aspiration of gastroesophageal reflux, as may a GJ tube." (host_summary) [Ep 6 · 2:09](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=129)
- "Children with tight fundoplication and non-motile esophagus can develop accumulation and spillover of esophageal contents leading to aspiration." (host_summary) [Ep 6 · 2:21](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=141)
- "In a child with tracheostomy, the simplest test for aspiration is to put colored dye in the mouth and see if it comes out of the trach tube." — Bob (clinical) [Ep 6 · 2:55](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=175)
- "The dye test can be done at home in a normal setting and repeated, and is helpful to convince skeptical parents that the child is aspirating." — Bob (clinical) [Ep 6 · 3:05](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=185)
- "Video swallow studies and endoscopic swallow studies can be very useful for testing aspiration." — Bob (clinical) [Ep 6 · 3:18](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=198)
- "There are no unequivocal endoscopic markers of aspiration." — Bob (clinical) [Ep 6 · 3:23](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=203)
- "Lipid-laden macrophages are non-specific markers of aspiration." — Bob (clinical) [Ep 6 · 3:35](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=215)
- "Recovery of lipid-laden macrophages depends on what material was aspirated, how much lipid it contained, the amount aspirated, and how long since the aspiration event." — Bob (clinical) [Ep 6 · 3:35](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=215)
- "Lots of lipid-laden macrophages in the right clinical setting provide convincing evidence of aspiration, but it is not a black and white yes/no answer." — Bob (clinical) [Ep 6 · 3:57](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=237)
- "For saliva aspiration testing in a child with tracheotomy, a drop of green food dye on the tongue can be used to see if it comes out the trach tube." (host_summary) [Ep 6 · 4:10](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=250)
- "Green is a good dye color because it is not natural, unlike red or blue which might be confused with body-produced substances." (host_summary) [Ep 6 · 4:24](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=264)
- "For saliva aspiration testing without tracheotomy, a nuclear medicine scan with a drop of radioactive material on the tongue can show if it ends up in the lungs or stomach." (host_summary) [Ep 6 · 4:35](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=275)
- "As markers for aspiration, reflux tests are not particularly good." — Phil (clinical) [Ep 6 · 5:02](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=302)
- "Multi-channel intraluminal impedance testing has mostly replaced simple pH testing for detection of reflux." — Phil (clinical) [Ep 6 · 5:08](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=308)
- "Multi-channel intraluminal impedance testing does not add anything to the diagnosis of aspiration itself; it tells whether something is being delivered from the stomach to the esophagus but not what happens after that." — Phil (clinical) [Ep 6 · 5:08](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-aspiration-in-tefs-1039?t=308)
- "In a 7-year-old child, a 2-centimeter transverse incision is placed midway between the cricoid cartilage and the suprasternal notch for tracheostomy." — Tamer Ashraf Wafa (clinical) [Ep 9 · 0:00](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=0)
- "If the anterior jugular vein is encountered during tracheostomy dissection, it is coagulated and cut." — Tamer Ashraf Wafa (clinical) [Ep 9 · 0:35](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=35)
- "The deep cervical fascia is split in a vertical fashion during pediatric tracheostomy." — Tamer Ashraf Wafa (clinical) [Ep 9 · 0:45](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=45)
- "The thyroid isthmus can be cauterized and divided, or retracted downwards during tracheostomy." — Tamer Ashraf Wafa (clinical) [Ep 9 · 1:05](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=65)
- "In children, the third and fourth tracheal rings are the best level for tracheostomy opening." — Tamer Ashraf Wafa (clinical) [Ep 9 · 1:35](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=95)
- "Two non-absorbable stay sutures are placed on both sides of the tracheostomy opening and left in place for post-operative reinsertion of the tube if needed." — Tamer Ashraf Wafa (clinical) [Ep 9 · 1:45](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=105)
- "The side of the tracheal incision is cauterized with bipolar diathermy to minimize bleeding." — Tamer Ashraf Wafa (clinical) [Ep 9 · 2:00](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=120)
- "The trachea is sharply incised vertically for tracheostomy." — Tamer Ashraf Wafa (clinical) [Ep 9 · 2:08](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=128)
- "Suction should be continuously applied during tracheal incision to prevent blood from entering the airway." — Tamer Ashraf Wafa (clinical) [Ep 9 · 2:13](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=133)
- "Pulling the stay sutures laterally helps opening the tracheal lumen during tube insertion." — Tamer Ashraf Wafa (clinical) [Ep 9 · 2:20](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=140)
- "The tracheostomy opening should be widened just enough to admit the suitable tube." — Tamer Ashraf Wafa (clinical) [Ep 9 · 2:25](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=145)
- "The endotracheal tube is pulled back to the level of the tracheostomy opening before inserting the tracheostomy tube." — Tamer Ashraf Wafa (clinical) [Ep 9 · 2:30](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=150)
- "After tracheostomy tube insertion, the ventilator is connected and air entry is checked on both lungs." — Tamer Ashraf Wafa (clinical) [Ep 9 · 2:40](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=160)
- "The angles of the tracheostomy wound are approximated using absorbable sutures." — Tamer Ashraf Wafa (clinical) [Ep 9 · 2:47](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=167)
- "The neck is flexed and the tracheostomy tube is tied tightly around it for secure fixation." — Tamer Ashraf Wafa (clinical) [Ep 9 · 2:52](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=172)
- "The stay sutures are taped to the chest with clear labeling not to remove them." — Tamer Ashraf Wafa (clinical) [Ep 9 · 2:58](https://qa.library.globalcastmd.com/watch/pediatric-tracheostomy-in-a-7-year-old-child-dr-tamer-ashraf-wafa-4151?t=178)
- "A laryngeal cleft is a congenital condition in which the posterior wall of the laryngotracheal tract is open and food or liquids can pass from the esophagus into the trachea, leading to aspirations." — Michael Rutter (host_summary) [Ep 10 · 0:59](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=59)
- "Type 1 laryngeal cleft means the opening is above the vocal cords." — Rod Gerardo (host_summary) [Ep 10 · 1:41](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=101)
- "Type 2 laryngeal cleft means it extends below the vocal cords." — Rod Gerardo (host_summary) [Ep 10 · 1:41](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=101)
- "Type 3 laryngeal cleft means it extends down into the trachea." — Rod Gerardo (host_summary) [Ep 10 · 1:41](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=101)
- "The Benjamin Inglis classification should be modified to include a type 4 long because type 4 could be proximal above the carina, at the carina, or go straight through the carina." — Rod Gerardo (host_summary) [Ep 10 · 1:41](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=101)
- "Flexible bronchoscopy is not adequate for diagnosing a posterior laryngeal cleft." — Rod Gerardo (host_summary) [Ep 10 · 1:41](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=101)
- "The mass closure technique developed in Cincinnati uses the same concept as endoscopic tracheoesophageal fistula repair: you want raw against raw, with wide strips of raw tissue opposed after removing the non-stick mucosal surface." — Rod Gerardo (host_summary) [Ep 10 · 1:41](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=101)
- "KTP laser or CO2 laser can be used for broad mucosal removal in laryngeal cleft repair, and using laser is easier to use and easier to teach with." — Alessandro Dialicon (clinical) [Ep 10 · 3:43](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=223)
- "Open approach for laryngeal clefts is reserved for failed endoscopic repair cases, some type 2s and type 3s, using a laryngofissure approach." — Michael Rutter (host_summary) [Ep 10 · 4:15](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=255)
- "For type 4 clefts, a cervical approach is used." — Michael Rutter (host_summary) [Ep 10 · 4:15](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=255)
- "Type 4 long clefts present anesthetic challenges requiring double lumen tube, single lung ventilation, ECMO or bypass, and often have associated microgastria and multiple congenital anomalies." — Michael Rutter (host_summary) [Ep 10 · 4:15](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=255)
- "Type 4 long clefts have a very high mortality rate of approximately 50%." — Michael Rutter (host_summary) [Ep 10 · 4:15](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=255)
- "The Cincinnati team does not distinguish between anatomical type 1 cleft versus deep notch for treatment decisions; they care whether the patient is aspirating (physiological cleft)." — Michael Rutter (host_summary) [Ep 10 · 4:15](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=255)
- "Most type 3 clefts are attempted endoscopically unless there is a reason to go open." — Michael Rutter (host_summary) [Ep 10 · 7:04](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=424)
- "The transtracheal technique for type 4 clefts involves forming layers between trachea and esophagus, sewing the esophageal layer with knots in lumen, sewing the tracheal layer with knots in lumen, with optional interposition graft." — Michael Rutter (host_summary) [Ep 10 · 7:04](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=424)
- "The novel surgical technique for type 4 long clefts involves transecting the trachea at the lower border of the cricoid, peeling the trachea off the esophagus beyond the cleft while keeping the patient intubated into one bronchus, repairing the esophagus with optional second imbricating layer, placing an interposition graft (typically sternal or tibial periosteum), reconnecting the trachea to the cricoid, and placing a tracheostomy relatively late at two or three weeks." — Michael Rutter (host_summary) [Ep 10 · 8:53](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=533)
- "For the type 4 long cleft case, the team waited three months until the child was greater than 5 kilograms based on outcomes data from previous research." — Michael Rutter (host_summary) [Ep 10 · 10:16](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=616)
- "When placing an endotracheal tube for type 4 long cleft repair, think big, like 4.5 size." — Michael Rutter (host_summary) [Ep 10 · 10:16](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=616)
- "The biggest risk with laryngotracheal esophageal clefts is that the distal end turns into a tracheoesophageal fistula." — Michael Rutter (host_summary) [Ep 10 · 10:16](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=616)
- "Residual tracheoesophageal fistula can be repaired endoscopically using bugbee cautery to demucosalize the tract followed by endoscopic suture placement with P2 needle on 4-0 PDS to create raw-against-raw closure." — Michael Rutter (host_summary) [Ep 10 · 10:16](https://qa.library.globalcastmd.com/watch/laryngeal-clefts-4226?t=616)
- "The article about timing of pediatric tracheostomy after traumatic injury was published in the Journal of Pediatric Critical Care Medicine in 2021." — Brittany Levy (host_summary) [Ep 12 · 0:00](https://qa.library.globalcastmd.com/watch/article-of-interest-optimal-timing-of-tracheostomy-in-injured-adolescents-5788?t=0)
- "The authors analyzed the National Trauma Data Bank and identified over 40,000 adolescent trauma victims who were intubated for more than 24 hours and survived until discharge." — Brittany Levy (host_summary) [Ep 12 · 0:00](https://qa.library.globalcastmd.com/watch/article-of-interest-optimal-timing-of-tracheostomy-in-injured-adolescents-5788?t=0)
- "The study stratified patients into TBI and non-TBI groups and examined tracheostomy timing at 3 and 7 days." — Brittany Levy (host_summary) [Ep 12 · 0:00](https://qa.library.globalcastmd.com/watch/article-of-interest-optimal-timing-of-tracheostomy-in-injured-adolescents-5788?t=0)
- "At 3 days, there was no difference in overall hospital length of stay between early and late tracheostomy groups." — Brittany Levy (host_summary) [Ep 12 · 0:00](https://qa.library.globalcastmd.com/watch/article-of-interest-optimal-timing-of-tracheostomy-in-injured-adolescents-5788?t=0)
- "In adolescent trauma patients without TBI, tracheostomy before 3 days resulted in a decreased ICU length of stay by approximately 16 days compared to later tracheostomy." — Brittany Levy (host_summary) [Ep 12 · 0:00](https://qa.library.globalcastmd.com/watch/article-of-interest-optimal-timing-of-tracheostomy-in-injured-adolescents-5788?t=0)
- "Similar trends of decreased ICU length of stay were seen for all adolescent trauma patients regardless of TBI or non-TBI status if they received tracheostomy before 7 days of intubation." — Brittany Levy (host_summary) [Ep 12 · 0:00](https://qa.library.globalcastmd.com/watch/article-of-interest-optimal-timing-of-tracheostomy-in-injured-adolescents-5788?t=0)
- "The Pediatric Surgical Oncology Research Collaborative study reviewed 15 hospitals to examine how different institutions localize small pulmonary nodules in children." (host_summary) [Ep 13 · 0:24](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=24)
- "Different institutions use wires, methylene blue dye, indocyanine green, micro coils, and technetium 99 in different combinations for pulmonary nodule localization." (host_summary) [Ep 13 · 0:24](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=24)
- "There was no significant difference in the success of localization between all of the different pulmonary nodule localization techniques." (host_summary) [Ep 13 · 0:24](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=24)
- "The only significant differences in pulmonary nodule localization were in which institution performed each technique, and in IR, OR, and anesthesia times." (host_summary) [Ep 13 · 0:24](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=24)
- "In a single institution prospective study of around 40 pediatric patients who received Nuss bar repair for pectus excavatum with perioperative ERAS pain protocol, 92% of patients were discharged on post-operative day one." (host_summary) [Ep 13 · 1:31](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=91)
- "Patients receiving Nuss repair with ERAS protocol had a reduction in the total number of morphine equivalent doses received without any difference in their pain scores at the time of discharge." (host_summary) [Ep 13 · 1:31](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=91)
- "In a preclinical study of transamniotic stem cell therapy for intrauterine growth restriction, subjects were divided into four groups: untreated, saline only, MSC therapy, and MSC with primer." (host_summary) [Ep 13 · 2:33](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=153)
- "Overall survival in the intrauterine growth restriction stem cell study was 75%." (host_summary) [Ep 13 · 2:33](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=153)
- "Gross brain weight was significantly lower in IUGR subjects with no treatment or just saline, and significantly higher in those treated with MSC." (host_summary) [Ep 13 · 2:33](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=153)
- "The primed MSC group revealed significantly lowered levels of TNF alpha and interleukin beta in their brain." (host_summary) [Ep 13 · 3:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=223)
- "Primed MSC appears to reverse some of the central nervous system effects of intrauterine growth restriction." (host_summary) [Ep 13 · 3:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=223)
- "The National Trauma Data Bank analysis included over 40,000 adolescent trauma victims who were intubated for more than 24 hours and survived until discharge." (host_summary) [Ep 13 · 3:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=223)
- "At three days post-intubation, there was no difference in overall hospital length of stay for adolescent trauma victims receiving tracheostomy." (host_summary) [Ep 13 · 3:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=223)
- "In adolescent trauma victims without TBI, tracheostomy before three days decreased ICU length of stay by about 16 days compared to later tracheostomy." (host_summary) [Ep 13 · 3:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=223)
- "Similar trends of decreased ICU length of stay were seen for all children, regardless of TBI or non-TBI status, if they received a tracheostomy before 7 days of intubation." (host_summary) [Ep 13 · 3:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-8-6713?t=223)
- "The Eastern Pediatric Surgery Network in the US created a survey distributed among pediatric surgeons to understand current practices of esophageal surveillance in esophageal atresia patients" — Cecilia Gigena (host_summary) [Ep 14 · 0:00](https://qa.library.globalcastmd.com/watch/esophageal-surveillance-practices-in-esophageal-atresia-patients-6844?t=0)
- "139 pediatric surgeons responded to the survey" — Cecilia Gigena (host_summary) [Ep 14 · 0:00](https://qa.library.globalcastmd.com/watch/esophageal-surveillance-practices-in-esophageal-atresia-patients-6844?t=0)
- "75% of respondents strongly agree or agree with current guidelines for esophageal atresia surveillance" — Cecilia Gigena (host_summary) [Ep 14 · 0:00](https://qa.library.globalcastmd.com/watch/esophageal-surveillance-practices-in-esophageal-atresia-patients-6844?t=0)
- "Only 37% of respondents reported that their esophageal atresia patients have pre-determined outpatient clinic follow-up schedule" — Cecilia Gigena (host_summary) [Ep 14 · 0:00](https://qa.library.globalcastmd.com/watch/esophageal-surveillance-practices-in-esophageal-atresia-patients-6844?t=0)
- "80% of respondents agree or strongly agree that endoscopy should follow a set schedule" — Cecilia Gigena (host_summary) [Ep 14 · 0:00](https://qa.library.globalcastmd.com/watch/esophageal-surveillance-practices-in-esophageal-atresia-patients-6844?t=0)
- "Only 37% of respondents performed follow-up endoscopy regardless of symptoms" — Cecilia Gigena (host_summary) [Ep 14 · 0:00](https://qa.library.globalcastmd.com/watch/esophageal-surveillance-practices-in-esophageal-atresia-patients-6844?t=0)
- "There is high agreement with current guidelines but weak adherence to them in esophageal atresia surveillance" — Cecilia Gigena (host_summary) [Ep 14 · 0:00](https://qa.library.globalcastmd.com/watch/esophageal-surveillance-practices-in-esophageal-atresia-patients-6844?t=0)
- "Cincinnati Children's typically uses a combined cervical and thoracic approach for esophageal atresia cases." — Alessandro de Alarcon (clinical) [Ep 15 · 0:49](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=49)
- "Preoperative testing includes dynamic CT imaging, pulmonary function tests, microlaryngoscopy and bronchoscopy, and flexible bronchoscopy." — Todd Ponsky (host_summary) [Ep 15 · 0:55](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=55)
- "Required intraoperative equipment includes a neck tray, MLB tray, and Maloney dilators or NG tubes." — Alessandro de Alarcon (clinical) [Ep 15 · 1:15](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=75)
- "Flexible bronchoscopy during the operation is key, and endotracheal tube placement must allow visualization during the procedure." — Alessandro de Alarcon (clinical) [Ep 15 · 1:21](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=81)
- "Nasotracheal intubation is often used with the cuff positioned high, sometimes almost at the glottis." — Alessandro de Alarcon (clinical) [Ep 15 · 1:29](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=89)
- "A NIM tube is preferred when possible to prevent injury to recurrent nerves or provide awareness when approaching them." — Alessandro de Alarcon (clinical) [Ep 15 · 1:39](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=99)
- "The surgical approach uses subplatysmal flaps and addresses anterior compression as needed." — Alessandro de Alarcon (clinical) [Ep 15 · 1:55](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=115)
- "The cervical approach can assist thoracoscopic procedures by removing residual or regrown large thymus tissue." — Todd Ponsky (host_summary) [Ep 15 · 2:01](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=121)
- "Aortopexy and innominate artery pexy can be added at the same time as the cervical procedure." — Alessandro de Alarcon (clinical) [Ep 15 · 2:09](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=129)
- "In the lateral approach, the surgical team works on the side of the airway to find the esophagus." — Todd Ponsky (host_summary) [Ep 15 · 2:19](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=139)
- "Pediatric surgeons identify the recurrent nerve for the ENT team to help prevent injury." — Todd Ponsky (host_summary) [Ep 15 · 2:23](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=143)
- "The Cincinnati team has learned not to be afraid of mobilizing the esophagus, which is important for the procedure." — Alessandro de Alarcon (opinion) [Ep 15 · 2:29](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=149)
- "The esophagus is mobilized above the level where the team aims to perform the pexy, making suture placement easier." — Todd Ponsky (host_summary) [Ep 15 · 2:43](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=163)
- "Stitches are sometimes placed in the trachea to pull it up and out of the way for visualization of the posterior aspect and spine." — Alessandro de Alarcon (clinical) [Ep 15 · 2:54](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=174)
- "A pulmonologist assists with flexible endoscopy through the endotracheal tube to visualize inside the trachea while stitches are placed." — Todd Ponsky (host_summary) [Ep 15 · 3:02](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=182)
- "The team uses 3-0 prolene sutures and places all stitches before securing them down." — Alessandro de Alarcon (clinical) [Ep 15 · 3:15](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=195)
- "Suture placement is performed under spontaneous ventilation conditions." — Alessandro de Alarcon (clinical) [Ep 15 · 3:15](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=195)
- "The combined approach is valuable for complicated cases or patients needing additional operations for symptom relief." — Todd Ponsky (host_summary) [Ep 15 · 3:24](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=204)
- "A patient who had prior thoracoscopic tracheopexy with dysphagia from torqued esophagus underwent the combined approach and became symptom-free." — Alessandro de Alarcon (clinical) [Ep 15 · 3:33](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=213)
- "Outcome measures include follow-up endoscopy, pulmonary function tests when patients are old enough, and imaging." — Alessandro de Alarcon (clinical) [Ep 15 · 4:00](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=240)
- "At 36 months follow-up, imaging may still show tracheomalacia, but patients can be symptomatically better." — Alessandro de Alarcon (clinical) [Ep 15 · 4:09](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=249)
- "The team is still learning what measures should define good versus bad outcomes." — Alessandro de Alarcon (opinion) [Ep 15 · 4:15](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=255)
- "Managing complications including swallowing dysfunction and vocal fold paralysis is part of postoperative care." — Alessandro de Alarcon (clinical) [Ep 15 · 4:26](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=266)
- "Otolaryngology involvement is important both during the procedure and in follow-up due to potential complications." — Todd Ponsky (host_summary) [Ep 15 · 4:32](https://qa.library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=272)
- "Several years ago, the approach was that patients with tracheomalacia would undergo aortopexy." — Em Gootee (host_summary) [Ep 16 · 0:36](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=36)
- "In the last 4 to 5 years, it has become standard practice to determine which patients will respond best to tracheopexy versus aortopexy." — Em Gootee (host_summary) [Ep 16 · 0:43](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=43)
- "Pediatric surgery trainees were initially told that tracheomalacia is something that kids will grow out of and will get better." — Aaron Garrison (opinion) [Ep 16 · 0:58](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=58)
- "Recent data has shown that there are long term consequences for soiling into the lungs and having chronic lung aspiration, which over time is detrimental." — Aaron Garrison (clinical) [Ep 16 · 1:08](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=68)
- "Preoperative dynamic reconstruction studies give a lot of information for determining which procedure is best for each patient." — Aaron Garrison (clinical) [Ep 16 · 1:26](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=86)
- "Dynamic expiratory films show what you need to see with the airway that inspiratory films alone do not reveal." — Aaron Garrison (clinical) [Ep 16 · 1:31](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=91)
- "Part of the workup is making sure that there is space to anteriorly suspend the aorta so that the trachea diameter can actually be made larger." — Em Gootee (host_summary) [Ep 16 · 1:45](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=105)
- "Surgeons always look for the thymus and make sure that there is enough tissue to remove to be able to bring the trachea up anteriorly." — Aaron Garrison (clinical) [Ep 16 · 1:55](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=115)
- "Preoperative bronchoscopy gives the surgical team an idea of internal anatomy, which can assist in classifying the degree of tracheomalacia prior to surgical intervention." — Em Gootee (host_summary) [Ep 16 · 2:02](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=122)
- "The classification system for tracheomalacia is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging." — Aaron Garrison (opinion) [Ep 16 · 2:17](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=137)
- "The biggest benefit of minimally invasive approach is visualization and exposure." — Aaron Garrison (opinion) [Ep 16 · 2:34](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=154)
- "Disadvantages of minimally invasive approach include that it takes longer to learn and is more uncomfortable to learn." — Aaron Garrison (opinion) [Ep 16 · 2:39](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=159)
- "Anesthesia colleagues are sometimes hesitant to allow thoracoscopic cases to go on a little bit longer." — Aaron Garrison (opinion) [Ep 16 · 2:42](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=162)
- "A paper in Anesthesiology looked at open, thoracoscopic, and converted patients and found no difference in blood gases and metabolic derangements during surgery." — Aaron Garrison (host_summary) [Ep 16 · 3:03](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=183)
- "The same study found no difference when looking at blood pressure with acidosis and hypoxia between open and thoracoscopic approaches." — Aaron Garrison (host_summary) [Ep 16 · 3:17](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=197)
- "When using a thoracoscopic approach, correct positioning is the key to success." — Em Gootee (host_summary) [Ep 16 · 3:23](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=203)
- "It is best to use gravity to advantage as it aids in retracting the lungs and trachea placement." — Em Gootee (host_summary) [Ep 16 · 3:27](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=207)
- "For anterior mediastinal work, babies are positioned with the arm up and a bump underneath so that there is access to the axilla and anteriorly." — Aaron Garrison (clinical) [Ep 16 · 3:33](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=213)
- "The goal of aortopexy is to suspend the aorta." — Aaron Garrison (clinical) [Ep 16 · 3:51](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=231)
- "The first step in aortopexy is taking out the thymus, finding the innominate junction, and then identifying the arch of the aorta." — Aaron Garrison (clinical) [Ep 16 · 3:54](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=234)
- "Opening the pericardium and finding the area at the pericardial-adventitial junction to suspend is the key point of aortopexy." — Em Gootee (host_summary) [Ep 16 · 4:01](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=241)
- "If you go up too high during aortopexy, then you are doing a pericardiopexy and it is not quite as successful or durable." — Aaron Garrison (clinical) [Ep 16 · 4:10](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=250)
- "Passing suture transternally is preferred with the aortopexy approach, though it can be technically difficult." — Em Gootee (host_summary) [Ep 16 · 4:16](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=256)
- "For tracheopexy, a posterior approach via semiprone position is preferred." — Em Gootee (host_summary) [Ep 16 · 4:23](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=263)
- "Creating a pneumothorax by putting the Veress off the tip of the scapula helps collapse the lung for trocar placement." — Em Gootee (host_summary) [Ep 16 · 4:28](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=268)
- "When operating posteriorly, triangulating your hands gives the best visualization and working space." — Em Gootee (host_summary) [Ep 16 · 4:38](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=278)
- "The goal of posterior tracheopexy is taking the anterior spinal ligament and fixing it to the posterior membranous trachea." — Aaron Garrison (clinical) [Ep 16 · 4:45](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=285)
- "The area of floppy membrane is distal to the dilated pouch usually." — Aaron Garrison (clinical) [Ep 16 · 4:56](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=296)
- "When available, a multidisciplinary team which includes a pulmonologist can allow for internal visualization via bronchoscopy." — Em Gootee (host_summary) [Ep 16 · 4:56](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=296)
- "Bronchoscopic guidance technique is primarily used in non-esophageal atresia patients." — Em Gootee (host_summary) [Ep 16 · 5:05](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=305)
- "Surgeons can make an indent on the posterior wall of the trachea, and pulmonologists can see it pop up on their bronchoscopy to help guide suture placement." — Aaron Garrison (clinical) [Ep 16 · 5:09](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=309)
- "It usually takes about 2 or 3 sutures for posterior tracheopexy, leaving enough space for the esophagus to come through." — Aaron Garrison (clinical) [Ep 16 · 5:43](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=343)
- "Using the knot pusher and tension suture is helpful during tracheopexy." — Aaron Garrison (opinion) [Ep 16 · 5:48](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=348)
- "It is important to create enough tension in the suture to ensure that the pexy is secure." — Em Gootee (host_summary) [Ep 16 · 5:53](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=353)
- "Getting the suture to roll through the anterior spinal ligament is the hardest part and is pretty challenging." — Aaron Garrison (opinion) [Ep 16 · 5:58](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=358)
- "The approach changes for patients without esophageal atresia or with an esophagus in continuity." — Em Gootee (host_summary) [Ep 16 · 6:07](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=367)
- "For patients with esophagus in continuity, the first step is to dissect around the esophagus using a vessel loop for retraction." — Em Gootee (host_summary) [Ep 16 · 6:14](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=374)
- "There are times when the esophagus is put to the left of the trachea, and times when it is put to the right of the trachea." — Aaron Garrison (clinical) [Ep 16 · 6:20](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=380)
- "Dr. Garrison always worries a little bit about dysphagia when repositioning the esophagus, but it is not something he has seen a ton of." — Aaron Garrison (opinion) [Ep 16 · 6:26](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=386)
- "Using pre- and post-operative bronchoscopy allows the surgeon to see the improvement prior to case completion." — Em Gootee (host_summary) [Ep 16 · 6:32](https://qa.library.globalcastmd.com/watch/quad-2-thoracoscopic-tracheopexy-with-dr-aaron-garrison-7919?t=392)
- "Slide tracheoplasty can be used as a method of repairing challenging tracheoesophageal fistulas" — Michael Rutter (clinical) [Ep 18 · 0:49](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=49)
- "In a case with complete tracheal rings and TEF, both conditions were repaired simultaneously because there was no other option" — Michael Rutter (clinical) [Ep 18 · 1:11](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=71)
- "The slide tracheoplasty technique involves transecting the trachea above and below the hole with a bevel to avoid losing too much trachea" — Michael Rutter (clinical) [Ep 18 · 1:25](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=85)
- "Part of the trachea is used to repair the esophagus, then the trachea is slid over the top of it, often with a periosteal interposition graft" — Michael Rutter (clinical) [Ep 18 · 1:35](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=95)
- "Finding an H-type TEF can be quite difficult and is done via tracheoscopy or esophagoscopy" — Kim Pribben (host_summary) [Ep 18 · 2:06](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=126)
- "In the slide tracheoplasty repair, a flap of trachea is sewn onto the esophagus so the front wall of the esophagus becomes a piece of trachea, using a quick running suture technique with 4-0 PDS" — Michael Rutter (clinical) [Ep 18 · 2:18](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=138)
- "When the distance between trachea and esophagus is large, using nerve hooks and slowly tightening multiple throws brings the structures together" — Michael Rutter (clinical) [Ep 18 · 2:47](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=167)
- "Serial esophagoscopies provide a good picture of outcomes in challenging TEF repair cases" — Kim Pribben (host_summary) [Ep 18 · 2:59](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=179)
- "In the Swedish patient case, esophagoscopy at one month post-op showed the suture line where trachea was sewn to esophagus with the front wall being a piece of trachea" — Michael Rutter (clinical) [Ep 18 · 3:08](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=188)
- "The Swedish patient returned to eating and drinking everything despite having a very short trachea" — Michael Rutter (clinical) [Ep 18 · 3:24](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=204)
- "In the 4-year-old case, initial stabilization was achieved by placing an esophageal stent, which did not fix the holes but eliminated the mediastinal communication" — Michael Rutter (clinical) [Ep 18 · 4:23](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=263)
- "A slide tracheoplasty open approach provides much better visualization in the operating field for complex cases" — Kim Pribben (host_summary) [Ep 18 · 4:42](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=282)
- "A transsternal, transtracheal approach provides fantastic exposure to the esophagus" — Michael Rutter (clinical) [Ep 18 · 4:50](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=290)
- "Tibial periosteum serves as a good interposition graft" — Michael Rutter (clinical) [Ep 18 · 4:55](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=295)
- "Periosteum is effective at protecting one lumen from another" — Michael Rutter (clinical) [Ep 18 · 5:05](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=305)
- "A pulmonologist aids the surgeon by looking down the ET tube, which allows for additional visualization and identification of the fistula" — Kim Pribben (host_summary) [Ep 18 · 5:34](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=334)
- "The repair includes transection of the trachea and esophagus, performing a slide esophagoplasty, placing the interposition graft, and closing the trachea" — Kim Pribben (host_summary) [Ep 18 · 5:42](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=342)
- "In the 4-year-old case, the patient was extubated the next day with esophagram and bronchoscopy performed at one week" — Kim Pribben (host_summary) [Ep 18 · 6:03](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=363)
- "The 4-year-old patient was back to eating ice cream at 10 days post-op" — Kim Pribben (host_summary) [Ep 18 · 6:09](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=369)
- "Slide tracheoplasty is not appropriate for every TEF case, but it is useful to know the option is available" — Michael Rutter (opinion) [Ep 18 · 6:26](https://qa.library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=386)
- "A 1992 study reviewed more than 2000 cases of button battery ingestion in children and found no deaths." — Em Gootee (host_summary) [Ep 17 · 0:41](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=41)
- "Recent studies have found a sevenfold increase in fatalities following button battery ingestions." — Em Gootee (host_summary) [Ep 17 · 0:52](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=52)
- "The increase in fatalities is because of the change to a 20-volt lithium cell which causes coagulative necrosis." — Em Gootee (host_summary) [Ep 17 · 0:59](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=59)
- "There are 3 locations in the esophagus where button batteries tend to get stuck: the upper esophageal sphincter, behind the aortic arch, and at the lower esophageal sphincter." — Aaron Garrison (clinical) [Ep 17 · 1:06](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=66)
- "When a button battery sits in one of these positions, it causes transmural injury and will make a fistula between the esophagus and adjacent structures including trachea, blood vessels, or vocal cords." — Em Gootee (host_summary) [Ep 17 · 1:14](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=74)
- "High-risk criteria include younger patients with smaller esophagus." — Aaron Garrison (clinical) [Ep 17 · 1:33](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=93)
- "A larger battery over 20 millimeters or greater is riskier." — Em Gootee (host_summary) [Ep 17 · 1:39](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=99)
- "Longer duration that the battery has been in the esophagus is associated with worse outcomes." — Aaron Garrison (clinical) [Ep 17 · 1:43](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=103)
- "A battery behind the aortic arch is more concerning." — Em Gootee (host_summary) [Ep 17 · 1:49](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=109)
- "If a patient has had a battery removed and presents later with a bleed, that is an emergency that needs to be taken seriously and requires a plan." — Aaron Garrison (clinical) [Ep 17 · 1:52](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=112)
- "In a Colorado study of 13 patients with high severity button battery injuries, 30% had esophageal perforation." — Em Gootee (host_summary) [Ep 17 · 2:05](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=125)
- "In the Colorado study, 23% of patients developed stricture." — Em Gootee (host_summary) [Ep 17 · 2:14](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=134)
- "Some patients in the Colorado study required G-tube placement and stayed in the hospital for nearly 2 weeks." — Em Gootee (host_summary) [Ep 17 · 2:16](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=136)
- "Almost 25% of patients in the Colorado series died." — Aaron Garrison (epidemiological) [Ep 17 · 2:22](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=142)
- "Two of the fatalities in the Colorado series presented with the button batteries already in the stomach." — Aaron Garrison (epidemiological) [Ep 17 · 2:22](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=142)
- "Sentinel bleeds can be the first sign of aortoenteric fistulas." — Em Gootee (host_summary) [Ep 17 · 2:32](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=152)
- "Any small communication between the esophagus and the aorta can be potentially life-threatening." — Aaron Garrison (clinical) [Ep 17 · 2:41](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=161)
- "Some aortoesophageal fistulas showed up over 2 weeks after the batteries were removed." — Em Gootee (host_summary) [Ep 17 · 2:50](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=170)
- "Aortoesophageal fistulas do not always happen in the hospital, so having a high index of suspicion and a plan for what to do once the battery is removed is helpful." — Aaron Garrison (clinical) [Ep 17 · 2:55](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=175)
- "For sick patients with esophageal foreign bodies and active bleeding or clinical instability, it is recommended to have GI surgery and CT surgery available for the procedure." — Aaron Garrison (guideline) [Ep 17 · 3:26](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=206)
- "Imaging beforehand with a CTA to assess inflammation and proximity to the aorta is helpful." — Em Gootee (host_summary) [Ep 17 · 3:39](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=219)
- "If imaging shows injury close to the aorta, continue NPO and antibiotics and repeat MRI in 5 to 7 days to assess the trajectory of inflammation." — Aaron Garrison (guideline) [Ep 17 · 3:47](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=227)
- "If there is any bleeding or concern for sentinel bleed, have a plan with interventional radiology, cardiology, or anyone who can help in that situation." — Em Gootee (host_summary) [Ep 17 · 3:59](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=239)
- "In one case report with a pseudoaneurysm from the arch of the aorta, repair was done with a staged approach: sternotomy on bypass to fix the aorta with a graft, followed by flap repair of the esophagus." — Em Gootee (host_summary) [Ep 17 · 4:10](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=250)
- "For high-risk patients (less than 5 years old, larger battery size), endoscopic evaluation of the esophagus is recommended because the duration of battery presence higher up than the stomach is unknown." — Aaron Garrison (guideline) [Ep 17 · 4:30](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=270)
- "The need for ECMO or cardiopulmonary bypass depends on the location of the fistula and whether you can intubate past the injury enough to ventilate during the case." — Aaron Garrison (clinical) [Ep 17 · 4:43](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=283)
- "If the fistula is near the carina, complex airway reconstruction will be needed and adequate ventilation during the case will not be possible." — Aaron Garrison (clinical) [Ep 17 · 4:59](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=299)
- "In one case with a large tracheoesophageal fistula, the patient was placed on ECMO because they were unable to adequately ventilate." — Aaron Garrison (clinical) [Ep 17 · 5:21](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=321)
- "In the Cincinnati Children's case, an interposition graft was performed by removing a segment of trachea and using that trachea as the front wall of the esophagus." — Aaron Garrison (clinical) [Ep 17 · 5:45](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=345)
- "Button batteries are ingested more than 3500 times per year in the United States." — Em Gootee (host_summary) [Ep 17 · 6:10](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=370)
- "Caustic ingestion is most common in young children between 1 and 3 years of age." — Em Gootee (host_summary) [Ep 17 · 6:20](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=380)
- "Most caustic ingestions by children are accidental and the amounts ingested tend to be small." — Em Gootee (host_summary) [Ep 17 · 6:25](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=385)
- "The airway may take priority in caustic ingestion cases, and patients can present in extremis or with an allergic-reaction-like presentation." — Aaron Garrison (clinical) [Ep 17 · 6:31](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=391)
- "Acidic substances that are spit back up rather than swallowed can cause severe injury to the epiglottis." — Em Gootee (host_summary) [Ep 17 · 6:43](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=403)
- "For esophageal perforation, the approach is to maintain the same exposure, debride to viable tissue, achieve layered closure with coverage, and if possible use a muscle flap for coverage." — Aaron Garrison (clinical) [Ep 17 · 6:56](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=416)
- "If the perforation is too big, drain it to allow for delayed repair." — Aaron Garrison (clinical) [Ep 17 · 7:09](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=429)
- "Smaller children, bigger batteries, and longer ingestion time pose greater risk." — Em Gootee (host_summary) [Ep 17 · 7:20](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=440)
- "Do not be reassured by a battery in the stomach, as injuries can progress even after battery removal." — Em Gootee (host_summary) [Ep 17 · 7:25](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=445)
- "Having an imaging plan to be proactive about finding transmural and worsening inflammation toward vessels is important." — Em Gootee (host_summary) [Ep 17 · 7:31](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=451)
- "For caustic ingestions, be patient; small perforations can heal and be managed conservatively." — Em Gootee (host_summary) [Ep 17 · 7:39](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=459)
- "If strictures develop after caustic ingestion, either dilation or surgery may be necessary." — Em Gootee (host_summary) [Ep 17 · 7:43](https://qa.library.globalcastmd.com/watch/quad-4-surgical-management-of-button-battery-caustic-ingestion-with-dr-aaron-garrison-8088?t=463)
- "Birth history and patient size are important preoperative considerations for esophageal atresia repair." — Nathan Tighe (clinical) [Ep 19 · 0:53](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=53)
- "Physiologic status from ventilation and cardiac standpoints is particularly important in preoperative assessment." — Nathan Tighe (clinical) [Ep 19 · 0:57](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=57)
- "The association between esophageal atresia and cardiac abnormalities is particularly relevant to anesthetic technique." — Em Gootee (host_summary) [Ep 19 · 1:05](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=65)
- "Preoperative visualization of the child's airway allows better decision-making and potentially less time under anesthesia." — Nathan Tighe (clinical) [Ep 19 · 1:13](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=73)
- "Akinesis (keeping children still) can be very challenging in small children, especially when intraoperative neuromonitoring is involved." — Nathan Tighe (clinical) [Ep 19 · 1:33](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=93)
- "The most common technique for maintaining stillness is short-acting opioid infusions, which result in relatively little hemodynamic instability." — Em Gootee (host_summary) [Ep 19 · 1:42](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=102)
- "Volatile anesthetics are especially useful when preservation of spontaneous ventilation is desired." — Em Gootee (host_summary) [Ep 19 · 1:53](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=113)
- "Intraoperative neuromonitoring precludes the use of neuromuscular blocking drugs like rocuronium and vecuronium." — Nathan Tighe (clinical) [Ep 19 · 2:25](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=145)
- "Insufflation using pneumothorax created by trocar placement can facilitate surgical exposure by overcoming peak inspiratory pressures to allow lung collapse." — Em Gootee (host_summary) [Ep 19 · 2:31](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=151)
- "Insufflation is useful for small kids with good lung compliance but not effective in kids with severe bronchopulmonary dysplasia or other compliance abnormalities." — Em Gootee (host_summary) [Ep 19 · 2:48](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=168)
- "Patients with compliance abnormalities often require higher peak inspiratory or mean airway pressures, resulting in the need for very high insufflation pressures." — Nathan Tighe (clinical) [Ep 19 · 3:00](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=180)
- "Lung isolation utility is restricted by patient size and airway anatomy and requires expertise and specialized equipment." — Nathan Tighe (clinical) [Ep 19 · 3:20](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=200)
- "Three dimensions are important for lung isolation: tracheal diameter (particularly AP diameter), bronchial diameters, and the length of the right main stem bronchus between carina and right upper lobe takeoff." — Nathan Tighe (clinical) [Ep 19 · 3:34](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=214)
- "Regular endotracheal tube is the most common device for lung isolation in neonates because it is relatively straightforward to mainstem into the left bronchus, which has a good landing zone for the balloon." — Nathan Tighe (clinical) [Ep 19 · 4:05](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=245)
- "Endotracheal tube placement is technically easier than placement of other lung isolation devices." — Em Gootee (host_summary) [Ep 19 · 4:19](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=259)
- "Bronchial blockers or Fogarty catheters require enough space between the carina and right upper lobe takeoff for balloon placement." — Nathan Tighe (clinical) [Ep 19 · 4:24](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=264)
- "In kids with a pig bronchus, bronchial blocker placement becomes very difficult and may require selective lobar blockade." — Nathan Tighe (clinical) [Ep 19 · 4:39](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=279)
- "A tracheal bronchus (pig bronchus) is an anatomical variant where an accessory bronchus originates directly from the supracarinal trachea." — Em Gootee (host_summary) [Ep 19 · 4:48](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=288)
- "Bronchial blockers can be helpful in kids with abnormal parenchyma when higher ventilatory pressures are needed but higher insufflation pressures should be avoided." — Nathan Tighe (clinical) [Ep 19 · 4:58](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=298)
- "In larger kids (usually 8 years or above) with recurrent fistulas, double-lumen tubes can be used and are the easiest device for lung isolation because they allow independent ventilation of the two lungs." — Em Gootee (host_summary) [Ep 19 · 5:17](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=317)
- "Early conversations between anesthesiologists and surgeons about patient specifics are part of deciding the best modality for each individual patient." — Em Gootee (host_summary) [Ep 19 · 5:38](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=338)
- "Unrepaired single ventricle patients are sensitive to changes in ventilation because they can have swings in circulation direction based on pulmonary vascular resistance." — Nathan Tighe (clinical) [Ep 19 · 5:55](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=355)
- "Single ventricle patients may be candidates for open repair or ECMO support to ensure good outcomes." — Em Gootee (host_summary) [Ep 19 · 6:07](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=367)
- "Insufflation causes changes in preload, and patients with passive pulmonary circulations are particularly sensitive to this insufflation." — Nathan Tighe (clinical) [Ep 19 · 6:18](https://qa.library.globalcastmd.com/watch/quad-7-anesthesia-for-thoracoscopic-techniques-with-dr-nathaniel-tighe-8115?t=378)
- "Etiologies of pharyngeal stenosis include caustic ingestion, iatrogenic injury, or multi-level upper airway surgery" — Em Gootee (host_summary) [Ep 20 · 0:42](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=42)
- "In pharyngeal stenosis related to caustic ingestion, clinicians must address not only physical obstruction but also altered sensation and altered motor function" — Douglas von Allmen (clinical) [Ep 20 · 0:52](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=52)
- "Treatment goals for pharyngeal stenosis patients are tiered: achieving adequate voice, breathing without tracheostomy, preventing aspiration, and swallowing without G-tube" — Em Gootee (host_summary) [Ep 20 · 1:05](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=65)
- "The presented patient had extensive scarring in the hypopharynx with no discernible esophageal inlet and no discernible laryngeal structures, with base of tongue scarred to hypopharyngeal wall" — Douglas von Allmen (clinical) [Ep 20 · 1:48](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=108)
- "After scar tissue removal, the large raw surface area poses a risk of re-scarring" — Douglas von Allmen (clinical) [Ep 20 · 2:10](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=130)
- "Some surgeons have used free mucosal grafts to prevent re-scarring after scar tissue removal" — Douglas von Allmen (clinical) [Ep 20 · 2:19](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=139)
- "A modified suprastomal stent can be placed through the glottis and secured with suture, then wrapped with silastic sheeting to increase the stent diameter in the pharynx" — Douglas von Allmen (clinical) [Ep 20 · 2:22](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=142)
- "Prolonged stenting of about 4 to 6 weeks is typical for pharyngeal stenosis management" — Em Gootee (host_summary) [Ep 20 · 2:59](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=179)
- "Patients with caustic injuries sometimes tolerate suprastomal stents better than airway reconstruction patients because disrupted sensation in the hypopharynx and oropharynx reduces gagging and retching" — Douglas von Allmen (clinical) [Ep 20 · 3:09](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=189)
- "At one-year follow-up, the presented patient maintained a fairly decent opening to the glottis but remains tracheostomy and G-tube dependent" — Douglas von Allmen (clinical) [Ep 20 · 3:36](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=216)
- "The patient underwent colon interposition and was able to get PO taste with improved secretion management, but continues to have swallowing dysfunction" — Douglas von Allmen (clinical) [Ep 20 · 3:53](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=233)
- "Balloon dilation typically works mostly in the post-cricoid area for smaller circumferential stenosis" — Em Gootee (host_summary) [Ep 20 · 4:10](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=250)
- "In the oropharynx and hypopharynx, a larger caliber balloon is needed for dilation" — Douglas von Allmen (clinical) [Ep 20 · 4:15](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=255)
- "Adjuvant therapies including injectable steroids, mitomycin C, and 5-fluorouracil can be used to help delay formation of recalcitrant scar" — Em Gootee (host_summary) [Ep 20 · 4:24](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=264)
- "Rotational flaps and free flaps can be used to help break up scarring in pharyngeal stenosis" — Douglas von Allmen (clinical) [Ep 20 · 4:46](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=286)
- "Z-plasty technique can be used to break up scar orientation by rotating mucosal flaps" — Douglas von Allmen (clinical) [Ep 20 · 5:04](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=304)
- "Staged procedures are helpful to avoid creating circumferential scarring again" — Douglas von Allmen (clinical) [Ep 20 · 5:13](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=313)
- "Many pharyngeal stenosis patients require tracheostomy, often due to extensive supraglottic scarring" — Douglas von Allmen (clinical) [Ep 20 · 5:35](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=335)
- "Pharyngeal stenosis patients are at high risk for ongoing aspiration" — Em Gootee (host_summary) [Ep 20 · 5:48](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=348)
- "Tracheostomy can be helpful for managing aspiration risk in pharyngeal stenosis patients" — Em Gootee (host_summary) [Ep 20 · 5:53](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=353)
- "Swallowing outcomes can be difficult and poor in the long term for pharyngeal stenosis patients" — Em Gootee (host_summary) [Ep 20 · 5:55](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=355)
- "Involvement of speech language pathologists and pulmonary colleagues is important to help manage the sequelae of aspiration" — Douglas von Allmen (clinical) [Ep 20 · 6:03](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=363)
- "Pharyngeal stenosis patients warrant long-term surveillance as there is suggestion they may be at increased risk for malignancy, and surveillance for neoplasm development is helpful" — Douglas von Allmen (clinical) [Ep 20 · 6:11](https://qa.library.globalcastmd.com/watch/quad-5-pharyngeal-scar-management-with-dr-doug-von-allmen-8116?t=371)
- "A type 1 laryngeal cleft can appear normal on flexible bronchoscopy but be visible on rigid bronchoscopy using less sophisticated identification techniques." — Katherine Hart (clinical) [Ep 21 · 0:48](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=48)
- "Combined flexible and rigid bronchoscopy evaluations are complementary and necessary to avoid missing laryngeal clefts." — Katherine Hart (clinical) [Ep 21 · 1:09](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=69)
- "Surgical indications for laryngeal cleft repair include ongoing respiratory symptoms, aspiration, failure to thrive, recurrent pulmonary infections, and failure of conservative measures (or in some instances before trying conservative measures)." — Katherine Hart (clinical) [Ep 21 · 1:22](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=82)
- "The goal of endoscopic cleft repair is to remove the interarytenoid mucosa to create two raw surfaces and then suture the edges together." — Em Gootee (host_summary) [Ep 21 · 1:41](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=101)
- "Mass closure or layered closure technique can be used for laryngeal cleft repair, but the key requirement is that edges must be inverted when finished." — Katherine Hart (clinical) [Ep 21 · 1:52](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=112)
- "If suture bites are taken too deeply during cleft repair, edges will be inverted and the child will continue to have problems." — Em Gootee (host_summary) [Ep 21 · 2:05](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=125)
- "Interarytenoid mucosa can be resected using laser or cold steel (knife), and the choice does not matter clinically." — Em Gootee (host_summary) [Ep 21 · 2:22](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=142)
- "Cold steel is preferred over laser for minor cleft resection because it is simpler to set up, faster, and eliminates the risk of laser fire." — Katherine Hart (opinion) [Ep 21 · 2:30](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=150)
- "Complete demucosalization of the apex is essential; if incomplete, a hole will remain at the apex and the child will continue to aspirate." — Em Gootee (host_summary) [Ep 21 · 2:42](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=162)
- "Closure is performed using interrupted sutures, typically PDS on an RB1 or P3 needle depending on child size." — Katherine Hart (clinical) [Ep 21 · 2:52](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=172)
- "Typically 2 to 3 sutures are placed depending on the extent of the cleft." — Em Gootee (host_summary) [Ep 21 · 3:01](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=181)
- "Epiglottic folds are released after suturing to create extra space." — Em Gootee (host_summary) [Ep 21 · 3:01](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=181)
- "Postoperatively, children are observed overnight on the airway unit and resume their preoperative diet, which is continued until postoperative evaluation." — Katherine Hart (clinical) [Ep 21 · 3:10](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=190)
- "Postoperative evaluation is typically performed 6 to 8 weeks after surgery and includes repeat video swallow study and repeat endoscopy to ensure healing." — Katherine Hart (clinical) [Ep 21 · 3:15](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=195)
- "Failure of endoscopic cleft repair is not super common." — Katherine Hart (clinical) [Ep 21 · 3:29](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=209)
- "Incomplete demucosalization at the apex can result in healing at the top but a gap remaining at the back." — Katherine Hart (clinical) [Ep 21 · 3:32](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=212)
- "Layered closure technique (closing anterior and posterior portions separately) seems like more effort in minor clefts but is a more reasonable option for type 2 or 3 clefts to ensure good closure." — Katherine Hart (opinion) [Ep 21 · 3:46](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=226)
- "Conservative management (not surgery) achieves resolution over time in 51% of children with laryngeal clefts." — Katherine Hart (epidemiological) [Ep 21 · 4:09](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=249)
- "Injection laryngoplasty achieves improvement in symptoms in two-thirds of children and resolution in one-third." — Katherine Hart (epidemiological) [Ep 21 · 4:24](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=264)
- "Surgical closure of laryngeal clefts achieves improvement in symptoms in almost 80% of children and resolution in 70%." — Em Gootee (host_summary) [Ep 21 · 4:31](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=271)
- "Surgical closure has a slightly higher risk of complications compared to conservative management." — Em Gootee (host_summary) [Ep 21 · 4:36](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=276)
- "Complications of surgical cleft repair are often not terrible but include reports of laryngeal scarring, supraglottic infections, and lacerations." — Katherine Hart (clinical) [Ep 21 · 4:45](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=285)
- "A consensus guideline exists for diagnosing and managing laryngeal clefts in children and is a good resource, especially for those newer to practice." — Em Gootee (host_summary) [Ep 21 · 4:54](https://qa.library.globalcastmd.com/watch/quad-20-endoscopic-repair-of-minor-laryngeal-clefts-with-dr-catherine-hart-9373?t=294)
- "The CHARGE acronym stands for coloboma, heart defects, atresia of the choana, retardation of growth and development, genital and/or urinary anomalies, and ear malformations." (clinical) [Ep 22 · 0:00](https://qa.library.globalcastmd.com/watch/quad-22-what-is-charge-syndrome-with-dr-catherine-hart-9458?t=0)
- "CHARGE syndrome is caused by a CHD7 mutation on chromosome 8." (clinical) [Ep 22 · 0:11](https://qa.library.globalcastmd.com/watch/quad-22-what-is-charge-syndrome-with-dr-catherine-hart-9458?t=11)
- "A population of children with CHARGE syndrome will have a negative test for CHD7 but can still have CHARGE syndrome based on clinical criteria." (clinical) [Ep 22 · 0:11](https://qa.library.globalcastmd.com/watch/quad-22-what-is-charge-syndrome-with-dr-catherine-hart-9458?t=11)
- "To make the diagnosis of CHARGE syndrome, you must have at least two of the major criteria." (clinical) [Ep 22 · 0:24](https://qa.library.globalcastmd.com/watch/quad-22-what-is-charge-syndrome-with-dr-catherine-hart-9458?t=24)
- "The major criteria for CHARGE syndrome are coloboma, choanal atresia or cleft palate, characteristic ear abnormalities, and cranial nerve abnormalities." (clinical) [Ep 22 · 0:28](https://qa.library.globalcastmd.com/watch/quad-22-what-is-charge-syndrome-with-dr-catherine-hart-9458?t=28)
- "If you have the major criteria, you have CHARGE syndrome independent of other clinical features." (clinical) [Ep 22 · 0:37](https://qa.library.globalcastmd.com/watch/quad-22-what-is-charge-syndrome-with-dr-catherine-hart-9458?t=37)
- "To make a definitive clinical diagnosis of CHARGE syndrome, you need either 3 major features and at least 1 minor feature, or 2 major features and 2 minor features, or the CHD7 mutation." (clinical) [Ep 22 · 0:41](https://qa.library.globalcastmd.com/watch/quad-22-what-is-charge-syndrome-with-dr-catherine-hart-9458?t=41)
- "Flexible bronchoscopy is quite limited in evaluating a cleft unless it's a major cleft." — Em Gootee (host_summary) [Ep 23 · 0:54](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=54)
- "A deep interarytenoid notch is considered a minor cleft by Dr. Burg's team." — Em Gootee (host_summary) [Ep 23 · 1:13](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=73)
- "The case patient had a very inflammatory pattern on bronchoalveolar lavage but did not have lipid-laden macrophages despite being orally fed." — Greg Burg (clinical) [Ep 23 · 1:34](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=94)
- "Respiratory culture showed predominantly upper airway flora and two Candida species in the mucopurulent bronchitis." — Em Gootee (host_summary) [Ep 23 · 1:44](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=104)
- "Management of laryngeal clefts depends heavily on the degree of aspiration." — Greg Burg (clinical) [Ep 23 · 1:52](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=112)
- "Clinical assessment includes evaluating frequency of coughing, sick visits, emergency room visits, and hospitalizations." — Em Gootee (host_summary) [Ep 23 · 2:07](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=127)
- "Bronchoscopic assessment looks for airway edema, visibility of tracheal rings, mucus plugging, and secretions." — Em Gootee (host_summary) [Ep 23 · 2:15](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=135)
- "Patients with significant tracheobronchomalacia or upper airway obstruction from tonsils and adenoids may generate greater respiratory forces that push more air across the glottis and can increase aspiration risk." — Greg Burg (clinical) [Ep 23 · 2:34](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=154)
- "BAL analysis examines inflammatory cell types, culture results, and macrophage contents." — Greg Burg (clinical) [Ep 23 · 2:50](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=170)
- "Parental report of choking and coughing with water intake raises suspicion for a minor cleft." — Greg Burg (clinical) [Ep 23 · 3:05](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=185)
- "Chest CT is the most important differential imaging study, used to look for chronic changes related to aspiration." — Em Gootee (host_summary) [Ep 23 · 3:18](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=198)
- "A child with a deepened interarytenoid notch plus evidence of aspiration on BAL or other assessments plus bronchiectasis on imaging warrants consideration for surgical repair." — Greg Burg (clinical) [Ep 23 · 3:27](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=207)
- "For patients with an interarytenoid notch and genetic components with concern for central swallowing control, brain MRI may be checked to assess neurologic and functional comorbidities." — Greg Burg (clinical) [Ep 23 · 3:42](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=222)
- "Safe swallowing techniques include thickening, pacing, and volume modification." — Greg Burg (clinical) [Ep 23 · 4:04](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=244)
- "G-tubes and NG-tubes are used as needed for nutritional intake." — Em Gootee (host_summary) [Ep 23 · 4:12](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=252)
- "Aspiration can occur from three locations: things that start in the upper airway, things put in the upper airway, and things that come up from the GI system." — Greg Burg (clinical) [Ep 23 · 4:20](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=260)
- "Medical management addresses excessive drooling and esophageal or GI motility issues that increase vomiting and reflux aspiration risk." — Greg Burg (clinical) [Ep 23 · 4:29](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=269)
- "Pulmonary therapies are mostly considered reactive band-aids." — Greg Burg (opinion) [Ep 23 · 4:49](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=289)
- "Inhaled steroids may be tried to reduce inflammation." — Greg Burg (clinical) [Ep 23 · 4:54](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=294)
- "Chronic macrolide therapy can be used as an anti-neutrophilic agent, derived from cystic fibrosis literature." — Em Gootee (host_summary) [Ep 23 · 4:57](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=297)
- "Saline is used to thin out secretions." — Em Gootee (host_summary) [Ep 23 · 4:57](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=297)
- "Albuterol may be used for bronchodilation if there is a reactive airway component to aspiration pneumonitis." — Greg Burg (clinical) [Ep 23 · 5:06](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=306)
- "For patients with significant tracheomalacia, ipratropium may be used over albuterol." — Em Gootee (host_summary) [Ep 23 · 5:14](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=314)
- "Airway clearance augmentation is needed for neurodevelopmentally limited or musculoskeletally limited patients who lack effective cough or airway clearance ability." — Greg Burg (clinical) [Ep 23 · 5:19](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=319)
- "Health maintenance for aspiration-risk patients includes vaccination against respiratory illnesses and reducing environmental hazards including smoke exposure." — Greg Burg (clinical) [Ep 23 · 5:41](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=341)
- "For non-operative monitoring, pulmonologists track clinical symptoms, hospitalization frequency, response to interventions, and may repeat bronchoscopy and swallow assessments to guide further management." — Greg Burg (clinical) [Ep 23 · 5:54](https://qa.library.globalcastmd.com/watch/quad-25-medical-management-of-minor-laryngeal-clefts-with-dr-greg-burg-9773?t=354)
- "Prior to the 1970s, bougie dilation using progressively larger dilators was the mainstay of airway stenosis management but caused significant shear forces and mucosal damage." — Michael Rutter (clinical) [Ep 11 · 1:34](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=94)
- "The development of open airway surgery in the 1970s allowed for costocartilage grafts and laryngotracheal reconstruction." — Michael Rutter (clinical) [Ep 11 · 1:34](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=94)
- "In the 21st century, endoscopic airway surgery is experiencing a resurgence and often complements open surgery." — Michael Rutter (clinical) [Ep 11 · 1:34](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=94)
- "Balloon dilation should not be performed on complete tracheal rings due to rupture risk." — Brittany Levy (host_summary) [Ep 11 · 2:35](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=155)
- "Balloon dilation achieves nothing in tracheomalacia and is not useful for tracheal A-frame deformity or elliptical cricoid because these are framework problems." — Brittany Levy (host_summary) [Ep 11 · 2:35](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=155)
- "Endoluminal dilation is best for patients with intraluminal scar and an intact framework." — Brittany Levy (host_summary) [Ep 11 · 2:35](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=155)
- "Balloon dilation delivers all dilation radially with no shear forces involved and can deliver precise high pressure dilation at low risk when the right size balloon is chosen." — Brittany Levy (host_summary) [Ep 11 · 2:35](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=155)
- "Balloon dilators are single use and expensive, can be difficult to control when filling to high pressure, and are slippery with risk of watermelon seeding." — Brittany Levy (host_summary) [Ep 11 · 2:35](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=155)
- "The balloon is inflated to rated burst pressure and held for two minutes or until oxygen saturations drop to 90%, whichever happens first." — Michael Rutter (clinical) [Ep 11 · 4:26](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=266)
- "When dilating a balloon in a stenosis, pressure keeps dropping for about 90 seconds as the fibrous tissue is stretched open, requiring continuous addition of water to the syringe pump." — Michael Rutter (clinical) [Ep 11 · 5:26](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=326)
- "Some patients have complete and sustained improvement after a single dilation." — Brittany Levy (host_summary) [Ep 11 · 6:27](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=387)
- "For patients requiring a second dilation, adjunctive scar removing procedures can be beneficial." — Brittany Levy (host_summary) [Ep 11 · 6:27](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=387)
- "Kenalog injection with orotracheal injector set followed by division of scar bands in a Mercedes-Star incision with a blitzer knife is used as an adjunctive procedure." — Michael Rutter (clinical) [Ep 11 · 7:04](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=424)
- "The technique for scar division is to place the blitzer knife with the point away from the airway, get it into the stenosis, turn it 180 degrees and cut towards the lumen for a better result." — Michael Rutter (clinical) [Ep 11 · 7:33](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=453)
- "Endoscopic dilation works for stenosis at multiple levels - if you can do it in the larynx, you can do it in the trachea." — Michael Rutter (clinical) [Ep 11 · 7:48](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=468)
- "At Cincinnati Children's Hospital, endoscopic dilations have been performed for about 20 years with thousands of patients dilated." — Brittany Levy (host_summary) [Ep 11 · 8:31](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=511)
- "Current knowledge gaps include what size balloon to select, how much pressure is appropriate, how long to leave it inflated, when to repeat it, how often to repeat it, who should not be dilated, and when to use adjunctive procedures." — Michael Rutter (opinion) [Ep 11 · 8:56](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=536)
- "The protocol for dilation is usually three or four times at seven to ten day intervals for established scar." — Michael Rutter (guideline) [Ep 11 · 9:33](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=573)
- "On the second dilation, adjunctive procedures may include Kenalog injection, scar tissue division, increasing balloon size, or nebulizing cipridex if there are significant raw areas after dilation." — Michael Rutter (guideline) [Ep 11 · 9:33](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=573)
- "If after five dilations you are not winning, you should take a step back and think about doing something else." — Michael Rutter (guideline) [Ep 11 · 9:33](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=573)
- "The ideal candidate for balloon dilation has thin scar and young scar; thicker or established scar may require adjunctive procedures like scar division or steroid injection." — Michael Rutter (clinical) [Ep 11 · 10:28](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=628)
- "The formula for balloon sizing is to take the outer diameter of an age-appropriate endotracheal tube and add one millimeter for the larynx or two millimeters for the trachea." — Michael Rutter (guideline) [Ep 11 · 10:55](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=655)
- "A free app has been developed to help choose the right size balloon to minimize risk." — Michael Rutter (clinical) [Ep 11 · 11:17](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=677)
- "In patients with intact laryngeal tracheal exoskeleton with fresher thin webs, endoscopic dilation works well, but thick and fixed scar may need adjuvant procedures or open procedure if sequential dilations are unsuccessful." — Brittany Levy (host_summary) [Ep 11 · 11:52](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=712)
- "If you choose the right size balloon, the risk of balloon dilation is extraordinarily low." — Brittany Levy (host_summary) [Ep 11 · 11:52](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=712)
- "Cases where balloon dilation is not enough include posterior glottic stenosis, greater than grade three posterior subglottic stenosis, and bilateral vocal cord paralysis." — Brittany Levy (host_summary) [Ep 11 · 11:52](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=712)
- "Open airway reconstruction requires an easily exposed larynx and is easier in a patient with a tracheotomy, but not required as long as the child can be kept spontaneously breathing under anesthesia." — Michael Rutter (clinical) [Ep 11 · 12:58](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=778)
- "The open procedure involves harvesting rib, exposing the larynx, placing vocal cord spreaders, dividing the posterior cricoid with a sickle knife and micro scissors, and may require dividing the inter-arytenoid muscle." — Michael Rutter (clinical) [Ep 11 · 12:58](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=778)
- "A balloon can be placed anteriorly and inflated to push the cartilage graft into place during open reconstruction." — Michael Rutter (clinical) [Ep 11 · 13:39](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=819)
- "Significant force is required to anchor the graft under the cut edges of the cricoid." — Brittany Levy (host_summary) [Ep 11 · 14:12](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=852)
- "For minor laryngeal webs, endoscopic repair is feasible and does not necessarily require a tracheotomy tube." — Michael Rutter (clinical) [Ep 11 · 14:47](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=887)
- "After dividing web scar tissue with a sickle knife, a keel must be placed to prevent raw mucosal surfaces from re-adhering." — Michael Rutter (clinical) [Ep 11 · 14:47](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=887)
- "The keel placement technique uses a keith needle threaded through silastic, taken out using a hollow angiocath as a guide." — Michael Rutter (clinical) [Ep 11 · 15:01](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=901)
- "The keel is kept in place for 10 days to allow tissue to re-mucosalize without re-adherence or risk of re-stenosis from scar tissue." — Michael Rutter (clinical) [Ep 11 · 15:21](https://qa.library.globalcastmd.com/watch/laryngotracheal-stenosis-5406?t=921)
- "Esophageal atresia patients often have tracheobronchomalacia" — Lizzie Lee (host_summary) [Ep 25 · 0:13](https://qa.library.globalcastmd.com/watch/tracheobronchopexy-to-avoid-tracheostomy-in-esophageal-atresia-patients-with-severe-life-threatening-tracheobronchomalacia-10435?t=13)
- "Tracheobronchomalacia can cause serious breathing problems like blue spells in esophageal atresia patients" — Lizzie Lee (host_summary) [Ep 25 · 0:13](https://qa.library.globalcastmd.com/watch/tracheobronchopexy-to-avoid-tracheostomy-in-esophageal-atresia-patients-with-severe-life-threatening-tracheobronchomalacia-10435?t=13)
- "A retrospective observational study reviewed 80 esophageal atresia patients who underwent tracheobronchopexy at two hospitals between 2013 and 2021" — Lizzie Lee (host_summary) [Ep 25 · 0:23](https://qa.library.globalcastmd.com/watch/tracheobronchopexy-to-avoid-tracheostomy-in-esophageal-atresia-patients-with-severe-life-threatening-tracheobronchomalacia-10435?t=23)
- "94% of esophageal atresia patients who underwent tracheobronchopexy were able to avoid a tracheostomy" — Lizzie Lee (host_summary) [Ep 25 · 0:33](https://qa.library.globalcastmd.com/watch/tracheobronchopexy-to-avoid-tracheostomy-in-esophageal-atresia-patients-with-severe-life-threatening-tracheobronchomalacia-10435?t=33)
- "Tracheobronchopexy significantly reduced life-threatening breathing events in esophageal atresia patients" — Lizzie Lee (host_summary) [Ep 25 · 0:38](https://qa.library.globalcastmd.com/watch/tracheobronchopexy-to-avoid-tracheostomy-in-esophageal-atresia-patients-with-severe-life-threatening-tracheobronchomalacia-10435?t=38)
- "Tracheobronchopexy significantly reduced the need for positive pressure ventilation in esophageal atresia patients" — Lizzie Lee (host_summary) [Ep 25 · 0:38](https://qa.library.globalcastmd.com/watch/tracheobronchopexy-to-avoid-tracheostomy-in-esophageal-atresia-patients-with-severe-life-threatening-tracheobronchomalacia-10435?t=38)
- "Tracheobronchopexy significantly reduced ventilator dependence in esophageal atresia patients" — Lizzie Lee (host_summary) [Ep 25 · 0:38](https://qa.library.globalcastmd.com/watch/tracheobronchopexy-to-avoid-tracheostomy-in-esophageal-atresia-patients-with-severe-life-threatening-tracheobronchomalacia-10435?t=38)
- "Cincinnati Children's Hospital hosted the Quad Conference in October 2022, combining four conferences: International Organization for Esophageal Atresia, Aerodigestive Society Conference, Cincinnati Children's Airway Course, and Cincinnati Children's Pediatric Dysphagia Series." — Lizzie Lee (host_summary) [Ep 24 · 0:15](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=15)
- "Cincinnati Children's has one of the largest aerodigestive centers in the world." — Lizzie Lee (host_summary) [Ep 24 · 0:47](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=47)
- "The expert multidisciplinary team includes speech pathology, otolaryngology, gastroenterology, pulmonology, and pediatric general surgery." — Lizzie Lee (host_summary) [Ep 24 · 0:55](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=55)
- "The vision of the Aerodigestive and Esophageal Center is to improve efficiency and communication between team members and the family." — Claire Miller (clinical) [Ep 24 · 1:28](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=88)
- "The center provides coordinated multidisciplinary care to children with congenital or acquired complex digestive and airway disorders." — Lizzie Lee (host_summary) [Ep 24 · 1:37](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=97)
- "The clinical assessment is a poor predictor when there are airway protection issues." — Claire Miller (clinical) [Ep 24 · 2:44](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=164)
- "Video fluoroscopic swallowing study analyzes different phases of swallowing." — Lizzie Lee (host_summary) [Ep 24 · 2:52](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=172)
- "FEES (fiber optic endoscopic evaluation of swallowing study) allows visualization of pharyngeal and laryngeal structures and assessment of function, aspiration, and residual after each swallow." — Lizzie Lee (host_summary) [Ep 24 · 2:59](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=179)
- "High-resolution pharyngeal manometry allows objective assessment of the pressures of the swallow to understand what is underlying a swallowing dysfunction." — Claire Miller (clinical) [Ep 24 · 3:13](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=193)
- "ENT looks at swallowing study results and helps stratify the risk of proceeding with airway reconstruction and decannulation." — Lizzie Lee (host_summary) [Ep 24 · 3:48](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=228)
- "In aerodigestive patients, ENT performs esophageal and airway reconstruction, cleft repair, drool procedures, and manages vocal folds and mobility." — Lizzie Lee (host_summary) [Ep 24 · 3:54](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=234)
- "GERD pathophysiology includes an incompetent lower esophageal sphincter." — Lizzie Lee (host_summary) [Ep 24 · 4:19](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=259)
- "Patients with TEF have a lot of other things other than incompetent lower esophageal sphincters, including motility problems, hernias, and delayed emptying." — Scott Pentik (clinical) [Ep 24 · 4:31](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=271)
- "General signs and symptoms of GERD include regurgitation, vomiting, and heartburn." — Lizzie Lee (host_summary) [Ep 24 · 4:42](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=282)
- "Impedance is a tool used to measure reflux and distinguish between a swallow versus actual reflux." — Scott Pentik (clinical) [Ep 24 · 4:48](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=288)
- "Patients with eosinophilic esophagitis often have procedures performed on them even before their diagnosis." — Scott Pentik (clinical) [Ep 24 · 5:21](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=321)
- "Data shows an increase in airway surgery complications in patients who were later found to have eosinophilic esophagitis." — Lizzie Lee (host_summary) [Ep 24 · 5:28](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=328)
- "The center now performs endoscopy as part of workup prior to even considering surgery." — Scott Pentik (guideline) [Ep 24 · 5:35](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=335)
- "Anatomic issues in aerodigestive patients include strictures that need balloon dilations or stenting." — Lizzie Lee (host_summary) [Ep 24 · 5:40](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=340)
- "Kids will have Nissans and then have hernias later." — Scott Pentik (clinical) [Ep 24 · 5:49](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=349)
- "Motility issues after TEF repairs include narrowing of the esophagus and the esophagus not squeezing, leading to more reflux, more dysphagia, and impactions." — Scott Pentik (clinical) [Ep 24 · 5:58](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=358)
- "When 25 patients in the aerodigestive program were assessed, 76% of them had a feeding disorder." — Lizzie Lee (host_summary) [Ep 24 · 6:13](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=373)
- "Patients at risk for pulmonary insufficiency include preemies with chronic lung disease, patients with restrictive lung disease, congenital or acquired abnormalities, and heart disease like pulmonary hypertension." — Lizzie Lee (host_summary) [Ep 24 · 6:54](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=414)
- "Patients at risk for pulmonary insufficiency typically present with chronic symptoms including tachypnea, shortness of breath, retractions, non-apneic hypoxemia, and in older patients, exercise intolerance." — Sherry Torres Silva (clinical) [Ep 24 · 7:06](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=426)
- "Underlying pulmonary insufficiency should be suspected if patients have had complicated respiratory infections requiring positive pressure ventilation." — Lizzie Lee (host_summary) [Ep 24 · 7:20](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=440)
- "Patients at risk for chronic pulmonary aspiration include preemie babies, those with swallowing dysfunction, GI dysmotility, cardiothoracic esophageal and airway history, and syndromes including CHARGE syndrome, Mobius, Criducha, and trisomy." — Sherry Torres Silva (clinical) [Ep 24 · 7:32](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=452)
- "Risk factors for upper airway obstruction include airway abnormalities like mid-face hypoplasia, skeletal dysplasia, decreased muscle tone, and syndromes associated with airway obstruction." — Lizzie Lee (host_summary) [Ep 24 · 7:48](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=468)
- "Patients with airway obstruction, especially upper airway, will have symptoms with sleep and significant exertion or agitation, and noisy breathing might be one of the most significant symptoms reported." — Sherry Torres Silva (clinical) [Ep 24 · 8:02](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=482)
- "Risk factors for lower airway obstruction include acquired or congenital thoracic deformities and those who had thoracotomies done in the past." — Lizzie Lee (host_summary) [Ep 24 · 8:13](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=493)
- "Tracheomalacia is a very common comorbidity in patients with history of esophageal fistula or atresia." — Sherry Torres Silva (clinical) [Ep 24 · 8:22](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=502)
- "High-resolution CT is the gold standard for diagnosis because it is highly sensitive and detects early changes of the small airways, and 3D reconstructions can be performed." — Sherry Torres Silva (clinical) [Ep 24 · 8:36](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=516)
- "Flexible bronchoscopy is used starting in the nose and ending in the subsegmental bronchi, and bronchoalveolar lavage helps with identification of infections and markers of aspiration." — Sherry Torres Silva (clinical) [Ep 24 · 8:49](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=529)
- "Pulmonologists perform medical management of aspiration including control of sialorrhea, optimization of airway clearance, and use of anti-inflammatory medications for chronic aspiration or inflammation." — Sherry Torres Silva (clinical) [Ep 24 · 9:02](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=542)
- "For patients with ventilatory insufficiency, the pulmonologist determines if the child still needs ventilatory support and whether they are ready for decannulation." — Lizzie Lee (host_summary) [Ep 24 · 9:15](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=555)
- "The pulmonologist assesses how ready the patient is for weaning from the vent and whether they can start or advance feeding." — Lizzie Lee (host_summary) [Ep 24 · 9:26](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=566)
- "In the NICU, general surgeons obtain feeding access, manage anorectal malformations, and perform surgical procedures such as tracheopexies and lung resections." — Lizzie Lee (host_summary) [Ep 24 · 9:41](https://qa.library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=581)
- "A subset of children after esophageal atresia repair experience severe airway collapse, leaving them ventilator dependent or suffering repeated cyanotic spells" — Em Gootee (host_summary) [Ep 26 · 1:48](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=108)
- "The tracheobronchopexy series included 80 patients, which is a huge number - most pediatric surgeons won't see 10 of these patients in their career, and many wouldn't see 5" — George W. Holcomb III (epidemiological) [Ep 26 · 2:17](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=137)
- "90% of patients on dynamic bronchoscopy showed complete airway collapse" — George W. Holcomb III (host_summary) [Ep 26 · 2:34](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=154)
- "Three-quarters of tracheobronchopexy procedures used a posterior approach" — George W. Holcomb III (host_summary) [Ep 26 · 2:40](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=160)
- "Tracheobronchopexy was performed on thoracic trachea alone in over half the patients, but had to be extended onto the bronchi in 40%" — George W. Holcomb III (host_summary) [Ep 26 · 2:44](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=164)
- "94% of tracheobronchopexy patients avoided tracheostomy with a mortality rate of 5%" — George W. Holcomb III (host_summary) [Ep 26 · 2:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=177)
- "Tracheobronchopexy significantly reduced pressure ventilation and ventilator dependence" — George W. Holcomb III (host_summary) [Ep 26 · 2:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=177)
- "In experienced hands who have done numerous or hundreds of these type procedures, tracheobronchopexy can have very good outcomes for patients with severe airway collapse symptoms" — George W. Holcomb III (opinion) [Ep 26 · 3:14](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=194)
- "Canada is the 2nd largest country in the world geographically, though population-wise smaller than California" — Eric Skarsgard (epidemiological) [Ep 26 · 5:28](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=328)
- "The majority of Canada's population lives within 200 kilometers of the US border, but there are definitely lots of children in remote communities where it is not easy to access care" — Eric Skarsgard (epidemiological) [Ep 26 · 5:38](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=338)
- "Outreach services were present in only 7 out of 10 provinces, and only 8 out of 18 children's hospitals (44%) provided outreach services" — Preet Bir (epidemiological) [Ep 26 · 6:43](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=403)
- "A significant number of outreach services are located within 50 kilometers of a children's hospital, leaving vast regions without access to pediatric surgical care" — Em Gootee (host_summary) [Ep 26 · 6:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=417)
- "In most places in Canada, no one would ever transfer a 16 or 17 year old with appendicitis to a children's hospital for surgery - physiologically and every other way they're an adult and clearly do not need the expertise of a pediatric surgeon" — Eric Skarsgard (opinion) [Ep 26 · 7:36](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=456)
- "Access to surgical care for children in Canada has been in need of improvement for decades" — Eric Skarsgard (opinion) [Ep 26 · 7:51](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=471)
- "It's a misconception that the Canadian healthcare system ensures timely care - it actually doesn't, and children wait for surgery beyond their wait time target" — Eric Skarsgard (clinical) [Ep 26 · 8:01](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=481)
- "Newfoundland and Labrador has the best outreach setup with only two pediatric surgeons who have established outreach clinics all over the province, serving as a model for others" — Eric Skarsgard (opinion) [Ep 26 · 8:16](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=496)
- "The population of Newfoundland and Labrador is really rural and spread out, and geographically and weather-wise it can be impossible sometimes to access care or financially devastating" — Eric Skarsgard (epidemiological) [Ep 26 · 8:31](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=511)
- "There are measurable costs in terms of time required to be seen and actual clinical outcomes for patients living remote from accessible high quality care" — Eric Skarsgard (clinical) [Ep 26 · 9:01](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=541)
- "In the NSQIP database, 5% of all pediatric procedures were G-tube, which is a pretty sizable percent" — Sean Kunisaki (epidemiological) [Ep 26 · 11:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=716)
- "The study examined 4,612 G-tube placements from 71 NSQIP-Pediatric hospitals in 2023" — Em Gootee (host_summary) [Ep 26 · 12:38](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=758)
- "77% of G-tube cases were first-time G-tubes as opposed to redos" (epidemiological) [Ep 26 · 12:46](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=766)
- "Upper GI studies were obtained in 45% of first-time G-tube cases with substantial interhospital variability from 0 to 99%" — Em Gootee (host_summary) [Ep 26 · 13:04](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=784)
- "The heterogeneity in use of preoperative upper GIs was extremely broad with no real reason for it, indicating a potential teaching moment" — Sean Kunisaki (opinion) [Ep 26 · 13:23](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=803)
- "14% of G-tube cases resulted in an ED visit within 0 to 30 days" — Em Gootee (host_summary) [Ep 26 · 13:45](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=825)
- "5.2% of G-tube cases involved dislodgement within 0 to 30 days" — Em Gootee (host_summary) [Ep 26 · 13:45](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=825)
- "An additional 5.5% of G-tubes were dislodged in the 31 to 60 day period" (epidemiological) [Ep 26 · 13:55](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=835)
- "Dislodgement rates are higher than rates of readmissions or IR interventions, making them a great QI target" (opinion) [Ep 26 · 13:55](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=835)
- "If you can get dislodgements down, ED visits go down - when dislodgements happen early, patients are told to come back to the ED" (clinical) [Ep 26 · 14:15](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2025-10786?t=855)
- "Most children who aspirate have a functional or neurological problem (cerebral palsy, CHARGE syndrome); some have anatomical problems (TEF, laryngeal cleft, pharyngeal scar, esophageal stenosis)." — Michael Rutter (clinical) [Ep 3 · 4:39](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=279)
- "Lipid-laden macrophages are non-specific markers of aspiration; their recovery depends on the lipid content of aspirated material, the amount aspirated, and time since aspiration." — Bob Wood (clinical) [Ep 3 · 8:05](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=485)
- "Multi-channel intraluminal impedance testing detects reflux but does not diagnose aspiration; it tells you whether something is delivered from the stomach to the esophagus, not what happens after." — Phil Putnam (clinical) [Ep 3 · 9:38](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=578)
- "If a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse." — Daniel von Allmen (clinical) [Ep 3 · 9:58](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=598)
- "A 3-French bugbee cautery is a smooth, excellent probe for identifying subtle tracheoesophageal fistulas." — Michael Rutter (clinical) [Ep 3 · 12:10](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=730)
- "A 70-degree endoscope is a difficult tool to use but can visualize TEFs that are otherwise hard to see with standard forward-viewing scopes." — Michael Rutter (clinical) [Ep 3 · 13:21](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=801)
- "Routine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues." — Daniel von Allmen (clinical) [Ep 3 · 14:02](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=842)
- "Pediatric surgery fellows at Cincinnati Children's complete a one-month attachment with ENT to perform bronchoscopies and gain airway expertise." — Michael Rutter (clinical) [Ep 3 · 14:51](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=891)
- "Dual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings." — Daniel von Allmen (clinical) [Ep 3 · 19:37](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1177)
- "A 2.8 mm flexible bronchoscope and a 5.4–6 mm infant gastroscope are the typical scopes used for combined airway-esophageal examination in small children." — Phil Putnam (clinical) [Ep 3 · 21:02](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1262)
- "Endoscopic TEF closure requires demucosalization of the tract (mucosa is a non-stick surface); the goal is raw-against-raw apposition with minimal fibrin glue (0.1 mL) to seal the tract while scarring occurs." — Michael Rutter (clinical) [Ep 3 · 23:41](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1421)
- "Endoscopic TEF repair success rate is approximately 80%, typically requiring 2 attempts; after 3–4 failed attempts, open repair should be considered." — Michael Rutter (clinical) [Ep 3 · 37:01](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2221)
- "Positive-pressure air insufflation (30 cm H₂O) via an endotracheal tube in the esophagus can reveal a TEF by causing air to bubble out of the tracheal opening." — Michael Rutter (clinical) [Ep 3 · 34:20](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2060)
- "Injection of an inert material (e.g., Radiesse voice gel) into the walls adjacent to a TEF tract can obliterate the potential space and promote raw-on-raw apposition; the material is absorbed over a few weeks." — Michael Rutter (clinical) [Ep 3 · 39:48](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2388)
- "Slide tracheoplasty for TEF involves transecting the trachea above and below the fistula, beveling the edges, turning in the tracheal wings to repair the esophagus, interposing sternal periosteum, and reconnecting the trachea; it is a three-layer repair." — Michael Rutter (clinical) [Ep 3 · 45:48](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2748)
- "Sternal periosteum is an excellent interposition graft material: it is abundant, in the surgical field, and extremely strong ('like Kevlar'), though difficult to suture." — Michael Rutter (clinical) [Ep 3 · 46:52](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2812)
- "Button batteries can cause ongoing tissue injury for weeks after ingestion, even if 'dead' (they retain ~2 volts); institutional protocol mandates removal within 2 hours of identification." — Michael Rutter (guideline) [Ep 3 · 53:37](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=3217)
- "Button battery injuries in the esophagus can progress to aortoesophageal fistula; CT angiography and close follow-up for 6 weeks post-removal are recommended, especially if the battery was at the aortoesophageal junction." — Phil Putnam (guideline) [Ep 3 · 59:02](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=3542)
- "Two slide tracheoplasty repairs for button battery TEF both dehisced (one at 10 days, one at 3 months); both were successfully revised. This may be more than coincidence, suggesting button battery injuries pose unique challenges." — Michael Rutter (clinical) [Ep 3 · 54:02](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=3242)
- "Transtracheal TEF repair is a two-dimensional operation with lower complication risk than slide tracheoplasty; the primary complication is re-fistulization, whereas slide tracheoplasty dehiscence is a more serious event." — Michael Rutter (opinion) [Ep 3 · 69:04](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=4144)
- "Transtracheal repair technique: anterior tracheotomy, identify the fistula from within the trachea, separate tracheal and esophageal layers, three-layer closure (esophageal mucosa with knots in lumen, sternal periosteum, tracheal wall with knots in lumen)." — Michael Rutter (clinical) [Ep 3 · 64:43](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=3883)
- "In patients with retroesophageal subclavian artery, the right recurrent laryngeal nerve is non-recurrent and at higher risk during neck dissection; awareness is critical during transtracheal or slide tracheoplasty approaches." — Michael Rutter (clinical) [Ep 3 · 94:43](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5683)
- "Flexible bronchoscopy cannot reliably diagnose laryngeal clefts; rigid microlaryngoscopy with active probing is mandatory when posterior glottic pathology is suspected." — Bob Wood (clinical) [Ep 3 · 116:27](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6987)
- "When examining the cervical trachea and subglottis with a flexible bronchoscope, it is easier to see pathology while slowly withdrawing the scope than while advancing it, due to the need to flex and extend the tip to navigate the glottis." — Bob Wood (clinical) [Ep 3 · 87:43](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5263)
- "Insufflation with oxygen at 2 L/min through the suction channel of a flexible bronchoscope spreads tissue apart, improves visualization, and does not impair respirations." — Bob Wood (clinical) [Ep 3 · 86:58](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5218)
- "The degree of angulation at the tip of a flexible bronchoscope is much greater in one direction (retroflexion) than the other; rotating the scope 180° (Sabode maneuver) can reveal posterior tracheal pathology more easily." — Bob Wood (clinical) [Ep 3 · 86:30](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5190)
- "Endoscopic closure of bronchoesophageal fistulas is feasible but challenging; proximity to large vessels (e.g., pulmonary artery branches) may preclude safe cautery and necessitate surgical resection." — Michael Rutter (clinical) [Ep 3 · 107:43](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6463)
- "In a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured." — Daniel von Allmen (clinical) [Ep 3 · 112:36](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6756)
- "A Y-shaped airway stent from both bronchi into the trachea, with the tracheostomy tube sitting within the stent, can effectively bypass a bronchoesophageal fistula and allow clinical stability when further repair is not feasible." — Michael Rutter (clinical) [Ep 3 · 100:56](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6056)
- "Tracheal pouches (diverticula) can be marsupialized endoscopically using a Storz ClickLine laparoscopic biopsy forceps with cautery at 40 watts; the technique is quick, well-tolerated, and eliminates the risk of tracheostomy tube misplacement." — Michael Rutter (clinical) [Ep 3 · 118:01](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=7081)
- "When cauterizing in the airway with a bugbee, oxygen concentration should be kept below 30% to minimize fire risk; brief periods of lower oxygen saturation are tolerable." — Michael Rutter (clinical) [Ep 3 · 38:35](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2315)
- "A 3-French bugbee cautery fits through the 1.2 mm suction channel of a 2.8 mm flexible bronchoscope, allowing precise control and steering of the cautery tip." — Bob Wood (clinical) [Ep 3 · 27:54](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1674)
- "Trichloroacetic acid (TCA) can be used to demucosalize TEF tracts, but control is less precise than with bugbee cautery; TCA is applied on a pledget and can cause unintended burns if it contacts tissue during insertion." — Todd Ponsky (clinical) [Ep 3 · 25:08](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1508)
- "Anal fistula plugs (biologic, cone-shaped, made of Surgisis) can theoretically be used to occlude distal airway fistulas; they are wrapped with barbed suture and inserted into the tract to promote collagen matrix formation and scarring." — Todd Ponsky (clinical) [Ep 3 · 110:04](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6604)
- "Slide tracheoplasty appears to be a learning-curve, surgeon-dependent operation; revision cases have been necessary as experience was gained." — Michael Rutter (opinion) [Ep 3 · 69:59](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=4199)
- "After 7 years of aspiration through a TEF, a child may have significant bronchiectasis; repair of the fistula does not immediately resolve lower airway disease, and ongoing chest physiotherapy and airway clearance are required." — Michael Rutter (clinical) [Ep 3 · 95:23](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5723)
- "Hearing aid molds are radiolucent and can be missed on chest X-ray; high clinical suspicion is required when a foreign body ingestion is reported but not visualized." — Michael Rutter (clinical) [Ep 3 · 97:35](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5855)
- "Pectus excavatum can worsen tracheobronchomalacia; placement of a pectus bar can improve airway support and reduce the need for stenting or tracheostomy." — Michael Rutter (clinical) [Ep 3 · 99:49](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5989)
- "Airway stents can erode into the esophagus, creating secondary fistulas; long-term stent management requires vigilance and may necessitate alternative strategies (e.g., Y-stent with tracheostomy tube within the stent)." — Michael Rutter (clinical) [Ep 3 · 100:32](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6032)
- "When repairing a high TEF from a thoracic approach, ligation of the fistula on the esophageal side can leave a large tracheal pouch; if the patient has tracheomalacia and requires a tracheostomy, the tube may enter the pouch, causing life-threatening obstruction." — Michael Rutter (clinical) [Ep 3 · 77:21](https://qa.library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=4641)
- "Aspiration is defined as any solid or liquid matter passing below the vocal cords, though some define it as requiring pulmonary compromise in addition to passage below the cords." — Catherine Hart (host_summary) [Ep 7 · 0:16](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=16)
- "Aspiration can be silent with no clinical indication, or obvious with coughing, choking, and sputtering." — Catherine Hart (host_summary) [Ep 7 · 0:39](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=39)
- "Children with CHARGE syndrome have 80 to 90% prevalence of aspiration at some point in their lifetime and should be assumed to aspirate until proven otherwise." — Catherine Hart (host_summary) [Ep 7 · 1:51](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=111)
- "Children with severe neurologic compromise regardless of etiology should be assumed to aspirate until demonstrated otherwise." — Catherine Hart (host_summary) [Ep 7 · 2:01](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=121)
- "The clinical significance of aspiration depends on the quantity—small isolated events are usually cleared by host defenses (cough, mucociliary transport), while large or repeated events overcome host defenses." — Catherine Hart (host_summary) [Ep 7 · 2:32](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=152)
- "A single aspiration event of caustic substance can have lifelong consequences." — Catherine Hart (host_summary) [Ep 7 · 3:06](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=186)
- "Chronic pulmonary aspiration is defined as repeated aspiration into the lower airways causing pulmonary injury or chronic respiratory disease, with consequences determined by frequency, magnitude, nature of material, and effectiveness of host defenses." — Catherine Hart (clinical) [Ep 7 · 3:31](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=211)
- "Four major groups aspirate: premature babies, those with neurologic disabilities, those with airway disease (anatomic, dynamic, or functional), and those with gastrointestinal disorders." — Catherine Hart (clinical) [Ep 7 · 4:34](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=274)
- "Syndromes with significant swallowing dysfunction include CHARGE, Cri-du-chat, Möbius syndrome (cranial nerve abnormalities), and craniofacial defects like Pfeiffer, Crouzon, and Treacher Collins." — Catherine Hart (host_summary) [Ep 7 · 5:02](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=302)
- "Dysphagia can occur in any of the four swallowing phases (oral preparatory, oral transit, pharyngeal, esophageal) and can result in aspiration or retrograde flow into the nasal cavity." — Claudia Schweiger (host_summary) [Ep 7 · 6:09](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=369)
- "Children who aspirate may present with breathing difficulties during feeding (increased respiratory rate, bradycardia, tachycardia, cyanosis, apnea, desaturation), coughing/choking during or after swallowing, frequent congestion after meals, noisy or wet vocal quality, prolonged meal times, food refusal, or vomiting." — Claudia Schweiger (host_summary) [Ep 7 · 6:48](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=408)
- "Children with associated obstructive airway symptoms (snoring, retractions, stridor, desaturation) should undergo airway endoscopy to look for anatomic causes of dysphagia." — Claudia Schweiger (clinical) [Ep 7 · 10:17](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=617)
- "Video swallow study (VFSS) and functional endoscopic evaluation of swallowing (FEES) are complementary tests that show different things and evaluate different parts of the swallow—it is important to explain to families they are not the same test." — Sandra Stinnett (clinical) [Ep 7 · 16:33](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=993)
- "A radionucleotide spit scan (placing radioactive tracer on tongue) can test for saliva aspiration but involves radiation and is a one-off window in time." — Michael Rutter (host_summary) [Ep 7 · 17:21](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=1041)
- "Impedance probe is the best test for gastroesophageal reflux but is not necessarily widely available." — Michael Rutter (clinical) [Ep 7 · 18:05](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=1085)
- "Medication for reflux generally stops acid but does not stop reflux events." — Michael Rutter (host_summary) [Ep 7 · 18:31](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=1111)
- "CT scanning is excellent for evaluating long-term consequences of aspiration but shows damage already done (tells about the past, not the present) and requires anesthesia, radiation, and radiologic expertise." — Michael Rutter (clinical) [Ep 7 · 19:23](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=1163)
- "Lipid-laden macrophages are the most commonly used aspiration biomarker, with a lipid-laden macrophage index >90 or >20% of macrophages containing lipid suggesting aspiration." — Catherine Hart (host_summary) [Ep 7 · 44:25](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2665)
- "Elevated lipid-laden macrophages are not pathognomonic of aspiration—they can result from natural airway debris (dead neutrophils, macrophages from inflammation) or circulation after bleeding or airway surgery." — Catherine Hart (clinical) [Ep 7 · 45:56](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2756)
- "Lipid-laden macrophages are a limited tool because aspirated material has variable lipid content (saliva has no lipid), there is variable time between aspiration and BAL sampling affecting lipid metabolism, and individuals have variable rates of lipid catabolism." — Catherine Hart (clinical) [Ep 7 · 46:38](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2798)
- "Having a tracheostomy tube changes the dynamics of laryngeal elevation but most studies show it does not create aspiration." — Catherine Hart (host_summary) [Ep 7 · 48:08](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2888)
- "Decanulation should not proceed until the child has proven capacity to clear their airway through a prolonged capping trial that includes going through illnesses without needing the tracheostomy for clearance." — Catherine Hart (clinical) [Ep 7 · 49:10](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2950)
- "Speaking valves help with airway clearance by allowing glottic closure for better cough and creating positive end-expiratory pressure that distends airways, even if they do not decrease aspiration coming in." — Catherine Hart (clinical) [Ep 7 · 49:56](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=2996)
- "CHARGE patients frequently need tracheostomy or interventions for salivary aspiration at young age but often develop compensatory strategies over time and can be decannulated as they mature." — Sandra Stinnett (clinical) [Ep 7 · 50:54](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3054)
- "The pulmonologist's role in the aerodigestive team is to protect children from developing irreversible long-term pulmonary sequelae while managing anatomic abnormalities or waiting for maturity." — Catherine Hart (opinion) [Ep 7 · 51:44](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3104)
- "Medical management of functional aspiration should target five aspects: decrease aspiration events, improve airway clearance, address quality of aspirated material, control inflammation, and treat or prevent infections." — Catherine Hart (clinical) [Ep 7 · 58:16](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3496)
- "Positive pressure ventilation (CPAP or BiPAP) can decrease aspiration events, especially during sleep in patients with reflux aspiration, even in patients who do not need it for gas exchange or ventilation." — Catherine Hart (clinical) [Ep 7 · 65:45](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3945)
- "Cuff tubes cannot stop aspiration because inflating the cuff enough to decrease leak causes unacceptable tracheal injury or dilation." — Catherine Hart (clinical) [Ep 7 · 64:56](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3896)
- "Passy-Muir valves should never be used during sleep because they allow inhalation through the tracheostomy but not exhalation, risking obstruction from mucus accumulation, and they cause over-drying of secretions leading to mucus plugging." — Catherine Hart (clinical) [Ep 7 · 66:39](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3999)
- "For airway clearance, comorbidities that compromise clearance include tracheobronchomalacia, airway compression/stenosis/hypoplasia, restrictive lung disease (neuromuscular, chest wall deformities, scoliosis), and vocal cord or diaphragmatic dysfunction/paralysis from esophageal or cardiac surgery." — Catherine Hart (host_summary) [Ep 7 · 60:11](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3611)
- "Chronic inflammation from aspiration is managed with inhaled steroids and systemic anti-inflammatory medication (azithromycin, not systemic steroids as first-line), with systemic steroids reserved for acute aspiration events to prevent pneumonitis." — Catherine Hart (clinical) [Ep 7 · 62:17](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3737)
- "Patients with bronchiectasis from chronic aspiration should receive longer antibiotic courses (10-14 days instead of 7-10 days) because bronchiectatic cavities have more difficult clearance." — Catherine Hart (clinical) [Ep 7 · 63:30](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3810)
- "Prophylactic inhaled antibiotics (tobramycin or colistimethate, either every other month or 14 days per month) are reserved for patients with severe bronchiectasis and pulmonary injury or significant frequency of infections." — Catherine Hart (clinical) [Ep 7 · 63:42](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=3822)
- "Botox for sialorrhea has 90% success rate in the speaker's experience and is first-line treatment." — Hugo Rodríguez (clinical) [Ep 7 · 78:03](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4683)
- "Bilateral submandibular gland excision and bilateral parotid duct ligation (drool procedure) has 60-100% success rate in the literature." — Hugo Rodríguez (host_summary) [Ep 7 · 78:38](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4718)
- "Laryngotracheal separation guarantees no aspiration but eliminates voice, and attempts to restore voice with speaking valves (Blom-Singer) are not effective in children because the larynx remains in the way—complete laryngectomy with cricopharyngeal myotomy is required for voice restoration." — Michael Rutter (clinical) [Ep 7 · 81:41](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4901)
- "The Cincinnati laryngotracheal separation technique involves peeling mucosa up subperichondrially within the cricoid, purse-string closure, splitting cricoid laterally at 3 and 9 o'clock, quilting sutures to sandwich cricoid, tisseal in subglottis, and crisscrossing medial heads of SCM over the laryngeal stump—this has eliminated fistula formation and stomal stenosis." — Michael Rutter (clinical) [Ep 7 · 83:52](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=5032)
- "In children, laryngotracheal separation stomas will stenose without a tube until growth stops, so a relatively big, wide, short tube must remain in the tracheal stoma." — Michael Rutter (clinical) [Ep 7 · 85:19](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=5119)
- "Temporary laryngeal injection is a useful test-drive procedure before permanent medialization, can be repeated, and serves as a bridge between more permanent operations." — Sandra Stinnett (host_summary) [Ep 7 · 70:04](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4204)
- "Early injection (1-3 months after recurrent nerve injury) may lead to less need for permanent procedures based on adult literature, though pediatric data is limited." — Sandra Stinnett (host_summary) [Ep 7 · 70:28](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4228)
- "For injection materials, radiance gels dissipate within weeks in animal models and do not work well; Restylane is used as a bridge and fat for longer-term injection." — Sandra Stinnett (clinical) [Ep 7 · 71:40](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4300)
- "Reinnervation (ansa-to-recurrent laryngeal nerve) is not a new concept but has gained popularity in the last few years; ideal candidates are <40 years old, within 1-2 years of injury, with known injury location." — Sandra Stinnett (host_summary) [Ep 7 · 72:46](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4366)
- "Reinnervation advantages include single general anesthetic (no awake thyroplasty needed for children), one-and-done if successful, low risk, allows other procedures later, and uses patient's own tissue; disadvantages include lack of long-term pediatric data, 6-9 months to final results, and neck incision." — Sandra Stinnett (clinical) [Ep 7 · 74:11](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4451)
- "Reinnervation is a misnomer—it does not restore movement but provides tone and better closure, with outcomes measured by voice and swallowing improvement." — Sandra Stinnett (clinical) [Ep 7 · 75:46](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4546)
- "Sensory reinnervation (great auricular nerve to superior laryngeal nerve) can restore sensation and is valuable when the sensory component is the primary deficit, allowing recognition of secretions and swallowing." — Sandra Stinnett (clinical) [Ep 7 · 77:07](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=4627)
- "Tracheoesophageal fistulas can be surprisingly challenging to find and require high index of suspicion, angled telescopes, probing, and positive pressure breath with endotracheal tube in esophagus to visualize bubbling." — Michael Rutter (clinical) [Ep 7 · 92:40](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=5560)
- "Endoscopic TEF repair is ideal for long skinny tracts (usually recurrent TEFs after congenital repair); the concept is to demucosalize the tract with Bugby cautery to get raw-against-raw, inject filler beside the tract to compress it, and place fibrin glue." — Michael Rutter (clinical) [Ep 7 · 98:43](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=5923)
- "Endoscopic TEF repair has a recognized failure rate and surgeons must be prepared to repeat the procedure multiple times." — Michael Rutter (clinical) [Ep 7 · 104:26](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=6266)
- "Congenital H-type tracheoesophageal fistulas, with very few exceptions, do not do well with endoscopic repairs and typically require open repair." — Michael Rutter (clinical) [Ep 7 · 106:03](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=6363)
- "For H-type TEFs, the upper 2/3 of trachea is accessible through the neck, the lower third is easier through the chest, and the middle third is no-man's land where whoever has better expertise (pediatric surgery or ENT) should do it." — Michael Rutter (clinical) [Ep 7 · 106:27](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=6387)
- "Slide tracheoplasty technique for large or multiply-failed TEFs involves transecting trachea above and below the hole, peeling trachea off esophagus, using the tracheal segment attached to the hole to repair the esophagus, and reconnecting the trachea over the top with a slide technique that oversizes the airway and reduces tension." — Michael Rutter (clinical) [Ep 7 · 109:45](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=6585)
- "For the case of isolated esophagus with multiple TEFs connecting to trachea, leaving the esophagus isolated at both ends prevents aspiration through the holes while the holes prevent mucocele formation by allowing drainage." — Michael Rutter (clinical) [Ep 7 · 120:59](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7259)
- "Flexible bronchoscopy is not a good tool for evaluating posterior laryngeal clefts—rigid bronchoscopy is required for diagnosis." — Michael Rutter (clinical) [Ep 7 · 127:00](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7620)
- "The Cincinnati endoscopic cleft repair technique uses laser (KTP or CO2) to remove a wide swath of mucosa on both sides of the cleft, creating raw-against-raw surfaces, then places 2-3 sutures (60 PDS on bent BV1 for babies, 40 PDS on P2 for older children) and releases aryepiglottic folds." — Sandra Stinnett (clinical) [Ep 7 · 128:10](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7690)
- "Endoscopic cleft repair has become a fellow-level case in Cincinnati due to the volume performed (at least 20, likely way more)." — Sandra Stinnett (clinical) [Ep 7 · 131:18](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7878)
- "Open cleft repair is reserved for failed endoscopic repairs (some type 2s and type 3s), type 4 clefts (cervical approach), and type 4 long clefts (which present anesthetic challenges requiring double lumen tube, single lung ventilation, ECMO, or bypass)." — Sandra Stinnett (host_summary) [Ep 7 · 129:02](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7742)
- "Type 4 long laryngeal clefts have very high mortality rate hovering around 50%, and families must be counseled about this before attempting repair." — Sandra Stinnett (host_summary) [Ep 7 · 129:46](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=7786)
- "Almost all children under 4 kg who had type 4 cleft repairs died; waiting until the child is over 5 kg improves outcomes." — Michael Rutter (clinical) [Ep 7 · 137:44](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=8264)
- "For long type 4 clefts, the Cincinnati technique involves transecting trachea at cricoid, peeling trachea off esophagus to beyond the cleft, repairing esophagus, placing sternal periosteum interposition graft, reconnecting trachea, and placing tracheostomy 2-3 weeks later after healing." — Michael Rutter (clinical) [Ep 7 · 135:26](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=8126)
- "The greatest risk with laryngotracheoesophageal clefts is that the distal end of the repair may form a tracheoesophageal fistula." — Michael Rutter (clinical) [Ep 7 · 139:09](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=8349)
- "For severe pharyngeal stenosis, management is a step ladder approach: voice, breathing without trach, no aspiration, swallowing without G-tube—typically cannot achieve all four, usually one or two steps up the ladder, rarely three." — Michael Rutter (clinical) [Ep 7 · 153:04](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=9184)
- "Composite stents (suprastomal stent with silastic sheet wrapped around it supraglottically) are effective for severe pharyngeal stenosis—the stent goes through vocal cords and locks in trachea while the silastic holds open the supraglottic raw areas during re-mucosalization." — Michael Rutter (clinical) [Ep 7 · 154:27](https://qa.library.globalcastmd.com/watch/aerodigestive-management-of-pediatric-aspiration-full-show-2796?t=9267)

## Common questions
### Tell me more about charge syndrome?
CHARGE syndrome is a rare genetic disorder caused by a CHD7 mutation on chromosome 8. The acronym represents coloboma, heart defects, atresia of the choana, retardation of growth and development, genital and/or urinary anomalies, and ear malformations. Diagnosis can be established based on clinical criteria even without confirmed CHD7 mutation testing. Notably, 80–90% of children with CHARGE syndrome will experience aspiration at some point in their lifetime, making it a significant functional/neurological cause of aspiration risk in the pediatric population.
### When is tracheopexy indicated?
Tracheopexy is indicated for patients with tracheomalacia who require surgical intervention. Clinical decision-making has evolved to determine which patients will respond best to tracheopexy versus aortopexy using preoperative dynamic studies. The procedure is primarily used in non-esophageal atresia patients. Both aortopexy and tracheopexy are beneficial for tracheomalacia; preoperative dynamic imaging guides selection of the most appropriate procedure for each patient.

## Changelog
- Sep 9: Summaries and takeaways published for 4 audiences
- Sep 7: 1 promo item hidden (trailer / commercial); unhide from the owner view
- Sep 7: 1 item hidden — never mention Aerodigestive / ENT; unhide from the owner view
- Aug 31: 38 doctors auto-found from episode dossiers
- Aug 30: 32 doctors auto-found from episode dossiers
- Aug 30: 27 doctors auto-found from episode dossiers
- Aug 30: Members-only episodes removed from this collection
- Aug 29: 74 doctors auto-found from episode dossiers
- Aug 29: 72 doctors auto-found from episode dossiers
- Aug 29: Collection generated from campaign corpus: 55 items, 38 dossiers, summaries for 4 audience(s)
- Aug 29: Collection reviewed and published
- Aug 29: Collection generated from campaign corpus: 45 items, 38 dossiers, summaries for 2 audience(s)
- Aug 29: Collection generated from campaign corpus: 45 items, 38 dossiers, summaries for 2 audience(s)

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