# Appendicitis — GCMD Library living collection Everything in the library about appendicitis — built automatically from dossiers that name it. Updated: n/a · 11 episodes · 220 cited statements ## Episodes ### Evidence & Research - [Standardization of Care for Pediatric Perforated Appendicitis](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389) — video · 2:20 · [machine version](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389.md) - [Appendicitis Management & APPY Trial: Update Course 2016](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549) — video · 31:55 · [machine version](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549.md) - [Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929) — podcast · 44:19 · [machine version](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929.md) - [Non-Operative Management of Appendicitis: 2018 Pediatric Surgery Practice Gap #2](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462) — video · 1:21 · [machine version](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462.md) - [Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308) — podcast · 44:19 · [machine version](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308.md) - [Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819) — video · 27:50 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819.md) - [Quick Literature Updates Episode 11](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954) — video · [machine version](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954.md) - [Quick Literature Updates Ep 24](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235) — video · 4:42 · [machine version](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235.md) ### In-Depth Reviews - [Hirschsprung Disease Part I with Marc Levitt](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933) — podcast · 59:20 · [machine version](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933.md) - [Hirschsprung Disease Part I with Marc Levitt](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311) — podcast · 59:20 · [machine version](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311.md) - [Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314) — podcast · 58:22 · [machine version](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314.md) ## Chapters - [0:00](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=0) Introduction and series overview (Ep 6) - [0:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=55) Corticosteroids after Kasai for biliary atresia (Dr. von Almen) (Ep 6) - [10:54](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=654) Skin antiseptic agents and surgical site infections (Dr. Holcomb, part 1) (Ep 6) - [20:18](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1218) Non-operative antibiotic treatment for non-perforated appendicitis (Dr. Holcomb, part 2) (Ep 6) - [30:41](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1841) Predictors of enteral autonomy in pediatric intestinal failure (Dr. Lipskar, part 1) (Ep 6) - [36:44](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2204) Anesthetic neurotoxicity in the developing brain (Dr. Lipskar, part 2) (Ep 6) - [0:00](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=0) Introduction and Appendicitis Review (Ep 7) - [5:10](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=310) Initial Evaluation and Diagnosis of Hirschsprung Disease (Ep 7) - [12:36](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=756) Pathologic Confirmation and Surgical Timing (Ep 7) - [17:50](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1070) Historical Evolution of Surgical Techniques (Ep 7) - [27:53](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1673) Current Surgical Approach: Transanal Swenson (Ep 7) - [32:15](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1935) Technical Details: Exposure and Dissection Plane (Ep 7) - [37:13](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2233) Laparoscopic Approach and Biopsy Technique (Ep 7) - [47:56](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2876) Postoperative Management (Ep 7) - [56:08](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3368) Special Circumstance: Hepatic Flexure Transition Zone (Ep 7) - [0:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=5) Introduction and speaker background (Ep 8) - [2:20](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=140) Diagnostic approach and imaging for suspected appendicitis (Ep 8) - [10:52](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=652) Antibiotic selection and dosing protocols (Ep 8) - [15:11](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=911) Surgical technique: single-incision versus three-port laparoscopy (Ep 8) - [21:32](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1292) Defining and identifying perforation intraoperatively (Ep 8) - [25:46](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1546) Same-day discharge for non-perforated appendicitis (Ep 8) - [28:22](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1702) Outcomes of single-incision versus three-port appendectomy (Ep 8) - [34:28](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2068) Irrigation versus suction-only for perforated appendicitis (Ep 8) - [38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301) Technical considerations: staplers, energy devices, and cautery (Ep 8) - [41:00](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2460) Postoperative management of perforated appendicitis (Ep 8) - [45:34](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2734) Management of well-defined abscess: early versus interval appendectomy (Ep 8) - [52:00](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3120) Non-operative management and future directions (Ep 8) - [0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) Standardization of perforated appendicitis care improves outcomes (Ep 1) - [0:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=0) APPY Trial Design and Background (Ep 2) - [9:14](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=554) Protocol Details and Early Results (Ep 2) - [20:45](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1245) Discussion: Antibiotic Stewardship, Fecoliths, and Clinical Applications (Ep 2) - [0:00](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=0) Introduction and series overview (Ep 3) - [0:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=55) Corticosteroids after Kasai for biliary atresia (Dr. von Almen) (Ep 3) - [10:54](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=654) Skin antiseptic agents and surgical site infections (Dr. Holcomb, part 1) (Ep 3) - [20:18](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1218) Non-operative antibiotic treatment for non-perforated appendicitis (Dr. Holcomb, part 2) (Ep 3) - [30:41](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1841) Predictors of enteral autonomy in pediatric intestinal failure (Dr. Lipskar, part 1) (Ep 3) - [36:44](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2204) Anesthetic neurotoxicity in the developing brain (Dr. Lipskar, part 2) (Ep 3) - [0:00](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=0) Introduction and Appendicitis Review (Ep 4) - [5:10](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=310) Initial Evaluation and Diagnosis of Hirschsprung Disease (Ep 4) - [12:36](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=756) Pathologic Confirmation and Surgical Timing (Ep 4) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - "Non-operative management of perforated appendicitis has been known for a long time." (clinical) [Ep 5 · 0:19](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=19) - "Treating appendicitis with antibiotics had equal outcome measures compared to initial operative management." (clinical) [Ep 5 · 0:19](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=19) - "There was a 15% risk of recurrence of appendicitis at one-year follow-up with non-operative management." (clinical) [Ep 5 · 0:35](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=35) - "Non-operative management resulted in decreased hospital stays compared to operative management." (clinical) [Ep 5 · 0:35](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=35) - "Non-operative management resulted in decreased days of disability compared to operative management." (clinical) [Ep 5 · 0:35](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=35) - "Non-operative management of appendicitis is an option with risks and benefits that need to be taken into account." (guideline) [Ep 5 · 0:52](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=52) - "APSA was not making a flat out recommendation to start doing non-operative appendicitis." — Gibbons (opinion) [Ep 5 · 1:08](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=68) - "The data on non-operative appendicitis management is becoming more clear." — Gibbons (opinion) [Ep 5 · 1:14](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=74) - "The choice between operative and non-operative appendicitis management remains dealer's choice." — Gibbons (opinion) [Ep 5 · 1:06](https://qa.library.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=66) - "The best treatment for Hirschsprung disease is irrigations using a large bore tube (20 French Foley) with warm saline, instilling 10-20 cc aliquots at a time and allowing fluid mixed with stool to drain back." — Marc Levitt (clinical) [Ep 4 · 8:43](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=523) - "It is very rare that Hirschsprung disease is a surgical emergency, but if you don't irrigate and overcome the distal obstruction, it will become an emergency." — Marc Levitt (clinical) [Ep 4 · 8:55](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=535) - "For rectal biopsy in suspected Hirschsprung disease, you must be at least 1 centimeter in from the dentate line. If you biopsy too close to the dentate line, everyone has an aganglionic segment there and you could get the wrong answer." — Marc Levitt (clinical) [Ep 4 · 12:38](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=758) - "The pathologist must report both the absence of ganglion cells AND the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung disease - that could be a biopsy taken too low." — Marc Levitt (clinical) [Ep 4 · 13:23](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=803) - "Hirschsprung disease has an immune component and the lining of the bowel (mucosa) is much more susceptible to bacterial translocation. Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia." — Marc Levitt (clinical) [Ep 4 · 14:59](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=899) - "If irrigations are not working and the baby is ill, you need to divert. The recommendation is to divert in the ileum rather than doing a leveling colostomy, because frozen section can be inaccurate, particularly as you move higher in the colon." — Marc Levitt (clinical) [Ep 4 · 15:42](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=942) - "The Swenson operation involved full-thickness transabdominal dissection down below the peritoneal reflection. The operation was often done incorrectly with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence." — Marc Levitt (clinical) [Ep 4 · 18:14](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1094) - "The Suave operation used a mucosal dissection to keep the outer rectal wall intact and avoid injury. The original Suave would leave the colon coming through the anus for a week before doing the coloanal anastomosis; Dr. Scott Boley modified it to do everything in one stage." — Marc Levitt (clinical) [Ep 4 · 19:28](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1168) - "The Duhamel operation leaves the original rectum in place, removes the aganglionic portion from the peritoneal reflection, and pulls ganglionic bowel in a retrorectal position, connecting the two lumens with a stapler." — Marc Levitt (clinical) [Ep 4 · 20:18](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1218) - "Of the four classic procedures (Swenson, Suave, Duhamel, Rabine), only the Swenson actually leaves behind virtually no Hirschsprung tissue. The others leave behind outer rectal wall or original rectum. Many patients did well despite this because ganglionic bowel, if it's good, can overcome a lot." — Marc Levitt (clinical) [Ep 4 · 21:18](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1278) - "Dr. Henrys in the Philippines pioneered primary pull-through operations (without initial colostomy) out of necessity because patients would never return to clinic due to social stigma against colostomies." — Marc Levitt (clinical) [Ep 4 · 22:19](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1339) - "Keith Jorgeson applied laparoscopic skills to Hirschsprung disease, doing the colonic work laparoscopically with a Suave dissection from above. Luis de la Torre and Jack Langer developed the transanal approach, starting the dissection from below." — Marc Levitt (clinical) [Ep 4 · 23:21](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1401) - "The current preferred approach is a transanal Swenson (full-thickness dissection). It is the purest operation, leaving behind no Hirschsprung except the very bottom just above the dentate line. If you find the right plane, it's elegant and bloodless." — Marc Levitt (opinion) [Ep 4 · 25:34](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1534) - "Dr. Orvar Swenson, who recently died at age 105, maintained that the Swenson operation was good all along and people just weren't doing it right, which gave it a bad reputation." — Marc Levitt (clinical) [Ep 4 · 26:23](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1583) - "Even Suave enthusiasts are making shorter and shorter cuffs over time. Jorgeson's original laparoscopic Suave recommended a 5 cm cuff; nowadays Langer and de la Torre do 1-1.5 cm cuffs, essentially approaching a Swenson." — Marc Levitt (clinical) [Ep 4 · 27:06](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1626) - "Laparoscopy is appropriate for all cases to find the transition zone level. A transanal-only approach is only appropriate when you have a very reachable, obvious transition zone at mid-sigmoid that you can comfortably reach transanally." — Marc Levitt (opinion) [Ep 4 · 28:50](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1730) - "There is significant morbidity from an overly aggressive transanal-only approach trying to reach the transition zone without going into the abdomen. If you're too aggressive transanally trying to visualize the dissection, you would have been better off with laparoscopic dissection." — Marc Levitt (clinical) [Ep 4 · 29:18](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1758) - "Total colonic Hirschsprung patients present differently: the diagnosis isn't made right away, the contrast study is not typical, and irrigations don't go well. These patients need laparoscopy first to find the biopsy location." — Marc Levitt (clinical) [Ep 4 · 31:18](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1878) - "The biggest technical problems are: (1) surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or (2) they give very aggressive exposure and overstretch the sphincters." — Marc Levitt (clinical) [Ep 4 · 34:09](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2049) - "Proper technique requires marking 1 cm proximal to the dentate line with a purple mark and placing 5-0 silk stitches circumferentially at that level. This preserves the anal canal, dentate line, plus an additional 1 cm of columnar epithelium before starting dissection." — Marc Levitt (clinical) [Ep 4 · 35:30](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2130) - "By definition, you're leaving behind 1 cm of columnar epithelium that is Hirschsprung disease, plus the internal sphincter which has a problem with relaxation. However, good ganglionic bowel is able to overcome that, and the baby eventually learns to relax the sphincter." — Marc Levitt (clinical) [Ep 4 · 36:39](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2199) - "The rectum doesn't really have a mesentery; the rectum's blood supply is intramural. As you get higher and reach the peritoneal reflection, that's when you start to see sigmoidal vessels where rectum transitions to sigmoid." — Marc Levitt (clinical) [Ep 4 · 38:19](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2299) - "The anterior rectum frees up much quicker than the posterior rectum. Break into the peritoneal reflection anteriorly first. In transanal-only cases, you can pull the sigmoid out anteriorly, do a full-thickness biopsy, and send it while continuing the posterior dissection." — Marc Levitt (clinical) [Ep 4 · 38:45](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2325) - "For laparoscopic biopsies through the umbilicus, a seromuscular biopsy (without violating mucosa) may show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa. If using this technique, send a full-thickness biopsy later to confirm the level is appropriate." — Marc Levitt (clinical) [Ep 4 · 40:56](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2456) - "Pathologists must report not only ganglion cells but also the quality of nerves with actual micron measurements. Nerves should be 40 microns or less. Anything bigger than 40 microns is transition zone bowel." — Marc Levitt (clinical) [Ep 4 · 44:03](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2643) - "The concept of 'go 5 cm above the transition zone' is inaccurate. Transition zone is a spectrum - some are 10 cm, some are 3 cm. You need confirmatory biopsy with ganglion cell information and nerve quality measured in microns." — Marc Levitt (clinical) [Ep 4 · 44:20](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2660) - "It's preferable to take the IMA, preserve the arcade, and have the left colon and sigmoid nice and straight down into the perineum. This makes for an easy-to-irrigate baby. Many patients have not had enough of a pull-through with the entire sigmoid loop still there, requiring redo to remove more." — Marc Levitt (clinical) [Ep 4 · 45:57](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2757) - "For anything proximal to the splenic flexure, do colonic biopsies and an ileostomy and wait, because frozen section has been notoriously fraught with errors in those cases. There is no urgency. Another option is to take biopsies, quit without diverting, and return 3-4 days later for pull-through with permanent section results." — Marc Levitt (clinical) [Ep 4 · 47:02](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2822) - "Postoperatively, wait until the belly is absolutely soft and flat with bowel function before feeding. Get an X-ray because abdominal distention is sometimes subclinical. This usually takes 3-4 days. Feeding too early risks the baby going home distended and returning with enterocolitis." — Marc Levitt (clinical) [Ep 4 · 53:23](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3203) - "Routine postoperative management: at one month, check the anus with Hagar dilators (not finger). Most babies need calibration rather than true dilation. The stimulation of passing the Hagar has value to help the baby more successfully empty." — Marc Levitt (clinical) [Ep 4 · 54:39](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3279) - "Flagyl is only used to treat enterocolitis, not routinely postoperatively. Give a pre-op dose of second-generation cephalosporin and maybe 2 post-op doses." — Marc Levitt (clinical) [Ep 4 · 55:52](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3352) - "Routine irrigations are only done postoperatively if the baby develops significant distention, which is rare. However, for total colonic patients after ileoanal pull-through, send all patients home on irrigations for 3 months." — Marc Levitt (clinical) [Ep 4 · 56:31](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3391) - "For hepatic flexure transition zone (rare), open the patient rather than laparoscopy. Take down the entire right colon, recognize the ileocolic vessel and how it feeds the vessel paralleling the right colon. Often need to take the right colic artery. De-rotate the colon so cecum is at the hepatic liver bed, then do pull-through down the right side of abdomen." — Marc Levitt (clinical) [Ep 4 · 57:05](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3425) - "If bringing de-rotated colon down the left side of abdomen, must mobilize the ligament of Treitz so the mesenteric vessel is not draped across the third portion of duodenum, which can cause duodenal obstruction." — Marc Levitt (clinical) [Ep 4 · 58:02](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3482) - "The negative appendectomy rate among hospitals is a median of 2.6% with a range from 0 to 17%, according to Kurt Newman's 2003 paper in Journal of Pediatric Surgery reviewing the PHIS database." — Nick Bruns (host_summary) [Ep 4 · 1:59](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=119) - "For incidental Meckel's diverticulum during laparoscopy, Zani's 2008 Annals of Surgery review recommended leaving it, stating the risk of complications is not worth the extremely low mortality rate of 0.001%." — Nick Bruns (host_summary) [Ep 4 · 2:44](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=164) - "The 50-year Mayo Clinic experience (Park et al., 2005, Annals of Surgery) recommended selective resection of Meckel's diverticulum based on four features: age less than 50, male sex, length greater than 2 cm, or presence of histologically abnormal tissue." — Nick Bruns (host_summary) [Ep 4 · 3:10](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=190) - "A Miami Children's Hospital paper (Al-Khoury et al., JAMA Surgery 2012) studied 200 consecutive non-perforated appendicitis patients. 80% were same-day discharges with similar complication and readmission rates compared to overnight stays." — Nick Bruns (host_summary) [Ep 4 · 4:28](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=268) - "The best treatment for Hirschsprung disease is irrigations using a large bore tube (20 French Foley) with warm saline, instilling 10-20 cc aliquots at a time and allowing fluid mixed with stool to drain back." — Marc Levitt (clinical) [Ep 7 · 8:43](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=523) - "It is very rare that Hirschsprung disease is a surgical emergency, but if you don't irrigate and overcome the distal obstruction, it will become an emergency." — Marc Levitt (clinical) [Ep 7 · 8:55](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=535) - "For rectal biopsy in suspected Hirschsprung disease, you must be at least 1 centimeter in from the dentate line. If you biopsy too close to the dentate line, everyone has an aganglionic segment there and you could get the wrong answer." — Marc Levitt (clinical) [Ep 7 · 12:38](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=758) - "The pathologist must report both the absence of ganglion cells AND the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung disease - that could be a biopsy taken too low." — Marc Levitt (clinical) [Ep 7 · 13:23](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=803) - "Hirschsprung disease has an immune component and the lining of the bowel (mucosa) is much more susceptible to bacterial translocation. Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia." — Marc Levitt (clinical) [Ep 7 · 14:59](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=899) - "If irrigations are not working and the baby is ill, you need to divert. The recommendation is to divert in the ileum rather than doing a leveling colostomy, because frozen section can be inaccurate, particularly as you move higher in the colon." — Marc Levitt (clinical) [Ep 7 · 15:42](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=942) - "The Swenson operation involved full-thickness transabdominal dissection down below the peritoneal reflection. The operation was often done incorrectly with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence." — Marc Levitt (clinical) [Ep 7 · 18:14](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1094) - "The Suave operation used a mucosal dissection to keep the outer rectal wall intact and avoid injury. The original Suave would leave the colon coming through the anus for a week before doing the coloanal anastomosis; Dr. Scott Boley modified it to do everything in one stage." — Marc Levitt (clinical) [Ep 7 · 19:28](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1168) - "The Duhamel operation leaves the original rectum in place, removes the aganglionic portion from the peritoneal reflection, and pulls ganglionic bowel in a retrorectal position, connecting the two lumens with a stapler." — Marc Levitt (clinical) [Ep 7 · 20:18](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1218) - "Of the four classic procedures (Swenson, Suave, Duhamel, Rabine), only the Swenson actually leaves behind virtually no Hirschsprung tissue. The others leave behind outer rectal wall or original rectum. Many patients did well despite this because ganglionic bowel, if it's good, can overcome a lot." — Marc Levitt (clinical) [Ep 7 · 21:18](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1278) - "Dr. Henrys in the Philippines pioneered primary pull-through operations (without initial colostomy) out of necessity because patients would never return to clinic due to social stigma against colostomies." — Marc Levitt (clinical) [Ep 7 · 22:19](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1339) - "Keith Jorgeson applied laparoscopic skills to Hirschsprung disease, doing the colonic work laparoscopically with a Suave dissection from above. Luis de la Torre and Jack Langer developed the transanal approach, starting the dissection from below." — Marc Levitt (clinical) [Ep 7 · 23:21](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1401) - "The current preferred approach is a transanal Swenson (full-thickness dissection). It is the purest operation, leaving behind no Hirschsprung except the very bottom just above the dentate line. If you find the right plane, it's elegant and bloodless." — Marc Levitt (opinion) [Ep 7 · 25:34](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1534) - "Dr. Orvar Swenson, who recently died at age 105, maintained that the Swenson operation was good all along and people just weren't doing it right, which gave it a bad reputation." — Marc Levitt (clinical) [Ep 7 · 26:23](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1583) - "Even Suave enthusiasts are making shorter and shorter cuffs over time. Jorgeson's original laparoscopic Suave recommended a 5 cm cuff; nowadays Langer and de la Torre do 1-1.5 cm cuffs, essentially approaching a Swenson." — Marc Levitt (clinical) [Ep 7 · 27:06](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1626) - "Laparoscopy is appropriate for all cases to find the transition zone level. A transanal-only approach is only appropriate when you have a very reachable, obvious transition zone at mid-sigmoid that you can comfortably reach transanally." — Marc Levitt (opinion) [Ep 7 · 28:50](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1730) - "There is significant morbidity from an overly aggressive transanal-only approach trying to reach the transition zone without going into the abdomen. If you're too aggressive transanally trying to visualize the dissection, you would have been better off with laparoscopic dissection." — Marc Levitt (clinical) [Ep 7 · 29:18](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1758) - "Total colonic Hirschsprung patients present differently: the diagnosis isn't made right away, the contrast study is not typical, and irrigations don't go well. These patients need laparoscopy first to find the biopsy location." — Marc Levitt (clinical) [Ep 7 · 31:18](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1878) - "The biggest technical problems are: (1) surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or (2) they give very aggressive exposure and overstretch the sphincters." — Marc Levitt (clinical) [Ep 7 · 34:09](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2049) - "Proper technique requires marking 1 cm proximal to the dentate line with a purple mark and placing 5-0 silk stitches circumferentially at that level. This preserves the anal canal, dentate line, plus an additional 1 cm of columnar epithelium before starting dissection." — Marc Levitt (clinical) [Ep 7 · 35:30](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2130) - "By definition, you're leaving behind 1 cm of columnar epithelium that is Hirschsprung disease, plus the internal sphincter which has a problem with relaxation. However, good ganglionic bowel is able to overcome that, and the baby eventually learns to relax the sphincter." — Marc Levitt (clinical) [Ep 7 · 36:39](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2199) - "The rectum doesn't really have a mesentery; the rectum's blood supply is intramural. As you get higher and reach the peritoneal reflection, that's when you start to see sigmoidal vessels where rectum transitions to sigmoid." — Marc Levitt (clinical) [Ep 7 · 38:19](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2299) - "The anterior rectum frees up much quicker than the posterior rectum. Break into the peritoneal reflection anteriorly first. In transanal-only cases, you can pull the sigmoid out anteriorly, do a full-thickness biopsy, and send it while continuing the posterior dissection." — Marc Levitt (clinical) [Ep 7 · 38:45](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2325) - "For laparoscopic biopsies through the umbilicus, a seromuscular biopsy (without violating mucosa) may show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa. If using this technique, send a full-thickness biopsy later to confirm the level is appropriate." — Marc Levitt (clinical) [Ep 7 · 40:56](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2456) - "Pathologists must report not only ganglion cells but also the quality of nerves with actual micron measurements. Nerves should be 40 microns or less. Anything bigger than 40 microns is transition zone bowel." — Marc Levitt (clinical) [Ep 7 · 44:03](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2643) - "The concept of 'go 5 cm above the transition zone' is inaccurate. Transition zone is a spectrum - some are 10 cm, some are 3 cm. You need confirmatory biopsy with ganglion cell information and nerve quality measured in microns." — Marc Levitt (clinical) [Ep 7 · 44:20](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2660) - "It's preferable to take the IMA, preserve the arcade, and have the left colon and sigmoid nice and straight down into the perineum. This makes for an easy-to-irrigate baby. Many patients have not had enough of a pull-through with the entire sigmoid loop still there, requiring redo to remove more." — Marc Levitt (clinical) [Ep 7 · 45:57](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2757) - "For anything proximal to the splenic flexure, do colonic biopsies and an ileostomy and wait, because frozen section has been notoriously fraught with errors in those cases. There is no urgency. Another option is to take biopsies, quit without diverting, and return 3-4 days later for pull-through with permanent section results." — Marc Levitt (clinical) [Ep 7 · 47:02](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2822) - "Postoperatively, wait until the belly is absolutely soft and flat with bowel function before feeding. Get an X-ray because abdominal distention is sometimes subclinical. This usually takes 3-4 days. Feeding too early risks the baby going home distended and returning with enterocolitis." — Marc Levitt (clinical) [Ep 7 · 53:23](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3203) - "Routine postoperative management: at one month, check the anus with Hagar dilators (not finger). Most babies need calibration rather than true dilation. The stimulation of passing the Hagar has value to help the baby more successfully empty." — Marc Levitt (clinical) [Ep 7 · 54:39](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3279) - "Flagyl is only used to treat enterocolitis, not routinely postoperatively. Give a pre-op dose of second-generation cephalosporin and maybe 2 post-op doses." — Marc Levitt (clinical) [Ep 7 · 55:52](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3352) - "Routine irrigations are only done postoperatively if the baby develops significant distention, which is rare. However, for total colonic patients after ileoanal pull-through, send all patients home on irrigations for 3 months." — Marc Levitt (clinical) [Ep 7 · 56:31](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3391) - "For hepatic flexure transition zone (rare), open the patient rather than laparoscopy. Take down the entire right colon, recognize the ileocolic vessel and how it feeds the vessel paralleling the right colon. Often need to take the right colic artery. De-rotate the colon so cecum is at the hepatic liver bed, then do pull-through down the right side of abdomen." — Marc Levitt (clinical) [Ep 7 · 57:05](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3425) - "If bringing de-rotated colon down the left side of abdomen, must mobilize the ligament of Treitz so the mesenteric vessel is not draped across the third portion of duodenum, which can cause duodenal obstruction." — Marc Levitt (clinical) [Ep 7 · 58:02](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3482) - "The negative appendectomy rate among hospitals is a median of 2.6% with a range from 0 to 17%, according to Kurt Newman's 2003 paper in Journal of Pediatric Surgery reviewing the PHIS database." — Nick Bruns (host_summary) [Ep 7 · 1:59](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=119) - "For incidental Meckel's diverticulum during laparoscopy, Zani's 2008 Annals of Surgery review recommended leaving it, stating the risk of complications is not worth the extremely low mortality rate of 0.001%." — Nick Bruns (host_summary) [Ep 7 · 2:44](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=164) - "The 50-year Mayo Clinic experience (Park et al., 2005, Annals of Surgery) recommended selective resection of Meckel's diverticulum based on four features: age less than 50, male sex, length greater than 2 cm, or presence of histologically abnormal tissue." — Nick Bruns (host_summary) [Ep 7 · 3:10](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=190) - "A Miami Children's Hospital paper (Al-Khoury et al., JAMA Surgery 2012) studied 200 consecutive non-perforated appendicitis patients. 80% were same-day discharges with similar complication and readmission rates compared to overnight stays." — Nick Bruns (host_summary) [Ep 7 · 4:28](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=268) - "The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy." — Daniel von Allmen (host_summary) [Ep 6 · 2:48](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=168) - "The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference." — Daniel von Allmen (host_summary) [Ep 6 · 3:32](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=212) - "High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo." — Daniel von Allmen (host_summary) [Ep 6 · 4:01](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=241) - "Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo." — Daniel von Allmen (host_summary) [Ep 6 · 4:39](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=279) - "Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events." — Daniel von Allmen (host_summary) [Ep 6 · 4:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=295) - "Dr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results." — Daniel von Allmen (opinion) [Ep 6 · 5:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=331) - "The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids." — Daniel von Allmen (host_summary) [Ep 6 · 7:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=431) - "Two proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant)." — Daniel von Allmen (clinical) [Ep 6 · 9:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=549) - "The START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen." — Daniel von Allmen (clinical) [Ep 6 · 10:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=609) - "A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other." — Whit Holcomb (host_summary) [Ep 6 · 11:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=680) - "Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol." — Whit Holcomb (host_summary) [Ep 6 · 13:49](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=829) - "The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge." — Whit Holcomb (host_summary) [Ep 6 · 14:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=860) - "Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days." — Whit Holcomb (host_summary) [Ep 6 · 14:48](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=888) - "Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision)." — Whit Holcomb (clinical) [Ep 6 · 16:30](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=990) - "Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice." — Whit Holcomb (opinion) [Ep 6 · 17:03](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1023) - "Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day." — Whit Holcomb (clinical) [Ep 6 · 18:16](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1096) - "A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year." — Whit Holcomb (host_summary) [Ep 6 · 20:35](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1235) - "Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation." — Whit Holcomb (host_summary) [Ep 6 · 22:42](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1362) - "In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate)." — Whit Holcomb (host_summary) [Ep 6 · 23:14](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1394) - "Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization." — Whit Holcomb (host_summary) [Ep 6 · 24:35](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1475) - "Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation." — Whit Holcomb (host_summary) [Ep 6 · 24:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1495) - "The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned." — Whit Holcomb (host_summary) [Ep 6 · 25:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1520) - "Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics." — Whit Holcomb (opinion) [Ep 6 · 26:33](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1593) - "Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics." — Whit Holcomb (clinical) [Ep 6 · 27:00](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1620) - "The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation." — Whit Holcomb (opinion) [Ep 6 · 27:22](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1642) - "Long-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis." — Whit Holcomb (opinion) [Ep 6 · 27:52](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1672) - "Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment." — Whit Holcomb (host_summary) [Ep 6 · 29:19](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1759) - "If appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk." — Whit Holcomb (opinion) [Ep 6 · 29:45](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1785) - "A PIFCON multi-center cohort study of 272 children with intestinal failure (median follow-up 33 months) found enteral autonomy was achieved in 43%, 13% remained PN-dependent, and 43% died or underwent transplant." — Aaron Lipskar (host_summary) [Ep 6 · 31:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1891) - "Necrotizing enterocolitis as the underlying diagnosis, care at an intestinal rehab facility without a transplant center, and presence of an ileocecal valve were all statistically significantly associated with higher rates of enteral autonomy." — Aaron Lipskar (host_summary) [Ep 6 · 32:58](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1978) - "Residual small bowel length was also a statistically significant predictor of enteral autonomy, though less impressive than the other three variables." — Aaron Lipskar (host_summary) [Ep 6 · 33:19](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1999) - "The protective effect of necrotizing enterocolitis on enteral autonomy is surprising and goes against understanding of that inflammatory illness, showing how much remains to be learned." — Aaron Lipskar (opinion) [Ep 6 · 33:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2035) - "A companion paper in the same journal (Journal of Pediatrics, July 2015) found necrotizing enterocolitis was a poor predictor of growth outcome in infants with short bowel syndrome." — Aaron Lipskar (host_summary) [Ep 6 · 34:46](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2086) - "The PIFCON study underscores the importance of managing children with intestinal failure in multidisciplinary intestinal rehab programs, where catheter-associated bloodstream infection elimination and cholestasis prevention have changed outcomes." — Aaron Lipskar (opinion) [Ep 6 · 36:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2171) - "Animal studies show that commonly used anesthetics and sedatives (propofol, etomidate, sevoflurane, isoflurane, ketamine) that increase GABA receptor activity or block glutamate receptors produce neurotoxic effects in laboratory animals from nematodes to nonhuman primates." — Aaron Lipskar (host_summary) [Ep 6 · 38:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2289) - "Observational studies in children undergoing early anesthesia offer conflicting results and are confounded by multiple factors, but suggest some children may have deficits—association, not causation." — Aaron Lipskar (host_summary) [Ep 6 · 38:43](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2323) - "SmartTots June 2014 statement concluded that animal data is sufficiently convincing to warrant large-scale clinical studies and recommended avoiding anesthesia in children under 3 unless urgent or potentially harmful if not attended to." — Aaron Lipskar (host_summary) [Ep 6 · 39:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2351) - "Dr. Lipskar has not yet delayed an inguinal hernia repair for anesthetic concerns." — Aaron Lipskar (opinion) [Ep 6 · 40:53](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2453) - "At Cohen Children's Medical Center, circumcisions outside the neonatal period are done with general plus regional anesthesia." — Aaron Lipskar (clinical) [Ep 6 · 41:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2469) - "Regional anesthesia and agents like precedex may help decrease the amount of potentially neurotoxic general anesthesia; almost every laparoscopic, thoracoscopic, or open operation has a regional block option." — Aaron Lipskar (opinion) [Ep 6 · 41:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2491) - "Dr. Ponsky's chief of anesthesiology instituted a 'rule of two': defer elective operations until after age 2 and avoid two anesthetics in one year." — Todd Ponsky (clinical) [Ep 6 · 42:16](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2536) - "Dr. Ponsky now defers dermoid cyst excision in a 6-month-old until 18 months but does not delay inguinal hernia repair due to known incarceration risk in young infants." — Todd Ponsky (opinion) [Ep 6 · 42:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2551) - "A survey of ~150 parents in a primary care pediatrics office found the vast majority did not know anesthetic neurotoxicity was a major issue (Dr. Lipskar's unpublished study, to be presented at AAP)." — Aaron Lipskar (clinical) [Ep 6 · 43:17](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2597) - "The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy." — Daniel von Allmen (host_summary) [Ep 3 · 2:48](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=168) - "The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference." — Daniel von Allmen (host_summary) [Ep 3 · 3:32](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=212) - "High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo." — Daniel von Allmen (host_summary) [Ep 3 · 4:01](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=241) - "Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo." — Daniel von Allmen (host_summary) [Ep 3 · 4:39](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=279) - "Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events." — Daniel von Allmen (host_summary) [Ep 3 · 4:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=295) - "Dr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results." — Daniel von Allmen (opinion) [Ep 3 · 5:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=331) - "The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids." — Daniel von Allmen (host_summary) [Ep 3 · 7:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=431) - "Two proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant)." — Daniel von Allmen (clinical) [Ep 3 · 9:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=549) - "The START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen." — Daniel von Allmen (clinical) [Ep 3 · 10:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=609) - "A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other." — Whit Holcomb (host_summary) [Ep 3 · 11:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=680) - "Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol." — Whit Holcomb (host_summary) [Ep 3 · 13:49](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=829) - "The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge." — Whit Holcomb (host_summary) [Ep 3 · 14:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=860) - "Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days." — Whit Holcomb (host_summary) [Ep 3 · 14:48](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=888) - "Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision)." — Whit Holcomb (clinical) [Ep 3 · 16:30](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=990) - "Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice." — Whit Holcomb (opinion) [Ep 3 · 17:03](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1023) - "Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day." — Whit Holcomb (clinical) [Ep 3 · 18:16](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1096) - "A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year." — Whit Holcomb (host_summary) [Ep 3 · 20:35](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1235) - "Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation." — Whit Holcomb (host_summary) [Ep 3 · 22:42](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1362) - "In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate)." — Whit Holcomb (host_summary) [Ep 3 · 23:14](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1394) - "Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization." — Whit Holcomb (host_summary) [Ep 3 · 24:35](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1475) - "Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation." — Whit Holcomb (host_summary) [Ep 3 · 24:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1495) - "The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned." — Whit Holcomb (host_summary) [Ep 3 · 25:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1520) - "Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics." — Whit Holcomb (opinion) [Ep 3 · 26:33](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1593) - "Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics." — Whit Holcomb (clinical) [Ep 3 · 27:00](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1620) - "The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation." — Whit Holcomb (opinion) [Ep 3 · 27:22](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1642) - "Long-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis." — Whit Holcomb (opinion) [Ep 3 · 27:52](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1672) - "Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment." — Whit Holcomb (host_summary) [Ep 3 · 29:19](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1759) - "If appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk." — Whit Holcomb (opinion) [Ep 3 · 29:45](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1785) - "A PIFCON multi-center cohort study of 272 children with intestinal failure (median follow-up 33 months) found enteral autonomy was achieved in 43%, 13% remained PN-dependent, and 43% died or underwent transplant." — Aaron Lipskar (host_summary) [Ep 3 · 31:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1891) - "Necrotizing enterocolitis as the underlying diagnosis, care at an intestinal rehab facility without a transplant center, and presence of an ileocecal valve were all statistically significantly associated with higher rates of enteral autonomy." — Aaron Lipskar (host_summary) [Ep 3 · 32:58](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1978) - "Residual small bowel length was also a statistically significant predictor of enteral autonomy, though less impressive than the other three variables." — Aaron Lipskar (host_summary) [Ep 3 · 33:19](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1999) - "The protective effect of necrotizing enterocolitis on enteral autonomy is surprising and goes against understanding of that inflammatory illness, showing how much remains to be learned." — Aaron Lipskar (opinion) [Ep 3 · 33:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2035) - "A companion paper in the same journal (Journal of Pediatrics, July 2015) found necrotizing enterocolitis was a poor predictor of growth outcome in infants with short bowel syndrome." — Aaron Lipskar (host_summary) [Ep 3 · 34:46](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2086) - "The PIFCON study underscores the importance of managing children with intestinal failure in multidisciplinary intestinal rehab programs, where catheter-associated bloodstream infection elimination and cholestasis prevention have changed outcomes." — Aaron Lipskar (opinion) [Ep 3 · 36:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2171) - "Animal studies show that commonly used anesthetics and sedatives (propofol, etomidate, sevoflurane, isoflurane, ketamine) that increase GABA receptor activity or block glutamate receptors produce neurotoxic effects in laboratory animals from nematodes to nonhuman primates." — Aaron Lipskar (host_summary) [Ep 3 · 38:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2289) - "Observational studies in children undergoing early anesthesia offer conflicting results and are confounded by multiple factors, but suggest some children may have deficits—association, not causation." — Aaron Lipskar (host_summary) [Ep 3 · 38:43](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2323) - "SmartTots June 2014 statement concluded that animal data is sufficiently convincing to warrant large-scale clinical studies and recommended avoiding anesthesia in children under 3 unless urgent or potentially harmful if not attended to." — Aaron Lipskar (host_summary) [Ep 3 · 39:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2351) - "Dr. Lipskar has not yet delayed an inguinal hernia repair for anesthetic concerns." — Aaron Lipskar (opinion) [Ep 3 · 40:53](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2453) - "At Cohen Children's Medical Center, circumcisions outside the neonatal period are done with general plus regional anesthesia." — Aaron Lipskar (clinical) [Ep 3 · 41:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2469) - "Regional anesthesia and agents like precedex may help decrease the amount of potentially neurotoxic general anesthesia; almost every laparoscopic, thoracoscopic, or open operation has a regional block option." — Aaron Lipskar (opinion) [Ep 3 · 41:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2491) - "Dr. Ponsky's chief of anesthesiology instituted a 'rule of two': defer elective operations until after age 2 and avoid two anesthetics in one year." — Todd Ponsky (clinical) [Ep 3 · 42:16](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2536) - "Dr. Ponsky now defers dermoid cyst excision in a 6-month-old until 18 months but does not delay inguinal hernia repair due to known incarceration risk in young infants." — Todd Ponsky (opinion) [Ep 3 · 42:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2551) - "A survey of ~150 parents in a primary care pediatrics office found the vast majority did not know anesthetic neurotoxicity was a major issue (Dr. Lipskar's unpublished study, to be presented at AAP)." — Aaron Lipskar (clinical) [Ep 3 · 43:17](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2597) - "The Chilean Society of Pediatric Surgery screens approximately 1,200 articles each month from non-pediatric surgical journals to identify the 3% relevant to pediatric surgery." — Jose Campos (clinical) [Ep 9 · 1:38](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=98) - "A multi-institutional prospective randomized trial comparing piperacillin-tazobactam to ceftriaxone-metronidazole for perforated appendicitis was stopped at 75% enrollment when interim analysis favored the piperacillin-tazobactam group." — Jose Campos (host_summary) [Ep 9 · 4:40](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=280) - "Intra-abdominal abscess formation was significantly lower in the piperacillin-tazobactam group with an odds ratio of 4.8." — Jose Campos (host_summary) [Ep 9 · 5:30](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=330) - "The number needed to treat with piperacillin-tazobactam to prevent one intra-abdominal abscess was 5.7." — Jose Campos (host_summary) [Ep 9 · 5:50](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=350) - "One participating hospital in the appendicitis antibiotic trial did not see a difference in abscess rates between the two antibiotic regimens in their cohort, while the overall study results were driven entirely by Phoenix Children's Hospital's experience." — Shawn St. Peter (clinical) [Ep 9 · 7:04](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=424) - "NSQIP-P national data shows no difference in abscess rates between ceftriaxone-metronidazole and piperacillin-tazobactam across much larger patient numbers." — Shawn St. Peter (epidemiological) [Ep 9 · 7:45](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=465) - "Necrotizing enterocolitis treated surgically is associated with high mortality rates and poor neurodevelopmental outcomes." — Jose Campos (host_summary) [Ep 9 · 10:30](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=630) - "Two previous randomized controlled trials comparing surgical techniques for NEC both failed to enroll enough patients to answer the clinical question." — Jose Campos (host_summary) [Ep 9 · 10:50](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=650) - "A 20-center randomized controlled trial by Marty Blakely comparing initial laparotomy versus peritoneal drainage for NEC randomized 310 premature newborns." — Jose Campos (host_summary) [Ep 9 · 11:05](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=665) - "At 18 to 22 months of corrected age, the composite outcome of death and neurodevelopmental impairment was similar in both the laparotomy and peritoneal drainage groups in frequentist analysis." — Jose Campos (host_summary) [Ep 9 · 11:25](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=685) - "Bayesian analysis of the NEC trial showed a high probability of laparotomy being superior to peritoneal drainage." — Jose Campos (host_summary) [Ep 9 · 11:40](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=700) - "In the NEC trial, there was significant surgeon intention to treat, with most patients who received initial peritoneal drainage going to laparotomy shortly after drain placement." — Shawn St. Peter (clinical) [Ep 9 · 12:40](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=760) - "Peritoneal drainage for NEC often serves as a temporizing measure to stabilize septic patients before laparotomy rather than as definitive therapy." — Shawn St. Peter (opinion) [Ep 9 · 13:42](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=822) - "In the original papers by Ziggy Hein on peritoneal drainage for NEC, approximately one-third of patients died, one-third received laparotomy, and one-third were managed with drainage alone." (host_summary) [Ep 9 · 13:51](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=831) - "Peritoneal drainage started as a temporizing measure for NEC but morphed into a definitive management strategy in approximately 40-50% of surgeons' minds." (opinion) [Ep 9 · 14:10](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=850) - "The original description of percutaneous endoscopic gastrostomy (PEG) was done by Todd Ponsky Sr." — Jose Campos (clinical) [Ep 9 · 15:50](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=950) - "A systematic review examining gastrostomy insertion techniques reviewed 900 publications, with 58 being used for final recommendations." — Jose Campos (host_summary) [Ep 9 · 18:20](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1100) - "Twelve studies directly compared outcomes between laparoscopic and percutaneous endoscopic gastrostomy, showing major complication rates were significantly less common with laparoscopic placement." — Jose Campos (host_summary) [Ep 9 · 18:50](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1130) - "The number needed to treat to prevent one major complication from PEG (by using laparoscopic approach instead) is 24." — Jose Campos (host_summary) [Ep 9 · 19:20](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1160) - "PEG tubes are difficult to change to button tubes, often requiring a second anesthetic with GI specialists to remove the PEG endoscopically before placing a button." — Meera Kotagal (clinical) [Ep 9 · 20:29](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1229) - "The article by Todd Ponsky Sr. and Mike Goddard on PEG tube placement remains the most cited article in the history of the Journal of Pediatric Surgery, with approximately three times the citations of the number two article." — Todd Ponsky (clinical) [Ep 9 · 17:36](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1056) - "The Teen Labs Consortium has been conducting NIH-funded prospective trials on bariatric surgery in adolescents since 2007." (clinical) [Ep 9 · 24:10](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1450) - "Sleeve gastrectomy is a very safe operation in adolescents with good long-term data showing resolution of comorbidities, especially in pre-diabetic and diabetic patients." (clinical) [Ep 9 · 23:14](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1394) - "A database comparison of 3,000 patients with differentiated papillary thyroid cancer found no survival difference between total thyroidectomy and thyroid lobectomy." — Jose Campos (host_summary) [Ep 9 · 25:49](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1549) - "The average time pediatric patients spend in bariatric surgery programs before proceeding to surgery is approximately nine months." (clinical) [Ep 9 · 25:11](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1511) - "Stevens et al. examined CDC Wonder database data between 1999 and 2020 for pediatric firearm and automobile fatalities." — Ellen Encisco (host_summary) [Ep 10 · 0:46](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=46) - "Stevens et al. used the Gifford's Law Center annual gun law scorecard between 2014 and 2020 to assess state gun law scores." — Ellen Encisco (host_summary) [Ep 10 · 0:46](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=46) - "In recent years, the fatality rate for firearms has surpassed the fatality rate for automobiles in children." — Ellen Encisco (host_summary) [Ep 10 · 0:46](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=46) - "Stronger gun laws were associated with decreased fatality rates, with a 55% lower firearm fatality rate for states with the strongest gun laws compared to those with the weakest gun laws." — Ellen Encisco (host_summary) [Ep 10 · 0:46](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=46) - "Gabapentin is an anticonvulsant often used off-label as part of multimodal pain control after major surgery." — Alex Halpern (host_summary) [Ep 10 · 2:11](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=131) - "Lascano et al. performed a retrospective cohort study at Children's Hospital of LA looking at kids age 2 to 18 who underwent appendectomy for perforated appendicitis between 2014 and 2019." — Alex Halpern (host_summary) [Ep 10 · 2:11](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=131) - "In the Lascano et al. study, kids who received gabapentin had decreased postoperative opioid use." — Alex Halpern (host_summary) [Ep 10 · 2:11](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=131) - "In the Lascano et al. study, kids who received gabapentin had decreased postoperative length of stay." — Alex Halpern (host_summary) [Ep 10 · 2:11](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=131) - "Frazier et al. conducted a retrospective study from the Midwest Pediatric Surgery Consortium following 375 patients with gastroschisis who underwent closure between 2013 and 2016." — Cecilia Gigena (host_summary) [Ep 10 · 3:07](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187) - "The overall rate for periumbilical hernias after gastroschisis closure was 22.7%." — Cecilia Gigena (host_summary) [Ep 10 · 3:07](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187) - "Periumbilical hernia rate was significantly higher in patients who underwent primary closure versus those who needed silo placement." — Cecilia Gigena (host_summary) [Ep 10 · 3:07](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187) - "Patients who underwent sutureless gastroschisis closures had 50% rates of persistent hernia." — Cecilia Gigena (host_summary) [Ep 10 · 3:07](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187) - "Only 16.4% of patients who underwent sutured gastroschisis closure had a persistent hernia." — Cecilia Gigena (host_summary) [Ep 10 · 3:07](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187) - "Spontaneous closure of periumbilical hernias after gastroschisis was seen in 38.8% of cases." — Cecilia Gigena (host_summary) [Ep 10 · 3:07](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187) - "Only 31.8% of patients with periumbilical hernias after gastroschisis needed surgery." — Cecilia Gigena (host_summary) [Ep 10 · 3:07](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187) - "Sutureless gastroschisis closures lead to more periumbilical hernias, but they can be managed as any other congenital umbilical hernia and have no additional risk." — Cecilia Gigena (host_summary) [Ep 10 · 3:07](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187) - "The Donnati et al. study was an observational prospective study in Italy from 2013 to 2022 on 468 patients around 15 years old." — Lizzie Lee (host_summary) [Ep 11 · 1:03](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=63) - "Surgeons placed 733 pectus bars total across the 468 patients in the Donnati study." — Lizzie Lee (host_summary) [Ep 11 · 1:13](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=73) - "Bar dislocation is defined as when a pectus bar rotates more than 30 degrees out of place." — Lizzie Lee (host_summary) [Ep 11 · 1:21](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=81) - "Bridge fixation was significantly more stable than single bar fixation for pectus repair." — Lizzie Lee (host_summary) [Ep 11 · 1:28](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=88) - "None of the patients with bridge fixation had dislocated bars compared to those who underwent the single bar technique." — Lizzie Lee (host_summary) [Ep 11 · 1:33](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=93) - "Bridge fixation is the best technique for preventing bar dislocation in pectus excavatum patients." — Lizzie Lee (host_summary) [Ep 11 · 1:39](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=99) - "University of Split researchers developed a machine learning model to accurately identify appendicitis cases while minimizing unnecessary surgery." — Carlos Colunga (host_summary) [Ep 11 · 2:14](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=134) - "The machine learning model was trained using data from 551 pediatric patients who underwent appendectomy, using their clinical, laboratory, and anthropometric information." — Carlos Colunga (host_summary) [Ep 11 · 2:24](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=144) - "The best performing machine learning model achieved 99.7% sensitivity in identifying appendicitis cases." — Carlos Colunga (host_summary) [Ep 11 · 2:37](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=157) - "The machine learning model has specificity that could potentially help reduce up to 17% of negative appendectomies in high risk patients." — Carlos Colunga (host_summary) [Ep 11 · 2:37](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=157) - "The machine learning model can differentiate between complicated and uncomplicated appendicitis with a high degree of accuracy." — Carlos Colunga (host_summary) [Ep 11 · 2:54](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=174) - "The machine learning model uses readily available clinical and lab data without using any advanced imaging." — Carlos Colunga (host_summary) [Ep 11 · 2:54](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=174) - "The Rao et al. study is a multi-center retrospective study done in the US from 2018 to 2022." — Cecilia Gigena (host_summary) [Ep 11 · 3:34](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=214) - "The Rao study compared patients with suspected choledocholithiasis who underwent transcystic laparoscopic common bile duct exploration versus those who underwent ERCP first." — Cecilia Gigena (host_summary) [Ep 11 · 3:34](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=214) - "The Rao study included 252 patients total: 156 in the transcystic laparoscopic common bile duct exploration group and 96 in the ERCP-first group." — Cecilia Gigena (host_summary) [Ep 11 · 3:53](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=233) - "Patients who underwent transcystic laparoscopic common bile duct exploration had significantly less complication rates compared to ERCP-first patients." — Cecilia Gigena (host_summary) [Ep 11 · 4:02](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=242) - "Patients who underwent transcystic laparoscopic common bile duct exploration had lower length of stay compared to ERCP-first patients." — Cecilia Gigena (host_summary) [Ep 11 · 4:02](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=242) - "Attempting a transcystic laparoscopic common bile duct exploration may benefit pediatric choledocholithiasis patients." — Cecilia Gigena (host_summary) [Ep 11 · 4:16](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=256) - "Classic acute appendicitis presentation (pain migration to right lower quadrant, McBurney's point tenderness, elevated WBC and CRP, low-grade fever in thin patient with short symptom duration) can proceed directly to laparoscopic appendectomy without imaging" — Whit Holcomb (clinical) [Ep 8 · 3:25](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=205) - "At Children's Mercy Hospital, emergency department physicians often perform imaging studies before surgical consultation, though this is at their discretion not surgeon direction" — Whit Holcomb (clinical) [Ep 8 · 4:00](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=240) - "Symptom duration over 24-36 hours raises concern for perforation and warrants imaging starting with ultrasound" — Whit Holcomb (clinical) [Ep 8 · 5:11](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=311) - "If ultrasound is not diagnostic but raises concern, proceed to CT scan; if ultrasound is diagnostic of appendicitis, CT is not needed" — Whit Holcomb (clinical) [Ep 8 · 6:25](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=385) - "Non-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and likely perforation; absence of both findings makes appendicitis unlikely though not zero" — Whit Holcomb (clinical) [Ep 8 · 7:28](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=448) - "Children's Mercy uses IV contrast for CT and performs limited/focused CT scans to minimize radiation exposure; rectal contrast protocol was attempted but not adopted by ED physicians" — Whit Holcomb (clinical) [Ep 8 · 8:40](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=520) - "Ceftriaxone and metronidazole is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple antibiotic regimens" — Whit Holcomb (clinical) [Ep 8 · 11:11](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=671) - "In 2008 Journal of Pediatric Surgery randomized trial of 100 patients, daily ceftriaxone/metronidazole showed no difference in abscess rate or wound infections versus ampicillin/gentamicin/clindamycin but resulted in lower antibiotic charges" — Whit Holcomb (clinical) [Ep 8 · 14:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=858) - "Ceftriaxone dosing is 50 mg/kg once daily and metronidazole is 30 mg/kg once daily for appendicitis" — Whit Holcomb (clinical) [Ep 8 · 15:11](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=911) - "Non-perforated appendicitis receives only single preoperative antibiotic dose with no postoperative antibiotics" — Whit Holcomb (clinical) [Ep 8 · 12:58](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=778) - "Once-daily ceftriaxone/metronidazole dosing facilitates home health care transition if needed, does not require serum levels like gentamicin, and avoids gentamicin toxicities" — Whit Holcomb (clinical) [Ep 8 · 13:29](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=809) - "Single-incision or double-incision laparoscopic approaches are used only for thin patients with non-perforated appendicitis" — Whit Holcomb (clinical) [Ep 8 · 16:35](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=995) - "In double-incision approach, 5mm umbilical port is placed with 5mm suprapubic port for mobilization, then appendix is exteriorized through umbilicus for extracorporeal appendectomy" — Whit Holcomb (clinical) [Ep 8 · 17:51](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1071) - "Locking grasper is essential when exteriorizing appendix to prevent dropping it back into abdomen" — Whit Holcomb (clinical) [Ep 8 · 19:40](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1180) - "Fascial incision of 10-12mm is needed to safely exteriorize appendix because grasper creates U-shaped configuration rather than end-on grasp" — Whit Holcomb (clinical) [Ep 8 · 20:53](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1253) - "Perforation is strictly defined as stool in the abdomen (fecalith in abdominal cavity) or a visible hole in the appendix; without these findings the patient does not have perforation" — Whit Holcomb (clinical) [Ep 8 · 21:58](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1318) - "This strict perforation definition was necessary because literature uses terms like gangrenous, necrotic, and perforated inconsistently, all meaning different things to different surgeons" — Whit Holcomb (clinical) [Ep 8 · 21:58](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1318) - "In Ponsky's inter-observer variation study published in Journal of Laparoendoscopic and Advanced Surgical Techniques, attending surgeons viewing same images agreed on perforation status only 25% of the time without defined criteria" — Whit Holcomb (host_summary) [Ep 8 · 23:41](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1421) - "Children's Mercy has been sending non-perforated appendicitis patients home the same day (within 6 hours of surgery) for over a year with over 100 patients managed this way" — Whit Holcomb (clinical) [Ep 8 · 25:46](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1546) - "Same-day discharge for non-perforated appendicitis uses local anesthesia in incisions, pain medications at home, and no postoperative antibiotics" — Whit Holcomb (clinical) [Ep 8 · 25:46](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1546) - "Rationale for same-day discharge includes patient satisfaction, opening hospital beds for patients who need them, and preparing for potential future trials of antibiotics versus day-surgery appendectomy" — Whit Holcomb (opinion) [Ep 8 · 27:33](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1653) - "October 2011 Annals of Surgery study randomized 360 patients (August 2009-November 2010) comparing single-incision to three-port laparoscopy for non-perforated appendicitis" — Whit Holcomb (clinical) [Ep 8 · 28:30](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1710) - "Single-incision appendectomy showed no difference versus three-port in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity" — Whit Holcomb (clinical) [Ep 8 · 28:30](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1710) - "Single-incision approach had longer operative time (5 minutes, statistically significant but not clinically relevant), more narcotic doses, greater surgical difficulty, and higher hospital charges than three-port" — Whit Holcomb (clinical) [Ep 8 · 28:30](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1710) - "Wound infection rate was 3.3% (6/180) for single-incision versus 1.7% (3/180) for three-port, p=0.5, not statistically different" — Todd Ponsky (host_summary) [Ep 8 · 30:23](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1823) - "For single-incision approach, umbilical fascia is closed and interrupted plain sutures placed in umbilical skin; for three-port, umbilical incision closed similarly and 5mm port sites closed with 5-0 Vicryl in U-fashion" — Whit Holcomb (clinical) [Ep 8 · 31:32](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1892) - "Interrupted plain sutures allow wound infection drainage while not requiring removal due to short half-life; wounds dressed with rolled gauze and Tegaderm" — Whit Holcomb (clinical) [Ep 8 · 32:09](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1929) - "St. Peter study compared irrigation plus suction versus suction-only for perforated appendicitis and found no difference in abscess rate or location; both groups had approximately 20% postoperative abscess rate" — Whit Holcomb (clinical) [Ep 8 · 33:00](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1980) - "Study used strict perforation definition (hole in appendix or fecalith in abdomen), not just distended, angry, necrotic, or gangrenous appendix" — Whit Holcomb (clinical) [Ep 8 · 33:00](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1980) - "Across 6-7 appendectomy studies for perforated disease at Children's Mercy, abscess rate has consistently been 15-20%; Holcomb counsels families on 20% abscess risk" — Whit Holcomb (clinical) [Ep 8 · 34:28](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2068) - "Surgeons reporting lower abscess rates for perforation likely include gangrenous/necrotic non-perforated cases in their perforated group, lowering the rate" — Whit Holcomb (opinion) [Ep 8 · 34:28](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2068) - "At Children's Mercy, OR billing is $225 per minute; a $600 stapler is cost-effective if it saves 3 minutes of OR time" — Whit Holcomb (clinical) [Ep 8 · 38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301) - "Children's Mercy surgeons use stapler for both mesoappendix and appendix because it can be justified as cost-effective under their per-minute billing model" — Whit Holcomb (clinical) [Ep 8 · 38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301) - "Standard stapler load is used for appendix and vascular load for mesoappendix, which is another reason not to staple both simultaneously" — Whit Holcomb (clinical) [Ep 8 · 38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301) - "In early 1990s at Vanderbilt, three children who had cautery used for appendectomy developed adjacent small bowel injuries requiring reoperation due to electrical arc" — Whit Holcomb (clinical) [Ep 8 · 38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301) - "When using cautery for appendectomy, must carefully watch entire field to prevent electrical arc to adjacent small bowel loops" — Whit Holcomb (clinical) [Ep 8 · 38:21](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301) - "Murky fluid throughout abdomen in non-perforated appendicitis is very unusual and would prompt placement of additional port for better visualization and investigation of source" — Whit Holcomb (clinical) [Ep 8 · 39:48](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2388) - "In single-incision approach, pelvic fluid should be suctioned before incising the bridge between ports because it becomes difficult to suction after appendix removal" — Whit Holcomb (clinical) [Ep 8 · 39:48](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2388) - "For normal appendix found at surgery, if imaging study was done preoperatively, full small bowel run is often not performed; without prior imaging, full small bowel examination is done" — Whit Holcomb (clinical) [Ep 8 · 41:15](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2475) - "Initial perforated appendicitis protocol at Children's Mercy was 5 days of IV antibiotics postoperatively, developed when beginning prospective randomized trials" — Whit Holcomb (clinical) [Ep 8 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525) - "Discharge criteria for perforated appendicitis: normal WBC on day 5, afebrile, tolerating regular diet; then discharged without oral antibiotics" — Whit Holcomb (clinical) [Ep 8 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525) - "If WBC elevated on day 5, patient receives 2 additional days of antibiotics and repeat WBC; if still elevated, receives 3 more days and CT scan to look for abscess" — Whit Holcomb (clinical) [Ep 8 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525) - "Almost all postoperative abscesses in perforated appendicitis develop while patient is in hospital, very few develop after discharge" — Whit Holcomb (clinical) [Ep 8 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525) - "Follow-up study randomized 100 patients (50 per group) comparing mandatory 5 days IV antibiotics versus early discharge with oral Augmentin to complete 7 total days if discharge criteria met" — Whit Holcomb (clinical) [Ep 8 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525) - "Early discharge study found no difference in postoperative abscess rate between groups; 40% of patients in early discharge group went home before day 5" — Whit Holcomb (clinical) [Ep 8 · 42:05](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525) - "For well-defined abscess at 5-6 days symptom duration, two options exist: immediate appendectomy or non-operative management with interval appendectomy" — Whit Holcomb (clinical) [Ep 8 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772) - "At 3-4 days symptom duration, would operate; at 6-7 days with well-defined abscess, would treat non-operatively; 5 days is transition zone requiring clinical judgment" — Whit Holcomb (clinical) [Ep 8 · 50:23](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3023) - "2010 Journal of Pediatric Surgery study of 40 patients compared initial appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess from perforated appendicitis" — Whit Holcomb (clinical) [Ep 8 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772) - "Study found no difference between immediate versus interval appendectomy in total length of hospitalization, recurrent abscess rates, or overall charges" — Whit Holcomb (clinical) [Ep 8 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772) - "Initial appendectomy took longer (61 minutes) versus interval appendectomy (42 minutes)" — Whit Holcomb (clinical) [Ep 8 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772) - "Holcomb prefers initial non-operative management with interval appendectomy because immediate operations can be difficult, patients have prolonged hospitalization, bad ileus, sometimes need NG tube, and risk recurrent abscess complications" — Whit Holcomb (opinion) [Ep 8 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772) - "Interval appendectomy is performed 8-10 weeks after non-operative abscess management and is becoming a day surgery procedure" — Whit Holcomb (clinical) [Ep 8 · 46:12](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772) - "Even if abscess can be managed for 2 weeks non-operatively, that operation is much easier than going in early through dense inflammation and purulent material" — Whit Holcomb (opinion) [Ep 8 · 51:01](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3061) - "Adult literature reports approximately 2/3 of appendicitis patients can be treated non-operatively without surgery, about 1/3 require operation" — Whit Holcomb (host_summary) [Ep 8 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138) - "Nationwide Children's Hospital has performed work on non-operative appendicitis management and has ongoing prospective randomized trial; another multi-hospital trial is in planning stages" — Whit Holcomb (host_summary) [Ep 8 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138) - "Current data suggests 50-60% of patients could likely be managed non-operatively with antibiotics" — Whit Holcomb (clinical) [Ep 8 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138) - "Non-operative candidates will likely be non-perforated appendicitis patients, though Marty Blakely's study shows some perforated patients can also be treated non-operatively" — Whit Holcomb (host_summary) [Ep 8 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138) - "High-quality studies on non-operative appendicitis management will emerge in next 5 years showing good percentage can be treated without operation" — Whit Holcomb (opinion) [Ep 8 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138) - "Long-term follow-up of 25-30 years will be needed to determine if non-operatively treated patients develop recurrent appendicitis years later" — Whit Holcomb (opinion) [Ep 8 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138) - "Inflammation and infection may cause appendiceal scarring leading to closed-loop obstruction and recurrent appendicitis, but this won't be known for 25-30 years" — Whit Holcomb (opinion) [Ep 8 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138) - "Current data is not mature enough to justify non-operative management, especially when patients can have surgery and go home same day returning to routine activities" — Whit Holcomb (opinion) [Ep 8 · 52:18](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138) - "Los Angeles study showed approximately 10% of patients initially managed non-operatively for perforated appendicitis without interval appendectomy returned for recurrent appendicitis, but follow-up was only 1-1.5 years" — Whit Holcomb (host_summary) [Ep 8 · 56:15](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3375) - "Longer-term data (5, 10, 20 years) is needed to determine true recurrence rate after non-operative management; if patients return years later, this justifies interval appendectomy when young" — Whit Holcomb (opinion) [Ep 8 · 56:15](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3375) - "Children's Mercy currently proceeds with interval laparoscopic appendectomy after non-operative abscess management because families do not want child at risk for recurrent appendicitis" — Whit Holcomb (clinical) [Ep 8 · 57:28](https://qa.library.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3448) - "The way pediatric surgery is done is quite variable and not standardized, especially appendicitis." — Todd Ponsky (opinion) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "The hospital had a clinical pathway in place for about 30 years before implementing a new pathway in 2015." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "The new pathway initiated a disease severity classification for perforated appendicitis." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "The new pathway refined discharge criteria for perforated appendicitis." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "The new pathway standardized the operative technique for perforated appendicitis." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "The new pathway established criteria for the use of postoperative TPN in perforated appendicitis." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "The new pathway established criteria for the use of postoperative imaging in perforated appendicitis." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "The new pathway established criteria for the use of postoperative invasive procedures such as draining an abscess." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "The study prospectively evaluated outcomes of all children treated on the new standardized protocol over 20 months." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "The study compared prospective outcomes to all patients treated in the 58 months prior to standardization." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "Median follow-up time post-discharge was 14 days in the pre-standardized group." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "Median follow-up time post-discharge was 25 days in the post-standardized group." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "Standardization significantly reduced postoperative abscess in perforated appendicitis." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "Standardization significantly reduced hospital stay in perforated appendicitis." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "Standardization reduced the odds of developing a postoperative abscess by 4 times." — Todd Ponsky (host_summary) [Ep 1 · 0:06](https://qa.library.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6) - "The APPY trial is a multi-center randomized trial comparing appendectomy to non-operative treatment for non-perforated appendicitis." (clinical) [Ep 2 · 0:09](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=9) - "The initial working group included Agostino Piero, Nigel Hall, Simon Eaton, Thomas Wester, and several others, with the current group joining about 2.5 years ago." (clinical) [Ep 2 · 1:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=80) - "The first two rounds of funding failed, requiring modifications to sample size calculation and study design to make it more pragmatic." (clinical) [Ep 2 · 2:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=120) - "Appendicitis can be treated without surgery, as demonstrated by experience with complicated appendicitis where patients are treated to completion regardless of perforation severity." (clinical) [Ep 2 · 3:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=200) - "Bob Parry developed appendicitis in Ireland, was treated with antibiotics, and went a full year before having a recurrent bout requiring appendectomy." (clinical) [Ep 2 · 4:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=240) - "In adult studies reviewing approximately 300 patients managed non-operatively versus 500 managed operatively, treatment failure trended toward favoring surgical approach, but complications favored non-operative management." (host_summary) [Ep 2 · 5:50](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=350) - "Adult estimates of non-operative management success revolve around 80%, which was integral in developing the sample size for the randomized trial." (host_summary) [Ep 2 · 7:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=420) - "Thomas Wester's pilot randomized trial in Sweden enrolled 50 patients, with 24 receiving antibiotics. 22 of 24 (92%) had initial resolution of symptoms, and one patient had recurrent appendicitis." (host_summary) [Ep 2 · 8:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=480) - "In the preference trial, any appendix that has to come out—even if due to parental preference after symptom resolution—must be considered a treatment failure because that reflects real-world practice." (clinical) [Ep 2 · 8:50](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=530) - "In the preference trial, parents of sicker-appearing children are less likely to choose non-operative management, even if objective measures like white count are similar." (clinical) [Ep 2 · 10:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=600) - "At 77 patients in the preference trial, 30 chose non-operative treatment (about one-third), with 90% success at 30 days and fewer disability days, earlier return to school, and improved quality of life versus surgery." (host_summary) [Ep 2 · 10:50](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=650) - "Patients who respond to antibiotics are literally normal the next day, going to school on Wednesday after discharge on Tuesday, whereas laparoscopic appendectomy patients restrict themselves for several days despite no formal restrictions." (clinical) [Ep 2 · 11:40](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=700) - "The APPY trial is designed as a non-inferiority study because non-operative management cannot possibly be superior to appendectomy, which has a 100% cure rate." (clinical) [Ep 2 · 13:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=800) - "The trial includes patients aged 5 to 16 with suspected non-perforated appendicitis, excluding those under 5 because they frequently have perforation regardless of presentation." (clinical) [Ep 2 · 14:10](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=850) - "The trial uses broad inclusion criteria without requiring specific Alvarado scores, PAS scores, or imaging findings, allowing surgeons to use their standard diagnostic approach for non-perforated appendicitis." (clinical) [Ep 2 · 15:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=900) - "Exclusion criteria include suspicion of perforation, more than two doses of antibiotics initiated at an outside facility, previous episode of appendicitis treated non-operatively, and systemic disease." (clinical) [Ep 2 · 15:50](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=950) - "The trial uses central randomization with minimization based on sex, center, and duration of symptoms to maintain balance across these factors." (clinical) [Ep 2 · 16:40](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1000) - "The protocol was modified to allow patients to go home the next day if doing well, rather than requiring 24-48 hour evaluations at fixed time points, because the original schedule was impractical for overnight enrollments." (clinical) [Ep 2 · 17:30](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1050) - "If patients are not better after initial therapy, they are given another day, but after 48 hours of IV therapy (by Wednesday morning), it is time to proceed with appendectomy because 3 days in the hospital is too much when the alternative is going home Monday." (clinical) [Ep 2 · 18:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1100) - "The primary outcome is treatment failure defined as an intervention for appendicitis requiring general anesthesia within 1 year in both groups, which essentially compares negative appendectomy versus recurrent appendicitis." (clinical) [Ep 2 · 19:10](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1150) - "The non-inferiority margin is 20% because polling showed most people consider failure rates in the twenties too high for non-operative management." (opinion) [Ep 2 · 20:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1200) - "The actual failure rate percentage is what matters to parents when counseling, not whether the trial concludes non-inferiority—some parents will accept 26% failure to avoid surgery while others won't accept 2%." (opinion) [Ep 2 · 20:45](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1245) - "As of the presentation, 52 patients have been enrolled: Stockholm 25, Helsinki 7, with Vancouver, Ontario, and Calgary recently receiving IRB approval." (clinical) [Ep 2 · 21:40](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1300) - "Early results show in the operative group: 4 perforations and 2 negative appendectomies. In the non-operative group: 1 readmitted for abscess, 3 failed early (didn't leave hospital), 4 failed after discharge (within 2-5 days), and 1 recurrence at 6 months." (epidemiological) [Ep 2 · 22:25](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1345) - "All recurrences and failures in the non-operative group have had confirmed appendicitis; no normal appendix has been removed yet." (clinical) [Ep 2 · 23:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1400) - "The two negative appendectomies in the operative group had imaging showing secondary signs like fluid but not visualizing the appendix." (clinical) [Ep 2 · 20:45](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1245) - "Of the 3 early failures in the non-operative group, 2 were due to parental impatience on the morning after enrollment, not giving the treatment a real chance." (clinical) [Ep 2 · 21:20](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1280) - "The reason for limiting antibiotics is that Augmentin is given daily in pediatric offices to thousands of children with sniffles who don't need it, whereas the APPY trial treats an active intra-abdominal bacterial infection." (opinion) [Ep 2 · 23:00](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1380) - "All perforated appendicitis cases are treated with antibiotics, and if complications develop, long-term antibiotics are used until resolution, so treating intra-abdominal infection is different from unnecessary antibiotic use." (clinical) [Ep 2 · 23:50](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1430) - "The value of the study is knowing the exact failure rates and outcomes to counsel patients who might want to avoid surgery or are in circumstances where surgery isn't immediately feasible, even if non-operative management proves inferior." (opinion) [Ep 2 · 25:07](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1507) - "No adult literature has examined long-term outcomes beyond one year for non-operative management of appendicitis." (epidemiological) [Ep 2 · 25:07](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1507) - "The trial plans to follow the cohort in perpetuity with annual telephone follow-up to determine recurrence rates at 5 years, 10 years, and beyond." (clinical) [Ep 2 · 25:40](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1540) - "Perforation is defined as a hole in the appendix or a fecolith in the abdomen—irrefutable proof of contamination—and is only an intraoperative diagnosis, not a preoperative one." (clinical) [Ep 2 · 27:25](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1645) - "The presence of a fecolith is an exclusion criterion in the Midwest Pediatric Surgery Consortium preference trial but not in the APPY trial." (clinical) [Ep 2 · 28:10](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1690) - "At Nationwide, a separate small population with appendicoliths was allowed enrollment, but that arm was stopped based on the failure rate." — Todd Ponsky (clinical) [Ep 2 · 29:02](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1742) - "In a cohort of patients with post-appendectomy abscesses, outcomes were relatively equivalent between drain and no drain, but the biggest abscesses and worst patients received drains." — Todd Ponsky (epidemiological) [Ep 2 · 29:56](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1796) - "After size-matching to 17.5 cm² (AP versus lateral in axial dimension), there was an advantage to not having a drain." — Todd Ponsky (epidemiological) [Ep 2 · 30:40](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1840) - "For abscesses less than 20 cm² (less than 4 x 5 cm), drains are typically discouraged because the advantage is small and drains add an extra anesthetic, procedure, and may increase length of stay." — Todd Ponsky (clinical) [Ep 2 · 31:10](https://qa.library.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1870) ## Changelog - Sep 15: 3 items added automatically - Sep 12: 1 item added automatically - Sep 8: 2 items added automatically - Sep 7: Published again automatically — condition is back above threshold - Sep 7: 2 items added automatically - Sep 7: 2 items no longer name appendicitis - Sep 7: 2 items added automatically - Sep 7: Unpublished automatically — folded or below threshold - Sep 7: Audit reverted — short clips unhidden - Sep 7: 3 items added automatically --- Educational content from recorded physician discussions — not medical advice. 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