# Intestinal Rehab — GCMD Library living collection

Also covered as: gastroschisis · necrotizing enterocolitis · intestinal failure · short bowel syndrome · Hirschsprung disease · malrotation · intestinal atresia · omphalocele

Experts: Dr. Todd Ponsky, Dr. Rod Gerardo, Dr. Ellen Encisco, Dr. Paul Wales

Updated: n/a · 109 episodes · 2185 cited statements

## Episodes
### Fundamentals
- [Multidisciplinary Approach: Intestinal Failure Innovations](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036) — video · 97:52 · [machine version](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036.md)
- [Pyloric Stenosis](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532) — video · 12:30 · [machine version](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532.md)
- [Intestinal rehabilitation: What is intestinal rehab? - Episode 1](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741) — video · 14:33 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741.md)
- [Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742) — podcast · 14:33 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742.md)
- [Omphalocele and Gastroschisis With Dr. Foong-Yen Lim](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006) — podcast · 9:31 · [machine version](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006.md)
- [Omphalocele & Gastroschisis](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255) — video · 9:32 · [machine version](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255.md)
- [Stay Current Throwbacks Necrotizing Enterocolitis with Dr. Gail Besner](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402) — podcast · 47:54 · [machine version](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402.md)
- [Malrotation with Dr. Meera Kotagal](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621) — podcast · 13:25 · [machine version](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621.md)

### Diagnosis & Workup
- [Overview of Prenatal Diagnosis: Cincinnati Fetal Center](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743) — video · 40:34 · [machine version](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743.md)
- [Prenatal diagnosis of fetal lower urinary tract obstruction: Fetal...](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919) — video · 40:14 · [machine version](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919.md)
- [The Colorectal Quiz Episode 8: Motility Disorders Part 1](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824) — podcast · 14:04 · [machine version](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824.md)
- [Colorectal Collaboration: Neurogastroenterology/Motility Disorders](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366) — video · 14:55 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366.md)
- [Availability, utilization, and barriers to bowel ultrasound for necrotizing enterocolitis...](https://qa.library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575) — video · 0:55 · [machine version](https://qa.library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575.md)

### Acute Management
- [Necrotizing Enterocolitis](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636) — video · 35:06 · [machine version](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636.md)
- [Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954) — podcast · 13:27 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954.md)
- [Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993) — podcast · 17:21 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993.md)

### Medical Management
- [Gastroesophageal Reflux Disease](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289) — podcast · 81:04 · [machine version](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289.md)

### Nutritional Management
- [Intestinal Failure - Feeding Access and Nutrition](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740) — video · 118:06 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740.md)
- [Practical Approach: Intestinal Failure Innovations](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035) — video · 116:52 · [machine version](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035.md)
- [Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141) — podcast · 16:18 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141.md)
- [Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 2](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240) — podcast · 13:37 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240.md)
- [Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824) — video · 21:09 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824.md)
- [Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209) — podcast · 16:09 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209.md)
- [Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227) — podcast · 12:05 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227.md)

### Surgical Management
- [Renal transplantation: Cincinnati Fetal Center](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623) — video · 13:51 · [machine version](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623.md)
- [Malrotation - Volvulus - Meconium Ileus - Solid Organ Injury: Update Course 2015](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673) — video · 27:04 · [machine version](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673.md)
- [Renal transplantation: Fetal Genitourinary Disease 2015](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915) — video · 13:44 · [machine version](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915.md)
- [Sutureless Gastroschisis Repair: Technique](https://qa.library.globalcastmd.com/watch/sutureless-gastroschisis-repair-technique-960) — video · [machine version](https://qa.library.globalcastmd.com/watch/sutureless-gastroschisis-repair-technique-960.md)
- [Gastroschisis: Advanced Practice Providers](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049) — video · 43:21 · [machine version](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049.md)
- [Staged Closure of Gastroschisis with Spring-loaded Silo](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235) — video · 27:29 · [machine version](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235.md)
- [Staged Closure of Gastroschisis with Spring-loaded Silo](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251) — video · 27:11 · [machine version](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251.md)
- [Sutureless Closure of Gastroschisis - APSA Practice Gaps 2019](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302) — video · 21:04 · [machine version](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302.md)
- [Umbilical Cord Defects with Dr. Kenneth Azarow](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298) — podcast · 30:16 · [machine version](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298.md)
- [Duodeno-duodenostomy for Duodenal Atresia](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139) — video · 7:04 · [machine version](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139.md)
- [Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870) — video · 13:54 · [machine version](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870.md)
- [Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909) — video · 19:07 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909.md)
- [Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913) — podcast · 19:07 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913.md)
- [Malrotation Infant](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940) — video · 9:22 · [machine version](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940.md)
- [Malrotation and Volvulus with Trinity](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941) — video · 8:02 · [machine version](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941.md)

### Complications
- [Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099) — podcast · 12:24 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099.md)
- [Intestinal Rehabilitation, Episode 6: Cholestasis](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734) — podcast · 15:25 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734.md)

### Evidence & Research
- [91% Decrease in Mortality with Gastroschisis Bundle!](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816) — video · 3:12 · [machine version](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816.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)
- [Immediate vs Silo Closure for Gastroschisis](https://qa.library.globalcastmd.com/watch/immediate-vs-silo-closure-for-gastroschisis-2022) — video · 0:26 · [machine version](https://qa.library.globalcastmd.com/watch/immediate-vs-silo-closure-for-gastroschisis-2022.md)
- [7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797) — video · 285:42 · [machine version](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797.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)
- [Gastroschisis and sutureless abdominal wall closure](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557) — podcast · 12:17 · [machine version](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557.md)
- [Journal of Pediatric Surgery Article Review: October 2021](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661) — podcast · 19:10 · [machine version](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661.md)
- [Journal of Pediatric Surgery Article Review: January 2022 APSA Issue](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103) — podcast · 13:09 · [machine version](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103.md)
- [Update Course 2021: TOP PUBLICATIONS IN NON - PED SURG JOURNALS](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404) — video · 22:13 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404.md)
- [Update Course 2021: UPDATE COURSE 2020: REVIEW OF LAST YEAR'S IMPORTANT T OPICS](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405) — video · 23:20 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405.md)
- [CAPS - The use of urine sodium to creatinine ratio as a marker of total body sodium in infants with intestinal failure - Sara Choi](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432) — video · 8:40 · [machine version](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432.md)
- [Update Course 2022 - APSA PDC UPDATES - Mary Edwards, Paul Jeziorczak, Craig Lillehei, and Charles Snyder,](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820) — video · 64:30 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820.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)
- [Journal of Pediatric Surgery Article Review: June 2022, AAP Issue](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878) — video · 15:54 · [machine version](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878.md)
- [Journal of Pediatric Surgery Article Review: June 2022, AAP Issue](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881) — podcast · 15:54 · [machine version](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881.md)
- [Routine contrast enema prior to stoma reversal seems only required following treatment for necrotizing enterocolitis: An evaluation of the diagnostic accuracy of the contrast enema](https://qa.library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603) — video · 0:56 · [machine version](https://qa.library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603.md)
- [Quick Literature Updates Episode 6](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636) — video · [machine version](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636.md)
- [Quick Literature Updates Episode 7](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686) — video · [machine version](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686.md)
- [Quick Literature Updates Episode 10](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801) — video · [machine version](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801.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)
- [Disruption of enterohepatic Circulation of Bile acids ameliorates small bowel resection associated hepatic injury](https://qa.library.globalcastmd.com/watch/disruption-of-enterohepatic-circulation-of-bile-acids-ameliorates-small-bowel-resection-associated-hepatic-injury-7050) — video · 0:59 · [machine version](https://qa.library.globalcastmd.com/watch/disruption-of-enterohepatic-circulation-of-bile-acids-ameliorates-small-bowel-resection-associated-hepatic-injury-7050.md)
- [Expectant Management or Early Ibuprofen for Patent Ductus Arteriosus](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075) — video · 1:14 · [machine version](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075.md)
- [Association of Exclusive Breast Milk Intake and Outcomes in Infants With Uncomplicated Gastroschisis: A National Cohort Study](https://qa.library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037) — video · 0:56 · [machine version](https://qa.library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037.md)
- [Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154) — podcast · 17:03 · [machine version](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154.md)
- [Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308) — podcast · 19:28 · [machine version](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308.md)
- [Use of a new vertical traction device for early traction-assisted staged closure of congenital abdominal wall defects: a prospective series of 16 patients](https://qa.library.globalcastmd.com/watch/use-of-a-new-vertical-traction-device-for-early-traction-assisted-staged-closure-of-congenital-abdominal-wall-defects-a-prospective-series-of-16-patients-9436) — video · 0:56 · [machine version](https://qa.library.globalcastmd.com/watch/use-of-a-new-vertical-traction-device-for-early-traction-assisted-staged-closure-of-congenital-abdominal-wall-defects-a-prospective-series-of-16-patients-9436.md)
- [Management of Gastroschisis: Timing of Delivery, Antibiotic Usage, and Closure Considerations](https://qa.library.globalcastmd.com/watch/management-of-gastroschisis-timing-of-delivery-antibiotic-usage-and-closure-considerations-9626) — video · 0:55 · [machine version](https://qa.library.globalcastmd.com/watch/management-of-gastroschisis-timing-of-delivery-antibiotic-usage-and-closure-considerations-9626.md)
- [Quick Literature Updates Episode 16](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732) — video · 4:21 · [machine version](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732.md)
- [Conservative Management of Necrotizing Enterocolitis in Newborns: Incidence and Management of Intestinal Strictures](https://qa.library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738) — video · 0:50 · [machine version](https://qa.library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738.md)
- [Outcomes of Children With Short Bowel Syndrome: Experiences in a Multidisciplinary Intestinal Rehabilitation Unit Over Two Decades](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027) — video · 0:45 · [machine version](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027.md)
- [STAT trial: stoma or intestinal anastomosis for necrotizing enterocolitis: a multicentre randomized controlled trial](https://qa.library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427) — video · 0:57 · [machine version](https://qa.library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427.md)
- [Educational Outcomes in School-Aged Children With a History of Simple and Complex Gastroschisis are Poor Compared to Controls](https://qa.library.globalcastmd.com/watch/educational-outcomes-in-school-aged-children-with-a-history-of-simple-and-complex-gastroschisis-are-poor-compared-to-controls-10437) — video · 0:53 · [machine version](https://qa.library.globalcastmd.com/watch/educational-outcomes-in-school-aged-children-with-a-history-of-simple-and-complex-gastroschisis-are-poor-compared-to-controls-10437.md)
- [Journal of Pediatric Surgery Article Review: 1st Quarter (Jan-Mar) 2025](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484) — podcast · 16:35 · [machine version](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484.md)
- [Quick Literature Updates Ep 22](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118) — video · 4:23 · [machine version](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118.md)
- [Quick Literature Updates Ep 27](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580) — video · 4:20 · [machine version](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580.md)
- [Impact of social determinants of health on outcomes in pediatric short bowel syndrome...](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896) — video · 0:43 · [machine version](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896.md)

### Case-Based Learning
- [Malrotation](https://qa.library.globalcastmd.com/watch/malrotation-629) — video · 42:31 · [machine version](https://qa.library.globalcastmd.com/watch/malrotation-629.md)
- [Abdominal Wall Defects](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639) — video · 37:50 · [machine version](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639.md)
- [Tricks - Total Colonic Aganglionosis Associated with Malrotation & Multiple...](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645) — video · 15:41 · [machine version](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645.md)
- [Bilateral Wilm's Tumor - Complex Gastroschisis - Complex Ileal Atresia:...](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669) — video · 29:44 · [machine version](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669.md)
- [Malrotation Rapid Fire Session: Update Course 2015](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879) — video · 8:59 · [machine version](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879.md)
- [Compiled Sandler Rapid Fire Sessions: Update Course 2015](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992) — video · 29:44 · [machine version](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992.md)
- [Total Colonic Hirschsprung Disease with Malrotation: Difficult Cases](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052) — video · 13:15 · [machine version](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052.md)
- [Abdominal Wall Defects: Update Course 2013](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059) — video · 37:40 · [machine version](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059.md)
- [NEC: Update Course 2013](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060) — video · 34:22 · [machine version](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060.md)
- [Gastroschisis - Clinical Practice Updates](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996) — video · [machine version](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996.md)
- [The Colorectal Quiz Episode 9: Motility Disorders Part 2](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888) — podcast · 13:52 · [machine version](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888.md)
- [Neonatal Gastric Volvulus with Dr. Jason Frischer](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494) — podcast · 11:17 · [machine version](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494.md)
- [Colorectal Quiz: Episode 42 - HD Constipation](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506) — podcast · 14:48 · [machine version](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506.md)
- [Gastroschisis](https://qa.library.globalcastmd.com/watch/gastroschisis-13502) — video · [machine version](https://qa.library.globalcastmd.com/watch/gastroschisis-13502.md)

### In-Depth Reviews
- [Intestinal Failure with Dr. Brad Warner](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927) — podcast · 52:46 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927.md)
- [Necrotizing Enterocolitis with Dr. Gail Besner](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930) — podcast · 46:29 · [machine version](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930.md)
- [Abdominal Wall Defects with Dr. Jacob Langer](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959) — podcast · 52:45 · [machine version](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959.md)
- [Intestinal Failure with Dr. Brad Warner](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296) — podcast · 52:46 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296.md)
- [Necrotizing Enterocolitis with Dr. Gail Besner](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297) — podcast · 46:29 · [machine version](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297.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)
- [Abdominal Wall Defects with Dr. Jacob Langer](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821) — podcast · 52:45 · [machine version](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821.md)
- [Update Course Rewind: 2022 Top Ten Key Takeaways](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766) — video · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766.md)
- [Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768) — video · 12:14 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768.md)
- [Umbilical Disorders with Dr. Rebeccah Brown](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616) — podcast · 11:27 · [machine version](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616.md)
- [Update Course Rewind: Omphalocele & Gastroschisis 2020](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507) — podcast · 15:18 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507.md)
- [Update Course Rewind 2025: Updates in NEC Management](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612) — video · 11:03 · [machine version](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612.md)
- [Advancements in Pediatric Intestinal Failure: Innovative Therapies and Improved Outcomes](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892) — video · 17:45 · [machine version](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892.md)

### Emerging & Future Directions
- [Dr. Colleen Nofi - Best of the Best in Pediatric Surgery 2025](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047) — video · 8:06 · [machine version](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047.md)
- [Remote Ischemic Conditioning (RIC) Decreases the Incidence and Severity of Necrotizing Enterocolitis (NEC) - Validation in a Large Animal Model](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417) — video · 0:59 · [machine version](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417.md)

### Patient & Family Education
- [Reliance on total parenteral nutrition (TPN) and travelling abroad](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804) — video · 1:42 · [machine version](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804.md)
- [What is Gastroschisis? An ERNICA animation for parents and families](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812) — video · 2:59 · [machine version](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812.md)

### Long-Term Care
- [Care transition from a pediatric intestinal rehabilitation program to adult care and the risk of all-cause mortality: A retrospective cohort study](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901) — video · 1:01 · [machine version](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=0) Introduction and Background (Ep 39)
- [4:03](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=243) Gastroschisis: Prenatal Counseling and Delivery Planning (Ep 39)
- [8:34](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=514) Gastroschisis: Initial Management and Closure Techniques (Ep 39)
- [17:04](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1024) Gastroschisis: Intestinal Atresia Management (Ep 39)
- [22:17](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1337) Gastroschisis: Prolonged Ileus and Complications (Ep 39)
- [28:27](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1707) Omphalocele: Prenatal Counseling and Associated Anomalies (Ep 39)
- [32:22](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1942) Omphalocele: Surgical Management and Reduction Techniques (Ep 39)
- [40:17](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2417) Omphalocele: Delayed Closure and Patch Repair (Ep 39)
- [45:54](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2754) Omphalocele: Feeding Issues and Associated Problems (Ep 39)
- [0:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=0) Defining Team-Based Care Models (Ep 21)
- [10:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=600) Patient Identification and Early Intervention (Ep 21)
- [20:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1200) Central Line Management and Infection Prevention (Ep 21)
- [40:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2400) TPN Composition and Lipid Management (Ep 21)
- [60:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3600) Growth, Nutrition, and Functional Assessment (Ep 21)
- [80:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4800) Feeding Challenges and Surgical Decision-Making (Ep 21)
- [0:00](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=0) Introduction and Appendicitis Review (Ep 37)
- [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 37)
- [12:36](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=756) Pathologic Confirmation and Surgical Timing (Ep 37)
- [17:50](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1070) Historical Evolution of Surgical Techniques (Ep 37)
- [27:53](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1673) Current Surgical Approach: Transanal Swenson (Ep 37)
- [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 37)
- [37:13](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2233) Laparoscopic Approach and Biopsy Technique (Ep 37)
- [47:56](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2876) Postoperative Management (Ep 37)
- [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 37)
- [0:09](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=9) Defining Intestinal Failure and the Role of Intestinal Rehabilitation (Ep 108)
- [5:10](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=310) Intestinal Rehabilitation Programs and Outcomes (Ep 108)
- [7:54](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=474) Evolution of Lipid Emulsions in Parenteral Nutrition (Ep 108)
- [11:55](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=715) Central Line Complications and Lock Solutions (Ep 108)
- [13:45](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=825) GLP-2 Analogs for Intestinal Adaptation (Ep 108)
- [16:29](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=989) Summary and Future Directions (Ep 108)
- [0:00](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=0) Introduction and Guest Introductions (Ep 33)
- [2:49](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=169) Initial Workup of Infant with Vomiting and Respiratory Symptoms (Ep 33)
- [8:20](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=500) Eosinophilic Esophagitis as a Masquerader (Ep 33)
- [13:20](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=800) Role of Proton Pump Inhibitors in Infants (Ep 33)
- [20:00](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1200) Medical Management Strategies (Ep 33)
- [28:00](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1680) NICU Premature Infant Management (Ep 33)
- [35:00](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2100) Diagnostic Testing: Upper GI and pH Impedance (Ep 33)
- [41:40](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2500) Rome IV Classification and Reflux Hypersensitivity (Ep 33)
- [50:00](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3000) Surgical Technique: Minimal Mobilization Nissen (Ep 33)
- [60:00](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3600) Post-Fundoplication Retching Management (Ep 33)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "The frequency and incidence of abdominal wall defects appears to be increasing" (host_summary) [Ep 39 · 0:00](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=0)
- "With gastroschisis, the main issue is that the bowel gets damaged through fetal life" — Jack Langer (clinical) [Ep 39 · 4:36](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=276)
- "Most gastroschisis patients don't have any other associated anomalies, and it's pretty rare to have abnormal chromosomes" — Jack Langer (clinical) [Ep 39 · 4:46](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=286)
- "Early papers showed a benefit to cesarean section in gastroschisis, but cesarean sections were usually done early at 36 or 37 weeks, raising the question of whether timing rather than cesarean section itself gave the benefit" — Jack Langer (clinical) [Ep 39 · 5:46](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=346)
- "Many studies have failed to show an advantage to cesarean section, and most people nowadays would not do routine cesarean section for gastroschisis" — Jack Langer (clinical) [Ep 39 · 6:13](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=373)
- "There has not been any large randomized trial looking specifically at the issue of early delivery in gastroschisis" — Jack Langer (clinical) [Ep 39 · 6:29](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=389)
- "Toronto's approach is to deliver gastroschisis patients at around 37 weeks unless they've already gone into spontaneous labor" — Jack Langer (clinical) [Ep 39 · 6:58](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=418)
- "The mean gestational age of onset of labor is a lot earlier in gastroschisis pregnancies, possibly because of inflammatory mediators produced by the inflamed bowel" — Jack Langer (clinical) [Ep 39 · 7:07](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=427)
- "In gastroschisis pregnancies, labor can usually be successfully induced at 37 weeks, unlike regular pregnancies" — Jack Langer (clinical) [Ep 39 · 7:30](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=450)
- "Most evidence, including from the CapsNet database, suggests that delivery in a perinatal center is beneficial for gastroschisis" — Jack Langer (clinical) [Ep 39 · 8:36](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=516)
- "During transport of gastroschisis patients, it's important for the baby to be nursed on his or her side, usually right side down, to prevent kinking of the mesentery and ischemia of the bowel" — Jack Langer (clinical) [Ep 39 · 10:01](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=601)
- "For gastroschisis, bedside closure is the first choice if the bowel is not too thickened and there's not too much peel" — Jack Langer (clinical) [Ep 39 · 10:57](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=657)
- "Adrian Bianchi first described bedside closure for gastroschisis" — Jack Langer (clinical) [Ep 39 · 11:21](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=681)
- "Using forceps at the bedside to push bowel back in can damage the bowel in a squiggling baby" — Jack Langer (clinical) [Ep 39 · 11:29](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=689)
- "The current approach uses pre-formed silos, slowly pushing on them with fentanyl or morphine sedation in an awake baby, aiming to keep intraabdominal pressure below 20" — Jack Langer (clinical) [Ep 39 · 11:47](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=707)
- "If reduction is successful with good pressure and perfusion, the silo can be removed immediately and the umbilical cord stump used to cover the hole with a Duoderm dressing left for about 5 days" — Jack Langer (clinical) [Ep 39 · 12:27](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=747)
- "The sutureless plastic closure technique was described by Anthony Sandler and doesn't require suturing the umbilical cord" — Todd Ponsky (host_summary) [Ep 39 · 13:15](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=795)
- "A study by Dr. Baird published in JPS showed that patients with flap closure did better in every way than those with sutured fascial closure, including lower rates of umbilical hernia repair" — Todd Ponsky (host_summary) [Ep 39 · 14:19](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=859)
- "Umbilical hernias from plastic closure generally close by age 2 or 3 years, just like any umbilical hernia" — Jack Langer (clinical) [Ep 39 · 14:56](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=896)
- "Some gastroschisis patients become tachypneic with bluish legs after reduction and require intubation by neonatologists an hour or two later" — Jack Langer (clinical) [Ep 39 · 16:12](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=972)
- "The disadvantage of leaving a silo on for 24-48 hours is that the abdominal wall defect gets stretched out and bigger, taking longer to close with plastic closure" — Jack Langer (clinical) [Ep 39 · 17:25](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1045)
- "Spring-loaded silos apply pressure outward as you push down, making the defect larger over time" — Todd Ponsky (clinical) [Ep 39 · 18:10](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1090)
- "The incidence of intestinal atresia in gastroschisis is between 5 and 10%" — Jack Langer (epidemiological) [Ep 39 · 18:51](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1131)
- "There are two types of intestinal atresia in gastroschisis: early-onset atresia where bowel gets very dilated but not thick-walled, and late atresia where the abdominal wall defect becomes very small causing ischemia and potentially vanishing gastroschisis" — Jack Langer (clinical) [Ep 39 · 19:01](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1141)
- "The prognosis for short bowel syndrome has improved dramatically over the last 10-15 years because of intestinal failure centers, better TPN that doesn't damage the liver as much, and control of sepsis" — Jack Langer (clinical) [Ep 39 · 20:15](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1215)
- "For atresia in gastroschisis, there are three management choices: repair at time of closure, bring out stomas, or drop everything back in and repair the atresia later" — Jack Langer (clinical) [Ep 39 · 20:54](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1254)
- "There's no good evidence for optimal management of atresia in gastroschisis because it's such a rare occurrence" — Jack Langer (opinion) [Ep 39 · 21:15](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1275)
- "If bowel looks good without much peel, primary repair of atresia at initial closure is appropriate; if there's concern, drop it back in and repair later" — Jack Langer (clinical) [Ep 39 · 21:35](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1295)
- "Stomas are brought out only when there's necrotic bowel requiring resection and the bowel is not healthy enough to anastomose" — Jack Langer (clinical) [Ep 39 · 22:01](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1321)
- "The umbilicus is the preferred site for neonatal stomas because it results in a scar that would have been there anyway and is convenient for appliance placement" — Jack Langer (clinical) [Ep 39 · 22:50](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1370)
- "Neonatal stomas prolapse no matter where they are placed" — Jack Langer (clinical) [Ep 39 · 23:00](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1380)
- "Three weeks is average time to bowel function in gastroschisis, so investigations typically aren't started until 4 weeks" — Jack Langer (clinical) [Ep 39 · 24:27](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1467)
- "Metoclopramide (Reglan) can be given intravenously for gastroschisis hypomotility, unlike oral prokinetics where absorption is uncertain" — Jack Langer (clinical) [Ep 39 · 25:02](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1502)
- "A UK study showed cisapride helped gastroschisis patients achieve bowel function more quickly, but cisapride is no longer available" — Jack Langer (clinical) [Ep 39 · 25:02](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1502)
- "A randomized prospective trial is currently underway to determine if intravenous metoclopramide can shorten the period of hypomotility in gastroschisis" — Jack Langer (clinical) [Ep 39 · 25:37](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1537)
- "At 4 weeks without bowel function, contrast enema is performed to look for mechanical obstruction, sometimes followed by upper GI if enema is inconclusive" — Jack Langer (clinical) [Ep 39 · 25:57](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1557)
- "If still no bowel function at 6 weeks, laparotomy is typically performed, often finding adhesions which are taken down" — Jack Langer (clinical) [Ep 39 · 26:44](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1604)
- "Going in too early on gastroschisis patients with prolonged ileus is a mistake" — Jack Langer (opinion) [Ep 39 · 27:21](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1641)
- "In gastroschisis, it's usually the right testis that is extruded, and in about half the cases it finds its way down into the scrotum after being reduced" — Jack Langer (clinical) [Ep 39 · 28:03](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1683)
- "Omphalocele has a much higher incidence of associated anomalies and chromosomal abnormalities compared to gastroschisis" — Jack Langer (clinical) [Ep 39 · 28:43](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1723)
- "Karyotype analysis and testing for Beckwith-Wiedemann syndrome are routinely performed for omphalocele patients" — Jack Langer (clinical) [Ep 39 · 28:59](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1739)
- "Small omphaloceles without liver are more likely to be associated with abnormal chromosomes than large omphaloceles" — Jack Langer (clinical) [Ep 39 · 29:47](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1787)
- "For small omphaloceles, there's no rationale for routine cesarean section, delivery at a perinatal center, or preterm delivery" — Jack Langer (clinical) [Ep 39 · 30:05](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1805)
- "Small omphaloceles are simple to repair surgically" — Jack Langer (clinical) [Ep 39 · 30:23](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1823)
- "For giant omphaloceles (defined as any omphalocele with a lot of liver out), most surgeons recommend cesarean section, though this is not evidence-based" — Jack Langer (clinical) [Ep 39 · 31:04](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1864)
- "Giant omphaloceles should be delivered at a perinatal center because they need a pediatric surgeon and experienced neonatologists" — Jack Langer (clinical) [Ep 39 · 31:42](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1902)
- "Pulmonary hypoplasia is associated with giant omphaloceles and is very difficult to diagnose prenatally" — Jack Langer (clinical) [Ep 39 · 31:55](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1915)
- "Some giant omphalocele patients have severe pulmonary hypoplasia requiring early intubation and respiratory support" — Jack Langer (clinical) [Ep 39 · 32:09](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1929)
- "The goal in omphalocele management is to reduce viscera without injury from direct trauma or increased intraabdominal pressure" — Jack Langer (clinical) [Ep 39 · 32:38](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1958)
- "Intraabdominal pressure monitoring is very helpful in omphalocele management" — Jack Langer (clinical) [Ep 39 · 33:14](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=1994)
- "Stuart Lacy established the guideline of keeping intraabdominal pressure below 20 mmHg based on rabbit studies in the 1980s, which showed improved outcomes in a prospective study in children" — Jack Langer (clinical) [Ep 39 · 33:28](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2008)
- "Lacy also described an increase in central venous pressure of more than 4 as a concerning threshold" — Jack Langer (clinical) [Ep 39 · 33:56](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2036)
- "Intraabdominal pressure can be measured through the nasogastric tube or via Foley catheter measuring intravesical pressure" — Jack Langer (clinical) [Ep 39 · 34:02](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2042)
- "The trend of pressure is more important than the absolute number during reduction" — Jack Langer (clinical) [Ep 39 · 34:17](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2057)
- "Primary closure is attempted for full-term omphalocele patients without significant cardiac disease, respiratory issues, or pulmonary hypoplasia" — Jack Langer (clinical) [Ep 39 · 34:43](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2083)
- "The Montreal group described using the omphalocele sac as a silo by sequentially ligating it over several days to allow abdominal wall stretching" — Jack Langer (clinical) [Ep 39 · 35:07](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2107)
- "Sequential sac ligation requires a thick enough sac and umbilical cord insertion at the top rather than the side" — Jack Langer (clinical) [Ep 39 · 35:44](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2144)
- "Using Duoderm to gradually reduce omphaloceles appears to achieve reduction more quickly than sac ligation" — Jack Langer (clinical) [Ep 39 · 37:34](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2254)
- "Indications for escharotic therapy include prematurity, severe cardiac disease, pulmonary hypoplasia, multiple anomalies, chromosomal abnormalities, or giant omphaloceles where reduction is not feasible" — Jack Langer (clinical) [Ep 39 · 38:12](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2292)
- "Mushroom-shaped omphaloceles have a small abdominal wall defect but large external contents, making reduction impossible" — Jack Langer (clinical) [Ep 39 · 38:49](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2329)
- "Sigy Ein had long experience using silver sulfadiazine (Silvadene) for escharotic therapy in omphaloceles" — Jack Langer (clinical) [Ep 39 · 39:26](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2366)
- "With escharotic therapy, the omphalocele is painted with the agent, forms an eschar, eventually epithelializes, and is later repaired like a large ventral hernia" — Jack Langer (clinical) [Ep 39 · 39:45](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2385)
- "Timing of definitive omphalocele repair after escharotic therapy depends on the individual child, ranging from 6-8 months to 3-4 years depending on defect size and medical comorbidities" — Jack Langer (clinical) [Ep 39 · 40:19](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2419)
- "Mushroom-shaped omphaloceles never reduce spontaneously and stay large" — Jack Langer (clinical) [Ep 39 · 41:10](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2470)
- "For mushroom-shaped omphaloceles, the abdominal wall defect can be enlarged surgically as a first step to allow more spontaneous reduction before definitive repair" — Jack Langer (clinical) [Ep 39 · 41:20](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2480)
- "The 'flip flop' technique (modification of component separation) involves incising laterally through anterior sheath only, folding it over while attached to posterior sheath, creating a single posterior sheath closure" — Todd Ponsky (clinical) [Ep 39 · 42:06](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2526)
- "Formal adult-style component separation in small children carries risk of devascularization and can leave patients in worse condition if complications occur" — Jack Langer (clinical) [Ep 39 · 43:06](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2586)
- "In omphalocele closure, the defect often extends to the costal margin, making the upper portion impossible to close primarily, requiring patch placement" — Jack Langer (clinical) [Ep 39 · 43:35](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2615)
- "Surgisis patch fails in approximately 50% of omphalocele repairs, requiring reoperation with non-absorbable mesh like Prolene" — Jack Langer (clinical) [Ep 39 · 44:01](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2641)
- "Omphaloceles can be part of pentalogy of Cantrell, commonly associated with diaphragmatic hernia of Morgagni" — Jack Langer (clinical) [Ep 39 · 44:44](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2684)
- "Pentalogy of Cantrell omphaloceles tend to be more superiorly placed" — Jack Langer (clinical) [Ep 39 · 45:08](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2708)
- "Most pentalogy of Cantrell patients have cardiac problems requiring escharotic therapy for the omphalocele" — Jack Langer (clinical) [Ep 39 · 45:19](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2719)
- "In pentalogy of Cantrell, the diaphragmatic patch can be placed from above through sternotomy during cardiac surgery, with abdominal wall repair performed later" — Jack Langer (clinical) [Ep 39 · 45:31](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2731)
- "Reflux is very common in omphalocele patients, and many don't eat normally, especially with cardiac disease or pulmonary hypoplasia" — Jack Langer (clinical) [Ep 39 · 46:08](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2768)
- "Interventional radiologists can place G-tubes under fluoroscopy in giant omphalocele patients by finding a window lateral to the defect" — Jack Langer (clinical) [Ep 39 · 46:30](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2790)
- "After G-tube maturation, a GJ tube can be placed to allow feeding despite severe reflux" — Jack Langer (clinical) [Ep 39 · 46:55](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2815)
- "Fundoplication in a child with unrepaired giant omphalocele is extremely difficult because the liver is midline and access to the hiatus is nearly impossible, especially with cardiac disease and congested liver" — Jack Langer (clinical) [Ep 39 · 47:15](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2835)
- "GJ tube is a better short-term solution than fundoplication for reflux in unrepaired omphalocele, with fundoplication performed at the time of definitive abdominal wall repair" — Jack Langer (clinical) [Ep 39 · 47:42](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2862)
- "In giant omphaloceles with midline liver, the liver can put pressure on the duodenum or pylorus causing mechanical gastric outlet obstruction that worsens reflux" — Jack Langer (clinical) [Ep 39 · 48:08](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2888)
- "Non-rotation in omphalocele is not associated with risk of midgut volvulus, so Ladd's procedure is not necessary" — Jack Langer (clinical) [Ep 39 · 48:49](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2929)
- "Inversion appendectomy during omphalocele repair makes sense if the surgeon performs appendectomies during Ladd's procedures" — Jack Langer (opinion) [Ep 39 · 49:06](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2946)
- "Children with repaired omphaloceles can develop perforated appendicitis with delayed diagnosis due to abnormal appendix location" — Jack Langer (clinical) [Ep 39 · 49:18](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2958)
- "If a child with omphalocele has renal abnormalities requiring potential Mitrofanoff procedure, the appendix should be preserved" — Jack Langer (clinical) [Ep 39 · 49:44](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=2984)
- "During omphalocele reduction with liver, hepatic veins are very superficial and can be injured during fascial dissection if not careful" — Jack Langer (clinical) [Ep 39 · 50:16](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=3016)
- "Kinking of hepatic veins during omphalocele reduction is prevented by using intraabdominal pressure monitoring and not being too aggressive with reduction when pressures exceed 20" — Jack Langer (clinical) [Ep 39 · 50:38](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=3038)
- "In immediate omphalocele reduction, fascial edges can usually be approximated at the bottom but often not at the top, requiring patch placement" — Jack Langer (clinical) [Ep 39 · 50:56](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=3056)
- "For partial omphalocele reduction with liver still protruding at the top, a temporary Gore-Tex or silastic patch can be sewn on with skin closed over it, then removed in 1-2 weeks for definitive fascial closure" — Jack Langer (clinical) [Ep 39 · 51:09](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=3069)
- "Team approach to intestinal failure reduced 1-year mortality from 30-40% to approximately 5% per year at University of Michigan" — Sam (clinical) [Ep 21 · 2:23](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=143)
- "Cincinnati's intestinal failure program was started in 1984" — Sam (clinical) [Ep 21 · 2:51](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=171)
- "Intestinal failure is defined by inadequate bowel length OR bowel that doesn't absorb nutrition and fluid adequately to maintain growth" — Monique (clinical) [Ep 21 · 3:47](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=227)
- "Almost 30% of patients leaving NICU without rotavirus vaccination were readmitted with rotavirus infection" (epidemiological) [Ep 21 · 16:56](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1016)
- "Joint weekly rounds with surgeons, gastroenterologists, dietitians, and neonatologists help identify protocol deviations and build family rapport" — Sam (clinical) [Ep 21 · 18:11](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1091)
- "Breast milk provides not just immunostimulatory benefits but motility effects through oligosaccharides and healing properties" (clinical) [Ep 21 · 30:13](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1813)
- "PIFCON study data showing 25% mortality or transplant referral are now archaic; outcomes have improved dramatically in past 5 years" — Sam (opinion) [Ep 21 · 33:36](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2016)
- "Cincinnati reduced catheter-related bloodstream infections from 12 per 1000 catheter-days to 2 per 1000, approaching <1 per 1000" (clinical) [Ep 21 · 37:31](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2251)
- "Standardized central line bundles and multi-hospital communication networks have reduced line infections across pediatric populations" (clinical) [Ep 21 · 38:54](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2334)
- "Intestinal failure patients have unique propensity for line infections and different infection types compared to general pediatric population" (clinical) [Ep 21 · 39:45](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2385)
- "Toronto experience paper in JPGN examined PICC lines for TPN administration" (clinical) [Ep 21 · 41:13](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2473)
- "Complication-free survival of PICC lines is approximately half that of broviacs according to IR literature" — Sam (clinical) [Ep 21 · 44:58](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2698)
- "Subclavian approach for central lines carries higher risk of stenosis compared to jugular approach" — Valerie (clinical) [Ep 21 · 46:26](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2786)
- "Lack of vascular access is no longer a common indication for intestinal transplant in past 3 years at some centers" (clinical) [Ep 21 · 50:04](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3004)
- "Ethanol locks use 70% concentration with 2-6 hour dwell time, can be given 3 times weekly (Monday/Wednesday/Friday) with good results" — Sam (clinical) [Ep 21 · 60:20](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3620)
- "Ethanol locks work better with 6.6 French catheters than smaller catheters; smaller PICC lines tend to occlude" — Sam (clinical) [Ep 21 · 61:04](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3664)
- "Younger NPO infants often cannot tolerate TPN windows required for ethanol locks" — Sam (clinical) [Ep 21 · 61:28](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3688)
- "UK predominantly uses taurolidine locks rather than ethanol locks for line infection prevention" — Girish (clinical) [Ep 21 · 63:55](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3835)
- "Line care education is crucial; recurrent infections warrant revisiting line care practices before implementing locks" — Girish (clinical) [Ep 21 · 64:23](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3863)
- "Fungal line infections are pulled more promptly, but some centers now treat through even fungal infections in patients with limited vascular access" (clinical) [Ep 21 · 65:32](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3932)
- "Phytosterols in soy-based lipids are cleared poorly, share cholesterol transporter (down-regulated by endotoxemia), and reduce FXR receptor expression causing hepatocyte damage" — Sam (clinical) [Ep 21 · 68:34](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4114)
- "Limiting lipid intake to 1 g/kg/day reduces cholestasis rate to less than 5% of patients" — Sam (clinical) [Ep 21 · 69:42](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4182)
- "Fish oil-based lipid (Omegaven) may have anti-inflammatory advantage and benefit patients who don't respond to lipid restriction" — Sam (clinical) [Ep 21 · 70:43](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4243)
- "Neonatologists often maintain higher lipid doses (2-3 g/kg/day) due to concern about depriving infants of linoleic acid and affecting brain development" — Sam (clinical) [Ep 21 · 71:50](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4310)
- "With lipid restriction protocols, cholestasis rarely emerges from Cincinnati NICU" (clinical) [Ep 21 · 72:39](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4359)
- "Standard metrics for essential fatty acid deficiency are based on malnourished children not on TPN, so altered triene:tetraene ratios may not apply the same way" (opinion) [Ep 21 · 74:14](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4454)
- "Symptomatic essential fatty acid deficiency is not seen in practice with lipid restriction protocols" (clinical) [Ep 21 · 74:41](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4481)
- "Higher glucose infusion rates become less efficient as caloric source and are pushed toward fatty acid and fat deposition" (clinical) [Ep 21 · 75:16](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4516)
- "Age-based glucose infusion rate limits: generally 15-16 in premature/infants, gradually decreasing with age" (guideline) [Ep 21 · 75:41](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4541)
- "Intestinal failure patients may not need to maintain 50th percentile growth; unclear what appropriate growth curve should be for this population" (opinion) [Ep 21 · 76:04](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4564)
- "Neurodevelopmental outcomes in intestinal failure are multifactorial (prolonged hospitalization, recurrent admissions, neonatal insults), not solely attributable to lipid strategies" — Girish (clinical) [Ep 21 · 79:31](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4771)
- "Babies with spontaneous intestinal perforation (no functional bowel removed) still require 2-3 months of parenteral nutrition" (clinical) [Ep 21 · 82:03](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4923)
- "Feed absorption and ability to progress feeds are the best measures of bowel function, not absolute bowel length" — Girish (clinical) [Ep 21 · 85:29](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5129)
- "Ability to wean TPN while maintaining good growth is the most important functional measure" (opinion) [Ep 21 · 86:18](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5178)
- "Upper GI studies can identify problems but cannot rule them out; absence of findings does not exclude anastomotic issues" (clinical) [Ep 21 · 88:16](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5296)
- "Delayed contrast films may reveal that barium flows into anastomosis but doesn't flow out well, suggesting functional problem" (clinical) [Ep 21 · 88:43](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5323)
- "Some anastomoses are not strictured but kinked or twisted, creating functional rather than anatomic obstruction" (clinical) [Ep 21 · 88:43](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5323)
- "Endoscopy is valuable for visualizing anastomosis diameter; sometimes can get scope on both sides but cannot see anastomosis itself" — Sam (clinical) [Ep 21 · 90:45](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5445)
- "Motility abnormalities in short bowel syndrome are not well described; manometric assessment is less helpful in this population" — Sam (opinion) [Ep 21 · 94:28](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5668)
- "Post-gastric tube feeding with gastric decompression can demonstrate distal bowel function and avoid unnecessary surgeries" (clinical) [Ep 21 · 95:24](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5724)
- "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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 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 37 · 4:28](https://qa.library.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=268)
- "Intestinal failure is defined as the reduction of functioning intestinal mass below that which can sustain life, resulting in dependence on supplemental parenteral support for a minimum of 60 days within a 74 consecutive day interval." — Stephanie Oliveira (clinical) [Ep 108 · 0:26](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=26)
- "More than 50% of intestinal failure cases are related to short bowel syndrome, with additional cases from mucosal enteropathies and dysmotility disorders." — Stephanie Oliveira (epidemiological) [Ep 108 · 0:43](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=43)
- "Most causes of short bowel syndrome in pediatrics occur during the neonatal period, including gastroschisis, necrotizing enterocolitis, bowel atresia, and intestinal volvulus." — Stephanie Oliveira (clinical) [Ep 108 · 0:55](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=55)
- "The field is now focusing on neurocognitive outcomes, quality of life, and caregiver burnout as more children survive intestinal failure." — Stephanie Oliveira (opinion) [Ep 108 · 1:18](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=78)
- "Chronic intestinal inflammation resembling Crohn's disease is now being observed in intestinal failure patients, requiring management with inflammatory bowel disease therapies like biologics." — Lizzie Lee (host_summary) [Ep 108 · 1:24](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=84)
- "The cause of chronic intestinal inflammation in intestinal failure survivors is not known." — Stephanie Oliveira (clinical) [Ep 108 · 1:37](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=97)
- "Intestinal rehabilitation treatment strategy lacks clear-cut guidelines because every patient is unique with different gestational age, bowel resection, anatomy, and comorbidities." — Stephanie Oliveira (clinical) [Ep 108 · 1:48](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=108)
- "The goal of intestinal rehabilitation is to optimize intestinal function and adaptation before the development of irreversible complications." — Stephanie Oliveira (clinical) [Ep 108 · 2:07](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=127)
- "Intestinal adaptation is an active compensatory process that starts immediately after bowel resection." — Stephanie Oliveira (clinical) [Ep 108 · 2:30](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=150)
- "Food, bacteria, and hormones in the gut are important factors that enhance intestinal adaptation." — Stephanie Oliveira (clinical) [Ep 108 · 2:42](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=162)
- "Enteral autonomy is defined as getting off TPN with all nutrition going to the gut, either by mouth or by feeding tube." — Stephanie Oliveira (clinical) [Ep 108 · 3:11](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=191)
- "A 2012 Pediatric Intestinal Failure Consortium study showed 50% of intestinal failure patients achieved enteral autonomy, while 25% either died or had intestinal transplant." — Lizzie Lee (host_summary) [Ep 108 · 3:19](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=199)
- "From 2010 to 2015, a repeat study with double the number of patients showed approximately 50% still reached enteral autonomy, but the number of transplants and deaths significantly decreased." — Stephanie Oliveira (epidemiological) [Ep 108 · 3:33](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=213)
- "The establishment of multidisciplinary teams is one factor that changed outcomes in intestinal failure." — Stephanie Oliveira (clinical) [Ep 108 · 3:46](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=226)
- "Studies from Canada, Michigan, and Spain show that multidisciplinary intestinal rehabilitation teams improve survival." — Lizzie Lee (host_summary) [Ep 108 · 3:51](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=231)
- "Predictors of reaching enteral autonomy include residual bowel length (more is better), follow-up at an institution with an intestinal rehabilitation program, and no STEP procedure." — Stephanie Oliveira (clinical) [Ep 108 · 4:03](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=243)
- "Patients should be referred to intestinal rehabilitation programs when not making progress, on prolonged TPN, or have significant comorbidities, preferably sooner rather than later." — Stephanie Oliveira (guideline) [Ep 108 · 4:19](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=259)
- "Patients should not be referred to intestinal rehabilitation when several irreversible complications have already occurred and transplant is the only remaining option." — Stephanie Oliveira (guideline) [Ep 108 · 4:39](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=279)
- "Intestinal transplantation is considered when there are irreversible complications, though the number of transplants has significantly decreased over the last several decades." — Stephanie Oliveira (clinical) [Ep 108 · 4:49](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=289)
- "Liver disease associated with intestinal failure ranges from mild cholestasis to profound steatosis (in older children/adolescents/adults), with progression through inflammation, fibrosis, and ultimately cirrhosis leading to death or transplantation." — Paul Wales (clinical) [Ep 108 · 5:23](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=323)
- "Risk factors for intestinal failure-associated liver disease include prematurity, lack of enteral feeding, inability to feed due to anatomy, recurrent infections/sepsis, and components of TPN." — Paul Wales (clinical) [Ep 108 · 5:41](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=341)
- "The term 'intestinal rehabilitation program' was coined in the year 2000." — Paul Wales (clinical) [Ep 108 · 6:08](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=368)
- "Intestinal rehabilitation teams improve outcomes through integration of care, improved communication, and better continuity." — Paul Wales (clinical) [Ep 108 · 6:12](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=372)
- "Intestinal rehabilitation programs rely heavily on speech, language, and occupational therapy specialists." — Paul Wales (clinical) [Ep 108 · 6:34](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=394)
- "While patients are on TPN, the goal is to mitigate progression of liver disease, sepsis, and vascular complications." — Paul Wales (clinical) [Ep 108 · 6:38](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=398)
- "Families of intestinal failure patients manage significant tasks at home including running TPN pumps, adding vitamins, programming pumps, recording ins and outs, managing G-tubes, and managing stomas." — Paul Wales (clinical) [Ep 108 · 6:54](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=414)
- "High-quality families demonstrate evidence of burnout over time despite education and empowerment efforts." — Paul Wales (clinical) [Ep 108 · 7:11](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=431)
- "Literature shows intestinal rehabilitation programs improve survival related to liver dysfunction, decrease septic episodes, reduce central line complications, reduce ICU admissions, and enable patients listed for transplant to come off the list due to improved status." — Paul Wales (epidemiological) [Ep 108 · 7:25](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=445)
- "Mortality in intestinal failure has decreased with intestinal rehabilitation programs." — Paul Wales (epidemiological) [Ep 108 · 7:43](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=463)
- "Lipids in parenteral nutrition are a source of essential fatty acids, a non-protein energy source important for growth, and fatty acids have a major role in cellular pathways." — Paul Wales (clinical) [Ep 108 · 8:02](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=482)
- "Historically, most lipid emulsions in North America are soybean-based with high phytosterol content, high omega-6 long-chain polyunsaturated fatty acid content, and low antioxidant content." — Paul Wales (clinical) [Ep 108 · 8:15](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=495)
- "Prolonged soybean-based lipid exposure is associated with deterioration of liver function, specifically cholestasis." — Paul Wales (clinical) [Ep 108 · 8:31](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=511)
- "For every day an infant is exposed to soybean lipid dosed at greater than 2.5 g/kg/day, there is a 3% increase in the odds ratio of developing advanced liver disease." — Paul Wales (epidemiological) [Ep 108 · 8:51](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=531)
- "First-generation lipid emulsions were soybean-based, rich in omega-6 PUFA (such as Intralipid), and have been in use for 40 years." — Paul Wales (clinical) [Ep 108 · 9:15](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=555)
- "Second-generation lipid emulsions attempt to reduce omega-6 exposure by diluting the soybean component." — Lizzie Lee (host_summary) [Ep 108 · 9:26](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=566)
- "Third-generation lipid emulsions reduce omega-6 component and change the omega-6 to omega-3 ratio by adding omega-3 lipids." — Paul Wales (clinical) [Ep 108 · 9:32](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=572)
- "Omega-6 fatty acids promote inflammation while omega-3 fatty acids lead to a more anti-inflammatory response." — Lizzie Lee (host_summary) [Ep 108 · 9:43](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=583)
- "Omega-6 lipids are metabolized to arachidonic acid, which produces leukotrienes and prostaglandins with a more pro-inflammatory profile." — Paul Wales (clinical) [Ep 108 · 9:51](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=591)
- "Omega-3 lipids are metabolized through EPA and DHA, leading to production of cytokines with a less inflammatory profile." — Paul Wales (clinical) [Ep 108 · 10:01](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=601)
- "Omega-3 lipids improve bile flow by decreasing lithogenicity of bile, decreasing steatosis, stimulating improved beta-oxidation and clearance, lowering oxidative stress, and supporting immune function." — Paul Wales (clinical) [Ep 108 · 10:15](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=615)
- "The two main strategies for improving lipids in parenteral nutrition are lipid minimization and change in composition." — Paul Wales (clinical) [Ep 108 · 10:32](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=632)
- "Literature dating back decades shows that restricting exposure to soybean lipid improves cholestasis, particularly when dosed at 1 g/kg/day or less." — Paul Wales (clinical) [Ep 108 · 10:42](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=642)
- "In preterm babies, fat is important for growth, especially for neurocognitive development, creating a risk of essential fatty acid deficiency if lipid dosing is restricted too much." — Paul Wales (clinical) [Ep 108 · 11:00](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=660)
- "In utero, babies receive significant amounts of DHA and arachidonic acid through the placenta, but standard lipid emulsions in TPN fall short of providing these." — Lizzie Lee (host_summary) [Ep 108 · 11:12](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=672)
- "DHA and arachidonic acid are important for retinal and brain development." — Paul Wales (clinical) [Ep 108 · 11:22](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=682)
- "None of the current lipid emulsions were designed for premature babies; they were all designed for adults in critical care settings." — Paul Wales (clinical) [Ep 108 · 11:26](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=686)
- "Work is currently underway with industry to create a lipid emulsion specifically tailored to preterm babies with higher arachidonic acid content." — Paul Wales (clinical) [Ep 108 · 11:38](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=698)
- "Central lines are the lifeline for intestinal failure patients, and without venous access, families cannot be supported." — Paul Wales (clinical) [Ep 108 · 12:03](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=723)
- "Central lines are at risk for complications including infections, blockages, thrombosis, and breakage." — Paul Wales (clinical) [Ep 108 · 12:10](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=730)
- "In the United States, there are approximately 240,000 central line-associated bloodstream infections (CLABSIs) annually, with each costing about $30,000, totaling approximately $2 billion per year nationwide." — Paul Wales (epidemiological) [Ep 108 · 12:24](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=744)
- "The team pivoted to 4% tetrasodium EDTA (Taurolock/Kitelock) when ethanol became too expensive and difficult to obtain." — Paul Wales (clinical) [Ep 108 · 12:48](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=768)
- "4% tetrasodium EDTA (Kitelock) is antithrombotic, anti-fibrinolytic, and antimicrobial, satisfying all three criteria important for a good lock solution." — Paul Wales (clinical) [Ep 108 · 12:48](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=768)
- "Kitelock addresses three issues of central line complications: organisms, clot/thrombosis, and biofilm." — Lizzie Lee (host_summary) [Ep 108 · 13:09](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=789)
- "Kitelock is licensed in Europe and Australia but not available in the United States." — Paul Wales (clinical) [Ep 108 · 13:23](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=803)
- "A multi-center randomized trial of Kitelock versus heparin went live 4 weeks ago and is actively recruiting patients, with results expected within the next year." — Paul Wales (clinical) [Ep 108 · 13:29](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=809)
- "In short bowel syndrome, there are three anatomical subtypes: Type 1 (high jejunostomy), Type 2 (loss of distal small bowel/ileum and part of colon with small bowel-colonic anastomosis), and Type 3 (loss of mid-small bowel with retained ileum and intact colon)." — Paul Wales (clinical) [Ep 108 · 13:58](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=838)
- "Patients with Type 3 short bowel syndrome have the best prognosis because they still have residual ileum." — Lizzie Lee (host_summary) [Ep 108 · 14:19](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=859)
- "The most common anatomical subtype of short bowel syndrome in pediatrics is Type 2." — Paul Wales (epidemiological) [Ep 108 · 14:26](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=866)
- "Type 1 and Type 2 short bowel syndrome patients struggle because they lack an ileum." — Paul Wales (clinical) [Ep 108 · 14:31](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=871)
- "The ileum is where GLP-2 is naturally produced." — Lizzie Lee (host_summary) [Ep 108 · 14:36](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=876)
- "Without an ileum, infants cannot generate the necessary GLP-2 hormone surge to drive their own intestinal adaptation." — Lizzie Lee (host_summary) [Ep 108 · 14:39](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=879)
- "Native GLP-2 hormone has a half-life of 7 minutes, making it impractical for clinical use." — Paul Wales (clinical) [Ep 108 · 14:53](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=893)
- "GLP-2 has been altered by one amino acid to create an analog called teduglutide, which has a half-life of 2 hours and is given once daily by subcutaneous injection." — Paul Wales (clinical) [Ep 108 · 14:58](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=898)
- "A multi-center phase 3 study published in 2020 at Cincinnati Children's showed patients receiving teduglutide had a 40% reduction in TPN fluid and calorie requirements over a six-month period." — Paul Wales (epidemiological) [Ep 108 · 15:23](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=923)
- "70% of patients who received teduglutide achieved the study endpoint of a 20% reduction in TPN requirements." — Paul Wales (epidemiological) [Ep 108 · 15:32](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=932)
- "Teduglutide is licensed for children greater than 1 year of age." — Paul Wales (guideline) [Ep 108 · 15:48](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=948)
- "Teduglutide has made a big difference in practice, with even children with very extreme anatomy able to get off TPN." — Paul Wales (clinical) [Ep 108 · 15:50](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=950)
- "Another GLP-2 analog, apraglutide, has a longer half-life and can be given once weekly." — Paul Wales (clinical) [Ep 108 · 16:02](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=962)
- "Apraglutide works even better than teduglutide, producing more bowel lengthening." — Paul Wales (clinical) [Ep 108 · 16:10](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=970)
- "These interventions (optimized lipids, central line infection prevention, GLP-2 analogs) have led to a decrease in transplantation since 2008." — Paul Wales (epidemiological) [Ep 108 · 16:36](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=996)
- "The decrease in transplantation is in large part because of the successes of intestinal rehabilitation." — Paul Wales (opinion) [Ep 108 · 16:41](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1001)
- "Outcomes of intestinal transplant at 5 years are approximately 65%." — Paul Wales (epidemiological) [Ep 108 · 16:41](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1001)
- "The goal is to avoid transplant and lifelong immunosuppression whenever possible." — Paul Wales (opinion) [Ep 108 · 16:49](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1009)
- "Children have much greater adaptive potential than adults because of their inherent gut growth capacity." — Lizzie Lee (host_summary) [Ep 108 · 16:54](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1014)
- "The proportion of children reaching enteral autonomy has improved over the past 20 years." — Lizzie Lee (host_summary) [Ep 108 · 17:00](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1020)
- "Controlling liver disease buys time for intestinal adaptation." — Lizzie Lee (host_summary) [Ep 108 · 17:06](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1026)
- "The vast majority of kids who have vomiting, respiratory symptoms, wheezing are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux." — Rachel Rosen (clinical) [Ep 33 · 3:23](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=203)
- "The peak age of reflux is between 4 and 6 months of age." — Rachel Rosen (epidemiological) [Ep 33 · 4:18](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=258)
- "In children under the age of 1, proton pump inhibitors are not beneficial because these kids reflux non-acidic gastric content (milk)." — Rachel Rosen (clinical) [Ep 33 · 5:26](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=326)
- "Normal gastric emptying of infants takes 2 to 3 hours; acid production only starts after the 3 hour mark when the stomach is empty." — Rachel Rosen (clinical) [Ep 33 · 5:45](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=345)
- "Studies have shown both with H2 blockers and PPIs you can get sepsis, UTIs, necrotizing enterocolitis, pneumonias, pharyngitis, upper respiratory infections, and C. diff in young children." — Rachel Rosen (clinical) [Ep 33 · 7:21](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=441)
- "In kids under the age of 5, the most common presentation of eosinophilic esophagitis is chronic cough." — Rachel Rosen (clinical) [Ep 33 · 9:27](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=567)
- "When you scope all kids under the age of 5 who are presenting with respiratory symptoms, you'll find eosinophilic esophagitis in about 10% of kids." — Rachel Rosen (epidemiological) [Ep 33 · 9:53](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=593)
- "You really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has eosinophilic esophagitis." — Rachel Rosen (guideline) [Ep 33 · 10:54](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=654)
- "In about 60 to 70% of kids with eosinophilic esophagitis, the most likely allergen is dairy." — Rachel Rosen (epidemiological) [Ep 33 · 11:57](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=717)
- "Macrolides like erythromycin are motilin agonists that make the antrum of the stomach contract and help with vomiting, plus they have anti-inflammatory effects for the airway and lungs." — Rachel Rosen (clinical) [Ep 33 · 16:28](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=988)
- "There are no great normal values for the number of reflux episodes in pediatric patients, making pH impedance interpretation difficult." — Rachel Rosen (clinical) [Ep 33 · 17:48](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1068)
- "Reflux in Dr. Rosen's opinion is rarely a cause of failure to thrive and respiratory symptoms in infants." — Rachel Rosen (opinion) [Ep 33 · 19:18](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1158)
- "The majority of kids with oropharyngeal dysphagia will outgrow it by 3 to 4 months of age according to a study in JPGN." — Rachel Rosen (clinical) [Ep 33 · 28:21](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1701)
- "In kids who aspirate from oropharyngeal dysphagia, rates of hospitalization after gastrostomy placement are about 15 times higher than if you just fed them by mouth, even in kids who aspirate all textures." — Rachel Rosen (epidemiological) [Ep 33 · 29:37](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1777)
- "In Boston Children's data, about 75% of NICU babies with severe dysphagia managed with NG tubes will not need to go on to gastrostomy." — Rachel Rosen (epidemiological) [Ep 33 · 28:42](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1722)
- "An upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux." — Whit Holcomb (clinical) [Ep 33 · 22:38](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1358)
- "In a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients." — Whit Holcomb (epidemiological) [Ep 33 · 23:17](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=1397)
- "The new GERD guidelines (joint North America and Europe) recommend treating with PPI for 2 months then attempting to wean, with goal of weaning twice yearly." — Rachel Rosen (guideline) [Ep 33 · 43:42](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2622)
- "If you have reflux beyond the age of 3 or 4, you're likely to continue to have it long term." — Rachel Rosen (clinical) [Ep 33 · 45:31](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2731)
- "In Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique." — Whit Holcomb (clinical) [Ep 33 · 46:40](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2800)
- "The primary reason for redo fundoplication is transmigration of the wrap into the chest." — Whit Holcomb (clinical) [Ep 33 · 46:43](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2803)
- "Before adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change." — Whit Holcomb (epidemiological) [Ep 33 · 57:23](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3443)
- "The key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach." — Whit Holcomb (clinical) [Ep 33 · 60:49](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3649)
- "Kids who present with aspiration during swallowing and then get a Nissen tend to do worse because their saliva pools in their esophagus over the Nissen or they continue to aspirate their saliva." — Rachel Rosen (clinical) [Ep 33 · 49:02](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2942)
- "Blenderized feeds through gastrostomy tubes have really changed management of reflux because the food is heavier and migrates to the antrum away from the LES and cardia." — Rachel Rosen (clinical) [Ep 33 · 52:39](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3159)
- "A study from Cincinnati showed that blenderized feeds are a really effective therapy for treatment of post-fundoplication retching." — Rachel Rosen (clinical) [Ep 33 · 63:11](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3791)
- "Pyloric Botox works not only for delays in emptying but also with the sensory component that triggers retching." — Rachel Rosen (clinical) [Ep 33 · 54:19](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3259)
- "Cyproheptadine (Periactin) helps with gastric accommodation and can control retching in children." — Rachel Rosen (clinical) [Ep 33 · 54:26](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3266)
- "Kids who wretch preoperatively will likely wretch postoperatively, and families should be counseled about this." — Rachel Rosen (clinical) [Ep 33 · 35:28](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2128)
- "Using an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation." — Whit Holcomb (clinical) [Ep 33 · 63:42](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=3822)
- "Post-fundoplication patients should have 10-20 reflux episodes per 24 hours on impedance probe, which is acceptable and indicates the Nissen is still functioning." — Rachel Rosen (clinical) [Ep 33 · 71:44](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4304)
- "Rome IV defines three categories: non-erosive reflux disease (NERD - abnormal acid burden, normal scope), reflux hypersensitivity (normal acid burden but symptoms correlate with reflux), and functional heartburn (no correlation between symptoms and reflux)." — Rachel Rosen (guideline) [Ep 33 · 40:54](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=2454)
- "Patients with rumination syndrome describe vomiting 50-100 times a day, typically within minutes of starting a meal or for the hour after a meal." — Rachel Rosen (clinical) [Ep 33 · 78:40](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4720)
- "On esophageal motility study, rumination shows simultaneous contraction of the stomach with bolus movement up into the esophagus." — Rachel Rosen (clinical) [Ep 33 · 79:13](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4753)
- "If you wrap patients with rumination syndrome, they continue to ruminate even with a wrap in place." — Rachel Rosen (clinical) [Ep 33 · 79:31](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4771)
- "Gastric stimulation may work through a sensory effect rather than purely a motility effect, as some patients improve without improvements in motility." — Rachel Rosen (opinion) [Ep 33 · 68:04](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4084)
- "Botox doesn't reliably improve gastric emptying but helps significantly with retching, suggesting a sensory mechanism." — Rachel Rosen (clinical) [Ep 33 · 68:18](https://qa.library.globalcastmd.com/watch/gastroesophageal-reflux-disease-289?t=4098)
- "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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 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 35 · 43:17](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2597)
- "Infants with renal failure are often called for gastrostomy tube and peritoneal dialysis catheter placement within the first few days of life." — Alonso (clinical) [Ep 1 · 0:13](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=13)
- "Babies that make urine are not likely to need peritoneal dialysis immediately but are likely to need it in the future." — Alonso (clinical) [Ep 1 · 0:31](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=31)
- "Peritoneal dialysis catheters should ideally be left alone for a couple of weeks after placement if possible." — Alonso (clinical) [Ep 1 · 0:49](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=49)
- "Gastrostomy tube placement is focused along the lesser curvature or close to it to preserve stomach tissue for potential future bladder augmentation by Doctor Reddy." — Alonso (clinical) [Ep 1 · 0:49](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=49)
- "Gastrostomy tube placement is performed laparoscopic-assisted to visualize exact stomach location, then the camera is turned into the pelvis to position the PD catheter." — Alonso (clinical) [Ep 1 · 1:21](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=81)
- "The nephrology team is generally good at predicting which babies will need a peritoneal dialysis catheter." — Alonso (opinion) [Ep 1 · 1:42](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=102)
- "Hemodialysis catheters need to be fairly large caliber and are preferentially placed in the right internal jugular site because it provides a straight shot into the atrium." — Alonso (clinical) [Ep 1 · 2:04](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=124)
- "Inguinal and umbilical hernias can develop when babies are on peritoneal dialysis." — Alonso (clinical) [Ep 1 · 3:03](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=183)
- "Hernias in dialysis patients are generally left alone if they are not affecting dialysis mechanics or causing symptoms." — Alonso (clinical) [Ep 1 · 3:03](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=183)
- "The ideal weight for infant renal transplantation is around 10 kg if the patient is not on peritoneal dialysis." — Alonso (clinical) [Ep 1 · 3:46](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=226)
- "Infants on peritoneal dialysis have a more accommodating abdominal cavity and laxity in the abdominal wall, allowing transplantation at weights closer to 8 kg." — Alonso (clinical) [Ep 1 · 4:08](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=248)
- "All infant renal transplant recipients at this center have been transplanted with adult donor kidneys." — Alonso (clinical) [Ep 1 · 4:24](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=264)
- "An extraperitoneal approach is used for infant renal transplantation with an incision extending to the upper edge close to the costal margin." — Alonso (clinical) [Ep 1 · 4:39](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=279)
- "Wound complications are the biggest complication from a general surgical perspective in infant renal transplantation, surprisingly more common than vascular complications." — Alonso (clinical) [Ep 1 · 5:06](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=306)
- "Some infant transplant patients can only be closed at the skin level initially and develop leaks or dehiscence requiring biologic mesh (such as derma matrix) for closure." — Alonso (clinical) [Ep 1 · 5:15](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=315)
- "In a 13-year follow-up study of gastrostomy tubes in babies, all G-tubes migrated superiorly onto the chest wall." (clinical) [Ep 1 · 7:21](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=441)
- "Placing gastrostomy tubes too close to peritoneal dialysis catheters creates infection risk early on because drainage can get underneath the PD catheter dressing when there is insufficient space between sites." — Alonso (clinical) [Ep 1 · 7:54](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=474)
- "The standard gastrostomy tube insertion site is 2 finger breadths below the costal margin." — Alonso (clinical) [Ep 1 · 8:31](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=511)
- "For patients with posterior urethral valves, gastrostomy tube location is placed high on the stomach toward the lesser curvature to preserve the ability to use a gastric segment for gastric augmentation later in life." (clinical) [Ep 1 · 8:48](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=528)
- "Some infants with posterior urethral valves will need urinary diversion with a vesicostomy placed about 1-2 finger breadths below the umbilicus, requiring mitigation of infection risks by spacing catheter sites appropriately." (clinical) [Ep 1 · 9:13](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=553)
- "Peritoneal dialysis catheters can be placed in a way that allows immediate use with lower volumes, though waiting for healing is preferable." — Alonso (clinical) [Ep 1 · 11:27](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=687)
- "Many infants with bladder outlet obstruction have unusually small stomachs, potentially related to minimal amniotic fluid during development." (host_summary) [Ep 1 · 11:50](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=710)
- "Amnioinfusions are performed when patients present for first imaging to assess the baby's capacity to swallow and see if the stomach fills." (clinical) [Ep 1 · 12:30](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=750)
- "Early onset large bladders that extend upward and push the diaphragm and stomach back may cause anatomical distortion that results in stomachs ending up higher long-term." (opinion) [Ep 1 · 13:23](https://qa.library.globalcastmd.com/watch/renal-transplantation-cincinnati-fetal-center-623?t=803)
- "There are no clear predictive factors to identify which premature infants with early NEC will progress to require surgical intervention." — Jose Zinter (clinical) [Ep 2 · 1:54](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=114)
- "Rate of feeding advancement does not correlate with development of necrotizing enterocolitis." — Todd Ponsky (host_summary) [Ep 2 · 3:11](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=191)
- "Probiotics have the most evidence for NEC prevention, supported by Cochrane database review." (host_summary) [Ep 2 · 3:35](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=215)
- "Many U.S. institutions do not routinely use probiotics despite evidence, due to uncertainty about formulation and dosing." — Jose Zinter (clinical) [Ep 2 · 4:19](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=259)
- "Pneumoperitoneum is the only single factor that would prompt operation; otherwise a constellation of findings (pneumatosis, hemodynamic instability, fixed loop, worsening acidosis/ventilation) is required." — Todd Ponsky (clinical) [Ep 2 · 7:17](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=437)
- "Focal abdominal wall erythema is one of the most sensitive indicators for underlying dead bowel in NEC." (clinical) [Ep 2 · 12:24](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=744)
- "In a 600-g infant with pneumoperitoneum, transport to the OR increases risk of demise; bedside intervention (drainage or laparotomy) is preferred." — Tim (clinical) [Ep 2 · 15:08](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=908)
- "Approximately 30% of infants treated with peritoneal drainage alone do not require subsequent laparotomy." (host_summary) [Ep 2 · 16:21](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=981)
- "The Moss New England Journal trial showed no difference in outcomes between peritoneal drainage and laparotomy in extremely low birth weight infants with NEC, but the study population was heterogeneous." — Todd Ponsky (host_summary) [Ep 2 · 17:44](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1064)
- "Most panelists use 1 kg as the weight threshold above which they favor laparotomy over peritoneal drainage." — Todd Ponsky (host_summary) [Ep 2 · 19:06](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1146)
- "Bilateral grade 4 intraventricular hemorrhage does not alter surgical decision-making unless the family requests comfort measures only." (opinion) [Ep 2 · 20:10](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1210)
- "Primary anastomosis at initial NEC operation is rarely performed (8–10% of audience) due to inability to detect anastomotic leak in a sick neonate." — Todd Ponsky (host_summary) [Ep 2 · 21:55](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1315)
- "Dr. Miguel Guelfand presented impressive results with primary anastomosis in NEC at a prior conference." — Todd Ponsky (host_summary) [Ep 2 · 22:01](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1321)
- "The 'Shishka baby' technique involves placing a tube through multiple necrotic segments with a few stitches to hold them together, then bringing both ends out as stomas with proximal diversion." (clinical) [Ep 2 · 23:29](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1409)
- "Stoma takedown is typically performed at 4–6 weeks postoperatively and 2 kg body weight, though recent data (Andrew Badillo) suggest earlier reversal may be safe." — Todd Ponsky (host_summary) [Ep 2 · 26:32](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1592)
- "Bringing stomas out side-by-side in the incision (rather than separated) facilitates easier takedown without disturbing the entire abdominal cavity." (opinion) [Ep 2 · 27:00](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1620)
- "In pan-intestinal necrosis, decompressing distended bowel may reduce ischemia and salvage additional segments." (clinical) [Ep 2 · 31:41](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1901)
- "As of one year ago, no child with true NEC totalis (complete small bowel and colonic necrosis) has successfully survived intestinal transplant." — Jose Zinter (epidemiological) [Ep 2 · 33:54](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=2034)
- "The threshold for viable bowel length has dropped to approximately 20 cm of small bowel, with better outcomes if the colon is intact." — Jose Zinter (clinical) [Ep 2 · 34:23](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=2063)
- "In the first two months of life, about 70% of volvulus cases occur, and by the first two years of life, 90% of volvulus cases that are going to occur do occur" (epidemiological) [Ep 3 · 27:23](https://qa.library.globalcastmd.com/watch/malrotation-629?t=1643)
- "In 20% of cases with true malrotations of the fore and mid-gut, you have a normal barium enema" (clinical) [Ep 3 · 19:27](https://qa.library.globalcastmd.com/watch/malrotation-629?t=1167)
- "A normal ultrasound does not rule out volvulus, supported by multiple studies" (clinical) [Ep 3 · 19:44](https://qa.library.globalcastmd.com/watch/malrotation-629?t=1184)
- "Ladd's bands do not cause midgut volvulus" — Jack (clinical) [Ep 3 · 4:02](https://qa.library.globalcastmd.com/watch/malrotation-629?t=242)
- "Ladd's bands are thought to be an attempt of the body to fuse the cecum to the lateral peritoneal wall" — Wit (clinical) [Ep 3 · 37:16](https://qa.library.globalcastmd.com/watch/malrotation-629?t=2236)
- "The key reason to operate on an asymptomatic patient is to avoid midgut volvulus" — Jack (clinical) [Ep 3 · 3:52](https://qa.library.globalcastmd.com/watch/malrotation-629?t=232)
- "The critical measurement is the distance between the ligament of Treitz and the ileocecal junction to prevent volvulus, though nobody knows the exact distance required" — Jack (clinical) [Ep 3 · 4:56](https://qa.library.globalcastmd.com/watch/malrotation-629?t=296)
- "In patients with heterotaxy syndromes who have asymptomatic malrotations and undergo operations, the complication rate is remarkably high, between 30 and 50%" (epidemiological) [Ep 3 · 16:13](https://qa.library.globalcastmd.com/watch/malrotation-629?t=973)
- "In a study from Edmonton on heterotaxy patients who underwent procedures for malrotation, the complication rate was about 50%" (host_summary) [Ep 3 · 24:59](https://qa.library.globalcastmd.com/watch/malrotation-629?t=1499)
- "In a study by Papillon from Children's LA of about 200 heterotaxy patients, a quarter got screening upper GIs and three quarters did nothing; in 4 years there was only one case of volvulus, and in patients without bilious emesis and symptoms, no cases of volvulus" (host_summary) [Ep 3 · 25:12](https://qa.library.globalcastmd.com/watch/malrotation-629?t=1512)
- "In the heterotaxy subgroup, the risk of volvulus in the early period (4-5 years) is actually very low if patients are not symptomatic" (epidemiological) [Ep 3 · 25:53](https://qa.library.globalcastmd.com/watch/malrotation-629?t=1553)
- "When bowel loops are dilated, this will always give you a low-lying ligament of Treitz" — Todd Ponsky (clinical) [Ep 3 · 11:53](https://qa.library.globalcastmd.com/watch/malrotation-629?t=713)
- "Atypical malrotation with a low-lying ligament of Treitz has some data showing lower risk of volvulus, though the data is not strong" (clinical) [Ep 3 · 16:35](https://qa.library.globalcastmd.com/watch/malrotation-629?t=995)
- "In patients with rotation abnormalities, reversed mesenteric vessels may or may not be seen; it doesn't definitively indicate malrotation" — Jack (clinical) [Ep 3 · 41:01](https://qa.library.globalcastmd.com/watch/malrotation-629?t=2461)
- "In Jack's series of several hundred patients, there was never a case where the vessels were normal in a patient who had risk for volvulus (narrow base mesentery), so they use it as a screening test in sick patients" — Jack (clinical) [Ep 3 · 41:15](https://qa.library.globalcastmd.com/watch/malrotation-629?t=2475)
- "Upper GI is clearly better than ultrasound for diagnosing malrotation, but in a sick patient who can't get to radiology, ultrasound can be useful" — Jack (clinical) [Ep 3 · 41:54](https://qa.library.globalcastmd.com/watch/malrotation-629?t=2514)
- "Laparoscopic Ladd's procedure can be very effective even in a newborn, though if there's too much twist and no room, conversion to open may be necessary" — Tim Kane (clinical) [Ep 3 · 8:18](https://qa.library.globalcastmd.com/watch/malrotation-629?t=498)
- "In cardiac patients between first stage and Glenn procedure who get G-tubes, Nissen fundoplication is often requested because they vomit and are too small for PEGs" — Tim Kane (clinical) [Ep 3 · 14:42](https://qa.library.globalcastmd.com/watch/malrotation-629?t=882)
- "A 45-minute Nissen at pressures of 8 is tolerated by cardiac patients between stages" — Tim Kane (clinical) [Ep 3 · 14:56](https://qa.library.globalcastmd.com/watch/malrotation-629?t=896)
- "In a published study combining experience with Kansas City, the cardiac risk group did not stratify out to be at higher risk for reflux complications; neurologically impaired CP kids maybe, but not cardiac kids" — Todd Ponsky (host_summary) [Ep 3 · 15:15](https://qa.library.globalcastmd.com/watch/malrotation-629?t=915)
- "Yama does not operate on asymptomatic malrotation as long as the patient has non-bilious vomiting, is gaining weight, and is clinically well" — Todd Ponsky (host_summary) [Ep 3 · 35:20](https://qa.library.globalcastmd.com/watch/malrotation-629?t=2120)
- "If a patient has a narrow pedicle, the patient always has vomiting and is symptomatic" — Todd Ponsky (host_summary) [Ep 3 · 36:16](https://qa.library.globalcastmd.com/watch/malrotation-629?t=2176)
- "Ladd's bands themselves are not risky; the risk is bilious vomiting and narrowing of the pedicle" — Todd Ponsky (host_summary) [Ep 3 · 36:39](https://qa.library.globalcastmd.com/watch/malrotation-629?t=2199)
- "In situs inversus or ambiguous cases, measuring the distance between ligament of Treitz and ileocecal junction matters regardless of where the bowels are; if less than half the diameter of the abdominal cavity, intervention is needed" — Jack (clinical) [Ep 3 · 39:27](https://qa.library.globalcastmd.com/watch/malrotation-629?t=2367)
- "Infant presented with delayed passage of meconium of more than 48 hours, but passed meconium after digital rectal examination and was kept for observation." — Jafar (clinical) [Ep 5 · 0:41](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=41)
- "At day 7 of age, infant presented with signs and symptoms of Hirschsprung disease including abdominal distension and tight rectum with passage of explosive stool after removing examining finger." — Jafar (clinical) [Ep 5 · 0:53](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=53)
- "Full thickness rectal biopsy confirmed the absence of ganglion cells." — Jafar (clinical) [Ep 5 · 1:08](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=68)
- "At laparotomy for colostomy creation, malrotation with multiple bands was found: one band between loops of bowel, one between bowel and liver, and one between bowel and abdominal wall." — Jafar (clinical) [Ep 5 · 1:16](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=76)
- "Collapsed colon and dilated ileum with typical cone segment were observed at surgery." — Jafar (clinical) [Ep 5 · 1:38](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=98)
- "All bands were released and ileostomy was created; biopsies from appendix and terminal ileum confirmed total colonic aganglionosis." — Jafar (clinical) [Ep 5 · 1:48](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=108)
- "Postoperatively, infant was given IV fluids, antibiotics, and total parenteral nutrition; after bowel function returned, feeding was started with Ensure high-calorie formula with vitamin B12 supplementation." — Jafar (clinical) [Ep 5 · 2:03](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=123)
- "Infant developed multiple episodes of dehydration requiring hospital admission for IV fluid replacement." — Jafar (clinical) [Ep 5 · 2:28](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=148)
- "At 70 days of age (now 4 months at time of presentation), infant's weight was 3.5 kg, indicating slow weight gain." — Jafar (clinical) [Ep 5 · 2:37](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=157)
- "Only a few cases have been reported of total colonic aganglionosis associated with malrotation: Philone reported 4 patients, Kors reported 1 patient, and 3 patients were reported by others; no cases have been reported with all three anomalies (total colonic aganglionosis, malrotation, and congenital bands)." — Jafar (epidemiological) [Ep 5 · 3:39](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=219)
- "Congenital bands in this case are rare; etiology is unknown but could be attributed to abnormal bowel rotation or other developmental findings." — Jafar (clinical) [Ep 5 · 4:08](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=248)
- "The typical scenario for malrotation with Hirschsprung disease is a child with bilious vomiting who undergoes Ladd procedure for malrotation, but then fails to open up postoperatively, prompting investigation that reveals total colonic aganglionosis." (clinical) [Ep 5 · 5:42](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=342)
- "After Ladd procedure, if the baby does not open up, other potential causes for bilious vomiting must be considered, including Hirschsprung disease." (clinical) [Ep 5 · 6:06](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=366)
- "When malrotation is associated with Hirschsprung disease, the segments are usually short, not total colonic, following the same distribution as Hirschsprung disease in general." (epidemiological) [Ep 5 · 6:18](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=378)
- "For total colonic Hirschsprung disease, the preferred operation is Duhamel because it is simple, safe, and provides a reservoir at the bottom, which Soave does not." (opinion) [Ep 5 · 6:43](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=403)
- "Timing of definitive repair should be based on consistency of ileostomy output rather than age or weight; repair should be delayed until output firms up, which usually occurs when the infant starts solid food." (opinion) [Ep 5 · 7:05](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=425)
- "Infants do not do well if definitive repair is performed too early when ileostomy output is still very liquid." (clinical) [Ep 5 · 7:14](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=434)
- "For long-segment or total colonic Hirschsprung disease, Duhamel is the taught and used procedure, but the modern approach uses a relatively short piece of colon to create a small reservoir rather than the long Martin modification." (clinical) [Ep 5 · 7:28](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=448)
- "Good continence control in long-segment Hirschsprung disease is achieved in only about 50% of patients; the data on outcomes is not great." (epidemiological) [Ep 5 · 7:55](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=475)
- "When aganglionosis extends more than 50 cm proximal to the ileocecal valve into small bowel, it represents a much more progressive disease with a bigger dysmotility element, and classic operations are less likely to provide a simple fix." (clinical) [Ep 5 · 8:14](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=494)
- "There is no evidence in the literature that any particular procedure (Duhamel vs Soave) is superior for long-segment Hirschsprung disease; surgeons should use the procedure with which they have the best results." — Sharif (opinion) [Ep 5 · 8:54](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=534)
- "In infants with ileostomy who are not gaining weight despite adequate calories and normal blood tests, sodium loss should be investigated by checking sodium levels in the ileostomy effluent." — Sharif (clinical) [Ep 5 · 9:42](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=582)
- "Serum sodium will remain normal for many months before decreasing, so checking effluent sodium is necessary to detect losses early." — Sharif (clinical) [Ep 5 · 10:12](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=612)
- "If ileostomy effluent contains more than 5 to 7 mEq/L of sodium, the infant will not gain weight." — Sharif (clinical) [Ep 5 · 10:21](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=621)
- "The infant must be gaining weight and growing before proceeding with definitive surgical repair." — Sharif (clinical) [Ep 5 · 10:28](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=628)
- "Measuring urinary sodium is the best way to guide sodium replacement therapy in infants with ileostomy." (clinical) [Ep 5 · 10:34](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=634)
- "Every baby with an ileostomy should probably receive sodium supplementation." (opinion) [Ep 5 · 10:49](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=649)
- "Iron deficiency is a significant long-term issue in children after any repair for Hirschsprung disease, though not an immediate concern in young infants." (clinical) [Ep 5 · 10:50](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=650)
- "For total colonic Hirschsprung disease, if Soave procedure is chosen, the surgeon should wait until the baby grows and the ileostomy is thicker before performing definitive repair." (opinion) [Ep 5 · 11:06](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=666)
- "After Soave or other procedures for total colonic disease, bulking agents or antidiarrheal agents can help manage stool consistency." (clinical) [Ep 5 · 11:29](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=689)
- "Some patients who underwent Duhamel abroad returned with problems including enterocolitis, obstruction, and distension of the Duhamel pouch." (clinical) [Ep 5 · 11:44](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=704)
- "Monitoring ileostomy output before deciding on definitive procedure is critically important." (clinical) [Ep 5 · 12:01](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=721)
- "Some patients who had ileoanal anastomosis developed severe perianal erosion requiring protective ileostomy and treatment before further procedures could be performed." (clinical) [Ep 5 · 12:05](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=725)
- "Patients with total colonic Hirschsprung disease should be managed with a long-term perspective rather than focusing only on immediate surgical decisions." (opinion) [Ep 5 · 12:38](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=758)
- "For regular (non-total colonic) Hirschsprung disease patients, Soave procedure does not result in incontinence if the procedure is performed correctly without damaging the sphincters." (opinion) [Ep 5 · 13:04](https://qa.library.globalcastmd.com/watch/tricks-total-colonic-aganglionosis-associated-with-malrotation-multiple-645?t=784)
- "Most damage to the intestine in gastroschisis occurs in the last few weeks of pregnancy, supported by animal and clinical studies." (clinical) [Ep 4 · 2:45](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=165)
- "Delivering gastroschisis at 37 weeks results in better neonatal outcomes compared to waiting for spontaneous labor." (clinical) [Ep 4 · 3:14](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=194)
- "The age at spontaneous onset of labor for gastroschisis pregnancy is 3 weeks earlier than the general population." (epidemiological) [Ep 4 · 3:44](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=224)
- "About half of gastroschisis pregnancies go into labor spontaneously before 37 weeks." (epidemiological) [Ep 4 · 3:56](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=236)
- "No perinatal center in Canada performs routine cesarean sections for gastroschisis." (epidemiological) [Ep 4 · 4:37](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=277)
- "Routine cesarean section for gastroschisis was standard of care 15-20 years ago but has gone out of favor." (guideline) [Ep 4 · 4:49](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=289)
- "Using forceps and retractors for bedside reduction can harm the bowel in some cases." (clinical) [Ep 4 · 8:18](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=498)
- "A pre-formed silo allows gentle reduction of gastroschisis contents without harming the bowel, and in about one-third of cases the bowel can be reduced immediately and the silo removed." (clinical) [Ep 4 · 8:27](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=507)
- "Waiting for the neonate to lose 10% of body weight reduces bowel edema and makes reduction easier." (clinical) [Ep 4 · 9:14](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=554)
- "Leaving a silo on for more than one day causes the fascial defect to enlarge significantly." (clinical) [Ep 4 · 9:41](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=581)
- "A larger fascial defect after silo removal takes longer to contract and heal if not surgically closed." (clinical) [Ep 4 · 9:54](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=594)
- "Rafensberger's group closed 80% of gastroschisis cases primarily; current practice has decreased to one-third to one-half primary closures." (epidemiological) [Ep 4 · 10:02](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=602)
- "Plastic closure (non-surgical closure with dressing) produces extremely good results for gastroschisis, often with a small umbilical hernia that closes by age 2 in the vast majority of cases." (clinical) [Ep 4 · 11:37](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=697)
- "Plastic closure avoids the need for operating room and general anesthesia in successful bedside reductions." (clinical) [Ep 4 · 11:50](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=710)
- "There are two types of intestinal atresia in gastroschisis: early-developing atresia not always associated with bowel thickening, and late atresia due to very small abdominal wall defect." (clinical) [Ep 4 · 15:58](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=958)
- "Primary repair of atresia in gastroschisis is appropriate when the bowel does not look damaged." (clinical) [Ep 4 · 15:00](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=900)
- "If the bowel looks nasty or matted, the atresia should be managed by reduction and delayed repair at 6 weeks." (clinical) [Ep 4 · 15:09](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=909)
- "Bringing an ostomy out through the umbilicus avoids a lateral scar and makes appliance placement easier." (clinical) [Ep 4 · 16:41](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1001)
- "Gord Cameron first described umbilical ostomies in the 1980s." (epidemiological) [Ep 4 · 17:53](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1073)
- "At 4 weeks post-gastroschisis repair with feeding intolerance, waiting longer is reasonable; at 8 weeks, exploration is warranted." (opinion) [Ep 4 · 20:07](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1207)
- "A mechanical stricture causing feeding intolerance after gastroschisis repair, when fixed surgically, can result in full feeds within 1-2 weeks." (clinical) [Ep 4 · 19:46](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1186)
- "Removing the omphalocele sac and attempting closure can lead to inability to achieve closure and need for prosthetic patch." (clinical) [Ep 4 · 22:13](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1333)
- "A partially ruptured omphalocele sac can be closed and painted, functioning as an autogenous silo." (clinical) [Ep 4 · 22:23](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1343)
- "Schuster-type repair uses mesh sutured to fascia with gradual closure over the intact sac, eventually allowing primary repair." (clinical) [Ep 4 · 22:31](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1351)
- "For large omphalocele in a full-term baby with no other problems, staged closure with patch and skin coverage is preferable to paint-and-wait, which takes months." (opinion) [Ep 4 · 23:05](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1385)
- "Lateral component separation can facilitate bringing fascial edges together in omphalocele closure." (clinical) [Ep 4 · 23:32](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1412)
- "Keeping the omphalocele sac supple with antibiotic ointment, applying stacked 4x4s, and wrapping with Ace wrap can facilitate gradual reduction." (clinical) [Ep 4 · 23:53](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1433)
- "Wrapping Duoderm around an omphalocele and tightening daily can achieve gradual reduction without sutures." (host_summary) [Ep 4 · 24:37](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1477)
- "Botox has been used successfully in adult ventral hernia repair to relax muscle and facilitate closure." (host_summary) [Ep 4 · 24:57](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1497)
- "Silver sulfadiazine is commonly used to paint omphaloceles, though some use Betadine initially or Xerform." (host_summary) [Ep 4 · 26:08](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1568)
- "Aquacel applied to omphalocele sac is not recommended as it does not come off easily." (opinion) [Ep 4 · 26:28](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1588)
- "Pharmacy may restrict silver sulfadiazine use in the first month due to sulfa interaction concerns." (guideline) [Ep 4 · 26:58](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1618)
- "Ventilatory parameters are the most reliable measure of safe abdominal closure tension." (opinion) [Ep 4 · 28:04](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1684)
- "Bladder pressure measurement is standard practice at Cincinnati Children's for 24 hours post-closure, though its reliability is questioned." (clinical) [Ep 4 · 28:51](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1731)
- "Intragastric pressure via NG tube is easy to measure intraoperatively and provides a useful guide, with 20 mmHg as a suggested threshold." (clinical) [Ep 4 · 29:56](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1796)
- "Intragastric pressure of 12 mmHg with a stable baby provides reassurance that closure is safe; pressure of 35-40 mmHg raises concern even if the baby appears stable." (clinical) [Ep 4 · 31:05](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=1865)
- "Omphaloceles with a big opening and much content externalized often reduce spontaneously over 6-12 months with paint-and-wait, making eventual closure straightforward." (clinical) [Ep 4 · 35:45](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=2145)
- "Omphaloceles with a narrow opening require staged enlargement of the defect to allow gradual reduction over 2-3 stages without need for patch or component separation." (clinical) [Ep 4 · 36:01](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=2161)
- "In older children with giant omphalocele, rapid reduction can cause abdominal compartment syndrome and death; time must be allowed for abdominal domain expansion." (clinical) [Ep 4 · 36:40](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=2200)
- "When enlarging the fascial defect in a giant omphalocele with liver externalized, the inferior direction is safer to avoid hepatic veins superiorly." (clinical) [Ep 4 · 37:03](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-639?t=2223)
- "97% of bilateral kidney tumors in children are Wilms tumor, so biopsy is not needed upfront—chemotherapy should be started empirically." — Tony Sandler (epidemiological) [Ep 7 · 9:12](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=552)
- "Current standard for bilateral Wilms tumor is to start chemotherapy, give 2 cycles, and stop when tumor shrinkage plateaus (defined as less than 50% volume reduction)." — Tony Sandler (guideline) [Ep 7 · 1:32](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=92)
- "Bilateral nephron-sparing surgery for Wilms tumor can be performed by placing kidneys on ice, clamping vessels, and performing sharp tumor dissection—surprisingly feasible even for large tumors." — Tony Sandler (clinical) [Ep 7 · 4:44](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=284)
- "When chemotherapy fails to shrink bilateral Wilms tumors and they have not been biopsied, changing to a more aggressive chemotherapy regimen should be considered to rule out anaplastic elements that might respond." — Dan (clinical) [Ep 7 · 3:02](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=182)
- "Biopsy of Wilms tumor is problematic because these are heterogeneous tumors and focal anaplasia may be missed on needle biopsy." — Dan (clinical) [Ep 7 · 3:22](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=202)
- "When Wilms tumors stop shrinking with chemotherapy, it is usually due to mesenchymal differentiation rather than anaplastic transformation." — Tony Sandler (clinical) [Ep 7 · 4:19](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=259)
- "Anaplastic recurrence of Wilms tumor portends a very bad outcome; salvage is difficult even with chemotherapy." — Dan (clinical) [Ep 7 · 6:48](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=408)
- "It is debated whether anaplasia in Wilms tumor is present initially or develops secondary to chemotherapy-induced differentiation; most pathologists believe it is present primarily, making these heterogeneous tumors." — Tony Sandler (opinion) [Ep 7 · 7:56](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=476)
- "Multifocal Wilms tumors raise concern about underlying embryologic kidney abnormalities and increased risk of developing additional tumors." — Dan (clinical) [Ep 7 · 8:15](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=495)
- "For gastroschisis, bedside reduction can be attempted under sedation (rectal acetaminophen and small-dose fentanyl) without intubation, with success in approximately 80% of cases even when all bowel is eviscerated." — Todd Ponsky (clinical) [Ep 7 · 9:58](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=598)
- "Gastroschisis babies are being delivered earlier by high-risk obstetric teams, resulting in less thick matted bowel at birth and higher rates of successful bedside reduction." (clinical) [Ep 7 · 11:11](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=671)
- "For gastroschisis closure using Tegaderm technique, if the fascia is not cut to widen the defect, most umbilical hernias will close spontaneously and do not require repair." — Tony Sandler (clinical) [Ep 7 · 12:54](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=774)
- "Spring-loaded Bianchi silos may enlarge the fascial defect because the compressive forces are directed outward at the ring level." — Todd Ponsky (opinion) [Ep 7 · 14:20](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=860)
- "Tegaderm can be applied directly over reduced gastroschisis without Betadine or other topical agents, left in place for approximately 3 days, then converted to dry dressing once tissues are adherent." — Tony Sandler (clinical) [Ep 7 · 14:52](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=892)
- "Even when a gastroschisis silo fails and the defect dilates significantly, Tegaderm-only closure can achieve successful cicatrization over 8 weeks." — Tony Sandler (clinical) [Ep 7 · 15:32](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=932)
- "For gastroschisis with intestinal atresia and pristine bowel, an ostomy can be created at the umbilical fascial ring, with the downstream limb tacked adjacent, allowing for delayed anastomosis and ostomy closure after 2-4 weeks." (clinical) [Ep 7 · 16:42](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1002)
- "For gastroschisis with atresia and thick inflamed bowel, the bowel should be reduced into the abdomen without repair, allowing inflammation to resolve, then re-explored at 4-6 weeks." (clinical) [Ep 7 · 17:23](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1043)
- "Primary anastomosis of intestinal atresia in gastroschisis is feasible if the bowel is pristine, but the size discrepancy (massively dilated proximal, decompressed distal) creates a tenuous anastomosis in bowel that has been outside the abdomen." (clinical) [Ep 7 · 18:32](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1112)
- "When gastroschisis is reduced without closing the fascia, ambient intra-abdominal pressure is lower than with fascial closure, which may benefit bowel function." — Tony Sandler (clinical) [Ep 7 · 19:26](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1166)
- "In vanishing gastroschisis with markedly inflamed bowel, it is impossible to determine bowel viability or the presence of atresia from external appearance—exploration is necessary but resection should be avoided." — Dan (clinical) [Ep 7 · 21:01](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1261)
- "Re-exploration at 2 weeks after initial gastroschisis reduction (rather than the traditional 4-6 weeks) can reveal that inflamed 'gastroschisis bowel' has transformed into viable intestine suitable for anastomosis." — Tony Sandler (clinical) [Ep 7 · 22:07](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1327)
- "For apple-peel ileal atresia with ischemic distal bowel, if the bowel does not pink up on the operating table and is not twisted, resection with primary anastomosis is appropriate." — Tony Sandler (clinical) [Ep 7 · 24:21](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1461)
- "If apple-peel bowel is ischemic (not necrotic) and not twisted, waiting until the next day to reassess viability is reasonable before committing to resection." — Todd Ponsky (opinion) [Ep 7 · 25:19](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1519)
- "Plication of massively dilated proximal bowel in intestinal atresia is helpful and the plication typically unravels over time, preserving bowel length for later lengthening procedures if needed." — Tony Sandler (clinical) [Ep 7 · 25:37](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1537)
- "STEP procedure in the perinatal period has poor outcomes according to the STEP registry and should be discouraged; outcomes are particularly difficult in gastroschisis patients due to motility disorders." — Greg (host_summary) [Ep 7 · 26:24](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1584)
- "Bianchi procedure is preferred over STEP for neonatal bowel lengthening because it creates two equal chambers without blind-ending outpouchings, and a patient can undergo Bianchi followed by STEP later, whereas STEP limits future lengthening options." — Greg (opinion) [Ep 7 · 26:46](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1606)
- "In newborns with questionable short-gut syndrome, tapering should be avoided to preserve bowel for potential lengthening procedures later; plication is preferred." — Tony Sandler (clinical) [Ep 7 · 28:10](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1690)
- "If a child has extensive bowel length and only a segment is dilated, tapering is reasonable." — Tony Sandler (clinical) [Ep 7 · 28:23](https://qa.library.globalcastmd.com/watch/bilateral-wilm-s-tumor-complex-gastroschisis-complex-ileal-atresia-669?t=1703)
- "In heterotaxy syndrome with right atrial isomerism, there is a higher incidence of malrotation compared to left atrial isomerism." — Todd Ponsky (epidemiological) [Ep 6 · 3:54](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=234)
- "In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd's procedure with no post-operative volvulus but 11% developed small bowel obstruction requiring admission and often surgery." — Kenneth Azarow (host_summary) [Ep 6 · 5:57](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=357)
- "In the same Texas Children's series, 25% of heterotaxy patients were observed without surgery and had no small bowel obstruction or volvulus during 10-15 year follow-up." — Kenneth Azarow (host_summary) [Ep 6 · 6:20](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=380)
- "Appendectomy carries a slight long-term complication rate from adhesions." — Kenneth Azarow (clinical) [Ep 6 · 6:56](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=416)
- "A low-lying ligament of Treitz defines malrotation, not simply the duodenum crossing midline, because a floppy duodenum can cross midline without malrotation." — Kenneth Azarow (clinical) [Ep 6 · 8:59](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=539)
- "Current literature shows overall success rates for meconium ileus enema reduction are declining on first attempts." — Kenneth Azarow (host_summary) [Ep 6 · 14:41](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=881)
- "To achieve success rates above 60-75% for meconium ileus reduction, multiple enemas are required." — Kenneth Azarow (host_summary) [Ep 6 · 14:41](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=881)
- "63% of successful meconium ileus enemas require more than one attempt in radiology." — Kenneth Azarow (host_summary) [Ep 6 · 15:11](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=911)
- "If a thorough enema has been performed with maximal pressure from below, it is not wrong to proceed with laparoscopy or laparotomy, because perforation in meconium ileus complicates things tremendously." — Kenneth Azarow (opinion) [Ep 6 · 15:36](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=936)
- "Many radiologists have switched from gastrografin to isotonic contrast (such as iohexol) for meconium ileus enemas, which defeats the therapeutic purpose of the enema." — Todd Ponsky (clinical) [Ep 6 · 12:12](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=732)
- "Radiologists avoid gastrografin due to concerns about the hypertonicity of the contrast medium." — Todd Ponsky (clinical) [Ep 6 · 12:29](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=749)
- "Using hypertonic gastrografin on second or third enema attempts has been the contrast of choice for meconium ileus." — Kenneth Azarow (host_summary) [Ep 6 · 16:19](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=979)
- "Current trend in solid organ injury management is to manage based on hemodynamics rather than CT grade." — Kenneth Azarow (guideline) [Ep 6 · 19:08](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1148)
- "Managing solid organ injuries based on hemodynamics allows patients to be discharged from the hospital much quicker than traditional protocols." — Kenneth Azarow (clinical) [Ep 6 · 19:17](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1157)
- "Tachycardia in solid organ injury patients may be due to pain, overlying broken ribs, or blood in the abdomen, requiring pain control to properly assess hemodynamic stability." — Kenneth Azarow (clinical) [Ep 6 · 20:34](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1234)
- "Patients with low-grade solid organ injuries and normal vital signs without tachycardia can be discharged in less than 24 hours." — Kenneth Azarow (clinical) [Ep 6 · 20:52](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1252)
- "A patient with grade 5 splenic injury can be discharged within 48 hours if hemodynamically stable and local to the hospital." — Kenneth Azarow (clinical) [Ep 6 · 21:13](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1273)
- "Literature is fairly clear that solid organ injury patients do not need to be reimaged after initial treatment." — Kenneth Azarow (host_summary) [Ep 6 · 22:55](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1375)
- "Activity restrictions after solid organ injury follow the grade plus 2 weeks rule (e.g., grade 3 injury = 5 weeks restriction)." — Todd Ponsky (guideline) [Ep 6 · 23:18](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1398)
- "Once a stable clot forms after solid organ injury (approximately 3 weeks), it is probably more stable than the remaining spleen." — Kenneth Azarow (opinion) [Ep 6 · 23:49](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1429)
- "In adults, 2 centimeters is the cutoff size for mesenteric vessel pseudoaneurysms at which intervention is typically considered." — Todd Ponsky (guideline) [Ep 6 · 26:19](https://qa.library.globalcastmd.com/watch/malrotation-volvulus-meconium-ileus-solid-organ-injury-update-course-2015-673?t=1579)
- "In Latin American countries, mortality from gastroschisis can exceed 15%" (host_summary) [Ep 10 · 0:23](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=23)
- "The study compared outcomes in the first 42 patients treated after protocol implementation to the last 42 patients treated before protocol adoption" (host_summary) [Ep 10 · 0:41](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=41)
- "Prior to the protocol, pre-transfer communication was incredibly limited" (host_summary) [Ep 10 · 0:50](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=50)
- "After protocol implementation, the accepting hospital was in much closer communication" (host_summary) [Ep 10 · 0:55](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=55)
- "Prior to the protocol, every patient got a central line" (host_summary) [Ep 10 · 0:59](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=59)
- "After the protocol, every patient had a PICC attempted" (host_summary) [Ep 10 · 1:03](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=63)
- "Prior to the protocol, all patients were taken to the operating room for primary reduction after extension of the defect, which was limited by OR availability and required general anesthesia" (host_summary) [Ep 10 · 1:06](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=66)
- "After the protocol, bedside reduction was attempted in most patients" (host_summary) [Ep 10 · 1:19](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=79)
- "Prior to the protocol, all patients were mechanically ventilated and paralyzed, and feeding advancement was totally at the discretion of the surgeon" (host_summary) [Ep 10 · 1:22](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=82)
- "After the protocol, only patients with respiratory distress were intubated" (host_summary) [Ep 10 · 1:31](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=91)
- "After the protocol, no patients were paralyzed" (host_summary) [Ep 10 · 1:35](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=95)
- "After the protocol, the authors followed a regimented feeding advancement schedule" (host_summary) [Ep 10 · 1:35](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=95)
- "The authors found a shorter time to arrival after protocol implementation" (host_summary) [Ep 10 · 1:42](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=102)
- "After protocol implementation, there was less general anesthesia use" (host_summary) [Ep 10 · 1:45](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=105)
- "After protocol implementation, fewer central lines were placed" (host_summary) [Ep 10 · 1:45](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=105)
- "After protocol implementation, fewer patients needed to be intubated" (host_summary) [Ep 10 · 1:45](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=105)
- "After protocol implementation, patients who were intubated spent less time on the ventilator" (host_summary) [Ep 10 · 1:45](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=105)
- "The mortality rate went from 22% to 2% after protocol implementation" (host_summary) [Ep 10 · 1:53](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=113)
- "The Hospital Infantil de Mexico team had a 22% mortality with gastroschisis before the protocol, which was higher than most" (host_summary) [Ep 10 · 2:11](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=131)
- "The five protocol changes resulted in a reduction from 22% mortality to 2% mortality" (host_summary) [Ep 10 · 2:17](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=137)
- "Moving from surgical central lines to PICC lines reduced mortality" (host_summary) [Ep 10 · 2:27](https://qa.library.globalcastmd.com/watch/91-decrease-in-mortality-with-gastroschisis-bundle-816?t=147)
- "Breast milk provides significant benefit to time to wean off parenteral nutrition in gastroschisis and NEC patients compared to formula-only feeding." — Michael Helmrath (clinical) [Ep 8 · 59:57](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3597)
- "Breast milk contains non-nutrient oligosaccharides (2-fucosyllactose, 3-fucosyllactose) that are immunomodulatory and affect microflora, not present in current formulas." — Michael Helmrath (clinical) [Ep 8 · 86:39](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5199)
- "STEP procedures done in the first year of life, especially in infants not progressing with enteral feeds, are not beneficial unless specifically avoiding line infections and bacterial overgrowth." — Michael Helmrath (opinion) [Ep 8 · 29:35](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1775)
- "In the STEP registry paper on early neonatal STEP, only 3 patients came off parenteral nutrition, whereas natural data predict 80-90% of such patients would be off TPN at 12 months without surgery." — Michael Helmrath (clinical) [Ep 8 · 31:32](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1892)
- "Dilated bowel does not become motile because you did a STEP procedure on it; if bowel hasn't been able to advance feeds, STEP will not make non-functioning bowel work." — Michael Helmrath (opinion) [Ep 8 · 29:46](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1786)
- "The one thing that makes bowel adapt is feeding the bowel; procedures that cause problems in reinitiating feeds cause damage to the patient." — Michael Helmrath (clinical) [Ep 8 · 30:13](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1813)
- "In a classic French study by Jolie, adults with short bowel syndrome had 60% absorption with ad lib feeding, 85% with continuous drip feeds, and 75% with half calories by mouth plus overnight drip feeds." — Sam Kocoshis (host_summary) [Ep 8 · 17:15](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1035)
- "Donor breast milk is less advantageous than maternal breast milk because it is usually from mothers 10-14 months postpartum, has lower caloric density and protein, and freezing may inactivate trophic factors." — Sam Kocoshis (clinical) [Ep 8 · 62:40](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3760)
- "About 60% of patients weaned off TPN have deficiencies in one micronutrient or another." — Sam Kocoshis (epidemiological) [Ep 8 · 71:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=4311)
- "Metronidazole is the wrong choice for bacterial overgrowth because it has limited spectrum, knocks off anaerobes, and facilitates aerobic overgrowth; 2/3 of bloodstream infections were seen in patients on prophylactic Flagyl." — Sam Kocoshis (clinical) [Ep 8 · 90:10](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5410)
- "Prebiotics (oligosaccharides) induce a more healthful flora; probiotics are not routinely recommended due to case reports of central line infections, though these likely occurred through direct line contamination rather than translocation." — Sam Kocoshis (opinion) [Ep 8 · 83:28](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5008)
- "If using antibiotics for bacterial overgrowth, selective decontamination with non-absorbable aminoglycosides (tobramycin) and colistin may be preferable to metronidazole." — Sam Kocoshis (opinion) [Ep 8 · 92:27](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5547)
- "Citrulline is produced by the gut and may predict ability to wean off TPN when measured as a total number, but as a weekly or monthly lab it does not inform clinical care changes." — Michael Helmrath (clinical) [Ep 8 · 75:49](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=4549)
- "GLP-2 analog can reduce fecal output such that TPN can be reduced by about 20% in 60-70% of adult patients, and totally emancipate about 20% from TPN in extension studies." — Sam Kocoshis (host_summary) [Ep 8 · 114:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6840)
- "When creating a jejunal feeding access, dividing the bowel 2-3 cm distal to ligament of Treitz and bringing the distal bowel up as a chimney with side-to-end anastomosis allows placement of a Mickey button without luminal obstruction." — Michael Helmrath (clinical) [Ep 8 · 3:15](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=195)
- "Placing a 3-4 French feeding tube in distal bowel and bringing it out as a stent (not maturing as mucous fistula) allows easy distal feeding by syringe injection without catheter access issues." — Michael Helmrath (clinical) [Ep 8 · 1:12](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=72)
- "When operating on a 2-month-old with jejunal atresia unable to advance feeds beyond 20 mL/kg, if the anastomosis is patent but dilated bowel is present and the child has 50% estimated bowel length, tapering is preferable to STEP." — Michael Helmrath (opinion) [Ep 8 · 28:07](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1687)
- "Acceptable stoma output is not defined by a hard number; patients with 40-50 cc/kg output can continue feeding if electrolyte profile is acceptable and CO2 is not dropping into the teens." — Michael Helmrath (clinical) [Ep 8 · 111:28](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6688)
- "Knee-jerk reactions to volume of output (unless patient is sick with acidosis and abnormal electrolytes) should be avoided; variable feeding amounts over longer periods are detrimental to weaning from TPN." — Michael Helmrath (opinion) [Ep 8 · 112:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6723)
- "In infants, only pancreatic proteases are present in adult quantities; amylases appear between 6-12 months and lipase reaches adult levels by end of first year." — Sam Kocoshis (clinical) [Ep 8 · 109:38](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6578)
- "Pancreatic enzymes in short gut patients go through before they've released, and there is concern they may cause strictures or stoma problems in areas of stenosis and dysmotility." — Michael Helmrath (opinion) [Ep 8 · 109:07](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6547)
- "Cholestyramine in effective doses will bind nutrients, fat-soluble vitamins, and fats, with risk of hyperchloremic acidosis and bezoars; homeopathic doses may improve stool appearance but not reduce volume." — Sam Kocoshis (clinical) [Ep 8 · 106:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6360)
- "Ursodiol (Actigall) in very short gut can contribute to diarrhea due to osmotic component and has no real benefit in preventing cholestasis." — Simon Horslen or Jeff Rudolph (clinical) [Ep 8 · 107:25](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6445)
- "Anti-inflammatory agents (5-ASA products, steroid-based enemas) can be helpful in managing hypermotility when there is documented inflammation, particularly in challenging Hirschsprung's patients with dysbiosis." — Michael Helmrath (clinical) [Ep 8 · 104:08](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6248)
- "Since developing a mature multidisciplinary intestinal rehabilitation program, internal transplant candidates have declined by 75%, and intestinal transplants are almost non-existent." — Sam Kocoshis (epidemiological) [Ep 8 · 41:08](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=2468)
- "In heterotaxy syndrome with volvulus, operative intervention is mandatory." (clinical) [Ep 11 · 0:16](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=16)
- "In right atrial isomerism, there is a higher incidence of malrotation compared to left atrial isomerism." (epidemiological) [Ep 11 · 2:44](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=164)
- "In the speaker's institutional data, children with right atrial isomerism were the ones that developed volvulus." (epidemiological) [Ep 11 · 3:26](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=206)
- "Only one patient with left atrial isomerism had any real issues, and it was not a true volvulus." (epidemiological) [Ep 11 · 3:43](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=223)
- "Failure to thrive should be considered a GI symptom warranting laparoscopic exploration to divide Ladd bands and perform appendectomy in heterotaxy patients." (opinion) [Ep 11 · 3:50](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=230)
- "In a Texas Children's series of 95 consecutive heterotaxy patients with malrotation, three-quarters underwent Ladd procedure with no post-operative volvulus but 11% small bowel obstruction rate requiring admission and often surgery." (host_summary) [Ep 11 · 4:38](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=278)
- "In the Texas Children's series, 25% of heterotaxy patients were observed with no small bowel obstruction and no volvulus over 10-15 year follow-up." (host_summary) [Ep 11 · 5:10](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=310)
- "Appendectomy is not without its long-term obstruction rate from adhesions." (clinical) [Ep 11 · 5:46](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=346)
- "In situs inversus with malrotation, the appendix is in the correct location (a double negative), so appendectomy may not be indicated." — Todd Ponsky (opinion) [Ep 11 · 5:57](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=357)
- "In heterotaxy, the cecum will be floppy, warranting inversion appendectomy if laparoscopy is performed." (opinion) [Ep 11 · 6:10](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=370)
- "Malrotation is defined by low-lying ligament of Treitz, not by structures crossing the midline, as structures can be floppy and cross midline without excluding malrotation." (clinical) [Ep 11 · 7:46](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=466)
- "The speaker has seen 3-4 cases (in addition to half a dozen during fellowship) where a good C-loop crossed midline but the patient had low-lying ligament of Treitz and was malrotated on exploration." (epidemiological) [Ep 11 · 8:01](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=481)
- "A baby with low-lying ligament of Treitz and reassuring imaging was observed and subsequently returned with volvulus." (clinical) [Ep 11 · 8:36](https://qa.library.globalcastmd.com/watch/malrotation-rapid-fire-session-update-course-2015-879?t=516)
- "Infants who make urine are not likely to need peritoneal dialysis immediately but will likely need it in the future" (clinical) [Ep 12 · 0:25](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=25)
- "When placing both G-tube and PD catheter together, the PD catheter should be left alone for a couple of weeks if possible" (clinical) [Ep 12 · 0:45](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=45)
- "Gastrostomy tube placement should focus on the lesser curvature to preserve the stomach for potential future bladder augmentation" (clinical) [Ep 12 · 0:54](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=54)
- "Hemodialysis catheters need to be fairly large caliber and placement should stay as much as possible to the right internal jugular site because that is a straight shot into the atrium" (clinical) [Ep 12 · 2:11](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=131)
- "Inguinal and umbilical hernias can develop when babies are on peritoneal dialysis" (clinical) [Ep 12 · 2:56](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=176)
- "If hernias are not affecting the mechanics of dialysis and not particularly symptomatic, they tend to be left alone" (clinical) [Ep 12 · 2:56](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=176)
- "The ideal weight for infant renal transplant is around 10 kg if not on PD" (clinical) [Ep 12 · 4:01](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=241)
- "Infants on PD can be transplanted closer to 8 kg because they have a more accommodating abdominal cavity and laxity in the abdominal wall" (clinical) [Ep 12 · 4:01](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=241)
- "All infant recipients have been transplanted with adult donors" (clinical) [Ep 12 · 4:17](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=257)
- "An extraperitoneal approach is used for infant renal transplantation with an incision extending to the upper edge close to the costal margin" (clinical) [Ep 12 · 4:32](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=272)
- "The biggest complication from a general surgical perspective in infant renal transplants are wound complications as opposed to vascular complications" (clinical) [Ep 12 · 4:59](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=299)
- "Some infants can only have skin closed initially and develop leaks or dehiscence requiring biologic mesh (such as derma matrix) for closure" (clinical) [Ep 12 · 5:08](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=308)
- "In a 13-year follow-up of G-tubes in babies, they all migrate up onto the chest" (clinical) [Ep 12 · 7:14](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=434)
- "Placing G-tube too close to PD catheter creates infection risk early on because there is not enough space between sites and drainage can get underneath the PD catheter dressing" (clinical) [Ep 12 · 7:47](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=467)
- "Standard G-tube insertion site is 2 finger breadths below the costal margin" (clinical) [Ep 12 · 8:24](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=504)
- "In small babies, G-tube should be placed 3 or 4 finger breadths below costal margin because it will rise up with growth" (clinical) [Ep 12 · 8:32](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=512)
- "G-tube location should be high up on the stomach towards lesser curvature to allow ability to use gastric segment for gastric augmentation later in life" (clinical) [Ep 12 · 8:46](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=526)
- "Some babies with posterior urethral valves will need urinary diversion with vesicostomy about 1-2 finger breadths below the umbilicus, requiring G-tube placement away from this site to mitigate infection risk" (clinical) [Ep 12 · 9:06](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=546)
- "PD catheters can be placed to allow immediate use with lower volumes rather than waiting 3-7 days" (clinical) [Ep 12 · 11:20](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=680)
- "Many babies with bladder outlet obstruction have small stomachs, possibly related to minimum amniotic fluid during development" (host_summary) [Ep 12 · 11:43](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=703)
- "Amnioinfusions are performed when patients present for first imaging to assess the baby's capacity to swallow and see if the stomach fills" (clinical) [Ep 12 · 12:23](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=743)
- "In fetal imaging, bladder and bladder wall thickness and isthmus are always measured" (clinical) [Ep 12 · 12:49](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=769)
- "Early onset large bladders that extend up and push the diaphragm and stomach back may cause anatomic distortion that results in stomachs ending up higher long term" (opinion) [Ep 12 · 13:16](https://qa.library.globalcastmd.com/watch/renal-transplantation-fetal-genitourinary-disease-2015-915?t=796)
- "The three major causes of LUTO are urethral atresia (complete obstruction with no communication from bladder neck through urethra), posterior urethral valves (flap of tissue in proximal urethra), and mid-urethral hypoplasia (significant tapering and narrowing)." — Mark (clinical) [Ep 13 · 0:32](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=32)
- "Incomplete urethral obstruction leads to progressive oligohydramnios until anhydramnios develops." — Mark (clinical) [Ep 13 · 1:30](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=90)
- "Oligohydramnios causes physical deformations including joint contractures, ear flattening, and Potter's phenotype, and leads to pulmonary hypoplasia by interfering with chest expansion." — Mark (clinical) [Ep 13 · 1:41](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=101)
- "Obstruction generates pressure to the kidneys causing severe hydronephrosis, collecting system dilation, and progressive renal fibrocystic dysplasia resulting in renal failure after birth." — Mark (clinical) [Ep 13 · 1:58](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=118)
- "The San Francisco group's sheep model demonstrated that early ureteral ligation produced fibrocystic dysplasia identical to human LUTO, with earlier and longer obstruction causing greater kidney damage." — Mark (clinical) [Ep 13 · 2:58](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=178)
- "Early mid-gestational reversal of obstruction in the sheep model prevented progressive dysplastic changes and preserved kidney function." — Mark (clinical) [Ep 13 · 3:33](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=213)
- "Many babies with LUTO have associated anomalies including myelomeningocele, higher frequency of cardiac disease, and genetic syndromes that would preclude benefit from shunting." — Mark (clinical) [Ep 13 · 4:53](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=293)
- "A significant portion of LUTO fetuses have chromosomal abnormalities including major trisomies and Klinefelter syndrome." — Mark (epidemiological) [Ep 13 · 5:36](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=336)
- "Female fetuses with large bladder-like structures are usually cloacal abnormalities and do not benefit from shunting due to different pathophysiology." — Mark (clinical) [Ep 13 · 5:53](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=353)
- "Renal function evaluation requires complete bladder drainage on several occasions to measure sodium, chloride, calcium, osmolarity, total proteins, and beta-2 microglobulin as markers of tubular and glomerular injury." — Mark (clinical) [Ep 13 · 6:17](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=377)
- "Increased kidney echogenicity represents compression of renal parenchyma rather than being a poor prognostic sign per se; following bladder drainage, kidneys re-expand and show more normal echogenicity." — Mark (clinical) [Ep 13 · 8:10](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=490)
- "Hydronephrosis pathophysiology involves the collecting system (like a water balloon) compressing the renal parenchyma (like a sponge) against the serosa (like a glass fishbowl), impairing delicate vasculature and causing cell death, fibrosis, and cystic dysplasia." — Mark (clinical) [Ep 13 · 8:49](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=529)
- "The presence of cortical cysts indicates irreversible kidney damage and the kidney is not amenable to in utero therapy." — Mark (clinical) [Ep 13 · 10:18](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=618)
- "Good prognostic urine values for potential survival with shunting are: sodium <100 mEq/L, chloride <90 mEq/L, osmolarity <210 mOsm, calcium <8 mg/dL, beta-2 microglobulin <6 mg/L, and total protein <40 mg/dL." — Mark (clinical) [Ep 13 · 18:00](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1080)
- "Fetuses with values above the prognostic thresholds showed significant fibrotic kidney injury on autopsy, while those below showed very little or early potentially salvageable changes." — Mark (clinical) [Ep 13 · 18:28](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1108)
- "The first urine specimen from bladder tap is not predictive or reliable due to degradation products and osmotic gradients; the third or fourth tap after serial drainages has much higher predictive value for detecting kidney injury." — Mark (clinical) [Ep 13 · 19:05](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1145)
- "Improving urine values across serial taps (e.g., sodium dropping from poor to good range) indicates an excellent shunting candidate, while worsening values indicate ongoing irreversible damage." — Mark (clinical) [Ep 13 · 20:18](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1218)
- "Bladder morphology after drainage correlates with etiology: urethral atresia shows symmetric thick-walled bladder with difficult keyhole; posterior urethral valves show elongated bladder with more proximal thickening; mid-urethral hypoplasia shows 'snowman appearance' with smooth muscle deficiency in upper bladder." — Mark (clinical) [Ep 13 · 21:19](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1279)
- "All electrolyte cutoff thresholds are based on urines analyzed between 18 to 22 weeks gestation and cannot be reliably used before 18 weeks or after 22 weeks without adjustment." — Mark (clinical) [Ep 13 · 26:18](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1578)
- "The primary goal of fetal intervention is to prevent pulmonary hypoplasia secondary to oligohydramnios; preservation of renal and bladder function are secondary goals." (clinical) [Ep 13 · 28:41](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=1721)
- "The PLUTO trial randomized only 31 patients over 4 years (20% of planned 150), showing apparent 3-fold increase in survival with shunting but results were not statistically significant with confidence intervals crossing unity." (clinical) [Ep 13 · 33:41](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2021)
- "All 12 deaths in the PLUTO trial were from pulmonary hypoplasia, suggesting improved survival may relate to decreased lung hypoplasia." (clinical) [Ep 13 · 34:36](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2076)
- "Only 7 of 12 live-born shunted babies in PLUTO were alive at age 2, and only 2 of the shunted survivors had normal renal function." (clinical) [Ep 13 · 34:47](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2087)
- "All 3 conservatively managed survivors in PLUTO had significant renal impairment." (clinical) [Ep 13 · 34:56](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2096)
- "Across 6 long-term outcome studies of shunted LUTO cases, survival rates are consistent at approximately 47-70%, but only 40-50% of survivors have normal renal function and approximately one-third require dialysis or transplant." (epidemiological) [Ep 13 · 36:18](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2178)
- "Some LUTO cases can resolve spontaneously, as demonstrated by a case where a baby began voiding and refilling amniotic fluid by 19 weeks with recollection by 23 weeks without intervention." (clinical) [Ep 13 · 37:28](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2248)
- "Spontaneous bladder decompression can occur through bladder rupture (usually after drainage, rarely spontaneous) resulting in urinary ascites or perinephric urinoma." (clinical) [Ep 13 · 37:55](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2275)
- "Megacystis-microcolon-intestinal hypoperistalsis syndrome and cloacal dysgenesis are contraindications to shunting intervention." (clinical) [Ep 13 · 38:26](https://qa.library.globalcastmd.com/watch/prenatal-diagnosis-of-fetal-lower-urinary-tract-obstruction-fetal-919?t=2306)
- "Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding." — Brad Warner (clinical) [Ep 15 · 1:42](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=102)
- "The intestine of a newborn or fetus doubles in length in the last trimester of gestation." — Brad Warner (clinical) [Ep 15 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=183)
- "For a neonate with an ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for potential salvageability." — Brad Warner (clinical) [Ep 15 · 4:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=243)
- "Without the colon and ileocecal valve, at least 15 to 20 centimeters of small intestine would be needed for potential salvageability in neonates." — Brad Warner (clinical) [Ep 15 · 4:37](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=277)
- "In adult studies, adults with less than 50 centimeters of intestine have about 40% mortality after 5 to 10 years." — Brad Warner (epidemiological) [Ep 15 · 4:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=291)
- "According to Pediatric Intestinal Failure Research Consortium data, approximately 25% of children with short gut syndrome die, 25% need a transplant, and 50% can wean off TPN." — Brad Warner (epidemiological) [Ep 15 · 6:38](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=398)
- "The most common causes of death in intestinal failure include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access." — Brad Warner (clinical) [Ep 15 · 7:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=431)
- "Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection." — Brad Warner (clinical) [Ep 15 · 7:49](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=469)
- "Stool outputs of up to 40 cc per kilo per day are acceptable when advancing enteral feeding; beyond that threshold, enteral feeding should be reduced." — Brad Warner (clinical) [Ep 15 · 8:30](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=510)
- "The most common causes of short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias, with trauma and inflammatory bowel disease further down the list." — Brad Warner (epidemiological) [Ep 15 · 9:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=562)
- "For TPN, the goal is about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and the remainder from fat and protein." — Brad Warner (clinical) [Ep 15 · 10:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=622)
- "TPN should provide about 2 to 3 grams of protein per kilo per day and about 2 to 3 grams of fat per kilo per day." — Brad Warner (clinical) [Ep 15 · 10:45](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=645)
- "Babies should gain about 20 to 30 grams a day, which approximates in utero weight gain for a newborn." — Brad Warner (clinical) [Ep 15 · 12:05](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=725)
- "Lipid reduction strategy involves reducing fat from 2-3 g/kg/day given daily down to about 1 g/kg/day delivered twice or three times a week, which has been effective in reducing TPN-associated cholestasis." — Brad Warner (clinical) [Ep 15 · 12:53](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=773)
- "Omegaven is a fish oil-based fat containing primarily omega-3 fatty acids that are anti-inflammatory, in contrast to soybean-based intralipid which contains pro-inflammatory omega-6 fatty acids." — Brad Warner (clinical) [Ep 15 · 13:46](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=826)
- "SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has recently been FDA approved in the United States." — Brad Warner (clinical) [Ep 15 · 15:08](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=908)
- "Breast milk is the best choice for neonates because it contains proper fat composition plus growth factors such as epidermal growth factor and insulin-like growth factors that promote adaptation." — Brad Warner (opinion) [Ep 15 · 18:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1091)
- "Complex formulas fed enterally may stimulate adaptation better than elemental formulas because they cause secretion of enterotrophic hormones to a greater extent." — Brad Warner (opinion) [Ep 15 · 19:26](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1166)
- "There is a threshold percentage of enteral calories that prevents the onset of TPN-related liver damage, though the exact number is unknown; 90% enteral feeding carries far less risk than 10% enteral feeding." — Brad Warner (clinical) [Ep 15 · 20:56](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1256)
- "Surgical intervention should be considered when patients regress in enteral tolerance (e.g., tolerating 50% enteral a month ago but now down to 20%), when there are multiple episodes of sepsis with abdominal distention and dilated bowel loops, or when the child develops jaundice." — Brad Warner (clinical) [Ep 15 · 22:33](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1353)
- "Dilated bowel loops greater than 4 to 5 centimeters in diameter, combined with failure to advance enteral feeds or regression, is an indication for surgical intervention." — Brad Warner (clinical) [Ep 15 · 25:43](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1543)
- "Less than 5 to 10% of patients with over 100 centimeters of intestine should require TPN, suggesting an underlying motility or mucosal problem if they remain TPN-dependent." — Brad Warner (clinical) [Ep 15 · 27:53](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1673)
- "The STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation because it is easier to perform with less risk of injuring the mesenteric blood supply." — Brad Warner (clinical) [Ep 15 · 29:31](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1771)
- "The Bianchi procedure takes advantage of the bifurcating blood supply to the bowel wall, allowing longitudinal division to create two tubes of bowel, effectively doubling the length." — Brad Warner (clinical) [Ep 15 · 30:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1800)
- "STEP procedures can redilate and require redo operations, and outcomes are not as good when a STEP needs to be redone compared to never needing a redo." — Brad Warner (clinical) [Ep 15 · 32:54](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1974)
- "A Bianchi can be performed first, then a STEP can be done later if needed, but a Bianchi cannot be done after a STEP has been performed (unless the STEP was inadequate)." — Brad Warner (clinical) [Ep 15 · 33:26](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2006)
- "Tapering should be considered for children with dilated bowel who have at least 90 to 100 centimeters of intestinal length." — Brad Warner (clinical) [Ep 15 · 38:21](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2301)
- "Teduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1 to 2 liters per week." — Brad Warner (clinical) [Ep 15 · 43:45](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2625)
- "Growth hormone and glutamine combinations have been administered to patients, but results are primarily mixed and it hasn't been a huge advance in weaning TPN." — Brad Warner (clinical) [Ep 15 · 45:40](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2740)
- "Current survival for small bowel transplant is about 50 to 60% at 5 years, with one-year survivals now above 70 to 80%." — Brad Warner (epidemiological) [Ep 15 · 46:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2811)
- "The intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression that increases risk for malignancies and infections." — Brad Warner (clinical) [Ep 15 · 47:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2831)
- "Ethanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters." — Brad Warner (clinical) [Ep 15 · 49:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2962)
- "Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival in intestinal failure patients, as demonstrated in series from Boston, Michigan, and Texas." — Brad Warner (clinical) [Ep 15 · 51:16](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=3076)
- "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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 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 14 · 43:17](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2597)
- "The infant presented with delayed passage of meconium of more than 48 hours, but passed meconium after examination." — Jafar (clinical) [Ep 22 · 0:18](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=18)
- "At day 7 of age, the infant presented with signs and symptoms of Hirschsprung disease including abdominal distension, tight rectum with passage of explosive stool after removing the examining finger." — Jafar (clinical) [Ep 22 · 0:30](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=30)
- "Full thickness rectal biopsy confirmed the absence of ganglion cells." — Jafar (clinical) [Ep 22 · 0:44](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=44)
- "On laparotomy for colostomy creation, malrotation with multiple bands was found: one band between loops of bowel, one between bowel and liver, and one between bowel and abdominal wall." — Jafar (clinical) [Ep 22 · 0:52](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=52)
- "Biopsy from the appendix and terminal ileum proved total colonic aganglionosis." — Jafar (clinical) [Ep 22 · 1:32](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=92)
- "Postoperatively, the infant received IV fluids, antibiotics, and total parenteral nutrition, then was started on high-calorie formula (Ensure) with vitamin B12 supplementation after bowel function returned." — Jafar (clinical) [Ep 22 · 1:39](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=99)
- "The infant developed multiple attacks of dehydration requiring hospital admission for IV fluid replacement." — Jafar (clinical) [Ep 22 · 2:04](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=124)
- "Only a few cases have been reported of total colonic Hirschsprung associated with malrotation: Philone reported 4 patients, one author reported 1 patient, and Zbra reported 3 patients, but no cases reported all three anomalies (total colonic Hirschsprung, malrotation, and congenital bands)." — Jafar (epidemiological) [Ep 22 · 3:16](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=196)
- "Congenital bands in this context are rare; the etiology is unknown but could be attributed to antenatal perforation of the bowel." — Jafar (clinical) [Ep 22 · 3:46](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=226)
- "The usual scenario for malrotation with Hirschsprung is a child with bilious vomiting who gets a contrast study showing malrotation, undergoes Ladd procedure, but then doesn't open up, prompting reconsideration of other causes." (clinical) [Ep 22 · 5:20](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=320)
- "Once a Ladd procedure is done, if the baby doesn't open up, you must think about other potential causes for bilious vomiting." (clinical) [Ep 22 · 5:42](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=342)
- "Hirschsprung associated with malrotation is usually short segment, not total colonic, but follows the same distribution as Hirschsprung in general." (epidemiological) [Ep 22 · 5:54](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=354)
- "For total colonic Hirschsprung, the preferred operation is Duhamel because it is simple, safe, and provides a reservoir at the bottom, which Soave does not." (opinion) [Ep 22 · 6:19](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=379)
- "Timing of definitive repair should be based on consistency of ileostomy output, not age or weight; patients don't do well if operated too early when output is still liquidy." (opinion) [Ep 22 · 6:41](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=401)
- "It is preferable to wait until ileostomy output firms up, which usually happens when the infant gets onto solid food." (opinion) [Ep 22 · 6:55](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=415)
- "For long segment or total colonic Hirschsprung, a relatively short piece of colon should be left, creating a small reservoir rather than the longer Martin modification element." (opinion) [Ep 22 · 7:07](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=427)
- "Good control in long segment Hirschsprung disease is really about 50% of patients; the data really isn't that great." (epidemiological) [Ep 22 · 7:32](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=452)
- "When long segment Hirschsprung involves more than 50 cm from the ileocecal valve, it is a much more progressive disease with a bigger dysmotility element." (clinical) [Ep 22 · 7:51](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=471)
- "There is no evidence in the literature that any particular procedure should be done just because the patient has long segment Hirschsprung; the best approach is to use whatever procedure the surgeon has had the best results with." — Sharif (opinion) [Ep 22 · 8:31](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=511)
- "Poor weight gain in an infant with ileostomy receiving adequate calories and normal blood tests often has to do with sodium loss." — Sharif (clinical) [Ep 22 · 9:18](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=558)
- "Unless sodium levels in the effluent are checked, sodium loss will not be caught because serum sodium will be normal for many months before it starts to decrease." — Sharif (clinical) [Ep 22 · 9:49](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=589)
- "If ileostomy output contains more than 5 to 7 mEq per liter of sodium, the baby will not grow or gain weight." — Sharif (clinical) [Ep 22 · 9:57](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=597)
- "The baby must be gaining weight and growing before proceeding with definitive repair." — Sharif (opinion) [Ep 22 · 10:04](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=604)
- "Measuring urinary sodium is the best way to guide how much sodium replacement to give." (opinion) [Ep 22 · 10:10](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=610)
- "Every baby with an ileostomy should probably get sodium supplementation." (opinion) [Ep 22 · 10:10](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=610)
- "Iron deficiency is a big long-term issue with any repairs in these patients and is often forgotten." (clinical) [Ep 22 · 10:26](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=626)
- "For total colonic Hirschsprung, if doing Soave or other procedure, you must wait until the baby grows and the ileostomy is thicker, then can continue with bulking agents or antidiarrheal agents." (opinion) [Ep 22 · 10:46](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=646)
- "Some patients who had Duhamel done abroad came back with problems including enterocolitis, obstruction, and distension of the Duhamel pouch." (clinical) [Ep 22 · 11:20](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=680)
- "The baby should be monitored for ileostomy output before deciding on any procedure; some patients with ileoanal anastomosis developed severe perianal erosion requiring protective ileostomy before further procedures." (clinical) [Ep 22 · 11:42](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=702)
- "Soave for regular Hirschsprung disease patients (not total colonic) does not result in incontinence if the procedure is followed well and sphincters are not damaged." (opinion) [Ep 22 · 12:40](https://qa.library.globalcastmd.com/watch/total-colonic-hirschsprung-disease-with-malrotation-difficult-cases-1052?t=760)
- "Hawkins et al. conducted a large multi-center study comparing silo versus immediate closure in gastroschisis." (host_summary) [Ep 26 · 0:06](https://qa.library.globalcastmd.com/watch/immediate-vs-silo-closure-for-gastroschisis-2022?t=6)
- "The Hawkins et al. study was published in the August issue of GPS (Journal of Pediatric Surgery)." (host_summary) [Ep 26 · 0:13](https://qa.library.globalcastmd.com/watch/immediate-vs-silo-closure-for-gastroschisis-2022?t=13)
- "The study showed no difference between silo and immediate closure for gastroschisis." (host_summary) [Ep 26 · 0:13](https://qa.library.globalcastmd.com/watch/immediate-vs-silo-closure-for-gastroschisis-2022?t=13)
- "The study examined mortality, sepsis, readmission rate, and time to full feeds as outcome measures." (host_summary) [Ep 26 · 0:18](https://qa.library.globalcastmd.com/watch/immediate-vs-silo-closure-for-gastroschisis-2022?t=18)
- "No difference was found in mortality between silo and immediate closure for gastroschisis." (host_summary) [Ep 26 · 0:18](https://qa.library.globalcastmd.com/watch/immediate-vs-silo-closure-for-gastroschisis-2022?t=18)
- "No difference was found in sepsis rates between silo and immediate closure for gastroschisis." (host_summary) [Ep 26 · 0:18](https://qa.library.globalcastmd.com/watch/immediate-vs-silo-closure-for-gastroschisis-2022?t=18)
- "No difference was found in readmission rates between silo and immediate closure for gastroschisis." (host_summary) [Ep 26 · 0:18](https://qa.library.globalcastmd.com/watch/immediate-vs-silo-closure-for-gastroschisis-2022?t=18)
- "No difference was found in time to full feeds between silo and immediate closure for gastroschisis." (host_summary) [Ep 26 · 0:18](https://qa.library.globalcastmd.com/watch/immediate-vs-silo-closure-for-gastroschisis-2022?t=18)
- "There are no clear predictive factors to identify which premature infants with early NEC will progress to require surgical intervention." (host_summary) [Ep 25 · 1:09](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=69)
- "Probiotics are the only preventative strategy with Cochrane database support for reducing NEC incidence." (host_summary) [Ep 25 · 2:59](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=179)
- "Rate of feeding and timing of feeding initiation do not impact NEC incidence." (host_summary) [Ep 25 · 3:14](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=194)
- "Most U.S. institutions do not routinely use probiotics despite evidence, due to uncertainty about formulation and dosing." (epidemiological) [Ep 25 · 3:31](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=211)
- "Free air (pneumoperitoneum) is the only single factor that would universally prompt surgical intervention in NEC." — Todd (host_summary) [Ep 25 · 12:16](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=736)
- "Focal abdominal wall erythema is one of the most sensitive indicators for underlying dead bowel." (clinical) [Ep 25 · 11:40](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=700)
- "A fixed loop on serial X-rays usually indicates dead bowel at exploration, but does not always dictate immediate operative timing." — Todd (clinical) [Ep 25 · 11:16](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=676)
- "In the Moss trial comparing drainage to laparotomy in ELBW infants, approximately 30% of drained patients never required subsequent laparotomy." — Todd (host_summary) [Ep 25 · 15:37](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=937)
- "Transporting a 600-g infant to the OR increases risk of demise due to ventilatory instability, fluid shifts, and PDA complications." — Tim (clinical) [Ep 25 · 14:20](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=860)
- "Peritoneal drainage was originally conceptualized as a temporizing measure to stabilize the baby before definitive laparotomy, but has evolved into definitive therapy in some centers." (clinical) [Ep 25 · 15:03](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=903)
- "Primary anastomosis in NEC is rarely performed; Miguel Gil presented impressive results at a prior conference, but most surgeons avoid it due to inability to assess for leak in a sick infant." — Todd (host_summary) [Ep 25 · 21:19](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1279)
- "The 'shish-kebab' technique (Pittsburgh paper) involves threading a tube through multiple necrotic segments with simple sutures, bringing both ends out as stomas, and diverting proximally." (clinical) [Ep 25 · 22:44](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1364)
- "Stoma takedown timing: minimum 4 weeks if infant is failing to thrive on TPN; 6–8 weeks and 2 kg are traditional thresholds, but recent data (Andrew Badillo) support earlier reversal." — Todd (host_summary) [Ep 25 · 25:48](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1548)
- "Bringing stomas out side-by-side in the same incision (rather than separated) allows easier re-exploration without disturbing the entire abdominal cavity." (clinical) [Ep 25 · 26:23](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1583)
- "Waiting 6 weeks for stoma takedown allows inflammatory response to subside and adhesions to become more flimsy." (clinical) [Ep 25 · 28:17](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1697)
- "In pan-intestinal necrosis, decompressing distended bowel may reduce ischemia and salvage additional segments." (clinical) [Ep 25 · 31:05](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1865)
- "As of one year ago, no child with NEC totalis has successfully survived small bowel transplant; transplant survivors with NEC typically have short-gut syndrome, not complete necrosis." (epidemiological) [Ep 25 · 33:20](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=2000)
- "The minimum viable bowel length threshold has dropped to approximately 20 cm of small bowel, particularly if the colon is intact." (clinical) [Ep 25 · 33:40](https://qa.library.globalcastmd.com/watch/nec-update-course-2013-1060?t=2020)
- "Gastroschisis has a reported incidence of 1 in 6,000 to 1 in 10,000, but is much more common in many parts of the U.S., including Southern California." (host_summary) [Ep 27 · 0:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=0)
- "At this pediatric surgery practice serving two neonatal intensive care units, 30 to 40 patients per year are treated for gastroschisis, making it second only to inguinal hernias as a congenital anomaly requiring surgical correction." (epidemiological) [Ep 27 · 1:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=60)
- "Traditional staged closure with sutured silastic silo carries risks of silo disruption, fascial dehiscence, and infectious complications." (host_summary) [Ep 27 · 2:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=120)
- "The spring-loaded silo allows for fast, pain-free, suture-less silo placement without need for a formal operation." (host_summary) [Ep 27 · 3:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=180)
- "Dr. James Fisher and colleagues from Loma Linda University were the first to publish a series of patients undergoing routine bedside silo placement." (host_summary) [Ep 27 · 4:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=240)
- "Several retrospective studies from large U.S. centers reported that routine silo placement with delayed closure showed one or more advantages: decreased airway pressures, earlier extubation, decreased incidence of necrotizing enterocolitis, decreased infectious complications, more rapid return of bowel function, decreased length of stay, and decreased hospital charges." (host_summary) [Ep 27 · 5:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=300)
- "For the last five years on the UCI pediatric surgery service, spring-loaded silos have been routinely placed for patients with gastroschisis with excellent results." (clinical) [Ep 27 · 6:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=360)
- "At these centers, most women carrying a fetus with gastroschisis are seen by the pediatric surgeon prior to delivery, with close collaboration with perinatologists." (clinical) [Ep 27 · 7:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=420)
- "Most babies are delivered vaginally after spontaneous onset of labor; routine cesarean section is not performed, nor is early labor induced." (clinical) [Ep 27 · 7:30](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=450)
- "The baby is sedated with fentanyl and midazolam drips, intubated, and given a single dose of Vecuronium for the silo placement procedure." (clinical) [Ep 27 · 8:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=480)
- "While silo placement is feasible without sedation, intubation, or paralysis, these interventions create optimal conditions and a well-controlled situation." (opinion) [Ep 27 · 8:30](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=510)
- "The Bentec silo is available in seven sizes, from 3 cm to 15 cm diameter, with the ring diameter determining the volume of the silastic cylinder." (host_summary) [Ep 27 · 9:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=540)
- "A ring that is 2 cm larger than the diameter of the defect is typically chosen." (clinical) [Ep 27 · 9:30](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=570)
- "Since most defects are 2 to 3 cm in diameter, 4 and 5 cm silos are the most commonly used." (clinical) [Ep 27 · 10:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=600)
- "A larger silo may be chosen if the bowel is more distended or edematous, or there is significant peel." (clinical) [Ep 27 · 10:30](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=630)
- "Gastroschisis cases involving an atresia typically contain severely distended bowel and often require a 7.5 cm silo." (clinical) [Ep 27 · 11:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=660)
- "A severely distended distal colon with meconium is a good indication of the probable absence of a proximal atresia or stenosis." (clinical) [Ep 27 · 13:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=780)
- "Evacuation of the colon is important as it will significantly decrease the size of the colon and allow for faster reduction." (clinical) [Ep 27 · 13:30](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=810)
- "If an obstruction exists without perforation, the institutional policy is to proceed with silo placement and closure, followed by exploration four to six weeks later." (clinical) [Ep 27 · 15:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=900)
- "The ring should be maintained just palpable under the fascia but not elevating the abdominal wall, which would lead to abdominal wall congestion and complicate final closure." (clinical) [Ep 27 · 18:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1080)
- "If the ring is too lax and allowed to sink in the abdomen, it may cause necrosis of the underlying duodenum or small bowel, especially if the silo is left in position for a prolonged period." (clinical) [Ep 27 · 18:30](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1110)
- "Over the ensuing days, resolution of bowel edema, accommodation by the abdominal cavity, and gravity result in gradual spontaneous reduction, aided by once or twice daily active reduction." (clinical) [Ep 27 · 19:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1140)
- "Final closure is performed when the silo contents are within 2 cm of the abdominal wall." (clinical) [Ep 27 · 19:30](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1170)
- "The silo is left in place for the shortest time possible; unnecessary prolongation has no advantages, may slowly enlarge the defect making closure more involved, and may increase infectious and other potential complications." (clinical) [Ep 27 · 20:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1200)
- "The abdominal wall is stretched to aid in a tension-free closure, which often produces some minor post-operative congestion of the abdominal wall." (clinical) [Ep 27 · 21:30](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1290)
- "It is important to stay in the correct plane during fascial mobilization in order not to compromise the fascia or skin." (clinical) [Ep 27 · 22:30](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1350)
- "Skin closure suture is taken from inside out approximately three millimeters from the skin edge; the edge is often slightly ischemic and bites exactly in the skin edge are likely to cause skin necrosis and possible wound infection." (clinical) [Ep 27 · 24:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1440)
- "Essential factors for optimal outcome include appropriate choice of silo size, avoiding mesenteric torsion, final closure when near-complete reduction is achieved and not prolonging silo duration, close observation of silo configuration and contents, purse-string closure of fascia and skin, and preservation of the umbilical stump." (clinical) [Ep 27 · 25:00](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1500)
- "The Bentec silo can be used for staged reduction of omphalocele after excision of the sac, with gradual reduction of liver along with bowel." (clinical) [Ep 27 · 26:20](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1580)
- "When a large silo is required for a prolonged period, a few corner stitches between the silo ring and the abdominal wall prevent premature dislodgement of the silo." (clinical) [Ep 27 · 26:40](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2235?t=1600)
- "Gastroschisis has a reported incidence of 1 in 6000 to 1 in 10,000, but is much more common in many parts of the US including Southern California." (host_summary) [Ep 28 · 0:39](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=39)
- "At UCI pediatric surgery practice serving 2 neonatal intensive care units, 30 to 40 patients per year with gastroschisis are treated, making it second only to inguinal hernias as a congenital anomaly requiring surgical correction." (epidemiological) [Ep 28 · 0:49](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=49)
- "Traditional staged closure with sutured elastic silo involves risks of silo disruption, fascial dehiscence, and infectious complications." (host_summary) [Ep 28 · 1:11](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=71)
- "The spring-loaded silo allows for fast, pain-free, sutureless silo placement without need for a formal operation." (host_summary) [Ep 28 · 1:27](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=87)
- "Doctor James Fisher and colleagues from Loma Linda University were the first to publish a series of patients to undergo routine silo placement at the bedside." (host_summary) [Ep 28 · 2:08](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=128)
- "Several retrospective studies from large US centers reported that patients who underwent routine silo placement with delayed closure showed one or more advantages: decreased airway pressures, earlier extubation, decreased incidence of necrotizing enterocolitis, decreased infectious complications, more rapid return of bowel function, decreased length of stay, and decreased hospital charges." (host_summary) [Ep 28 · 2:43](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=163)
- "For the last 5 years on the UCI pediatric surgery service, spring-loaded silos have been routinely placed for patients with gastroschisis with excellent results." (clinical) [Ep 28 · 3:26](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=206)
- "Most babies with gastroschisis are delivered vaginally after spontaneous onset of labor; routine cesarean section is not performed, nor is early labor induced." (clinical) [Ep 28 · 4:30](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=270)
- "For silo placement, the baby is sedated with fentanyl and midazolam drips, intubated, and given a single dose of vecuronium; while placement is feasible without these interventions, they create optimal conditions and a well-controlled situation." (clinical) [Ep 28 · 4:52](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=292)
- "The Bentek silo is available in 7 sizes from 3 centimeters to 15 centimeters, defined by the diameter of the reinforced ring." (host_summary) [Ep 28 · 5:20](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=320)
- "A ring that is 2 centimeters larger than the diameter of the defect is typically chosen; since most defects are 2 to 3 centimeters in diameter, 4 and 5 centimeter silos are most commonly used." (clinical) [Ep 28 · 5:37](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=337)
- "Gastroschisis cases involving an atresia typically contain severely distended bowel and often require a 7.5 centimeter silo." (clinical) [Ep 28 · 5:59](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=359)
- "A distal colon severely distended with meconium is typical and is a good indication of the probable absence of a proximal atresia or stenosis." (host_summary) [Ep 28 · 6:56](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=416)
- "Evacuation of the colon is important as it will significantly decrease the size of the colon and allow for faster reduction." (clinical) [Ep 28 · 7:07](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=427)
- "If an obstruction exists without perforation, the policy is to proceed with silo placement and closure, followed by exploration 4 to 6 weeks later." (clinical) [Ep 28 · 8:09](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=489)
- "If the ring has too much traction it will cause abdominal wall congestion and edema, complicating closure later on." (host_summary) [Ep 28 · 13:02](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=782)
- "Too little traction will allow the ring to exert constant pressure on the abdominal contents, most notably the duodenum, with a risk of pressure necrosis." (host_summary) [Ep 28 · 13:09](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=789)
- "Final closure is performed when the silo contents is within 2 centimeters of the abdominal wall." (clinical) [Ep 28 · 13:20](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=800)
- "The silo is left in place for the shortest time possible; unnecessary prolongation has no advantages, may make closure more involved by slowly enlarging the defect, and may increase infectious and other potential complications." (clinical) [Ep 28 · 13:26](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=806)
- "The silo creates a closed system by completely containing the bowel and peritoneal fluid." (host_summary) [Ep 28 · 13:52](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=832)
- "Stretching the abdominal wall aids in a tension-free closure and often produces some minor postoperative congestion of the abdominal wall." (clinical) [Ep 28 · 14:47](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=887)
- "A 1 centimeter fascial edge is mobilized in both directions to the border of the umbilical stump." (host_summary) [Ep 28 · 17:06](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=1026)
- "For skin closure, bites are taken approximately 3 millimeters from the skin edge because the edge is often slightly ischemic and bites exactly in the skin edge are likely to cause skin necrosis and possible wound infection." (clinical) [Ep 28 · 21:07](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=1267)
- "The baby remained stable without any increase in airway pressures during the closure procedure, which was completed in under 25 minutes." (host_summary) [Ep 28 · 23:38](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=1418)
- "Essential factors for optimal outcome include: appropriate choice of silo size, avoiding mesenteric torsion, final closure when near complete reduction is achieved and not prolonging silo duration, close observation of silo configuration and contents, purse string closure of fascia and skin, and preservation of the umbilical stump." (host_summary) [Ep 28 · 24:25](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=1465)
- "The Bentek silo can be used for staged reduction of omphalocele after excision of the sac, with the liver gradually reduced along with the bowel." (clinical) [Ep 28 · 25:31](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=1531)
- "When a large silo is required for a prolonged period, a few corner stitches between the silo ring and the abdominal wall prevent premature dislodgement of the silo." (clinical) [Ep 28 · 26:02](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=1562)
- "The silo can be used in cases of neonatal abdominal compartment syndrome, such as in severe diffuse necrotizing enterocolitis." (clinical) [Ep 28 · 26:34](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=1594)
- "At the University of California Irvine, this method is applied to all patients with gastroschisis and selectively used in other situations where abdominal wall closure is not possible." (clinical) [Ep 28 · 26:59](https://qa.library.globalcastmd.com/watch/staged-closure-of-gastroschisis-with-spring-loaded-silo-2251?t=1619)
- "Pyloric stenosis is hypertrophy and hyperplasia of the inner circular layer with associated mucosal hypertrophy" — Bhargava Muliudi (clinical) [Ep 30 · 0:31](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=31)
- "Pyloric stenosis leads to gastric outlet obstruction in infants between 2 to 10 weeks of age" — Bhargava Muliudi (clinical) [Ep 30 · 0:37](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=37)
- "Pyloric stenosis is more common in males" — Bhargava Muliudi (epidemiological) [Ep 30 · 0:46](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=46)
- "There is increased risk for first born infants with a positive family history" — Bhargava Muliudi (epidemiological) [Ep 30 · 0:49](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=49)
- "Patients with pyloric stenosis typically present with non-bilious vomiting, usually seen between 2 to 10 weeks of life" — Bhargava Muliudi (clinical) [Ep 30 · 1:04](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=64)
- "Infants with pyloric stenosis are otherwise well appearing and hungry after vomiting" — Bhargava Muliudi (clinical) [Ep 30 · 1:12](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=72)
- "Emesis in pyloric stenosis will progress until it is projectile" — Bhargava Muliudi (clinical) [Ep 30 · 1:16](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=76)
- "Hyperbilirubinemia can occur in up to 14% of patients with pyloric stenosis due to downregulation of hepatic enzymes associated with starvation" — Bhargava Muliudi (clinical) [Ep 30 · 1:24](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=84)
- "Bilious emesis should always be worked up to rule out intestinal malrotation with midgut volvulus" — Bhargava Muliudi (guideline) [Ep 30 · 2:00](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=120)
- "Ultrasound is the gold standard for diagnosing pyloric stenosis" — Bhargava Muliudi (clinical) [Ep 30 · 2:50](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=170)
- "Pyloric stenosis is diagnosed on ultrasound when pyloric muscle is 3 millimeters thick and 14 millimeters long or greater" — Bhargava Muliudi (clinical) [Ep 30 · 2:55](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=175)
- "The classic electrolyte abnormality in pyloric stenosis is hypochloremic, hypokalemic, metabolic alkalosis" — Bhargava Muliudi (clinical) [Ep 30 · 3:19](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=199)
- "Prolonged gastric outlet obstruction leads to persistent vomiting and loss of hydrochloric acid, which leads to hypochloremia and loss of protons leading to metabolic alkalosis" — Bhargava Muliudi (clinical) [Ep 30 · 3:29](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=209)
- "The kidneys compensate for dehydration by increasing the activity of the sodium potassium pump to retain fluid, leading to urinary excretion of potassium to preserve sodium and water" — Bhargava Muliudi (clinical) [Ep 30 · 3:41](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=221)
- "In later stages of pyloric stenosis, excretion of protons leads to paradoxical aciduria, which further worsens metabolic alkalosis" — Bhargava Muliudi (clinical) [Ep 30 · 3:56](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=236)
- "In the US, pyloromyotomy is the standard of care for pyloric stenosis" — Bhargava Muliudi (guideline) [Ep 30 · 4:17](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=257)
- "In some countries, atropine is used as a non-surgical option for pyloric stenosis, with a success rate of about 60 to 90%" — Bhargava Muliudi (clinical) [Ep 30 · 4:22](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=262)
- "Cincinnati Children's follows a resuscitation protocol published by the Children's Mercy Group in Kansas City for pyloric stenosis" — Bhargava Muliudi (guideline) [Ep 30 · 4:41](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=281)
- "If chloride is less than 85, give 3 boluses separated by an hour and then recheck labs" — Bhargava Muliudi (guideline) [Ep 30 · 5:01](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=301)
- "If chloride is between 85 and 97, give two boluses" — Bhargava Muliudi (guideline) [Ep 30 · 5:10](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=310)
- "If chloride is greater than 97, give 1 bolus" — Bhargava Muliudi (guideline) [Ep 30 · 5:15](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=315)
- "If bicarbonate is greater than 40, give 3 boluses" — Bhargava Muliudi (guideline) [Ep 30 · 5:24](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=324)
- "If bicarbonate is greater than or equal to 33, give 2 boluses" — Bhargava Muliudi (guideline) [Ep 30 · 5:29](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=329)
- "Prior to going to the operating room, serum chloride must be corrected to greater than 100 and bicarbonate to less than 30" — Bhargava Muliudi (guideline) [Ep 30 · 5:48](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=348)
- "The proximal edge of the pylorus can be easily identified as the antrum transitions to a thick pylorus" — Bhargava Muliudi (clinical) [Ep 30 · 7:00](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=420)
- "The distal extent of the pyloromyotomy is generally to the crossing vein of Mayo or the white line, which marks the pyloroduodenal junction" — Bhargava Muliudi (clinical) [Ep 30 · 7:07](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=427)
- "After the pyloromyotomy is completed, the submucosa should bulge into the myotomy site" — Bhargava Muliudi (clinical) [Ep 30 · 8:18](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=498)
- "After adequate pyloromyotomy, each side of the pylorus should move independently" — Bhargava Muliudi (clinical) [Ep 30 · 8:25](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=505)
- "Complications from pyloromyotomy include incomplete myotomy, mucosal perforation, aspiration, wound infection, and incisional hernias" — Bhargava Muliudi (clinical) [Ep 30 · 8:42](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=522)
- "There is a slight increased risk of incomplete myotomy and perforation with a laparoscopic approach, but the overall low incidence of complications decreases the clinical significance of the differences between the two approaches" — Bhargava Muliudi (clinical) [Ep 30 · 8:52](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=532)
- "For mucosal perforation during pyloromyotomy, you can close the mucosa using a low profile needle and suture like Vicryl on a TF needle, or perform a full thickness repair and redo a myotomy about 180 degrees from the first one, usually on the posterior wall" — Bhargava Muliudi (clinical) [Ep 30 · 9:17](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=557)
- "Most infants can be fed immediately after pyloromyotomy" — Bhargava Muliudi (clinical) [Ep 30 · 10:05](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=605)
- "Evidence supports ad-lib feeds after pyloromyotomy; once the infant is alert and awake, these infants achieve full feeds sooner with no increase in readmission rates" — Bhargava Muliudi (clinical) [Ep 30 · 10:13](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=613)
- "Small episodes of emesis after pyloromyotomy are almost to be expected as the stomach recovers from days to weeks of progressive dilation" — Bhargava Muliudi (clinical) [Ep 30 · 10:32](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=632)
- "Odds of emesis is slightly higher in early and ad-lib feedings compared to gradual or delayed feedings, but the length of stay for ad-lib feedings is much shorter" — Bhargava Muliudi (clinical) [Ep 30 · 10:44](https://qa.library.globalcastmd.com/watch/pyloric-stenosis-2532?t=644)
- "The sutureless gastroschisis closure technique originated when Tony Sandler at Iowa covered a large defect with umbilical cord and tachyderm, intending to return later, but found the wound had closed spontaneously." — Salim (clinical) [Ep 29 · 2:27](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=147)
- "Sandler's first series of sutureless closures included about 10 patients and reported that they did not need to go to the OR and closed on their own." — Salim (clinical) [Ep 29 · 4:30](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=270)
- "Multiple retrospective studies reported that sutureless repair patients eat quicker, go home faster, and are probably cheaper to manage." — Salim (host_summary) [Ep 29 · 4:50](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=290)
- "A randomized study by Brisoni et al. published in the Journal of the American College of Surgeons found that sutureless repair patients took longer to eat and had longer hospital length of stay." — Salim (host_summary) [Ep 29 · 5:10](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=310)
- "A subsequent 98-patient study from UCSF showed a benefit for sutureless repair in terms of time to feeding and length of stay, conflicting with the Brisoni randomized trial." — Salim (host_summary) [Ep 29 · 5:40](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=340)
- "The old adage that you must close the fascia for all gastroschisis babies is probably not true; some version of skin closure is adequate." — Salim (opinion) [Ep 29 · 6:00](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=360)
- "Data over five years shows that about 13% of sutureless repair patients will need an umbilical hernia repair, which is higher than babies who got fascial repair." — Salim (clinical) [Ep 29 · 6:00](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=360)
- "Robert Baird's paper from McGill showed everything was better about tape closure, including a lower umbilical hernia rate, which was surprising." — Todd (host_summary) [Ep 29 · 6:19](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=379)
- "Fear of feeding after sutureless closure—hesitation to feed because of concern about distension and evisceration—may be driving longer length of stay." — Todd (opinion) [Ep 29 · 7:20](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=440)
- "A feeding protocol was instituted at the speaker's NICU: if residual output is less than 20 per kilo, it comes out; if tolerating, advance by 20 per kilo each day." — Todd (clinical) [Ep 29 · 7:30](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=450)
- "In prospective trials, natural selection bias may occur if easier cases are chosen for sutureless closure, leading to better outcomes independent of technique." — Salim (opinion) [Ep 29 · 7:58](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=478)
- "The UCSF study with 98 patients published in JAMA Surgery found a 13% rate of umbilical hernia repair over five years of follow-up in sutureless closure patients." — Salim (host_summary) [Ep 29 · 9:45](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=585)
- "Studies have shown that when fascial closure is attempted without a silo (immediate repair), those patients tend to have a higher incidence of umbilical or ventral hernias requiring repair." — Salim (host_summary) [Ep 29 · 10:20](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=620)
- "Every single general anesthetic agent in every class (volatile gas, IV, ketamine, NMDA receptor blockers) has been shown in rat, mice, and sheep studies to cause increased apoptosis and pervasive developmental issues." — Salim (host_summary) [Ep 29 · 11:47](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=707)
- "The GAS trial and PANDA study in humans showed no difference in neurodevelopmental outcome at five years in babies randomized to spinal versus general anesthesia." — Salim (host_summary) [Ep 29 · 12:30](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=750)
- "The heterogeneity of the gastroschisis population—some cases are easy (one or two loops, little Tylenol) while others are complicated (need silo, OR)—makes a huge difference in results and biases non-randomized trials." — Mac (opinion) [Ep 29 · 12:54](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=774)
- "Tony Sandler no longer uses the umbilical cord for sutureless closure; it is not as important as once thought and just sits there." — Salim (host_summary) [Ep 29 · 15:06](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=906)
- "Some surgeons put a silo on, reduce with the silo, and then apply tape, so inability to immediately reduce does not preclude sutureless closure." — Salim (clinical) [Ep 29 · 15:30](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=930)
- "At UCLA's UC fetal consortium, all gastroschisis cases are attempted without general anesthesia, without intubation, and with minimal narcotics, using standardized antibiotic and feeding protocols." (clinical) [Ep 29 · 16:02](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=962)
- "The UCLA consortium found that length of stay did not decrease with the standardized protocol, but use of antibiotics, intubation days, and opioid use significantly decreased." (clinical) [Ep 29 · 16:40](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1000)
- "At UCLA, one surgeon was able to open the defect, reduce everything, and still do a skin or sutureless closure with great outcomes." (clinical) [Ep 29 · 16:40](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1000)
- "Complicated gastroschisis cases (atresia, perforation) are excluded from the UCLA sutureless closure pathway." (clinical) [Ep 29 · 16:51](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1011)
- "The gastroschisis prognostic score (GPS), which assigned a score based on degree of peel, bowel distension, and matting, did not prove useful in predicting outcomes." — Salim (clinical) [Ep 29 · 17:33](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1053)
- "If a gastroschisis case has a very thick peel, very distended bowel, and lots of bowel loops out, immediate closure should not be considered; a silo should be used for reduction." — Salim (opinion) [Ep 29 · 18:40](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1120)
- "At the end of silo reduction, a sutureless repair can be performed; immediate closure is not required." — Salim (clinical) [Ep 29 · 19:20](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1160)
- "There is no real big need for fascial closure, no matter the size of the gastroschisis defect; skin closure alone is probably adequate." — Salim (opinion) [Ep 29 · 20:00](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1200)
- "Matted bowel does not play into the decision for sutureless closure; if it cannot be immediately reduced, a silo is used, and sutureless repair can be done after reduction." — Todd (clinical) [Ep 29 · 20:31](https://qa.library.globalcastmd.com/watch/sutureless-closure-of-gastroschisis-apsa-practice-gaps-2019-2302?t=1231)
- "In 2004, Tony Sandler published the first manuscript about sutureless closures utilizing the natural umbilical properties to close the gastroschisis defect by itself." — Rod Gerardo (host_summary) [Ep 40 · 1:44](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=104)
- "The Midwest Pediatric Surgery Consortium study was a retrospective cohort of infants born with gastroschisis between 2013 and 2016, with a total of 315 patients." — Rod Gerardo (host_summary) [Ep 40 · 6:01](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- "The study divided patients into sutured versus sutureless abdominal wall closures and required subgroup analysis because some babies received silos and some did not." — Rod Gerardo (host_summary) [Ep 40 · 6:01](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- "Patients who underwent sutureless abdominal wall closure had no difference in days on TPN, time to goal feeds, time to initial feeds, or length of stay compared to sutured closure." — Rod Gerardo (host_summary) [Ep 40 · 6:01](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- "Sutureless closure patients had less antibiotic use compared to sutured closure patients." — Rod Gerardo (host_summary) [Ep 40 · 6:01](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- "Sutureless closure patients had fewer surgical site and deep space infections compared to sutured closure patients." — Rod Gerardo (host_summary) [Ep 40 · 6:01](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- "Sutureless closure patients had fewer episodes of general anesthetics compared to sutured closure patients." — Rod Gerardo (host_summary) [Ep 40 · 6:01](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- "Sutureless closure patients had less ventilator use compared to sutured closure patients." — Rod Gerardo (host_summary) [Ep 40 · 6:01](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- "The positive outcomes for sutureless repair were observed even when considering patients who required silo use." — Rod Gerardo (host_summary) [Ep 40 · 6:01](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=361)
- "Due to the heterogeneity of gastroschisis, patients able to undergo primary repair probably had more favorable bowel and theoretically would have less hospital stay and feed faster." — Jason Frischer (opinion) [Ep 40 · 7:20](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=440)
- "Many patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions." — Jason Frischer (opinion) [Ep 40 · 7:20](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=440)
- "In sutured repair, mobilizing flaps from the skin and fascia causes redness and bruising around the incision, which puts patients at higher risk for potential infection." — Jason Frischer (clinical) [Ep 40 · 8:05](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=485)
- "The finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation." — Jason Frischer (opinion) [Ep 40 · 8:05](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=485)
- "The next phase of the study is examining the same patients over several years of follow-up to assess growth and umbilical hernia repair rates." — Jason Frischer (clinical) [Ep 40 · 8:50](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=530)
- "Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate." — Jason Frischer (host_summary) [Ep 40 · 8:50](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=530)
- "The consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up." — Jason Frischer (clinical) [Ep 40 · 8:50](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=530)
- "Gastroschisis is an abdominal wall defect that used to necessitate a trip to the OR and is now more like a safe bedside procedure." — Rod Gerardo (host_summary) [Ep 40 · 11:22](https://qa.library.globalcastmd.com/watch/gastroschisis-and-sutureless-abdominal-wall-closure-3557?t=682)
- "Giant omphalocele (≥5 cm or liver in sac) patients had greater time to full feeds, required more TPN, had greater risk of respiratory insufficiency, and higher incidence of chromosomal anomalies compared to routine omphalocele in a two-center 20-year retrospective study of 97 survivors." (clinical) [Ep 32 · 0:00](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=0)
- "56 of 97 giant omphalocele patients were identified as having pulmonary hypertension, with most diagnosed within the first week of life." (epidemiological) [Ep 32 · 0:00](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=0)
- "Five patients with giant omphalocele had no signs of pulmonary hypertension on initial echo within first seven days but subsequently developed severe pulmonary hypertension after sepsis episodes, with two deaths and one requiring pulmonary vasodilator for more than a year." (clinical) [Ep 32 · 0:00](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=0)
- "One patient developed severe pulmonary hypertension 52 days after initial echo showed no pulmonary hypertension, triggered by a single episode of sepsis." (clinical) [Ep 32 · 0:00](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=0)
- "The sac-preserving active reduction technique developed by Dr. Abello from Colombia has been used in almost 40 patients over three years by Miguel Gilfoid's group." — Miguel Guelfand (clinical) [Ep 32 · 5:00](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=300)
- "Using the sac-preserving technique with hydrocolloid dressing, 97% of patients achieved closure within 30 days and 92% within 15 days." — Miguel Guelfand (clinical) [Ep 32 · 5:00](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=300)
- "All patients treated with the sac-preserving technique are kept in ICU, ventilated and completely paralyzed during the reduction process." — Miguel Guelfand (clinical) [Ep 32 · 5:00](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=300)
- "The hydrocolloid dressing should ideally be applied within the first 24 hours after birth so the sac doesn't become very stiff, and it keeps the sac very smooth and hydrated." — Miguel Guelfand (clinical) [Ep 32 · 6:47](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=407)
- "Three patients with ruptured omphalocele sac at birth were sutured and then had the hydrocolloid dressing applied successfully." — Miguel Guelfand (clinical) [Ep 32 · 6:47](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=407)
- "Compressions can usually start within 48 hours after hydrocolloid application once the baby is stable." — Miguel Guelfand (clinical) [Ep 32 · 8:01](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=481)
- "In a study by Amy Wegner comparing omphalocele and gastroschisis, gastroschisis had higher risk of adhesive bowel obstruction, but omphalocele had higher risk of midgut volvulus." (clinical) [Ep 32 · 9:16](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=556)
- "Patients with omphalocele have non-rotation or malrotation and will not have the same adhesions as gastroschisis patients." (clinical) [Ep 32 · 9:16](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=556)
- "If the surgical technique for omphalocele closure involves exposing the intestines, it may be worth considering a Ladd procedure, but not worth going through the sac if the technique maintains the sac." (opinion) [Ep 32 · 10:31](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=631)
- "During diaphragmatic hernia repair, the key move to decrease volvulus risk is to unroll the cecum and proximal bowel if they are rolled together like a scroll, ensuring small bowel is to the right, colon to the left, and anterior surface of mesentery is exposed." (clinical) [Ep 32 · 13:10](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=790)
- "Non-rotation does not exclude the possibility of having anatomy with a narrow base of mesentery and the two ends being fairly close together, creating volvulus risk." (clinical) [Ep 32 · 14:33](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=873)
- "In gastroschisis, the liver is not expected to be herniated outside the abdomen." (clinical) [Ep 32 · 17:52](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=1072)
- "For massive abdominal wall defects where there is no amnion and nothing to sew, Miguel Gilfoid uses a prolene mesh that stays in place until closure can be achieved, protecting it with a plastic bag around the bowel." — Miguel Guelfand (clinical) [Ep 32 · 19:10](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=1150)
- "With giant abdominal wall defects, when a spring-loaded (tech) silo is placed and pushed down, the forces go outward and can actually make the defect much bigger over time." (clinical) [Ep 32 · 20:24](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=1224)
- "Biologic mesh can be used as a scaffold that sticks to the bowel and allows skin to epithelialize over massive defects." (clinical) [Ep 32 · 21:23](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=1283)
- "Miguel Gilfoid reports that 80% of massive gastroschisis cases can be closed within two to three months using prolene mesh that remains in place for months." — Miguel Guelfand (clinical) [Ep 32 · 23:21](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=1401)
- "Tissue expanders placed inside the belly without any domain would push all contents up and out rather than creating useful space, according to plastic surgery colleagues." (host_summary) [Ep 32 · 26:33](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=1593)
- "Component separation technique involves separating tissue at the external oblique about a centimeter beyond the rectus sheath bilaterally, then dissecting between external oblique and the transversus/internal oblique, which creates substantial room for closure." (clinical) [Ep 32 · 26:33](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=1593)
- "An incision on top of the anterior rectus sheath can provide another centimeter of advancement during component separation." (clinical) [Ep 32 · 26:33](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=1593)
- "A group from UT Houston (Cogen, Rich, and Recy) reported using component separation in nine children aged 7 days to 10 years, majority with omphalocele and giant defects, achieving fascial closure in almost every case, with some requiring mesh to bridge defects." (host_summary) [Ep 32 · 26:33](https://qa.library.globalcastmd.com/watch/gastroschisis-clinical-practice-updates-2996?t=1593)
- "Failure of medical management is defined as appropriate treatment with no appropriate response" — Kahleb Graham (clinical) [Ep 41 · 2:51](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=171)
- "Patients who cannot take treatment (e.g., kids with autism or other cognitive problems) are considered to have failed medical management" — Kahleb Graham (clinical) [Ep 41 · 3:04](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=184)
- "Patients with persistent symptoms or pain with treatment, or failure to grow, are considered to have failed medical management" — Kahleb Graham (clinical) [Ep 41 · 3:04](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=184)
- "Failure of retrograde enemas is considered failure of medical management" — Kahleb Graham (clinical) [Ep 41 · 3:21](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=201)
- "Reliance on rectal therapy or retrograde enemas with continued soiling causing significant effect on functioning is considered failure of medical management" — Anil Darbari (clinical) [Ep 41 · 3:35](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=215)
- "General pediatricians typically prescribe osmotic laxatives (MiraLax, lactulose) and stimulant laxatives (Senna, bisacodyl), but there are other medications GI specialists use that pediatricians are not accustomed to prescribing" — Anil Darbari (clinical) [Ep 41 · 3:57](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=237)
- "Some children stool every day but don't completely evacuate" — Anil Darbari (clinical) [Ep 41 · 4:58](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=298)
- "Initial evaluation includes history (triggers, stooling frequency, sensation of complete emptying), physical exam (abdominal distension, palpable stool, rectal exam), and diagnostic imaging (abdominal X-ray, water-soluble contrast enema)" — Anil Darbari (clinical) [Ep 41 · 4:46](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=286)
- "In patients with long-standing constipation where appropriate treatments have been tried and failed, the first step is diagnostic studies including contrast enema to assess colonic dilation, redundancy, and ensure normal ratio" — Kahleb Graham (clinical) [Ep 41 · 5:27](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=327)
- "Water-soluble contrast (not barium) is used for contrast enemas because it helps empty the colon and acts as a cleanout for patients starting new medical therapy" — Jason Frischer (clinical) [Ep 41 · 8:06](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=486)
- "Contrast studies are not great predictors of how patients will respond to medical or surgical management; normal-looking colons may not respond while abnormal-appearing colons may respond well" — Jason Frischer (clinical) [Ep 41 · 7:12](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=432)
- "The rectoanal inhibitory reflex (RAIR) is the response where the internal anal sphincter relaxes when the rectum becomes distended with stool" — Rod (host_summary) [Ep 41 · 9:11](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=551)
- "Anorectal manometry uses a catheter with sensors measuring pressure and a balloon to assess anal sphincter function and its relationship to the rectum" — Anil Darbari (clinical) [Ep 41 · 9:35](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=575)
- "High pressures on anorectal manometry may suggest underlying inability to relax, causing a functional obstruction" — Anil Darbari (clinical) [Ep 41 · 10:00](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=600)
- "Patients with Hirschsprung disease have an absent rectoanal inhibitory reflex (RAIR)" — Anil Darbari (clinical) [Ep 41 · 10:09](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=609)
- "Anorectal manometry provides information about defecation dynamics by having patients bear down, squeeze, and attempt to defecate, comparing sensation to defecate with internal anal sphincter response" — Anil Darbari (clinical) [Ep 41 · 10:19](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=619)
- "Doctor Levitt states he doesn't know how he survived without anorectal manometry testing" — Marc Levitt (opinion) [Ep 41 · 10:47](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=647)
- "In the past, surgeons did not understand the major role the sphincter played in many patients" — Jason Frischer (opinion) [Ep 41 · 10:51](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=651)
- "Colonic motility assessment is critical because in the past, colons or sigmoid colons were resected based on appearance, but patients had motility disorders and did not need resection" — Marc Levitt (clinical) [Ep 41 · 7:36](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=456)
- "Many dilated colons will respond to treatment" — Marc Levitt (clinical) [Ep 41 · 7:54](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=474)
- "Anorectal manometry is critical for determining whether a patient needs surgery or resection, as patients with motility disorders do not need surgery" — Rod (host_summary) [Ep 41 · 12:03](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-8-motility-disorders-part-1-3824?t=723)
- "The patient is a two-day-old boy with duodenal atresia." (host_summary) [Ep 43 · 0:00](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=0)
- "A transverse right abdominal incision allows access to the duodenum and small intestine." (host_summary) [Ep 43 · 0:20](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=20)
- "Malrotation is present in this case." (host_summary) [Ep 43 · 1:00](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=60)
- "Duodenal atresia type III is present in this case." (host_summary) [Ep 43 · 1:00](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=60)
- "The proximal duodenal opening is made at the most dependent part." (host_summary) [Ep 43 · 2:00](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=120)
- "The distal limb is opened on the anterolateral surface to avoid injury to the opening of the common bile and pancreatic ducts." (host_summary) [Ep 43 · 2:30](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=150)
- "Bile coming out on opening of the distal limb confirms patency to that point." (host_summary) [Ep 43 · 2:45](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=165)
- "The diamond-shaped technique creates two openings with perpendicular axes." (host_summary) [Ep 43 · 2:55](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=175)
- "Distal patency is checked by injecting saline and observing its filling to the whole bowel." (host_summary) [Ep 43 · 3:10](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=190)
- "The anastomosis technique uses two opposing borders of the diamonds to make the posterior wall and the far-facing borders to make the anterior wall." (host_summary) [Ep 43 · 3:25](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=205)
- "The posterior wall is sutured from the inside with full-thickness sutures." (host_summary) [Ep 43 · 3:50](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=230)
- "The anterior wall is sutured from the outside." (host_summary) [Ep 43 · 4:00](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=240)
- "5-0 absorbable sutures are used for the anastomosis." (host_summary) [Ep 43 · 4:10](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=250)
- "Suturing starts with the middle of the posterior wall and advances toward the angles with interrupted sutures." (host_summary) [Ep 43 · 4:10](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=250)
- "The angle suture is placed from the outside in an extramucosal fashion." (host_summary) [Ep 43 · 4:35](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=275)
- "The anterior wall sutures are placed in an extramucosal fashion starting from the angles and working towards the middle." (host_summary) [Ep 43 · 5:10](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=310)
- "The proximal dilated pouch is brought downwards to meet the distal limb during anterior wall closure." (host_summary) [Ep 43 · 5:30](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=330)
- "Widening of the root of the mesentery is performed after completing the anastomosis." (host_summary) [Ep 43 · 5:50](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=350)
- "The superior mesenteric vessels should be visualized during mesenteric root widening." (host_summary) [Ep 43 · 6:05](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=365)
- "The peritoneal covering is carefully dissected to allow adequate widening of the mesenteric root." (host_summary) [Ep 43 · 6:15](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=375)
- "Appendectomy is performed as part of the procedure." (host_summary) [Ep 43 · 6:30](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=390)
- "The bowel is returned to the abdomen with the colon in the left side and the duodenojejunal junction in a straight direction." (host_summary) [Ep 43 · 6:40](https://qa.library.globalcastmd.com/watch/duodeno-duodenostomy-for-duodenal-atresia-4139?t=400)
- "Manometry is a catheter-based study of pressure changes within the lumen of the gut, involving visual pattern recognition of tracings to identify deviations from normal." — Ajay Hall (clinical) [Ep 44 · 1:24](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=84)
- "Colonic motility has four key components: diameter of the colon, tone, compliance of the colonic wall, and contraction pressures (how strong the contractions are)." — Ajay Hall (clinical) [Ep 44 · 1:34](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=94)
- "In megacolon, tone and compliance are usually abnormal, but colonic manometry may still show normal high-amplitude propagated contractions and transit may be normal." — Ajay Hall (clinical) [Ep 44 · 1:58](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=118)
- "There are three types of constipation: normal transit constipation, slow transit constipation (problem with neuromuscular integrity of colonic wall), and outlet obstruction or withholding (most common in anorectal malformation children)." — Ajay Hall (clinical) [Ep 44 · 2:35](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=155)
- "In a Sitz marker study, a patient should be able to pass all ingested radio-opaque markers in 5 days; markers remaining at 5 days indicate abnormal transit." — Ajay Hall (clinical) [Ep 44 · 3:19](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=199)
- "When Sitz markers are collected in the dilated rectum at 5 days, this is indicative of outlet obstruction or withholding." — Ajay Hall (clinical) [Ep 44 · 3:48](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=228)
- "When Sitz markers are scattered all over the colon at 5 days, this is indicative of slow transit constipation." — Ajay Hall (clinical) [Ep 44 · 4:06](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=246)
- "Scintigraphy studies colonic transit by tracking the geometric center of an ingested isotope and can identify specific colonic locations with transit issues." — Ajay Hall (clinical) [Ep 44 · 4:15](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=255)
- "The smart pill is a large capsule that measures pH, temperature, and pressure to assess transit from mouth to anus, but its size limits use to children approximately 10-12 years old or older." — Ajay Hall (clinical) [Ep 44 · 4:51](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=291)
- "There are two main types of colonic contractions: phasic (brief) or tonic (sustained), with segmental non-propagated contractions being the most common." — Ajay Hall (clinical) [Ep 44 · 6:05](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=365)
- "High-amplitude propagated contractions (HAPCs) move stool along the length of the colon and correspond to what radiologists see on contrast enema as mass movement." — Ajay Hall (clinical) [Ep 44 · 6:19](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=379)
- "The orthocolonic reflex (stimulus to colonic motility upon waking) and gastrocolonic reflex (stimulus upon eating) affect the timing of colonic contractions." — Ajay Hall (clinical) [Ep 44 · 6:45](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=405)
- "Sennosides or bisacodyl can be used to induce high-amplitude propagated contractions (HAPCs)." — Rod Gerardo (host_summary) [Ep 44 · 6:54](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=414)
- "The majority of HAPCs originate in the proximal colon, and most do not propagate beyond the midcolon; fewer than 5% reach the rectum." — Ajay Hall (clinical) [Ep 44 · 7:05](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=425)
- "When an HAPC occurs, the internal anal sphincter should relax (coloanal reflex) to allow stool evacuation." — Rod Gerardo (host_summary) [Ep 44 · 7:15](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=435)
- "Manometry catheters are typically placed during endoscopy, which allows evaluation of colonic mucosa, though interventional radiologists can also place them." — Ajay Hall (clinical) [Ep 44 · 7:48](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=468)
- "Fluoroscopy (C-arm) is used during manometry catheter placement to confirm exact positioning." — Rod Gerardo (host_summary) [Ep 44 · 8:06](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=486)
- "The rectal motor complex appears as multiple small spikes on manometry tracings at the rectum." — Ajay Hall (clinical) [Ep 44 · 8:33](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=513)
- "When an HAPC reaches the sigmoid or rectum, the internal anal sphincter relaxes to allow defecation." — Rod Gerardo (host_summary) [Ep 44 · 8:51](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=531)
- "Segmental dysmotility on manometry can show HAPCs present in the right colon but absent in the left colon." — Ajay Hall (clinical) [Ep 44 · 9:07](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=547)
- "Decisions about surgical intervention for segmental dysmotility are based not only on manometry but also on imaging (contrast enema), physical exam, and patient/family history." — Rod Gerardo (host_summary) [Ep 44 · 9:51](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=591)
- "If more than 40 to 50 centimeters of colon does not have HAPCs, that segment is considered dysfunctional colon." — Ajay Hall (clinical) [Ep 44 · 10:07](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=607)
- "The management approach at Cincinnati Children's is to maximize medical therapy and understand anatomic and functional issues before resorting to surgical intervention and potential resection." — Jason Frischer (opinion) [Ep 44 · 10:31](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=631)
- "The first step in management is to maximize stimulant laxatives to ensure evacuation; if that fails, irrigation or enemas are tried before considering surgical interventions." — Ajay Hall (clinical) [Ep 44 · 10:48](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=648)
- "Resection should not be performed immediately based on one abnormal finding; multiple factors must be considered." — Jason Frischer (opinion) [Ep 44 · 11:04](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=664)
- "The first step in evaluating a patient with suspected motility disorder is to ensure normal anatomy, which can be assessed with contrast studies." — Jason Frischer (clinical) [Ep 44 · 12:13](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=733)
- "In the presented case, duodenal and colonic manometry were normal, ruling out widespread dysmotility and confirming gastroparesis as the isolated abnormality." — Ajay Hall (clinical) [Ep 44 · 13:41](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=821)
- "Performing duodenal and colonic manometry in a patient with gastroparesis is valuable because it rules out more widespread dysmotility, which is especially important in patients with anorectal malformations." — Rod Gerardo (host_summary) [Ep 44 · 13:56](https://qa.library.globalcastmd.com/watch/colorectal-collaboration-neurogastroenterology-motility-disorders-4366?t=836)
- "The Texas Children's Hospital study tracked non-accidental trauma patients using their trauma database, examining hospital course, injuries, consults, discharge instructions, and one-year follow-up compliance with recommended visits." — Brittany Johnson (clinical) [Ep 45 · 1:44](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=104)
- "Follow-up rates for child physical abuse victims were actually quite high, with patients not following up as recommended but rates not being low, representing an opportunity as families are trying to make appointments." — Brittany Johnson (clinical) [Ep 45 · 2:19](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=139)
- "Complete metadata for medical education content includes title, description, summary, keywords, duration, content type, specialty area, target audience level, and language." — Rod Gerardo (host_summary) [Ep 45 · 2:50](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=170)
- "Pediatric surgery could adopt the model used for children with complex medical conditions where all appointments are scheduled on one day to decrease burden on families." — Brittany Johnson (opinion) [Ep 45 · 3:18](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=198)
- "The 85% follow-up rate in child abuse victims is surprising and encouraging." — Todd Ponsky (opinion) [Ep 45 · 3:58](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=238)
- "The UK NEC study was a secondary analysis of prospectively collected observational data from all 27 pediatric surgery centers in the UK, representing a whole population-based study over one year." — Nigel Hall (clinical) [Ep 45 · 5:15](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=315)
- "Primary outcomes in the NEC study were death or parenteral nutrition requirement at 28 days after surgery, examining the relationship between surgical indication, timing from presentation to surgery, and outcomes." — Nigel Hall (clinical) [Ep 45 · 5:47](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=347)
- "Of approximately 130 babies with surgical NEC, about half had bowel perforation; of the remaining half, one-third were critically ill and proceeded quickly to surgery, while two-thirds eventually had surgery for failed medical treatment." — Nigel Hall (epidemiological) [Ep 45 · 6:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=417)
- "Babies with NEC who had surgery for failed medical treatment had the longest time from presentation to operation and the worst outcomes compared to those operated for perforation or clinical deterioration." — Nigel Hall (clinical) [Ep 45 · 7:30](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=450)
- "In NEC, it is easy to make surgical decisions when there is free air, but without definitive protocol for other presentations, surgeons hedge and delay daily about whether to operate." — Todd Ponsky (opinion) [Ep 45 · 8:05](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=485)
- "We currently do not have objective clinical markers, whether clinical features or novel biomarkers, to help make earlier surgical decisions in NEC." — Rod Gerardo (host_summary) [Ep 45 · 8:32](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=512)
- "The Nationwide Children's Hospital bowel management program started recording outcomes in a standardized way in 2015 using standardized definitions and patient-reported outcome and experience measures." — Richard Wood (clinical) [Ep 45 · 10:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=637)
- "The bowel management study measured outcomes at one year rather than one week because one-week outcomes represent an artificial environment, and one-year measurement demonstrates sustained changes within the patient's normal environment." — Richard Wood (clinical) [Ep 45 · 11:32](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=692)
- "In the bowel management program, children who achieved continence had significantly improved quality of life, while those who remained incontinent had no quality of life improvement." — Richard Wood (clinical) [Ep 45 · 11:59](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=719)
- "After one year in the bowel management program, 30% of patients still struggled with fecal incontinence despite intensive resources." — Ellen Encisco (host_summary) [Ep 45 · 12:12](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=732)
- "In the bowel management study, 70% of children achieve good outcomes, allowing focus on understanding and improving outcomes for the remaining 30%." — Richard Wood (clinical) [Ep 45 · 12:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=776)
- "Many surgeons who see the value of bowel management programs lack the volume or resources to build formal programs, making it reasonable to refer patients to nearby established programs." — Todd Ponsky (opinion) [Ep 45 · 13:19](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=799)
- "The Italian anorectal malformation study was a retrospective review of 350 patients between 1999 and 2019, representing one of the largest series." — Ellen Encisco (host_summary) [Ep 45 · 14:46](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=886)
- "The Italian study demonstrated a close relationship between spinal cord abnormalities and spinal bone anomalies in anorectal malformation patients." — Ellen Encisco (host_summary) [Ep 45 · 15:29](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=929)
- "Despite correlation between spinal bone and cord abnormalities, many patients without sacral or vertebral anomalies still had spinal cord abnormalities, making MRI necessary for screening." — Ellen Encisco (host_summary) [Ep 45 · 15:44](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=944)
- "In typical US practice for anorectal malformations, ultrasound shortly after birth is usually sufficient to look for spinal cord abnormalities, whereas the Italian practice finds MRI necessary." — Ellen Encisco (host_summary) [Ep 45 · 16:01](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=961)
- "There is variability in the use of ultrasound versus MRI for detecting tethered cord in anorectal malformation patients, and radiographs are not a good substitute." — Todd Ponsky (clinical) [Ep 45 · 16:26](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=986)
- "The Italian study provides sufficient evidence to convince clinicians who are not doing routine spinal cord and spine assessment in anorectal malformation patients that they should be more serious with imaging." — Rod Gerardo (host_summary) [Ep 45 · 17:03](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=1023)
- "Until recently, there was no standardized definition for intestinal failure." — Paul Wales (clinical) [Ep 46 · 1:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=116)
- "Intestinal failure is when gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth." — Paul Wales (clinical) [Ep 46 · 2:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=123)
- "New guidelines define intestinal failure as requiring parenteral support for at least 60 days due to inadequate intestinal function." — Rod Gerardo (host_summary) [Ep 46 · 2:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=144)
- "Earlier recognition and taking advantage of the gut's biology to adapt are time dependent." — Michael Helmrath (clinical) [Ep 46 · 2:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=160)
- "An intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and other associated needs, as defined in recent ASPEN guidelines." — Paul Wales (guideline) [Ep 46 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=183)
- "Intestinal rehabilitation requires managing comorbidities including sepsis and liver disease that challenge infant growth." — Rod Gerardo (host_summary) [Ep 46 · 3:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=213)
- "The intestinal rehabilitation approach streamlines care and improves communication with families and between care providers." — Paul Wales (clinical) [Ep 46 · 3:44](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=224)
- "Intestinal rehabilitation depends on nutrition in the gut, nutrition in the body, and healing." — Michael Helmrath (clinical) [Ep 46 · 4:07](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=247)
- "Pattern recognition from multiple experienced clinicians observing patients over time is essential in intestinal rehabilitation." — Michael Helmrath (clinical) [Ep 46 · 4:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=259)
- "Causes of intestinal failure divide into three categories: short bowel syndrome, motility disorders, and congenital enteropathies." — Paul Wales (clinical) [Ep 46 · 4:39](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=279)
- "Short bowel syndrome is by far the most common category of intestinal failure in pediatric patients." — Paul Wales (epidemiological) [Ep 46 · 4:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=290)
- "Causes of short bowel syndrome include congenital anomalies (intestinal atresia, malrotation, volvulus, gastroschisis, long segment Hirschsprung disease) and acquired neonatal diseases (necrotizing enterocolitis)." — Paul Wales (clinical) [Ep 46 · 5:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=306)
- "Motility disorders occur when abnormalities of intestinal muscle or the nerves controlling that muscle prevent coordinated propulsion of food and stool." — Paul Wales (clinical) [Ep 46 · 5:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=345)
- "Congenital enteropathies are conditions where patients have all their bowel but the mucosal lining does not digest or absorb properly." — Paul Wales (clinical) [Ep 46 · 6:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=377)
- "Mucosal defects in enteropathies lead to hypersecretion and profuse fluid losses, preventing nutrient absorption." — Ellen Encisco (host_summary) [Ep 46 · 6:30](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=390)
- "Some patients have elements of two or all three categories of intestinal failure in their presentation." — Paul Wales (clinical) [Ep 46 · 7:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=431)
- "Gastroschisis can involve all three categories: short bowel from nonviable tissue, inflammation affecting absorption, and motility issues." — Ellen Encisco (host_summary) [Ep 46 · 7:22](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=442)
- "Most intestinal failure patients are infants or babies, but some older pediatric patients develop intestinal failure from inflammatory bowel disease, Crohn disease complications, trauma, malignancy, or vascular thrombosis." — Paul Wales (epidemiological) [Ep 46 · 7:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=465)
- "Access and availability to intestinal rehabilitation programs is still very rare." — Rod Gerardo (host_summary) [Ep 46 · 8:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=521)
- "Three time points exist for diagnosis and referral to intestinal rehab: prenatal diagnosis (atresia with cystic fibrosis, gastroschisis), postnatal acquired problems (volvulus, NEC), and later presentations after discharge when patients fail to progress." — Michael Helmrath (clinical) [Ep 46 · 8:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=533)
- "Innovation in intestinal rehabilitation comes from multiple approaches to problems and different visions, with more expertise leading to better outcomes." — Michael Helmrath (opinion) [Ep 46 · 10:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=615)
- "Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being adequately addressed." — Michael Helmrath (clinical) [Ep 46 · 10:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=651)
- "The intestinal rehabilitation team includes dietitians (for nutritional needs), social workers, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology." — Michael Helmrath (clinical) [Ep 46 · 11:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=712)
- "Overall long-term survival in major intestinal rehabilitation programs is usually over 90%." — Rod Gerardo (host_summary) [Ep 46 · 12:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=754)
- "Long-term survivors now develop chronic comorbidities not previously seen to the same extent because patients did not live long enough, including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life problems." — Paul Wales (clinical) [Ep 46 · 12:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=766)
- "Until recently, there was no standardized definition for intestinal failure." — Paul Wales (guideline) [Ep 47 · 1:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=116)
- "Intestinal failure is a functional problem where gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth." — Paul Wales (clinical) [Ep 47 · 2:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=123)
- "New guidelines define intestinal failure as inadequate intestinal function requiring parenteral support for at least 60 days." — Rod Gerardo (host_summary) [Ep 47 · 2:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=144)
- "Earlier recognition and taking advantage of the gut's adaptive biology are time dependent." — Michael Helmrath (clinical) [Ep 47 · 2:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=160)
- "An intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and other associated needs, as defined in recent ASPEN guidelines." — Paul Wales (guideline) [Ep 47 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=183)
- "Intestinal rehabilitation requires managing comorbidities including sepsis and liver disease that challenge infant growth." — Rod Gerardo (host_summary) [Ep 47 · 3:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=213)
- "Intestinal rehabilitation streamlines care and improves communication between family and care providers through an amalgamation of experts providing holistic, comprehensive, coordinated care." — Paul Wales (clinical) [Ep 47 · 3:44](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=224)
- "Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing." — Michael Helmrath (clinical) [Ep 47 · 4:07](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=247)
- "Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation." — Michael Helmrath (clinical) [Ep 47 · 4:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=259)
- "Short bowel syndrome is by far the most common category of intestinal failure in pediatric patients." — Paul Wales (epidemiological) [Ep 47 · 4:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=290)
- "Causes of short bowel syndrome are usually related to neonatal disorders including congenital anomalies (intestinal atresia, malrotation, volvulus, gastroschisis, long segment Hirschsprung disease) or acquired diseases (necrotizing enterocolitis)." — Paul Wales (clinical) [Ep 47 · 4:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=290)
- "Motility disorders occur when abnormalities of the intestinal muscle itself or the nerves controlling that muscle prevent coordinated propulsion of food and stool, making patients dependent on intravenous support." — Paul Wales (clinical) [Ep 47 · 5:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=345)
- "Enteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work, leading to hypersecretion and profuse fluid losses." — Paul Wales (clinical) [Ep 47 · 6:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=377)
- "Some patients will have elements of two or all three categories of intestinal failure; for example, gastroschisis can involve short bowel, inflammation affecting absorption, and motility issues." — Paul Wales (clinical) [Ep 47 · 7:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=431)
- "Although most intestinal failure patients are infants or babies, older pediatric patients can develop intestinal failure from inflammatory bowel disease, Crohn's disease complications, trauma, malignancy, or vascular thrombosis leading to gut loss." — Paul Wales (clinical) [Ep 47 · 7:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=465)
- "Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress." — Michael Helmrath (clinical) [Ep 47 · 8:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=533)
- "Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes." — Michael Helmrath (opinion) [Ep 47 · 10:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=615)
- "Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met." — Michael Helmrath (clinical) [Ep 47 · 10:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=651)
- "The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology." — Michael Helmrath (clinical) [Ep 47 · 11:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=712)
- "Overall survival in big intestinal rehabilitation programs is usually over 90% long-term." — Rod Gerardo (host_summary) [Ep 47 · 12:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=754)
- "Improved survival has revealed chronic comorbidities not previously seen to the same extent because patients did not live long enough, including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life concerns." — Paul Wales (clinical) [Ep 47 · 12:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=766)
- "The outlook for preterm infants with short bowel syndrome has changed over the last two decades as a result of advances in medical and surgical care." — Paul Wales (clinical) [Ep 48 · 0:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=51)
- "A more aggressive approach to surgical resection has accompanied improved outcomes in short bowel syndrome." — Paul Wales (clinical) [Ep 48 · 1:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=83)
- "Intestinal transplant is not experimental therapy; it is part of the continuum of therapy for a child with short bowel syndrome." — Paul Wales (clinical) [Ep 48 · 2:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=158)
- "Mistakes are commonly made because clinicians think they can predict the future with their eyes, predetermining care based on what they believe will happen rather than allowing the clinical scenario to drive the direction of care." — Michael Helmrath (opinion) [Ep 48 · 3:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=191)
- "There is an algorithm of children with overwhelming sepsis where surgery cannot salvage these patients and there is no life-saving option." — Michael Helmrath (clinical) [Ep 48 · 3:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=214)
- "Many infants will rally without having their bowel removed, which allows them an opportunity for recovery." — Michael Helmrath (clinical) [Ep 48 · 3:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=221)
- "In the acute phase with infarcted gut, the clinical picture is usually one of overwhelming sepsis, and even after resection leaving ultra-short bowel, patients are rocky and unstable due to sepsis, SIRS, or septic experience." — Paul Wales (clinical) [Ep 48 · 4:10](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=250)
- "In the very acute time, the primary cause of death is sepsis and multi-organ failure." — Paul Wales (clinical) [Ep 48 · 4:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=274)
- "In the intermediate and longer term, complications include intestinal failure-associated liver disease, recurrent sepsis, or line problems, which historically led to death or transplant." — Paul Wales (clinical) [Ep 48 · 4:44](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=284)
- "Much of the success seen in the last two decades is because clinicians are way better at preventing sepsis and liver disease." — Paul Wales (clinical) [Ep 48 · 5:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=302)
- "The first goal when seeing these infants is protecting the liver." — Michael Helmrath (clinical) [Ep 48 · 5:14](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=314)
- "Research at Dr. Helmrath's lab and elsewhere has shown that giving fish oils and trying to improve bilirubin is not enough; the liver must be taken care of to reach the point where bowel reconstruction is possible." — Ellen Gootee (host_summary) [Ep 48 · 5:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=331)
- "Decompressing the duodenum is needed to protect the liver, and when the liver is inflamed with high bilirubin, it is in a catabolic state." — Michael Helmrath (clinical) [Ep 48 · 5:49](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=349)
- "When in the OR wanting to buy time, one of the first things to consider is how to keep the proximal bowel decompressed." — Michael Helmrath (clinical) [Ep 48 · 6:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=363)
- "Babies born with duodenal atresia or very proximal jejunal atresia are born with elevated direct or conjugated bilirubins, supporting the concept that an undecompressed foregut affects liver function." — Paul Wales (clinical) [Ep 48 · 6:14](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=374)
- "Liver function is affected by multiple factors: prematurity, sepsis, choice of TPN, and presence or absence of enteral nutrition." — Paul Wales (clinical) [Ep 48 · 6:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=402)
- "Placing a retrograde tube in the duodenum or jejunum that goes up to the pylorus to decompress the bowel has given time to allow children to recover from the acute event." — Michael Helmrath (clinical) [Ep 48 · 7:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=435)
- "A 30-week-old baby's gut is in a highly developmental phase and its ability to regenerate is much more profound than a full-term baby and certainly a one-year-old baby." — Michael Helmrath (clinical) [Ep 48 · 7:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=454)
- "The distal bowel (ileum) is remarkably important and can be salvaged by ileocecal blood flow; leaving it alone has allowed salvage of a lot of tissue in Cincinnati." — Michael Helmrath (clinical) [Ep 48 · 8:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=484)
- "Proximal control allows tissue time to regenerate, which is often on the order of 6, 8, or 12 weeks based on the liver getting better." — Michael Helmrath (clinical) [Ep 48 · 8:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=497)
- "The inflection point of bowel loss that requires prolonged TPN is about 50%." — Michael Helmrath (clinical) [Ep 48 · 9:27](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=567)
- "If dealing with less than 50% bowel necrosis, the best option is to remove that bowel and the child's adaptive potential is really great, especially if ileum is preserved." — Michael Helmrath (clinical) [Ep 48 · 9:35](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=575)
- "If necrotic bowel is focal and less than 50%, it should be removed and the child managed accordingly; the approach is not to leave all dead bowel in place." — Michael Helmrath (clinical) [Ep 48 · 9:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=591)
- "When bowel necrosis is patchy with areas that look terrible, bad, and maybe a little good (mosaicism), proximally controlling the bowel with a drain and providing time to heal gives opportunity to return later; not all bowel will survive and islands of mucosa will need to be tubularized and reconnected." — Michael Helmrath (clinical) [Ep 48 · 10:00](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=600)
- "Once proximal bowel is controlled with a drain, stomas should be avoided because they lose abdominal domain and lose bowel down the road." — Michael Helmrath (clinical) [Ep 48 · 10:59](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=659)
- "The percentage of infants that do well with proximal drain therapy when facing dead gut is more than 70 to 80%." — Michael Helmrath (clinical) [Ep 48 · 11:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=671)
- "The approach to overwhelming bowel necrosis does not differ based on diagnosis (volvulus, infarct, mesenteric thrombosis), but the outcome does." — Michael Helmrath (clinical) [Ep 48 · 11:39](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=699)
- "Kids with NEC have the best outcomes because it is a microvascular disease." — Michael Helmrath (clinical) [Ep 48 · 11:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=708)
- "Controlling proximal bowel without allowing enteric content has been key to salvaging NEC patients with good outcomes." — Michael Helmrath (clinical) [Ep 48 · 11:54](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=714)
- "Gastroschisis is a full thickness abdominal wall defect just to the right of the umbilicus, in which peritoneal contents, most often intestines, protrude through the abdomen without any membranous cover." — Fung-Yen Lim (clinical) [Ep 50 · 0:55](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=55)
- "Omphalocele is right through the middle of the umbilicus and has a membranous cover." — Fung-Yen Lim (clinical) [Ep 50 · 0:55](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=55)
- "Omphalocele is a congenital disorder and can have associated anomalies, but gastroschisis occurs in otherwise normal babies that have an intrauterine event during development." — Fung-Yen Lim (clinical) [Ep 50 · 0:55](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=55)
- "Very high level of alpha fetal protein is associated with gastroschisis or omphalocele." — Fung-Yen Lim (clinical) [Ep 50 · 1:54](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=114)
- "Alpha fetal protein (AFP) is a screening test, but ultrasound imaging is needed to definitively diagnose abdominal wall defects." — Fung-Yen Lim (clinical) [Ep 50 · 1:54](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=114)
- "For gastroschisis, only ultrasound confirmed diagnosis is obtained without additional imaging." — Fung-Yen Lim (clinical) [Ep 50 · 1:54](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=114)
- "For omphalocele, besides ultrasound, MRI and echocardiogram are routinely obtained because these patients may have other associated anomalies." — Fung-Yen Lim (clinical) [Ep 50 · 1:54](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=114)
- "Fetal growth is tracked monthly in gastroschisis and omphalocele cases because there is concern for significant growth restriction." — Fung-Yen Lim (clinical) [Ep 50 · 1:54](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=114)
- "Biophysical profile and non-stress testing are needed because intrauterine growth restriction and intrauterine fetal demise (IUFD) can occur in these patients." — Fung-Yen Lim (clinical) [Ep 50 · 2:56](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=176)
- "If surveillance imaging becomes worrisome enough regarding intrauterine fetal demise, the mother and fetus need to be admitted for continuous monitoring or emergent delivery." — Fung-Yen Lim (clinical) [Ep 50 · 2:56](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=176)
- "Gastroschisis affects approximately one in every 2,200 live births." — Todd Ponsky (host_summary) [Ep 50 · 3:15](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=195)
- "Gastroschisis is most common among babies born to young mothers of low gravidity, usually first pregnancy, with 75% being first born and 25% in second or subsequent pregnancies." — Fung-Yen Lim (epidemiological) [Ep 50 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=207)
- "Nearly 60% of gastroschisis cases are premature." — Fung-Yen Lim (epidemiological) [Ep 50 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=207)
- "More than 90% of gastroschisis infants are born less than 2,500 grams in weight due to intrauterine growth restriction." — Fung-Yen Lim (epidemiological) [Ep 50 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=207)
- "Pseudoephedrine has an odds ratio of 4.2 times for gastroschisis compared to aspirin alone at 2.7." — Fung-Yen Lim (epidemiological) [Ep 50 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=207)
- "Other risk factors for gastroschisis include acetaminophen, vitamin B deficiencies, drug use, and some genetic predispositions." — Fung-Yen Lim (epidemiological) [Ep 50 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=207)
- "Mothers with omphalocele are usually advanced in age compared to the gastroschisis group, with advanced maternal age having an odds ratio of 3.3." — Fung-Yen Lim (epidemiological) [Ep 50 · 4:19](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=259)
- "Major risk factors for omphalocele are trisomy 13, 18, and 21, which occur in anywhere between 35 and 90% of patients with omphalocele." — Fung-Yen Lim (epidemiological) [Ep 50 · 4:19](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=259)
- "Crucial immediate postnatal procedures include minimizing heat loss and fluid loss, otherwise babies can show up extremely dehydrated and cold." — Fung-Yen Lim (clinical) [Ep 50 · 5:02](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=302)
- "These babies can have significant acidosis and pulmonary hypertension." — Fung-Yen Lim (clinical) [Ep 50 · 5:02](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=302)
- "Primary closure is considered if the bowel looks pristine, non-thickened, non-inflammatory, with only small amount outside and enough abdominal domain to push them all back very quickly." — Fung-Yen Lim (clinical) [Ep 50 · 5:34](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=334)
- "Staged closure is favored if the defect is large or there are issues with the bowel, including atresia, compromised bowel, or perforation." — Fung-Yen Lim (clinical) [Ep 50 · 6:07](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=367)
- "Some patients develop intestinal perforation after only two to four days of enteral feeding." — Fung-Yen Lim (clinical) [Ep 50 · 6:07](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=367)
- "In the last four and a half years at Cincinnati Children's Hospital, majority of babies are managed using sutureless closure." — Todd Ponsky (host_summary) [Ep 50 · 6:34](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=394)
- "In sutureless closure, after pushing the bowel back in, babies are not taken to the operating room for suture closure; instead, the umbilical cord is placed over with dressing, and skin will grow over, although a small umbilical defect may remain that can close spontaneously over time." — Fung-Yen Lim (clinical) [Ep 50 · 6:58](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=418)
- "For small bowel atresia encountered during closure, management options include tapering the dilated portion of bowel or resecting the bowel before tapering." — Fung-Yen Lim (clinical) [Ep 50 · 7:29](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=449)
- "For omphalocele with no significant respiratory issues, sequential reduction using meshes is the best option, sewing meshes to the edges of the fascia without interrupting the membrane." — Fung-Yen Lim (clinical) [Ep 50 · 7:57](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=477)
- "At Cincinnati Children's, Duoderm silo is placed on top of the skin of the patient, formed over the omphalocele, and plastic clips are used to sequentially clip it down until it's flush to the abdominal skin." — Todd Ponsky (host_summary) [Ep 50 · 8:17](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=497)
- "After sequential reduction with plastic clips, the patient is taken to the operating room for delayed primary closure of the fascia and skin." — Fung-Yen Lim (clinical) [Ep 50 · 8:43](https://qa.library.globalcastmd.com/watch/omphalocele-and-gastroschisis-with-dr-foong-yen-lim-5006?t=523)
- "Historically, surgeons have been incentivized based on work RVUs, which is important for clinical productivity but does not take advantage of other strengths surgeons have." — Gail Besner (opinion) [Ep 51 · 1:41](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=101)
- "The concept of academic RVUs was first described approximately 12-13 years ago but did not include how to incentivize people for academic work." — Gail Besner (clinical) [Ep 51 · 2:55](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=175)
- "Nationwide Children's Hospital implemented a point-based academic RVU system where people accumulate points based on number of publications, presentations, and other academic pursuits." — Gail Besner (clinical) [Ep 51 · 3:07](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=187)
- "The Nationwide system kept work RVUs as part of the incentivization plan along with other goals that must be achievable." — Gail Besner (clinical) [Ep 51 · 3:27](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=207)
- "After implementing the academic RVU system, Nationwide had an increase in presentations, peer-reviewed publications, and external federal research funding." (host_summary) [Ep 51 · 3:44](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=224)
- "External federal research funding at Nationwide increased from $750,000 to $5.7 million, representing a 7.7-fold increase." — Rod Gerardo (host_summary) [Ep 51 · 3:58](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=238)
- "At Akron Children's Hospital under Bob Perry, the bonus structure required the entire group to reach a certain RVU threshold for everyone to receive 50% of their bonus, eliminating competition for cases." — Todd Ponsky (clinical) [Ep 51 · 5:03](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=303)
- "The BC Children's Hospital gastroschisis study was a retrospective review comparing outcomes before and after implementation of a protocol in 2012, covering patients from 2008 to 2019." (host_summary) [Ep 51 · 5:51](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=351)
- "At Saint Justine Hospital, the approach to gastroschisis differed from other institutions in that there was very low use of silos, with pretty much every patient having an attempt at immediate bedside sutureless closure following a protocol developed several years prior." — Charza Jaharifard (clinical) [Ep 51 · 6:58](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=418)
- "Before and after protocol implementation at BC Children's Hospital, approximately 75% of gastroschisis patients could be closed immediately, whether in the OR pre-implementation with fascial closure or at bedside post-implementation." — Charza Jaharifard (clinical) [Ep 51 · 7:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=477)
- "With silo management, parents look at their newborn's intestines through a silo for 5-6 days and cannot hold their baby until the silo is completely reduced." — Charza Jaharifard (clinical) [Ep 51 · 8:27](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=507)
- "With immediate closure of gastroschisis, if babies are extubated within 48 hours, parents can hold them within 48 hours, or immediately if managed without intubation." — Charza Jaharifard (clinical) [Ep 51 · 8:43](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=523)
- "In prior studies of placental mesenchymal stem cells for in utero MMC repair, two surgeries were performed on lambs: one to create the defect and one to repair it, both in utero, with PMSCs used during repair." (host_summary) [Ep 51 · 10:17](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=617)
- "In the current study, a single operation was performed at approximately 100 days gestational age where the MMC defect was created and repaired simultaneously, with PMSCs placed directly onto the spinal cord." (host_summary) [Ep 51 · 10:43](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=643)
- "The PMSCs did not persist in the placentas, uteri, or lambs at 3 months follow-up." (host_summary) [Ep 51 · 11:23](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=683)
- "There was no histological evidence of abnormal growth or tumor development in the ovine model at 3 months." (host_summary) [Ep 51 · 11:30](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=690)
- "Human trials using PMSCs for in utero myelomeningocele repair have been initiated with the first two patients enrolled." (host_summary) [Ep 51 · 11:52](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-january-2022-apsa-issue-5103?t=712)
- "Gastroschisis is a full thickness abdominal wall defect just to the right of the umbilicus, in which peritoneal contents, most often intestines, protrude through the abdomen without any membranous cover." — Fung Lim (clinical) [Ep 54 · 0:55](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=55)
- "Omphalocele is right through the middle of the umbilicus and has a membranous cover." — Fung Lim (clinical) [Ep 54 · 0:55](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=55)
- "Omphalocele is a congenital disorder and can have associated anomalies, but gastroschisis occurs in otherwise normal babies that have an intrauterine event during development." — Fung Lim (clinical) [Ep 54 · 0:55](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=55)
- "For large omphalocele defects, besides intestine, a good amount of the liver is on the outside in the majority of cases." — Todd Ponsky (host_summary) [Ep 54 · 1:31](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=91)
- "A very high level of alpha fetal protein should prompt consideration of gastroschisis or omphalocele." — Fung Lim (clinical) [Ep 54 · 1:54](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=114)
- "Alpha fetal protein (AFP) is a great screening test, but ultrasound imaging is needed to definitively diagnose abdominal wall defects." — Fung Lim (clinical) [Ep 54 · 1:54](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=114)
- "For gastroschisis, only ultrasound is normally obtained to confirm the diagnosis without additional imaging." — Todd Ponsky (host_summary) [Ep 54 · 2:12](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=132)
- "For omphalocele, besides ultrasound, MRI and echocardiogram are routinely obtained because these patients may have other associated anomalies." — Todd Ponsky (host_summary) [Ep 54 · 2:12](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=132)
- "Fetal growth is tracked monthly in these cases because there is concern for significant growth restriction." — Todd Ponsky (host_summary) [Ep 54 · 2:12](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=132)
- "Biophysical profile and non-stress testing are needed because in utero growth restriction as well as intrauterine fetal demise (IUFD) can occur in these patients." — Fung Lim (clinical) [Ep 54 · 2:51](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=171)
- "If surveillance imaging becomes worrisome enough regarding intrauterine fetal demise, the mother and fetus need to be admitted for continuous monitoring or the fetus delivered emergently." — Fung Lim (clinical) [Ep 54 · 2:51](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=171)
- "Gastroschisis affects approximately one in every 2200 live births." — Todd Ponsky (host_summary) [Ep 54 · 3:15](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=195)
- "Gastroschisis is most common among babies born to young mothers of low gravidity and usually first pregnancy, with 75% being first born." — Fung Lim (epidemiological) [Ep 54 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=207)
- "Nearly 60% of gastroschisis infants are premature." — Fung Lim (epidemiological) [Ep 54 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=207)
- "More than 90% of gastroschisis infants are born with intrauterine growth restriction, weighing less than 2500 grams." — Fung Lim (epidemiological) [Ep 54 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=207)
- "Pseudoephedrine-containing pseudofed has an odds ratio of 4.2 times for gastroschisis compared to aspirin alone at 2.7." — Fung Lim (epidemiological) [Ep 54 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=207)
- "Acetaminophen is identified as a risk factor for gastroschisis." — Fung Lim (epidemiological) [Ep 54 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=207)
- "Other risk factors for gastroschisis include vitamin B deficiencies, drug use, and some genetic predispositions." — Fung Lim (epidemiological) [Ep 54 · 3:27](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=207)
- "Mothers of omphalocele babies are usually advanced in age compared to the gastroschisis group, with advanced maternal age having an odds ratio of 3.3." — Fung Lim (epidemiological) [Ep 54 · 4:21](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=261)
- "The major risk factors for omphalocele are trisomy 13, 18, and 21, which occur in anywhere between 35 and 90% of patients with omphalocele." — Fung Lim (epidemiological) [Ep 54 · 4:21](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=261)
- "Minimizing heat loss and fluid loss in these babies is crucial immediately after birth, otherwise they can show up extremely dehydrated as well as being cold." — Fung Lim (clinical) [Ep 54 · 5:02](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=302)
- "These babies can have significant acidosis and pulmonary hypertension." — Fung Lim (clinical) [Ep 54 · 5:02](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=302)
- "Primary closure is considered if the bowel looks pristine, non-thickened, non-inflammatory, with only a small amount on the outside and enough abdominal domain to push them all back very quickly." — Fung Lim (clinical) [Ep 54 · 5:32](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=332)
- "Staged closure is favored if the defect is large or there's an issue with the bowel, including atresia, compromised bowel, or perforation." — Fung Lim (clinical) [Ep 54 · 6:03](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=363)
- "Some patients develop intestinal perforation after only two to four days of enteral feeding." — Fung Lim (clinical) [Ep 54 · 6:03](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=363)
- "The majority of gastroschisis babies at Cincinnati Children's Hospital in the last four and a half years are managed using a sutureless closure." — Fung Lim (clinical) [Ep 54 · 6:46](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=406)
- "In the sutureless closure technique, after pushing the bowel back in, the umbilical cord is placed over the defect with dressing, and skin will grow over, with small umbilical defects closing spontaneously over time." — Fung Lim (clinical) [Ep 54 · 6:46](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=406)
- "For small bowel atresia encountered in gastroschisis, management options include tapering the dilated portion of bowel or resecting the bowel before tapering." — Fung Lim (clinical) [Ep 54 · 7:25](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=445)
- "For omphalocele babies without significant respiratory issues, sequential reduction using meshes is the best option, sewing meshes to the edges of the fascia without interrupting the membrane." — Fung Lim (clinical) [Ep 54 · 7:54](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=474)
- "At Cincinnati Children's, a Duoderm silo is formed on top of the skin of the patient with omphalocele, using plastic clips to sequentially clip it down until it's flush to the abdominal skin." — Fung Lim (clinical) [Ep 54 · 7:54](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=474)
- "After sequential reduction with plastic clips in omphalocele, the patient is taken to the operating room for delayed primary closure of the fascia and skin." — Todd Ponsky (host_summary) [Ep 54 · 8:38](https://qa.library.globalcastmd.com/watch/omphalocele-gastroschisis-5255?t=518)
- "Infants with intestinal failure have compromised intestinal function, putting them at increased risk of malabsorption and electrolyte and fluid deficits." — Sarah Choi (clinical) [Ep 58 · 0:36](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=36)
- "Sodium depletion can go unrecognized, resulting in poor growth refractory to increased caloric intake." — Sarah Choi (clinical) [Ep 58 · 0:45](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=45)
- "Sodium supplementation has been shown to be associated with weight gain and overall growth in infants with intestinal failure." — Sarah Choi (clinical) [Ep 58 · 1:00](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=60)
- "Serum sodium does not reflect total sodium stores." — Sarah Choi (clinical) [Ep 58 · 1:04](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=64)
- "Fractional excretion of sodium is the optimum measure of total body sodium but is inconvenient in the pediatric population as it requires a paired urine and blood sample." — Sarah Choi (clinical) [Ep 58 · 1:14](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=74)
- "At BC Women's Hospital, urine sodium is used as a non-invasive marker to estimate total body sodium in infants with intestinal failure, with a value above 30 suggesting sodium sufficiency." — Sarah Choi (clinical) [Ep 58 · 1:29](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=89)
- "Urine sodium doesn't account for volume status, therefore can result in oversupplementation or under supplementation with sodium." — Sarah Choi (clinical) [Ep 58 · 1:44](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=104)
- "The urine sodium to urine creatinine ratio offers a non-invasive measure which accounts for variable urine flow and has shown to be strongly correlated with fractional excretion of sodium." — Sarah Choi (clinical) [Ep 58 · 1:57](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=117)
- "The use of the urine sodium to creatinine ratio has not yet been validated in the intestinal failure population." — Sarah Choi (clinical) [Ep 58 · 2:13](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=133)
- "In the study cohort of 22 infants, median gestational age was 31 weeks, median birth weight was 1.9 kg, and median age of enrollment was 8 days." — Sarah Choi (epidemiological) [Ep 58 · 3:18](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=198)
- "Gastroschisis was the most common etiology of intestinal failure in the study cohort." — Sarah Choi (epidemiological) [Ep 58 · 3:30](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=210)
- "There was no significant correlation between either urine sodium or the ratio with daily weight gain when evaluating the entire data set." — Sarah Choi (clinical) [Ep 58 · 3:41](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=221)
- "The ratio was more strongly associated with sodium intake when compared to urine sodium alone." — Sarah Choi (clinical) [Ep 58 · 4:04](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=244)
- "Urine sodium values above 29 and ratio values above 35 best predicted adequate weight gain." — Sarah Choi (clinical) [Ep 58 · 4:18](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=258)
- "The urine sodium threshold of 29 is similar to previous studies, as it is generally accepted that urine sodium values above 30 is suggestive of sodium sufficiency." — Sarah Choi (clinical) [Ep 58 · 4:28](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=268)
- "In the majority of urine sodium and ratio values, both markers were concordant, meaning that if urine sodium value met the threshold, then the ratio also met the threshold." — Sarah Choi (clinical) [Ep 58 · 4:41](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=281)
- "In 19% of the time, the urine sodium and ratio values were discordant." — Sarah Choi (clinical) [Ep 58 · 4:54](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=294)
- "Patients with stomas, even those without intestinal failure, run the risk of sodium depletion, which has a significant impact on their growth." — Paul Wales (clinical) [Ep 58 · 6:08](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=368)
- "Stomas and high stool losses are a large source of sodium bicarbonate as well as magnesium loss." — Paul Wales (clinical) [Ep 58 · 6:19](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=379)
- "Sodium status needs to be thought of, especially in the setting of a baby experiencing poor weight gain in the exposure to what is believed to be adequate calories." — Paul Wales (clinical) [Ep 58 · 6:26](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=386)
- "When sodium is replaced, it helps restore growth, but it doesn't allow catch up growth." — Paul Wales (clinical) [Ep 58 · 6:38](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=398)
- "It's important to track these patients serially so that a trend can be detected and sodium depletion can be avoided in the first place." — Paul Wales (opinion) [Ep 58 · 6:45](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=405)
- "If it becomes part of practice to order urine electrolytes at the time that someone's doing their TPN blood work, it's easy to calculate the fractional excretion of sodium ratio." — Paul Wales (opinion) [Ep 58 · 7:12](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=432)
- "Having potassium, chloride, and osmolality added to the urine electrolytes in addition to just the sodium gives a better picture of whether someone is truly sodium depleted." — Paul Wales (opinion) [Ep 58 · 7:30](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=450)
- "If potassium level is higher than sodium level in urine, that often indicates the aldosterone pathway is turned on." — Paul Wales (clinical) [Ep 58 · 7:41](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=461)
- "Gastric volvulus is associated with congenital diaphragmatic hernia about 17% of the time." — Rod Gerardo (host_summary) [Ep 59 · 1:18](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=78)
- "Gastric volvulus is associated with eventration of the diaphragm about 25% of the time." — Rod Gerardo (host_summary) [Ep 59 · 1:18](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=78)
- "60% of gastric volvulus cases in the pediatric population happen in the first year of life, with about 21% in the first month." — Jason Frischer (epidemiological) [Ep 59 · 1:33](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=93)
- "In a 4-month-old child with gastric volvulus, acute presentation is more likely than chronic." — Jason Frischer (clinical) [Ep 59 · 1:58](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=118)
- "Acute gastric volvulus presentations are usually due to anatomic problems like congenital diaphragmatic hernia." — Rod Gerardo (host_summary) [Ep 59 · 2:13](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=133)
- "Key presentation findings in gastric volvulus include a weird looking fixed bubble in the chest that cannot be decompressed and inability to advance the NG tube." — Beth Rymeski (clinical) [Ep 59 · 2:38](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=158)
- "A little bit of bloody aspirate from the NG tube and a funny looking stomach bubble on X-ray are key findings in gastric volvulus." — Jason Frischer (clinical) [Ep 59 · 2:47](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=167)
- "Chronic gastric volvulus is more related to laxity of the gastric ligaments including gastrophrenic, gastrosplenic, gastrocolic, and gastrohepatic ligaments." — Jason Frischer (clinical) [Ep 59 · 3:10](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=190)
- "Without ligamentous attachments, the stomach is kept in place only at two points: the GE junction and the pylorus, and rotations occur about these points." — Rod Gerardo (host_summary) [Ep 59 · 3:27](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=207)
- "Organoaxial volvulus is the first and most common type of gastric volvulus." — Jason Frischer (clinical) [Ep 59 · 3:43](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=223)
- "In organoaxial volvulus, the stomach spins around an axis drawn between the GE junction and the pylorus, with the greater curvature flipping up and over to become more superior than the lesser curvature." — Jason Frischer (clinical) [Ep 59 · 3:55](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=235)
- "In mesenteroaxial volvulus, rotation occurs around a line through the middle of the stomach from lesser to greater curvature, with the stomach flipping behind and back over." — Jason Frischer (clinical) [Ep 59 · 4:18](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=258)
- "In gastric volvulus, when filled with contrast, the pylorus appears right next to or near the GE junction and above the body of the stomach." — Jason Frischer (clinical) [Ep 59 · 4:46](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=286)
- "Gastric volvulus typically presents in children in the first year of life with non-bilious emesis, gastric distention, and issues passing an NG tube." — Rod Gerardo (host_summary) [Ep 59 · 4:58](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=298)
- "On upper GI contrast study in gastric volvulus, contrast probably does not go past the stomach if it makes it into the stomach." — Ellen Encisco (clinical) [Ep 59 · 5:32](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=332)
- "A classic bird's beak appearance may be seen when contrast is swallowed or placed in a tube sitting in the esophagus in gastric volvulus." — Rod Gerardo (host_summary) [Ep 59 · 5:41](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=341)
- "In organoaxial volvulus, if contrast gets past the GE junction into the stomach, the greater curvature appears flipped up." — Ellen Encisco (clinical) [Ep 59 · 5:53](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=353)
- "In mesenteroaxial volvulus, the duodenum may fill above or superior to the GE junction because the pylorus has flipped up and over or behind and over the top of the stomach." — Jason Frischer (clinical) [Ep 59 · 6:08](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=368)
- "Surgical management of gastric volvulus should be attempted laparoscopically, with the first step being to bring the stomach down from the chest if herniated." — Carolina Pinzon Guzman (clinical) [Ep 59 · 7:09](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=429)
- "G-tube placement is used to pexy the stomach to the abdominal wall to prevent recurrent twisting in gastric volvulus." — Carolina Pinzon Guzman (clinical) [Ep 59 · 7:26](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=446)
- "Gastropexy should be performed at at least one other location in addition to G-tube placement, fixing the stomach in multiple planes to reduce the chance of re-volvulization." — Rod Gerardo (host_summary) [Ep 59 · 7:34](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=454)
- "Fundoplication is not required in pediatric gastric volvulus repair, unlike in some adult cases." — Rod Gerardo (host_summary) [Ep 59 · 7:47](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=467)
- "When managing gastric volvulus found during CDH repair, viability of the stomach must always be checked, especially if chronically volvulized or volvulized for a couple of days, by looking at the serosa and blood flow." — Jason Frischer (clinical) [Ep 59 · 8:40](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=520)
- "In acute gastric volvulus with sudden onset of symptoms, initial management includes securing two good points of IV access and managing the ABCs before proceeding to imaging or surgery." — Chris Pastor (clinical) [Ep 59 · 9:38](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=578)
- "In an acutely ill infant with suspected gastric volvulus, an urgent upper GI should be obtained while resuscitating, as malrotation is more common and must be differentiated from gastric volvulus." — Chris Pastor (clinical) [Ep 59 · 10:08](https://qa.library.globalcastmd.com/watch/neonatal-gastric-volvulus-with-dr-jason-frischer-5494?t=608)
- "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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 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 61 · 25:11](https://qa.library.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1511)
- "Several hospitals have changed their gastroschisis protocols based on recent publications." — Todd Ponsky (host_summary) [Ep 62 · 0:00](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=0)
- "Some institutions start feeds when NG output is less than 20 mL/kg/day." — Justin (clinical) [Ep 62 · 1:45](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=105)
- "Jason Fraser's institution starts feeding immediately after dressing placement as long as the baby is not sick, not having horrible output, and not vomiting." — Jason Frischer (clinical) [Ep 62 · 3:10](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=190)
- "Fraser's institution does not intubate gastroschisis babies for reduction." — Jason Frischer (clinical) [Ep 62 · 3:54](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=234)
- "Awake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching." — Jason Frischer (clinical) [Ep 62 · 5:13](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=313)
- "Some institutions perform gastroschisis reduction under general anesthesia." — Bindi (clinical) [Ep 62 · 5:52](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=352)
- "Cincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory." — Jason Frischer (clinical) [Ep 62 · 6:19](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=379)
- "Cincinnati Children's protocol includes standardized feed advancement and sham feeding to address poor oral feeding skills in gastroschisis patients." — Beth Rymeski (clinical) [Ep 62 · 6:52](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=412)
- "Cincinnati Children's attempted ad-lib feeding for gastroschisis but abandoned it after one year due to poor results, including delayed NG tube removal and starting feeds too late." — Beth Rymeski (clinical) [Ep 62 · 8:10](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=490)
- "Cincinnati Children's current gastroschisis feeding protocol has been in place for approximately four years." — Beth Rymeski (clinical) [Ep 62 · 8:40](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=520)
- "In a multi-institutional study, protocol-fed gastroschisis infants had fewer surgical site infections compared to non-protocol-fed infants." — Beth Rymeski (host_summary) [Ep 62 · 10:01](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=601)
- "The reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself." — Jason Frischer (opinion) [Ep 62 · 10:30](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=630)
- "The multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions." — Jason Frischer (epidemiological) [Ep 62 · 10:30](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=630)
- "Cincinnati Children's average gastroschisis length of stay was 49 days before protocol implementation, which was astronomically higher than comparable NICUs in their cooperative network." — Jason Frischer (epidemiological) [Ep 62 · 11:20](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=680)
- "After implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years." — Jason Frischer (epidemiological) [Ep 62 · 12:10](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=730)
- "Cincinnati Children's has seen a decrease in time from first feed to full feeds but has not yet reduced the time from admission to first feed (except in 2020)." — Jason Frischer (epidemiological) [Ep 62 · 12:10](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=730)
- "Continuous feeds in gastroschisis patients can lead to oral aversion and prolonged length of stay when patients are not taking anything orally." — Justin (clinical) [Ep 62 · 13:14](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=794)
- "Cincinnati Children's protocol includes both intermittent feeds and sham feeds, with sham feeds implemented for approximately one year." — Beth Rymeski (clinical) [Ep 62 · 13:51](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=831)
- "Approximately two-thirds of Cincinnati Children's gastroschisis patients are discharged home with an NG tube or G-tube for continued feeding support." — Beth Rymeski (epidemiological) [Ep 62 · 13:51](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=831)
- "Cincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization." — Jason Frischer (clinical) [Ep 62 · 14:20](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=860)
- "Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement." — Jason Frischer (host_summary) [Ep 62 · 15:17](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=917)
- "The most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition." — Jason Frischer (opinion) [Ep 62 · 16:00](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=960)
- "For significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based." — Jason Frischer (clinical) [Ep 62 · 16:40](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=1000)
- "Cincinnati Children's written protocol explicitly states that emesis is expected during gastroschisis feeding to set appropriate expectations for nursing staff and families." — Beth Rymeski (clinical) [Ep 62 · 16:58](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=1018)
- "One recent Cincinnati Children's gastroschisis patient who was primarily reduced on day of life zero was discharged at approximately two weeks and remained well at two-week follow-up, though this is an outlier on the faster end." — Jason Frischer (clinical) [Ep 62 · 17:22](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=1042)
- "Cincinnati Children's current average gastroschisis length of stay is 30 to 34 days." — Jason Frischer (epidemiological) [Ep 62 · 17:22](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=1042)
- "Cincinnati Children's has not seen any aspirations with their early aggressive feeding approach, though they acknowledge they are still early in implementation and continue to monitor data." — Jason Frischer (epidemiological) [Ep 62 · 18:14](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=1094)
- "Much of the data supporting early feeding in gastroschisis originated from resource-limited countries without TPN access, though implementing this approach in Africa has proven difficult due to poor tolerance." — Justin (epidemiological) [Ep 62 · 18:28](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=1108)
- "At Cincinnati Children's, approximately two-thirds of gastroschisis cases cannot be reduced immediately and are placed in a silo for gradual reduction followed by sutureless closure, with feeds started after closure." — Jason Frischer (clinical) [Ep 62 · 18:56](https://qa.library.globalcastmd.com/watch/update-course-2022-updates-in-gastroschisis-feeding-protocols-jason-fraser-beth-rymeski-and-steven-lee-5824?t=1136)
- "The Midwest Pediatric Surgery Research Consortium (MWPSC) was established by departments of Pediatric Surgery from 11 children's hospitals" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 64 · 2:15](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=135)
- "The NAT study used historical patterns captured by trauma registries to predict what the volume should have been during the initial COVID time period and compared that to observed rates" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 64 · 3:42](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=222)
- "NAT was higher after the lockdown, not during the lockdown" — Todd Ponsky and Biran Modi (clinical) [Ep 64 · 4:07](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=247)
- "Initially non-accidental trauma rates dropped a little bit, but after that the rate increased above what they had expected during the stay at home orders" — Nicole Chandler (host_summary) [Ep 64 · 4:16](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=256)
- "Patients disproportionately affected were older kids who were older than 5 years who would most commonly be in school, minority children, and lower socioeconomic groups as determined by the social vulnerability index" — Nicole Chandler (host_summary) [Ep 64 · 4:31](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=271)
- "CDC Social Vulnerability Index was uniquely created to see neighborhood's vulnerability during times of crises" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 64 · 5:12](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=312)
- "During times of public health crises, it's important to maintain systems of protection for children" — Nicole Chandler (opinion) [Ep 64 · 5:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=337)
- "One has to be careful not to make too strong of conclusions based on any data when it's related to simply ICD 10 codes, regardless of how many institutions and how long the evaluation period was" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 64 · 6:07](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=367)
- "There are very few cell lines available to study hepatoblastoma, and a number of cell lines touted to be hepatoblastoma are actually hepatocellular carcinoma" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 64 · 6:47](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=407)
- "Management of metastatic hepatoblastoma continues to pose significant treatment challenges" — Nicole Chandler (clinical) [Ep 64 · 7:13](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=433)
- "The new hepatoblastoma cell line was created by injecting labeled cells into mouse tail vein, harvesting lung metastases, culturing surviving cells, and repeating the process until establishing a reliably metastatic cell line" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 64 · 7:24](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=444)
- "Compared to the original human cell line, the new cell line exhibited increased tumorigenicity, invasiveness, and increased resistance to chemotherapy" — Nicole Chandler (host_summary) [Ep 64 · 8:14](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=494)
- "PSORC (Pediatric Surgical Oncology Research Collaborative) is a multi-institutional consortium of North American pediatric surgeons focused on advancing care of children with cancer" — Marcus Malik (clinical) [Ep 64 · 9:46](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=586)
- "PSORC was founded because there was a need to amalgamate data from multiple institutions to better study surgical questions in pediatric cancer" — Marcus Malik (clinical) [Ep 64 · 10:05](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=605)
- "The most common localization techniques for small pulmonary nodules were wire and methylene blue dye, followed by methylene blue dye only" — Nicole Chandler (host_summary) [Ep 64 · 10:49](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=649)
- "There was no difference in successful IR localization or successful resection of pulmonary nodules when comparing different localization techniques" — Nicole Chandler (host_summary) [Ep 64 · 10:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=656)
- "Image-guided localization techniques varied significantly among institutions but all were wildly successful, showing that experience is probably more important than the actual technique itself" — Nicole Chandler (opinion) [Ep 64 · 12:06](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=726)
- "Pediatric intestinal failure was defined as requirement of parenteral nutrition for 60 days or more at any time, with diagnosis before 8 years of age" — Todd Ponsky and Biran Modi (clinical) [Ep 64 · 12:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=777)
- "The hypothesis was that chronic pediatric intestinal failure would delay puberty and potentially dull the sharp spike of puberty in terms of peak height velocity" — Todd Ponsky and Biran Modi (clinical) [Ep 64 · 13:44](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=824)
- "Peak height velocity occurred at significantly younger ages for both males and females with intestinal failure" — Nicole Chandler (host_summary) [Ep 64 · 14:00](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=840)
- "Puberty onset occurred significantly earlier compared to established norms for males, meaning they reached pubertal onset earlier than the CDC 50th percentile" — Nicole Chandler (host_summary) [Ep 64 · 14:00](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=840)
- "There is a high incidence of short stature in chronic intestinal failure" — Todd Ponsky and Biran Modi (clinical) [Ep 64 · 14:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=877)
- "The finding that short stature is not because kids are missing out on pubertal timing and peak height velocity suggests we need to do a better job at setting them up to go into puberty with working on their height and linear growth" — Todd Ponsky and Biran Modi (opinion) [Ep 64 · 14:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=877)
- "In the United States, approximately 5 million central venous catheter lines are placed annually, with several thousand in pediatric surgical patients." — Rod Gerardo (host_summary) [Ep 63 · 0:13](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=13)
- "At Cincinnati Children's Hospital, the transplant surgery team manages complex vascular access and catheter-based dialysis access." — Alex Bondoc (clinical) [Ep 63 · 0:26](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=26)
- "Central venous catheters are non-tunneled, typically for temporary hospital use, and can have 1 to 3 lumens." — Rod Gerardo (host_summary) [Ep 63 · 1:00](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=60)
- "Ports are for long-term access (months to years), have tunneled catheters with totally implantable reservoirs, are often used for chemotherapy, and can have 1 or 2 lumens." (host_summary) [Ep 63 · 1:10](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=70)
- "Broviac catheters are tunneled lines with cuffs, used for months to years for chemotherapy, parenteral nutrition, or frequent blood transfusions, and can have 1 or 2 lumens." — Rod Gerardo (host_summary) [Ep 63 · 1:25](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=85)
- "Hemodialysis or pheresis catheters can be temporary (uncuffed) or permanent (cuffed), and can have 1 to 3 lumens." (host_summary) [Ep 63 · 1:40](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=100)
- "From a logistical standpoint, chest and neck central venous access is preferred over femoral access." — Alex Bondoc (clinical) [Ep 63 · 2:09](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=129)
- "There is evidence suggesting an increased rate of complications and infection with femoral access compared to chest and neck access." (host_summary) [Ep 63 · 2:17](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=137)
- "Contraindications for central venous access include thrombosis, collateralization, and central stenosis of the SVC, which may require exotic concurrent procedures or alternative access sites." — Alex Bondoc (clinical) [Ep 63 · 2:39](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=159)
- "Unless patients have congenital anomalies (usually cardiovascular), routine pre-procedural ultrasound is not necessary for first-time line placement." — Alex Bondoc (clinical) [Ep 63 · 3:09](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=189)
- "For patients requiring multiple lines (line number 4, 5, or 6), Doppler venous ultrasound of the jugulars is recommended, and in small children the SVC and subclavians can sometimes be visualized." — Alex Bondoc (clinical) [Ep 63 · 3:20](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=200)
- "Pre-procedural imaging may be escalated to contrast-enhanced MR or CT venography, and sometimes intraoperative venography with fluoroscopy is performed." — Alex Bondoc (clinical) [Ep 63 · 3:37](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=217)
- "For small children, neonates, and infants, positioning over a vertically oriented shoulder roll (parallel with the spine) provides hyperextension of the neck and allows shoulder weight to drop posteriorly, giving access to bilateral subclavians and jugulars." — Alex Bondoc (clinical) [Ep 63 · 3:59](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=239)
- "For very small neonates, many surgeons prefer a cut-down approach over percutaneous access." — Rod Gerardo (host_summary) [Ep 63 · 4:43](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=283)
- "Dr. Bonddo prefers using a micropuncture kit with a 21-gauge finder needle for small babies, which is smaller than the 18-gauge needle in standard tunnel line kits." — Alex Bondoc (clinical) [Ep 63 · 4:55](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=295)
- "Using ultrasound for internal jugular central line placement is the number one preferred method, with the lowest risk of pneumothorax and carotid artery injury." — Alex Bondoc (clinical) [Ep 63 · 5:25](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=325)
- "For large-bore access like dialysis catheters, the patient should be stuck as low as possible on the neck, using the ultrasound probe (approximately 12mm diameter) levered against the clavicle as a landmark." — Alex Bondoc (clinical) [Ep 63 · 5:52](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=352)
- "Low neck puncture leaves more catheter to curve in the neck; mid-neck puncture creates lax catheter that can lead to problems with neck turning and catheter displacement from the SVC." — Alex Bondoc (clinical) [Ep 63 · 6:22](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=382)
- "Subclavian line placement should be considered when both IJ access sites are lost or the patient is in a cervical collar." (host_summary) [Ep 63 · 6:42](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=402)
- "For subclavian access, the insertion point is at the junction of the median and medial aspects of the clavicle, at least one finger breadth (approximately 1cm) inferiorly and laterally, to allow levering under the bone." — Alex Bondoc (clinical) [Ep 63 · 6:56](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=416)
- "When approaching the clavicle during subclavian access, the needle should be kept flat with downward pressure on the skin rather than angling at 30 degrees." — Alex Bondoc (clinical) [Ep 63 · 7:14](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=434)
- "For subclavian access, the needle should be aimed directly at the sternal notch initially, then angled wider toward the angle of the mandible in a radial motion if unsuccessful." — Alex Bondoc (clinical) [Ep 63 · 7:34](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=454)
- "The catheter tip should typically be positioned at the junction between the right atrium and superior vena cava." (host_summary) [Ep 63 · 7:46](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=466)
- "The right triangle technique for catheter tip positioning uses the trachea as the theoretical midline continued from the carina, with the right main stem bronchus as the hypotenuse; the catheter tip should be within this triangle to ensure atriocaval junction placement." — Alex Bondoc (clinical) [Ep 63 · 8:04](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=484)
- "Post-procedural chest X-ray is not routinely ordered for single-stick, uncomplicated line placement using fluoroscopy, based on data from Children's Mercy Hospital Kansas City." — Alex Bondoc (clinical) [Ep 63 · 8:38](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=518)
- "Post-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rare complications like chylothorax or thoracic duct injury." — Alex Bondoc (clinical) [Ep 63 · 9:06](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=546)
- "Long-term complications include thrombosis, catheter displacement, kinking, and eventual line degradation over extended periods." — Rod Gerardo (host_summary) [Ep 63 · 9:21](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=561)
- "For line infection management, the first clinical decision is whether the patient is septic from the line; if septic and in the ICU, source control requires bedside line removal under light sedation." — Alex Bondoc (clinical) [Ep 63 · 9:41](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=581)
- "For non-septic line-dependent patients with complex vascular access, the organism and antibiotic sensitivity are determined, serial blood cultures are obtained, and the line may be salvaged if sustained culture negativity is achieved." — Alex Bondoc (clinical) [Ep 63 · 10:04](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=604)
- "Traditional locking solutions are predominantly antibiotic locks, but they lead to development of bacterial resistance." — Paul Wales (clinical) [Ep 63 · 10:35](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=635)
- "Ethanol locks are antimicrobial without resistance development and kill both planktonic bacteria (floating in the lumen) and sessile bacteria (embedded in biofilm along the catheter wall)." — Paul Wales (clinical) [Ep 63 · 10:56](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=656)
- "Kite lock is a 4% tetrasodium EDTA solution that is antimicrobial without resistance, and has antifibrinolytic and antithrombotic properties." — Paul Wales (clinical) [Ep 63 · 11:24](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=684)
- "Kite lock is licensed for pediatric use in Canada, Europe, and Australia, but availability varies by region." — Paul Wales (clinical) [Ep 63 · 11:59](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=719)
- "For patients with exhausted femoral, IJ, and subclavian access options, translumbar line placement through the back musculature into the intrahepatic IVC is an alternative approach performed with interventional radiology." — Alex Bondoc (clinical) [Ep 63 · 12:19](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=739)
- "For emergency vascular access via facial vein cutdown, a horizontal incision is made just lateral to the sternocleidomastoid at the angle of the mandible with the head turned to the patient's left, and the facial vein is typically the first large vein encountered." — Alex Bondoc (clinical) [Ep 63 · 12:48](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=768)
- "For facial vein cutdown, the catheter should be beveled hard to allow blind passage without wire guidance, theoretically allowing it to follow a path without bumping against the vessel wall." — Alex Bondoc (clinical) [Ep 63 · 13:04](https://qa.library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=784)
- "The Midwest Pediatric Surgery Research Consortium (MWPSC) was established by departments of Pediatric Surgery from 11 children's hospitals" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 65 · 2:15](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=135)
- "The NAT study used historical patterns captured by trauma registries to predict what the volume should have been during the initial COVID time period and compared that to observed rates" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 65 · 3:42](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=222)
- "NAT was higher after the lockdown, not during the lockdown" — Todd Ponsky and Biran Modi (clinical) [Ep 65 · 4:07](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=247)
- "Initially non-accidental trauma rates dropped a little bit, but after that the rate increased above what they had expected during the stay at home orders" — Nicole Chandler (host_summary) [Ep 65 · 4:16](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=256)
- "Patients disproportionately affected were older kids who were older than 5 years who would most commonly be in school, minority children, and lower socioeconomic groups as determined by the social vulnerability index" — Nicole Chandler (host_summary) [Ep 65 · 4:31](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=271)
- "CDC's Social Vulnerability Index was uniquely created to see neighborhood's vulnerability during times of crises" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 65 · 5:12](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=312)
- "During times of public health crises, it's important to maintain systems of protection for children" — Nicole Chandler (opinion) [Ep 65 · 5:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=337)
- "One has to be careful not to make too strong of conclusions based on ICD 10 codes, no matter how many institutions and how long the evaluation period was" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 65 · 6:07](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=367)
- "There are very few cell lines available to study hepatoblastoma, and a number of cell lines touted to be hepatoblastoma are actually hepatocellular carcinoma" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 65 · 6:47](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=407)
- "Management of metastatic hepatoblastoma continues to pose significant treatment challenges" — Nicole Chandler (clinical) [Ep 65 · 7:13](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=433)
- "The researchers labeled hepatoblastoma cells with luciferase, injected them into mouse tail veins where they preferentially went to lungs, harvested and cultured surviving cells, and repeated this process until establishing a reliable metastatic cell line" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 65 · 7:24](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=444)
- "The new metastatic hepatoblastoma cell line exhibited increased tumorigenicity, invasiveness, and increased resistance to chemotherapy compared to the original human cell line" — Nicole Chandler (host_summary) [Ep 65 · 8:14](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=494)
- "We never had a hepatoblastoma cell line mouse model before" — Todd Ponsky and Biran Modi (clinical) [Ep 65 · 8:29](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=509)
- "PSORC (Pediatric Surgical Oncology Research Collaborative) is a multi-institutional consortium of North American pediatric surgeons focused on advancing care of children with cancer" — Marcus Malik (clinical) [Ep 65 · 9:46](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=586)
- "There has not been consistency in localization techniques for small pulmonary nodules across North America, with surgeons doing their own thing" — Marcus Malik (clinical) [Ep 65 · 10:19](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=619)
- "The most common localization techniques were wire and methylene blue dye, followed by methylene blue dye only" — Nicole Chandler (host_summary) [Ep 65 · 10:49](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=649)
- "There was no difference in successful IR localization or successful resection of pulmonary nodules among the different localization techniques" — Nicole Chandler (host_summary) [Ep 65 · 10:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=656)
- "Time under anesthesia can be long and quite variable depending on whether institutions use hybrid ORs or have IR on different floors" — Marcus Malik (clinical) [Ep 65 · 11:10](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=670)
- "ICG will become much more popular and more effective for nodule localization in 5 years" — Todd Ponsky and Biran Modi (opinion) [Ep 65 · 11:54](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=714)
- "Image guided localization techniques varied significantly among institutions but all were wildly successful, showing that experience is probably more important than the actual technique itself" — Nicole Chandler (opinion) [Ep 65 · 12:06](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=726)
- "The study focused on patients with pediatric intestinal failure, defined as requirement of parenteral nutrition for 60 days or more at any time, who had the diagnosis before age 8 and were older than 8 at time of study" — Todd Ponsky and Biran Modi (clinical) [Ep 65 · 12:52](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=772)
- "Puberty is at least partially dependent on having good nutritional stores based on hormonal drivers of puberty" — Todd Ponsky and Biran Modi (clinical) [Ep 65 · 13:38](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=818)
- "The hypothesis was that chronic pediatric intestinal failure would delay puberty and potentially dull the sharp spike of peak height velocity" — Todd Ponsky and Biran Modi (clinical) [Ep 65 · 13:45](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=825)
- "Peak height velocity occurred at significantly younger ages for both males and females with intestinal failure" — Nicole Chandler (host_summary) [Ep 65 · 14:00](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=840)
- "Puberty onset occurred significantly earlier compared to established norms for males, meaning they reached pubertal onset earlier than the CDC 50th percentile" — Nicole Chandler (host_summary) [Ep 65 · 14:00](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=840)
- "Children with intestinal failure might be slightly short statured but are not severely undersized compared to the general population" — Todd Ponsky and Biran Modi (clinical) [Ep 65 · 14:20](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=860)
- "There is a high incidence of short stature in chronic intestinal failure" — Todd Ponsky and Biran Modi (clinical) [Ep 65 · 14:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=877)
- "The finding that kids with intestinal failure are not missing out on pubertal timing and peak height velocity suggests we need to do a better job at setting them up to go into puberty by working on their height and linear growth" — Todd Ponsky and Biran Modi (opinion) [Ep 65 · 14:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=877)
- "Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it." — Michael Helmrath (clinical) [Ep 66 · 1:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=83)
- "In the 1980s and 1990s, babies with intestinal failure had poor outcomes primarily due to liver progression to inflammation and fibrosis associated with parenteral nutrition, lipids, and phytosterols." — Ellen Encisco (host_summary) [Ep 66 · 1:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=110)
- "Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well." — Michael Helmrath (clinical) [Ep 66 · 2:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=133)
- "The first 4 months of life is when care for intestinal failure patients is most uncoordinated, and surgical decisions made during this period have the most profound effect on long-term outcome." — Todd Ponsky (host_summary) [Ep 66 · 2:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=149)
- "The gut doubles in length during the last trimester and the first year of life, and this maturation process occurs when the baby is fed." — Michael Helmrath (clinical) [Ep 66 · 2:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=175)
- "Healthy growth of the intestine requires nutrition; anything that disrupts this affects maturation of both absorptive/digestive capacity and peristalsis." — Michael Helmrath (clinical) [Ep 66 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=183)
- "Absorptive surface area comes from the waves of peristalsis moving over the villi, not from the exposed length of bowel." — Todd Ponsky (host_summary) [Ep 66 · 3:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=212)
- "Lengthening bowel that doesn't have peristalsis does not increase absorption; very short bowel children can sometimes come off TPN because their motility is good." — Michael Helmrath (clinical) [Ep 66 · 3:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=226)
- "The majority of pediatric short bowel syndrome cases present at birth due to neonatal causes: congenital GI anomalies or acquired conditions like necrotizing enterocolitis." — Paul Wales (epidemiological) [Ep 66 · 4:18](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=258)
- "When reestablishing bowel continuity, size discrepancy between bowel ends must be addressed or a functional obstruction will result even if the anastomosis is patent." — Paul Wales (clinical) [Ep 66 · 5:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=342)
- "Size discrepancy can be managed by resection to a more appropriate caliber, tapering enteroplasty, or serial transverse enteroplasty (STEP) depending on available bowel length." — Paul Wales (clinical) [Ep 66 · 6:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=362)
- "Gastroschisis patients tend to not do as well with STEP procedures regardless of whether atresia is present; among STEP procedures performed over the years, gastroschisis cases consistently had worse outcomes." — Paul Wales (epidemiological) [Ep 66 · 7:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=428)
- "Gastroschisis patients have inherent dysmotility." — Todd Ponsky (host_summary) [Ep 66 · 7:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=441)
- "The enteric nervous system in gastroschisis is damaged from exposure to amniotic fluid and requires a healing and recovery phase; this regeneration is attenuated by dysmotility and stasis, not enhanced." — Michael Helmrath (clinical) [Ep 66 · 7:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=452)
- "In atresia without gastroschisis, the bowel may have good peristalsis from working against an obstruction, and when done correctly with proper orientation, a longitudinal lengthening procedure may benefit the child." — Michael Helmrath (opinion) [Ep 66 · 7:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=475)
- "Children who undergo STEP procedures in their first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds." — Michael Helmrath (clinical) [Ep 66 · 8:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=499)
- "Among patients with limited gut, necrotizing enterocolitis patients do best because they have been fed before, have established GI motility, and the maturation phase has already been initiated." — Michael Helmrath (opinion) [Ep 66 · 8:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=520)
- "STEP procedure is not usually performed unless bowel is at least 5 centimeters dilated to make it worthwhile." — Paul Wales (clinical) [Ep 66 · 9:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=549)
- "At birth, neonatal bowel is usually not dilated enough to apply the STEP procedure." — Ellen Encisco (host_summary) [Ep 66 · 9:36](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=576)
- "In scenarios where bowel is not adequately dilated, options include resecting bulbs with tapering enteroplasty, establishing continuity if possible, or leaving bowel disconnected with distal feeding tube access to grow the distal bowel before reconnection." — Paul Wales (clinical) [Ep 66 · 9:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=581)
- "The STEP procedure was originally described by HP Kim and Tom Jackson." — Paul Wales (clinical) [Ep 66 · 10:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=645)
- "For STEP, a transverse supraumbilical abdominal incision is used, all adhesions are lysed, and the entire intestinal tract is laid out from top to bottom to understand anatomy and maximize mobility." — Paul Wales (clinical) [Ep 66 · 11:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=662)
- "The anti-mesenteric surface of the bowel is marked with surgical pen after drying with a lap sponge; maintaining this alignment prevents longitudinal twisting of the bowel during stapling." — Paul Wales (clinical) [Ep 66 · 11:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=689)
- "Bowel length is measured before the procedure using 30 silk dipped in mineral oil; caliber and length of the dilated segment to be stepped are also recorded." — Paul Wales (clinical) [Ep 66 · 11:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=718)
- "An endo-GIA stapler is preferred over an open GIA stapler because the smaller cartridge head is more amenable in smaller patients." — Paul Wales (opinion) [Ep 66 · 12:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=740)
- "Staple lines are applied perpendicular to the mesentery at 90° and 270° (3 o'clock and 9 o'clock positions if mesenteric vessels are at 0°)." — Paul Wales (clinical) [Ep 66 · 12:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=754)
- "A vascular (white) cartridge with 2.5 mm staples that crimp to 1 mm is used; this is more appropriate for younger patients' bowel thickness and prevents leaks that occurred with classic blue loads in early experience." — Paul Wales (clinical) [Ep 66 · 12:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=778)
- "Target caliber for STEP is 1.5 cm in babies and 2 to 2.5 cm in older infants or children; making it too narrow risks obstruction, especially in patients with borderline motility." — Paul Wales (clinical) [Ep 66 · 13:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=803)
- "Before firing the stapler, measurements are taken to both the end of the bowel and to the side to ensure proper caliber is maintained throughout the length." — Paul Wales (clinical) [Ep 66 · 14:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=849)
- "A U-stitch with 4-0 PDS is placed in the crotch of each staple line to prevent potential leaks at that point." — Paul Wales (clinical) [Ep 66 · 14:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=868)
- "The procedure is performed with a partner, alternating sides of the bowel, working down the length; 45 mm cartridges are most versatile, but 30 mm and 60 mm cartridges may be needed depending on bowel diameter." — Paul Wales (clinical) [Ep 66 · 14:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=890)
- "At the top and bottom of the STEP segment, an additional oblique staple line is fired to taper the transition and avoid a 'dog ear' blind loop that can dilate over time." — Paul Wales (clinical) [Ep 66 · 15:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=908)
- "If one part of the stepped bowel becomes dilated, the STEP segments can rotate away from each other separately, causing twisting and functional obstruction." — Ellen Encisco (host_summary) [Ep 66 · 15:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=957)
- "After completing the STEP, the length of stepped bowel, new total bowel length, and final caliber (2-2.5 cm) are recorded." — Todd Ponsky (host_summary) [Ep 66 · 16:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=973)
- "The STEP procedure is performed with staple lines perpendicular to the mesentery (90° and 270°), not in the anti-mesenteric to mesenteric orientation (180° and 0°)." — Paul Wales (clinical) [Ep 66 · 16:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=983)
- "The duodenum is not stepped; the STEP procedure starts where the bowel begins to dilate, usually distal to the duodenum." — Paul Wales (clinical) [Ep 66 · 16:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1016)
- "Avoiding staple lines in the duodenum allows proximal access if emergency reoperation is needed for a leak." — Paul Wales (opinion) [Ep 66 · 17:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1023)
- "If duodenal narrowing is needed, a stapler is used to partially narrow the lateral side away from the bile duct and ampulla; plication sutures are not used because they usually fail." — Paul Wales (clinical) [Ep 66 · 17:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1035)
- "The duodenum has no mesentery, making it impossible to orient 90° and 270° positions; surgeons who STEP the duodenum end up entering the bowel at inconsistent orientations." — Michael Helmrath (clinical) [Ep 66 · 17:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1052)
- "A retrospective study was conducted in the Netherlands between 1998 and 2018 examining contrast enema use prior to stoma reversal." — Cecilia Gigena (host_summary) [Ep 69 · 0:13](https://qa.library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=13)
- "The study included patients under three years old who underwent stoma reversal." — Cecilia Gigena (host_summary) [Ep 69 · 0:24](https://qa.library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=24)
- "The study gathered 244 patients." — Cecilia Gigena (host_summary) [Ep 69 · 0:38](https://qa.library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=38)
- "10% of patients developed strictures." — Cecilia Gigena (host_summary) [Ep 69 · 0:40](https://qa.library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=40)
- "95% of patients with strictures had necrotizing enterocolitis." — Cecilia Gigena (host_summary) [Ep 69 · 0:43](https://qa.library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=43)
- "Only 68% of all patients had a contrast enema prior to stoma reversal." — Cecilia Gigena (host_summary) [Ep 69 · 0:47](https://qa.library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=47)
- "Contrast enema was able to detect 92% of strictures." — Cecilia Gigena (host_summary) [Ep 69 · 0:51](https://qa.library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=51)
- "Contrast enema prior to stoma reversal is only useful if patients had necrotizing enterocolitis." — Cecilia Gigena (opinion) [Ep 69 · 0:54](https://qa.library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=54)
- "The biggest benefit of the STEP procedure is tapering the bowel and reestablishing a more normal caliber to improve motility." — Paul Wales (clinical) [Ep 68 · 1:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=112)
- "STEP does not create new bowel but redistributes it to reestablish more normal caliber bowel, which helps improve motility overall." — Ellen Encisco (host_summary) [Ep 68 · 2:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=124)
- "It can take up to 6 months before you actually start to see a significant improvement in absorptive capacity after STEP." — Paul Wales (clinical) [Ep 68 · 3:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=184)
- "Improvements in absorptive capacity are measured with fecal fat, alpha-1 antitrypsin clearance, xylose absorption, and citrulline levels as they rise over time." — Paul Wales (clinical) [Ep 68 · 3:16](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=196)
- "The reason absorptive improvement takes time is that inflamed, sick, leaky mucosa in the setting of bacterial overgrowth needs to heal." — Paul Wales (clinical) [Ep 68 · 3:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=204)
- "About 50% reduction in parental nutrition support can be expected after STEP." — Ellen Encisco (host_summary) [Ep 68 · 3:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=213)
- "Half of the people that have a STEP will have progression of improved enteral tolerance, and half will actually have a worsening." — Michael Helmrath (clinical) [Ep 68 · 3:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=220)
- "The six month postoperative period is very critical for analyzing how the patient is moving forward after STEP." — Michael Helmrath (clinical) [Ep 68 · 3:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=226)
- "Before operating for a STEP procedure, you need to first rule out other anatomical problems by laying out the bowel and getting the mesentery completely oriented." — Michael Helmrath (clinical) [Ep 68 · 4:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=248)
- "If you only focus on the STEP without examining the complete anatomy, you will miss some of the reasons why these kids aren't getting better." — Michael Helmrath (clinical) [Ep 68 · 4:14](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=254)
- "The management of these kids is not a one-stop shopping that you're going to fix with your operation; there is nothing wrong with staging." — Michael Helmrath (opinion) [Ep 68 · 4:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=293)
- "Ulcers at STEP staple lines are not uncommon, and many kids have been transfused every month for years because of that." — Anton Bash (host_summary) [Ep 68 · 5:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=353)
- "Recurrent bleeding from STEP staple lines is an absolute indication to operate." — Michael Helmrath (clinical) [Ep 68 · 6:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=361)
- "Bleeding at STEP staple lines is an underreported complication that is really difficult to manage in some cases." — Paul Wales (clinical) [Ep 68 · 6:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=384)
- "There is a whole spectrum of findings from ulcers at staple lines, from just having specks of blood in the stool to enough bleeding that kids might have to be transfused every week and a half." — Ellen Encisco (host_summary) [Ep 68 · 6:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=392)
- "Staple line ulcers can recur after treatment." — Ellen Encisco (host_summary) [Ep 68 · 6:47](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=407)
- "Staple line bleeding is hypothesized to be a microbiome problem occurring in a pro-inflammatory environment." — Paul Wales (opinion) [Ep 68 · 6:49](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=409)
- "Staple line bleeding tends to occur in type 2 anatomy, which is small bowel to colonic remnant in the absence of an intact colon ileocecal valve." — Paul Wales (clinical) [Ep 68 · 6:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=415)
- "Pathology of staple line ulcers shows non-specific inflammation with no vasculitis, no viral elements, and no obvious ischemia." — Paul Wales (clinical) [Ep 68 · 7:12](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=432)
- "Teams have tried enteral omega 3 lipid supplements, bacterial overgrowth management with cycled antibiotics or probiotics, 5ASA, budesonide, and immune modulators like Remicade for staple line bleeding, but none have been the perfect remedy." — Ellen Encisco (host_summary) [Ep 68 · 7:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=441)
- "The underlying issue in staple line bleeding is not in the bowel but actually in the mesentery." — Ellen Encisco (host_summary) [Ep 68 · 7:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=472)
- "Mesenteric inflammation and scarring creates an obstruction to venous outflow, resulting in venous hypertension along the staple lines." — Michael Helmrath (clinical) [Ep 68 · 8:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=483)
- "Mesenteric inflammation causes scarring and obstructs venous outflow, leading to enlarged veins and venous hypertension on the bowel, and even large lymph nodes from lymphatic obstruction." — Ellen Encisco (host_summary) [Ep 68 · 8:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=497)
- "During operation for staple line bleeding, you can see vessels the size of your thumb and really big adenopathy because the lymphatics are also obstructed." — Michael Helmrath (clinical) [Ep 68 · 8:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=513)
- "It is very important to free up the mesentery from scar, which is a dense scar." — Michael Helmrath (clinical) [Ep 68 · 8:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=522)
- "Once you free up the mesenteric scar, those big vessels come right back to normal." — Anton Bash (host_summary) [Ep 68 · 8:47](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=527)
- "Venous hypertension is what leads to the bleeding at staple lines." — Michael Helmrath (clinical) [Ep 68 · 8:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=536)
- "Dr. Helmrath typically revises the staple line with a hand sewn stitch when mesenteric scarring and venous hypertension are present." — Ellen Encisco (host_summary) [Ep 68 · 9:00](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=540)
- "The key in managing staple line bleeding is to look at the mesentery and free up the mesentery, not just look at the bowel." — Michael Helmrath (clinical) [Ep 68 · 9:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=549)
- "Mesenteric scarring causing venous hypertension is obvious if you're looking for it during operation." — Michael Helmrath (opinion) [Ep 68 · 9:27](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=567)
- "Most referrals for intestinal rehabilitation have had multiple operations before coming to the specialist center." — Paul Wales (clinical) [Ep 68 · 10:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=605)
- "Optimizing a child's anatomy may not be conducive to just one operation; you have to set yourself up sometimes planning for the next case." — Paul Wales (opinion) [Ep 68 · 10:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=609)
- "Doing things in a staged fashion is typical for the intestinal rehabilitation patient population." — Ellen Encisco (host_summary) [Ep 68 · 10:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=625)
- "Dr. Helmrath documents detailed operative notes for himself describing orientation, landmarks, and what was done to guide future operations." — Michael Helmrath (clinical) [Ep 68 · 10:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=633)
- "As intestinal rehabilitation patients grow and develop, more issues might arise requiring additional operations." — Ellen Encisco (host_summary) [Ep 68 · 10:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=645)
- "Surgeons should try not to be the hero and try not to do everything, especially in the first week of life; understand that biology, physiology, and growth are a spectrum." — Michael Helmrath (opinion) [Ep 68 · 10:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=652)
- "The surgeon plays a huge role in intestinal rehabilitation even when patients are doing well, because you have to see the progress." — Michael Helmrath (opinion) [Ep 68 · 11:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=668)
- "Intestinal rehabilitation is a lifelong issue, and surgeons typically follow these patients for a long time." — Ellen Encisco (host_summary) [Ep 68 · 11:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=675)
- "Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it." — Michael Helmrath (clinical) [Ep 67 · 1:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=83)
- "In the 1980s and 1990s, babies with intestinal failure had poor outcomes primarily due to liver progression to inflammation and fibrosis associated with parenteral nutrition, lipids, and phytosterols." — Ellen Encisco (host_summary) [Ep 67 · 1:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=110)
- "Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well." — Michael Helmrath (clinical) [Ep 67 · 2:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=133)
- "The first 4 months of life is when care for intestinal failure patients is most uncoordinated, and surgical decisions made during this period have the most profound effect on long-term outcome." — Todd Ponsky (host_summary) [Ep 67 · 2:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=149)
- "The gut doubles in length during the last trimester and the first year of life, and this maturation process occurs when the baby is fed." — Michael Helmrath (clinical) [Ep 67 · 2:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=175)
- "Healthy growth of the intestine requires nutrition; anything that disrupts this affects maturation of both absorptive/digestive capacity and peristalsis." — Michael Helmrath (clinical) [Ep 67 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=183)
- "Absorptive surface area comes from the waves of peristalsis moving over the villi, not from the exposed length of bowel." — Todd Ponsky (host_summary) [Ep 67 · 3:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=212)
- "Lengthening bowel that doesn't have peristalsis does not increase absorption; very short bowel children can sometimes come off TPN because their motility is good." — Michael Helmrath (clinical) [Ep 67 · 3:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=226)
- "The majority of pediatric short bowel syndrome cases present at birth due to neonatal causes: congenital GI anomalies or acquired conditions like necrotizing enterocolitis." — Paul Wales (epidemiological) [Ep 67 · 4:18](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=258)
- "When reestablishing bowel continuity, size discrepancy between bowel ends must be addressed or a functional obstruction will result even if the anastomosis is patent." — Paul Wales (clinical) [Ep 67 · 5:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=342)
- "Size discrepancy can be managed by resection to a more appropriate caliber, tapering enteroplasty, or serial transverse enteroplasty (STEP) depending on available bowel length." — Paul Wales (clinical) [Ep 67 · 6:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=362)
- "Gastroschisis patients tend to not do as well with STEP procedures regardless of whether atresia is present; among STEP procedures performed over the years, gastroschisis cases consistently had worse outcomes." — Paul Wales (epidemiological) [Ep 67 · 7:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=428)
- "Gastroschisis patients have inherent dysmotility." — Todd Ponsky (host_summary) [Ep 67 · 7:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=441)
- "The enteric nervous system in gastroschisis is damaged from exposure to amniotic fluid and requires a healing and recovery phase; this regeneration is attenuated by dysmotility and stasis, not enhanced." — Michael Helmrath (clinical) [Ep 67 · 7:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=452)
- "In atresia without gastroschisis, the bowel may have good peristalsis from working against an obstruction, and when done correctly with proper orientation, a longitudinal lengthening procedure may benefit the child." — Michael Helmrath (opinion) [Ep 67 · 7:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=475)
- "Children who undergo STEP procedures in their first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds." — Michael Helmrath (clinical) [Ep 67 · 8:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=499)
- "Among patients with limited gut, necrotizing enterocolitis patients do best because they have been fed before, have established GI motility, and the maturation phase has already been initiated." — Michael Helmrath (opinion) [Ep 67 · 8:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=520)
- "STEP procedure is not usually performed unless bowel is at least 5 centimeters dilated to make it worthwhile." — Paul Wales (clinical) [Ep 67 · 9:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=549)
- "At birth, neonatal bowel is usually not dilated enough to apply the STEP procedure." — Ellen Encisco (host_summary) [Ep 67 · 9:36](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=576)
- "In scenarios where bowel is not adequately dilated, options include resecting bulbs with tapering enteroplasty, establishing continuity if possible, or leaving bowel disconnected with distal feeding tube access to grow the distal bowel before reconnection." — Paul Wales (clinical) [Ep 67 · 9:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=581)
- "The STEP procedure was originally described by HP Kim and Tom Jackson." — Paul Wales (clinical) [Ep 67 · 10:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=645)
- "For STEP, a transverse supraumbilical abdominal incision is used, all adhesions are lysed, and the entire intestinal tract is laid out from top to bottom to understand anatomy and maximize mobility." — Paul Wales (clinical) [Ep 67 · 11:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=662)
- "The anti-mesenteric surface of the bowel is marked with surgical pen after drying with a lap sponge; maintaining this alignment prevents longitudinal twisting of the bowel during stapling." — Paul Wales (clinical) [Ep 67 · 11:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=689)
- "Bowel length is measured before the procedure using 30 silk dipped in mineral oil; caliber and length of the dilated segment to be stepped are also recorded." — Paul Wales (clinical) [Ep 67 · 11:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=718)
- "An endo-GIA stapler is preferred over an open GIA stapler because the smaller cartridge head is more amenable in smaller patients." — Paul Wales (opinion) [Ep 67 · 12:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=740)
- "Staple lines are applied perpendicular to the mesentery at 90° and 270° (3 o'clock and 9 o'clock positions if mesenteric vessels are at 0°)." — Paul Wales (clinical) [Ep 67 · 12:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=754)
- "A vascular (white) cartridge with 2.5 mm staples that crimp to 1 mm is used; this is more appropriate for younger patients' bowel thickness and prevents leaks that occurred with classic blue loads in early experience." — Paul Wales (clinical) [Ep 67 · 12:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=778)
- "Target caliber for STEP is 1.5 cm in babies and 2 to 2.5 cm in older infants or children; making it too narrow risks obstruction, especially in patients with borderline motility." — Paul Wales (clinical) [Ep 67 · 13:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=803)
- "Before firing the stapler, measurements are taken to both the end of the bowel and to the side to ensure proper caliber is maintained throughout the length." — Paul Wales (clinical) [Ep 67 · 14:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=849)
- "A U-stitch with 4-0 PDS is placed in the crotch of each staple line to prevent potential leaks at that point." — Paul Wales (clinical) [Ep 67 · 14:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=868)
- "The procedure is performed with a partner, alternating sides of the bowel, working down the length; 45 mm cartridges are most versatile, but 30 mm and 60 mm cartridges may be needed depending on bowel diameter." — Paul Wales (clinical) [Ep 67 · 14:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=890)
- "At the top and bottom of the STEP segment, an additional oblique staple line is fired to taper the transition and avoid a 'dog ear' blind loop that can dilate over time." — Paul Wales (clinical) [Ep 67 · 15:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=908)
- "If one part of the stepped bowel becomes dilated, the STEP segments can rotate away from each other separately, causing twisting and functional obstruction." — Ellen Encisco (host_summary) [Ep 67 · 15:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=957)
- "After completing the STEP, the length of stepped bowel, new total bowel length, and final caliber (2-2.5 cm) are recorded." — Todd Ponsky (host_summary) [Ep 67 · 16:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=973)
- "The STEP procedure is performed with staple lines perpendicular to the mesentery (90° and 270°), not in the anti-mesenteric to mesenteric orientation (180° and 0°)." — Paul Wales (clinical) [Ep 67 · 16:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=983)
- "The duodenum is not stepped; the STEP procedure starts where the bowel begins to dilate, usually distal to the duodenum." — Paul Wales (clinical) [Ep 67 · 16:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1016)
- "Avoiding staple lines in the duodenum allows proximal access if emergency reoperation is needed for a leak." — Paul Wales (opinion) [Ep 67 · 17:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1023)
- "If duodenal narrowing is needed, a stapler is used to partially narrow the lateral side away from the bile duct and ampulla; plication sutures are not used because they usually fail." — Paul Wales (clinical) [Ep 67 · 17:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1035)
- "The duodenum has no mesentery, making it impossible to orient 90° and 270° positions; surgeons who STEP the duodenum end up entering the bowel at inconsistent orientations." — Michael Helmrath (clinical) [Ep 67 · 17:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1052)
- "Teodoro et al. studied pediatric trauma patients presenting to a level one trauma center with gunshot wounds or MVCs between 2009 and 2019." — Ellen Encisco (host_summary) [Ep 71 · 0:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=20)
- "Teodoro et al. examined California Department of Public Health data on pediatric gunshot wounds and MVCs from 2006 to 2015." — Ellen Encisco (host_summary) [Ep 71 · 0:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=20)
- "Gunshot wound victims were more likely to require immediate surgery and had increased mortality compared to MVC victims." — Ellen Encisco (host_summary) [Ep 71 · 0:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=20)
- "Gunshot wound victims were 7.8 times more likely to die than MVC victims." — Ellen Encisco (host_summary) [Ep 71 · 0:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=20)
- "In California statewide data, the case fatality rate for gunshot wound victims was higher than that for motor vehicle collisions." — Ellen Encisco (host_summary) [Ep 71 · 0:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=20)
- "The case fatality rate for pediatric gunshot wounds increased from 2006 to 2015." — Britney Levy (host_summary) [Ep 71 · 1:29](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=89)
- "Petterson et al. examined 10 years of data comprising approximately 8800 pediatric trauma patients transported by helicopter or ground to pediatric trauma centers." — Britney Levy (host_summary) [Ep 71 · 1:29](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=89)
- "Children transported via helicopter had a higher injury severity score than those transported by ground." — Britney Levy (host_summary) [Ep 71 · 1:29](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=89)
- "1.3% of children transported by helicopter required an emergency operation, compared to 0.2% of those transported by ground." — Britney Levy (host_summary) [Ep 71 · 1:29](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=89)
- "98.7% of children transported by helicopter did not require an emergency intervention." — Britney Levy (host_summary) [Ep 71 · 1:29](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=89)
- "Helicopter transport may be over-utilized in pediatric trauma." — Britney Levy (host_summary) [Ep 71 · 1:29](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=89)
- "Miyata et al. used the Canadian Association of Pediatric Surgery Network to study pediatric patients with gastroschisis who underwent bedside reduction and closure." — Rod Gerardo (host_summary) [Ep 71 · 2:50](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=170)
- "There was no significant difference in the rate of successful primary closure between intubated and non-intubated neonates with gastroschisis." — Rod Gerardo (host_summary) [Ep 71 · 2:50](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=170)
- "Philips et al. conducted a retrospective study from 2015 to 2018 evaluating 117 patients from two trauma centers." — Cecilia Gigena (host_summary) [Ep 71 · 3:33](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=213)
- "Patients receiving massive transfusions had shortened alpha angles on TEG analysis." — Cecilia Gigena (host_summary) [Ep 71 · 3:33](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=213)
- "Patients receiving massive transfusions had lower maximum amplitude values on TEG analysis." — Cecilia Gigena (host_summary) [Ep 71 · 3:33](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=213)
- "Patients receiving massive transfusions had lower platelet counts." — Cecilia Gigena (host_summary) [Ep 71 · 3:33](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=213)
- "TEG may help identify hemorrhagic trauma patients who will benefit from cryoprecipitate or platelet transfusions." — Cecilia Gigena (host_summary) [Ep 71 · 3:33](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-6-6636?t=213)
- "Allen et al. studied 277 children with Hirschsprung's disease, approximately half had Soave procedure, one-third had Duhamel, and the rest had Swenson procedure." — Britney Levy (host_summary) [Ep 72 · 0:47](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=47)
- "217 of the 277 Hirschsprung's disease patients had long-term outcome data available." — Britney Levy (host_summary) [Ep 72 · 0:47](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=47)
- "Duhamel procedure has the lowest risk of incontinence but the highest risk of constipation in school age children with Hirschsprung's disease." — Britney Levy (host_summary) [Ep 72 · 0:47](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=47)
- "Peters et al. retrospectively reviewed 55 pediatric patients with small bowel syndrome to examine whether presence or absence of ileocecal valve and/or colon can predict enteral autonomy." — Rod Gerardo (host_summary) [Ep 72 · 1:35](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=95)
- "Infants with an ileocecal valve had significantly shorter duration on parenteral nutrition." — Rod Gerardo (host_summary) [Ep 72 · 1:35](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=95)
- "Patients with less than 50% of their colon had significantly less time on parenteral nutrition as long as they had their ileocecal valve." — Rod Gerardo (host_summary) [Ep 72 · 1:35](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=95)
- "Olsen et al. systematic review analyzed 10 studies with 6,430 patients examining surgeon volume and pediatric thyroid surgery outcomes." — Cecilia Gigena (host_summary) [Ep 72 · 2:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=163)
- "The definition of a high volume surgeon varies widely, ranging from 9 thyroidectomies per year to over 200 thyroidectomies with at least 30 being in pediatric patients." — Cecilia Gigena (host_summary) [Ep 72 · 2:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=163)
- "Thyroidectomies performed by high volume surgeons show shorter length of stays." — Cecilia Gigena (host_summary) [Ep 72 · 2:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=163)
- "Tendon et al. conducted a prospective randomized control trial between 2017 and 2018 comparing three skin closure methods: sutures with tissue adhesive, sutures with adhesive tape, and sutures alone." — Ellen Encisco (host_summary) [Ep 72 · 3:35](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=215)
- "Wounds were assessed at two weeks, six weeks, and more than six months after operation by surveying clinicians and parents." — Ellen Encisco (host_summary) [Ep 72 · 3:35](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=215)
- "Wounds with tissue adhesive had poorer cosmesis at six weeks compared to other closure methods." — Em Tombash (host_summary) [Ep 72 · 4:17](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=257)
- "The cosmesis difference between tissue adhesive and other closure methods disappears by six months." — Em Tombash (host_summary) [Ep 72 · 4:17](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=257)
- "At six months, there was no difference in wound outcomes between the three closure groups for either clinicians or parents." — Em Tombash (host_summary) [Ep 72 · 4:17](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-7-6686?t=257)
- "Malrotation occurs in about 1 in 200 to 500 live births." — Em Tombash (host_summary) [Ep 70 · 0:28](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=28)
- "In the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis." — Meera Kotagal (clinical) [Ep 70 · 1:17](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=77)
- "Normal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant." — Meera Kotagal (clinical) [Ep 70 · 1:44](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=104)
- "Intestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation." — Meera Kotagal (clinical) [Ep 70 · 2:22](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "In non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation." — Meera Kotagal (clinical) [Ep 70 · 2:22](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure." — Meera Kotagal (clinical) [Ep 70 · 2:22](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "Malrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus." — Meera Kotagal (clinical) [Ep 70 · 2:22](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=142)
- "Complications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery)." — Meera Kotagal (clinical) [Ep 70 · 3:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "About 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus." — Meera Kotagal (epidemiological) [Ep 70 · 3:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "About 70% of those who will have a midgut volvulus will present in the first year of life." — Meera Kotagal (epidemiological) [Ep 70 · 3:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases." — Meera Kotagal (clinical) [Ep 70 · 3:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "Children with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy." — Meera Kotagal (clinical) [Ep 70 · 3:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses." — Meera Kotagal (clinical) [Ep 70 · 3:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=229)
- "In the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal." — Meera Kotagal (clinical) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension." — Meera Kotagal (clinical) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Late signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia." — Meera Kotagal (clinical) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "The differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis." — Meera Kotagal (clinical) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it." — Meera Kotagal (clinical) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Upper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned." — Meera Kotagal (clinical) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "On upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position." — Meera Kotagal (clinical) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Contrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test." — Meera Kotagal (clinical) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Midgut volvulus is considered the number one surgical emergency in pediatric surgery." — Meera Kotagal (opinion) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "Surgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation." — Meera Kotagal (clinical) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability." — Meera Kotagal (clinical) [Ep 70 · 4:49](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=289)
- "You can have malrotation without midgut volvulus, but you cannot have midgut volvulus without malrotation." — Em Tombash (host_summary) [Ep 70 · 8:33](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=513)
- "The Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible." — Meera Kotagal (clinical) [Ep 70 · 8:54](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=534)
- "The reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms." — Meera Kotagal (clinical) [Ep 70 · 8:54](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=534)
- "Some believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus." — Meera Kotagal (opinion) [Ep 70 · 10:01](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Laparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus." — Meera Kotagal (opinion) [Ep 70 · 10:01](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "About one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease." — Meera Kotagal (epidemiological) [Ep 70 · 10:01](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Laparoscopic approach may reduce the risk of postoperative bowel obstruction." — Meera Kotagal (opinion) [Ep 70 · 10:01](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Dr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically." — Meera Kotagal (opinion) [Ep 70 · 10:01](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "There is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach." — Meera Kotagal (opinion) [Ep 70 · 10:01](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "There is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications." — Meera Kotagal (opinion) [Ep 70 · 10:01](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly." — Meera Kotagal (clinical) [Ep 70 · 10:01](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Decisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion." — Meera Kotagal (opinion) [Ep 70 · 10:01](https://qa.library.globalcastmd.com/watch/malrotation-with-dr-meera-kotagal-6621?t=601)
- "Children with life-threatening bleeding are different than adults." (host_summary) [Ep 75 · 0:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=20)
- "The Leonard et al. study was a prospective observational study of children presenting with life-threatening bleeding events across 24 centers between the US, Canada, and Italy." (host_summary) [Ep 75 · 0:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=20)
- "Children were eligible for the bleeding study if they received more than 40 ccs per kilo of total blood products over six hours, or if they were transfused under massive transfusion protocol (MTP)." (host_summary) [Ep 75 · 0:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=20)
- "The Leonard et al. study compared patients presenting with traumatic bleeding, operative bleeding, and medical bleeding." — Em Tombash (host_summary) [Ep 75 · 1:21](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=81)
- "The Western Pediatric Surgery Research Consortium conducted a prospective cohort study on children undergoing colorectal surgery across 10 hospitals in the US." (host_summary) [Ep 75 · 1:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=103)
- "The Tobias et al. study utilized an eight-part perioperative care bundle and split children into either a high or low compliance group." (host_summary) [Ep 75 · 1:43](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=103)
- "Children in the high compliance group had a statistically significant decrease in rates of superficial surgical site infection when compared to children in the low compliance group." — Em Tombash (host_summary) [Ep 75 · 2:16](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=136)
- "Standardization of perioperative care may decrease morbidity and improve outcomes in colorectal surgery." — Em Tombash (host_summary) [Ep 75 · 2:16](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=136)
- "The Efting Scharincark et al. study is a retrospective study done in Netherlands between 1998 and 2018." (host_summary) [Ep 75 · 2:39](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "The Dutch stoma reversal study looked at patients under three years old that got a stoma reversal to see if they had contrast enema prior to it and if they were able to detect strictures." (host_summary) [Ep 75 · 2:39](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "The Dutch study gathered 244 patients, of whom 10% got strictures." (host_summary) [Ep 75 · 2:39](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "95% of patients with strictures had necrotizing enterocolitis." (host_summary) [Ep 75 · 2:39](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "Of all 244 patients in the Dutch study, only 68% had a contrast enema prior to the stoma reversal." (host_summary) [Ep 75 · 2:39](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "Contrast enema was able to detect 92% of the strictures in the Dutch stoma reversal study." (host_summary) [Ep 75 · 2:39](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=159)
- "Contrast enema prior to stoma reversal is only useful if patients had necrotizing enterocolitis." — Em Tombash (host_summary) [Ep 75 · 3:29](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-10-6801?t=209)
- "Stevens et al. examined CDC Wonder database data between 1999 and 2020 for pediatric firearm and automobile fatalities." — Ellen Encisco (host_summary) [Ep 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 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 76 · 3:07](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187)
- "Cincinnati Children's Hospital institutionally defined cholestasis as conjugated bilirubin greater than 3 mg/dL or 50 micromoles/L sustained for 2 weeks and not associated with a septic event." — Paul Wales (guideline) [Ep 73 · 1:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=69)
- "A 2021 JPN publication defined cholestasis as conjugated bilirubin around 2 mg/dL or 34 micromoles/L for 2 weeks, not associated with a septic event." — Paul Wales (guideline) [Ep 73 · 1:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=80)
- "Advanced liver disease is defined as conjugated bilirubin above 5 or 6 mg/dL." — Cecilia Gigena (host_summary) [Ep 73 · 1:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=108)
- "As treatment has improved with different lipid emulsions and nutrition approaches, cholestasis has become more an indicator of underlying diseases to address rather than a primary morbidity/mortality factor." — Michael Helmrath (opinion) [Ep 73 · 1:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=117)
- "Historically, 25-50% of intestinal failure patients died because of associated liver disease; now it is less than 2%." — Cecilia Gigena (host_summary) [Ep 73 · 2:36](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=156)
- "In young children, intestinal failure-associated liver disease presents as cholestatic liver disease, whereas in adolescents and adults it tends to be steatosis (fatty deposition)." — Paul Wales (clinical) [Ep 73 · 2:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=177)
- "Risk factors for intestinal failure-associated liver disease include prematurity, lack of enteral feeding, sepsis, and TPN components." — Cecilia Gigena (host_summary) [Ep 73 · 3:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=199)
- "Prematurity is not modifiable by the clinical team, but lack of enteral feeding, sepsis, and TPN components are modifiable risk factors." — Paul Wales (clinical) [Ep 73 · 3:30](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=210)
- "Prevention of cholestasis requires aggressive introduction of enteral feeding to establish enterohepatic circulation and surgical procedures to optimize anatomy for feed delivery." — Paul Wales (clinical) [Ep 73 · 4:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=249)
- "Limiting intravenous fat to 1 g/kg/day can help prevent cholestasis." — Michael Helmrath (clinical) [Ep 73 · 5:12](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=312)
- "New lipid emulsions including Omegaven (used first in the US) and SMOF (used in Europe and Canada, now prevalent in the US for 3-4 years) can reverse or prevent cholestasis." — Michael Helmrath (clinical) [Ep 73 · 5:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=320)
- "SMOF lipid emulsion is composed of soybean oil, medium chain triglycerides, olive oil, and fish oil." — Ellen [last name unclear] (host_summary) [Ep 73 · 6:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=364)
- "A major advantage of SMOF is the ability to provide more calories from fat (as much as 2-2.5 g/kg) while supporting healthy growth." — Michael Helmrath (clinical) [Ep 73 · 6:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=375)
- "Patients on SMOF lipid emulsions can still develop cholestasis due to other factors beyond lipid composition." — Ellen [last name unclear] (host_summary) [Ep 73 · 6:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=401)
- "Two strategies for reversing cholestasis are dose restriction and change of lipid composition." — Paul Wales (clinical) [Ep 73 · 7:00](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=420)
- "Conventional intralipid (soybean-based) produces prostaglandins and eicosanoids that are pro-inflammatory when metabolized." — Paul Wales (clinical) [Ep 73 · 7:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=428)
- "SMOF lipid promotes bile flow, is hepatoprotective, and can be delivered at conventional dose to achieve somatic growth and provide neurologic nutrients while protecting the liver." — Paul Wales (clinical) [Ep 73 · 7:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=439)
- "SMOF lipid does not contain enough arachidonic acid, so dose restriction of SMOF can lead to essential fatty acid deficiency." — Paul Wales (clinical) [Ep 73 · 7:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=465)
- "When SMOF is delivered at conventional dosing, no patients develop essential fatty acid deficiency." — Paul Wales (clinical) [Ep 73 · 7:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=477)
- "Conventional dosing for lipids is settling around 2.5 g/kg/day, but nutrition guidelines for preterm infants and babies state 3-4 g/kg/day." — Paul Wales (guideline) [Ep 73 · 8:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=486)
- "A bilirubin of 2 mg/dL is not advanced liver disease, is not dangerous, and is usually transient; Dr. Wales would not change lipid emulsion at this threshold." — Paul Wales (opinion) [Ep 73 · 8:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=532)
- "When refeeding a cholestatic liver after proximal jejunostomy takedown, direct bilirubin typically rises in the first week as bile acid pool is reintroduced and the liver becomes more active in bile salt production." — Michael Helmrath (clinical) [Ep 73 · 9:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=578)
- "GGT, AST, and ALT will go up in the first week or two after anastomosis takedown surgery, then slowly come down over several weeks." — Michael Helmrath (clinical) [Ep 73 · 10:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=604)
- "When direct bilirubin rises after refeeding, the main differential to rule out is urinary tract infection or gram-negative infection; extensive imaging such as ultrasounds is not needed." — Michael Helmrath (clinical) [Ep 73 · 10:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=623)
- "It is important to provide proximal drainage of the duodenum in high-risk intestinal failure patients; Dr. Helmrath places a lake drain for this purpose." — Michael Helmrath (clinical) [Ep 73 · 10:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=646)
- "Ongoing cholestasis with proximal blockage puts pressure in the biliary system at a much higher level and speeds up the cholestatic process." — Michael Helmrath (clinical) [Ep 73 · 11:18](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=678)
- "G-tubes do not decompress the duodenum." — Michael Helmrath (clinical) [Ep 73 · 11:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=691)
- "A lake drain helps identify proximal bowel and leaves the bowel at appropriate size to make future anastomosis easier without large size mismatch." — Ellen [last name unclear] (host_summary) [Ep 73 · 11:36](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=696)
- "During secondary surgical or autologous reconstruction procedures, a liver biopsy is commonly taken to provide an up-to-date microscopic snapshot." — Paul Wales (clinical) [Ep 73 · 12:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=731)
- "Prophylactic cholecystectomy is not recommended because the gallbladder helps with enterohepatic circulation and many patients will not need it." — Cecilia Gigena (host_summary) [Ep 73 · 12:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=744)
- "Liver function and biochemistry are followed routinely as inpatient and at outpatient clinic visits." — Paul Wales (clinical) [Ep 73 · 12:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=773)
- "Elastography (FibroScan) is available for monitoring but is good for mild/no fibrosis or very advanced fibrosis; it is not as sensitive for patients with intermediate fibrosis." — Paul Wales (clinical) [Ep 73 · 13:00](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=780)
- "Follow-up visit frequency for children on TPN at home ranges from every 1-4 months depending on patient stability; actively adapting patients may be seen more frequently due to rapid changes being made." — Paul Wales (clinical) [Ep 73 · 13:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=811)
- "Disruption of the enterohepatic circulation of bile acids is beneficial for the liver" — Cecilia Gigena (host_summary) [Ep 77 · 0:00](https://qa.library.globalcastmd.com/watch/disruption-of-enterohepatic-circulation-of-bile-acids-ameliorates-small-bowel-resection-associated-hepatic-injury-7050?t=0)
- "The study was conducted at Saint Louis Children's Hospital and aimed to elucidate the driving force behind hepatic injury following bowel resection" — Cecilia Gigena (host_summary) [Ep 77 · 0:13](https://qa.library.globalcastmd.com/watch/disruption-of-enterohepatic-circulation-of-bile-acids-ameliorates-small-bowel-resection-associated-hepatic-injury-7050?t=13)
- "The study used three groups of mice: sham, 50% with proximal or duodenal resection, and 50% with distal resection or resection of the ileocecal valve" — Cecilia Gigena (host_summary) [Ep 77 · 0:22](https://qa.library.globalcastmd.com/watch/disruption-of-enterohepatic-circulation-of-bile-acids-ameliorates-small-bowel-resection-associated-hepatic-injury-7050?t=22)
- "Tissue samples were taken at the second and tenth post-operative weeks" — Cecilia Gigena (host_summary) [Ep 77 · 0:34](https://qa.library.globalcastmd.com/watch/disruption-of-enterohepatic-circulation-of-bile-acids-ameliorates-small-bowel-resection-associated-hepatic-injury-7050?t=34)
- "Mice with distal resection showed less hepatic oxidative stress compared to proximal resection" — Cecilia Gigena (host_summary) [Ep 77 · 0:41](https://qa.library.globalcastmd.com/watch/disruption-of-enterohepatic-circulation-of-bile-acids-ameliorates-small-bowel-resection-associated-hepatic-injury-7050?t=41)
- "Mice with distal resection showed a more hydrophilic bile acid profile compared to proximal resection" — Cecilia Gigena (host_summary) [Ep 77 · 0:41](https://qa.library.globalcastmd.com/watch/disruption-of-enterohepatic-circulation-of-bile-acids-ameliorates-small-bowel-resection-associated-hepatic-injury-7050?t=41)
- "Ileal resection could lead to less hepatic injury" — Cecilia Gigena (host_summary) [Ep 77 · 0:41](https://qa.library.globalcastmd.com/watch/disruption-of-enterohepatic-circulation-of-bile-acids-ameliorates-small-bowel-resection-associated-hepatic-injury-7050?t=41)
- "A multi-center non-inferiority trial compared preterm infants treated with expectant management versus early ibuprofen for PDA" — Cecilia Gigena (host_summary) [Ep 78 · 0:09](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=9)
- "The trial enrolled 273 infants total" — Cecilia Gigena (host_summary) [Ep 78 · 0:22](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=22)
- "136 infants were treated with expectant management and 137 with early ibuprofen" — Cecilia Gigena (host_summary) [Ep 78 · 0:25](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=25)
- "In the expectant management group, 17.6% developed necrotizing enterocolitis" — Cecilia Gigena (host_summary) [Ep 78 · 0:31](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=31)
- "In the expectant management group, 33% developed bronchopulmonary dysplasia" — Cecilia Gigena (host_summary) [Ep 78 · 0:31](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=31)
- "In the expectant management group, the death rate was 14%" — Cecilia Gigena (host_summary) [Ep 78 · 0:31](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=31)
- "In the ibuprofen group, 15.4% developed necrotizing enterocolitis" — Cecilia Gigena (host_summary) [Ep 78 · 0:43](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=43)
- "In the ibuprofen group, 50% developed bronchopulmonary dysplasia" — Cecilia Gigena (host_summary) [Ep 78 · 0:43](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=43)
- "In the ibuprofen group, the death rate was 80%" — Cecilia Gigena (host_summary) [Ep 78 · 0:43](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=43)
- "Expectant management is non-inferior to early ibuprofen in preterm patients with PDA" — Cecilia Gigena (host_summary) [Ep 78 · 1:01](https://qa.library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=61)
- "Infants with gastroschisis often require prolonged hospitalization for surgical repair and initiation and advancement of feeds." — Em Tombash (host_summary) [Ep 74 · 1:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=60)
- "Based on recently updated protocols from Cincinnati Children's Hospital and Children's Mercy Kansas City, feeds can be started immediately after sutureless abdominal closure for uncomplicated gastroschisis, beginning with 10-20 mL/kg/day and advancing by 20 mL/kg/day if tolerated." — Em Tombash (host_summary) [Ep 74 · 2:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=120)
- "Immediate feeding after gastroschisis closure has been shown to be associated with shorter length of stay and faster attainment of goal feeds." — Em Tombash (host_summary) [Ep 74 · 2:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=150)
- "For babies with uncomplicated gastroschisis tolerating feeds for a few days, it is okay to continue the feeding protocol even after one bout of emesis." — Em Tombash (host_summary) [Ep 74 · 2:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=165)
- "High resolution esophageal manometry, esophagography, and endoscopy can help determine the diagnosis of congenital esophageal stenosis." — Em Tombash (host_summary) [Ep 74 · 4:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=240)
- "Serial dilations may be used to manage congenital esophageal stenosis if there is no cartilage component suspected in the stenotic area." — Em Tombash (host_summary) [Ep 74 · 4:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=255)
- "Surgical resection for congenital esophageal stenosis can be reserved for patients where serial dilation is unsuccessful or there is concern for a cartilaginous component." — Em Tombash (host_summary) [Ep 74 · 4:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=270)
- "Initial conservative management should be considered for patients with congenital esophageal stenosis, especially if a cartilaginous component is not suspected." — Em Tombash (host_summary) [Ep 74 · 4:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=285)
- "Management of intussusception after enema reduction varies in practice, with historically recommended inpatient observation lacking evidence-based guidelines." — Em Tombash (host_summary) [Ep 74 · 5:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=345)
- "A systematic review and meta-analysis found that overall recurrence rates and recurrences within 24 and 48 hours were similar between inpatient and outpatient management groups after intussusception enema reduction." — Em Tombash (host_summary) [Ep 74 · 6:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=360)
- "There was no significant difference in the rate of return to the emergency department between inpatient and outpatient management after intussusception reduction, and both groups had similar rates of requiring operative intervention." — Em Tombash (host_summary) [Ep 74 · 6:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=390)
- "Outpatient management of intussusception after air enema reduction results in shorter hospital stay with no difference in rate of ED returns, recurrence, need for operation, or mortality." — Em Tombash (host_summary) [Ep 74 · 6:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=405)
- "There is no compelling evidence in pediatric or adult literature to support mechanical bowel preparation reducing surgical site infections in colorectal surgery." — Em Tombash (host_summary) [Ep 74 · 7:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=450)
- "Recent adult studies have shown no benefit from mechanical bowel preparation in reducing surgical site infections, with some studies showing an increase in wound infections." — Em Tombash (host_summary) [Ep 74 · 7:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=465)
- "Adult studies suggest a possible benefit of oral and IV antibiotics to reduce surgical site infections in colorectal surgery." — Em Tombash (host_summary) [Ep 74 · 8:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=480)
- "Recent retrospective studies have not shown the importance of oral antibiotics for pediatric colorectal operations." — Em Tombash (host_summary) [Ep 74 · 8:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=495)
- "Case-appropriate preoperative IV antibiotics may reduce surgical site infection incidence in colorectal surgery." — Em Tombash (host_summary) [Ep 74 · 8:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=525)
- "Firearms are now the leading cause of death in all children and adolescents in the United States, overtaking motor vehicle crashes in 2019." — Em Tombash (host_summary) [Ep 74 · 9:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=585)
- "There are controversies about whether pediatric surgeons should be involved in firearm violence prevention efforts and advocacy across the country." — Em Tombash (host_summary) [Ep 74 · 10:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=600)
- "As pediatric surgeons, we need to advocate for protecting children's health and well-being, no matter what the topic is." — Em Tombash (host_summary) [Ep 74 · 10:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=615)
- "Pediatric surgeons can play key roles for patients affected by firearms, including direct patient care and advocacy." — Em Tombash (host_summary) [Ep 74 · 10:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=645)
- "Unwitnessed foreign body aspiration can be challenging to manage, and many items are not radiopaque so cannot be seen on plain x-ray." — Em Tombash (host_summary) [Ep 74 · 11:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=705)
- "The gold standard for airway evaluation has been rigid or flexible bronchoscopy, but there are risks of negative bronchoscopy with subsequent airway compromise." — Em Tombash (host_summary) [Ep 74 · 12:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=720)
- "CT bronchoscopy has been proposed as an adjunct in cases of children without obvious respiratory distress." — Em Tombash (host_summary) [Ep 74 · 12:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=735)
- "Low-dose non-contrast CT of the chest has high sensitivity and specificity for identification of airway foreign bodies." — Em Tombash (host_summary) [Ep 74 · 12:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=750)
- "CT can avoid the cost and resources of taking a child to the operating room for a non-therapeutic bronchoscopy procedure." — Em Tombash (host_summary) [Ep 74 · 12:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=765)
- "The largest study looking at initial laparotomy versus peritoneal drainage for necrotizing enterocolitis was conducted at 20 US centers and examined combined death or neurodevelopmental impairment at corrected age 18-22 months." — Em Tombash (host_summary) [Ep 74 · 13:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=810)
- "Death or neurodevelopmental impairment occurred in 69% of patients with preoperative diagnosis of NEC who underwent initial laparotomy versus 85% of those who underwent initial peritoneal drainage." — Em Tombash (host_summary) [Ep 74 · 14:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=840)
- "The prospective randomized cohort study from the National Institute of Child Health and Human Development showed no difference in overall survival but did show improved long-term neurodevelopmental outcomes with initial laparotomy for NEC." — Em Tombash (host_summary) [Ep 74 · 14:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=855)
- "For infants with necrotizing enterocolitis, initial laparotomy may be associated with less neurodevelopmental impairment and improved outcomes for extremely low birth weight babies." — Em Tombash (host_summary) [Ep 74 · 14:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=885)
- "Racism and sexism that manifest as microaggressions are commonly experienced by members of minority groups." — Em Tombash (host_summary) [Ep 74 · 15:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=945)
- "Individuals from minoritized groups are often left weighing the potential benefits and risks of addressing microaggression comments." — Em Tombash (host_summary) [Ep 74 · 16:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=960)
- "Placing the burden to interrupt bias on marginalized colleagues is unjust, and microaggressions can harm trainees' performance and sense of belonging." — Em Tombash (host_summary) [Ep 74 · 16:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=975)
- "Bystanders can and should make an effort to become upstanders, which means bystanders who respond with action to interrupt microaggressions." — Em Tombash (host_summary) [Ep 74 · 16:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=1005)
- "Blunt head trauma represents the majority of pediatric trauma admissions, but there is very little evidence on how to best manage isolated skull fractures." — Em Tombash (host_summary) [Ep 74 · 17:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=1050)
- "A 10-year retrospective review of isolated traumatic skull fractures with normal neurologic exam findings showed that 77% of patients were admitted for observation, but none needed neurosurgical intervention or additional imaging during the index admission." — Em Tombash (host_summary) [Ep 74 · 18:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=1095)
- "Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications, and these patients can be discharged safely from the emergency department without inpatient observation." — Em Tombash (host_summary) [Ep 74 · 18:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=1125)
- "The IMPACT trial was a multi-institutional prospective randomized trial comparing piperacillin-tazobactam monotherapy versus ceftriaxone-metronidazole combination therapy for perforated appendicitis in children, with 30-day post-operative intra-abdominal abscess rate as the primary outcome." — Em Tombash (host_summary) [Ep 74 · 19:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=1170)
- "Patients taking piperacillin-tazobactam had lower incidence of intra-abdominal abscesses, lower usage of CT scans, and fewer ED revisits compared to combination therapy." — Em Tombash (host_summary) [Ep 74 · 20:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=1200)
- "Piperacillin-tazobactam monotherapy did not have an increase in antibiotic usage or increase in antibiotic-related complications compared to combination therapy." — Em Tombash (host_summary) [Ep 74 · 20:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=1215)
- "Monotherapy with piperacillin-tazobactam has been shown to be associated with decreased incidence of intra-abdominal abscesses after surgery for patients with perforated appendicitis." — Em Tombash (host_summary) [Ep 74 · 20:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-2022-top-ten-key-takeaways-6766?t=1230)
- "Children reliant on TPN and their families may face challenges when traveling abroad" (host_summary) [Ep 81 · 0:21](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=21)
- "Medication and appropriate medical supplies must accompany TPN-dependent children on their travels" (host_summary) [Ep 81 · 0:30](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=30)
- "Parents and families may have concerns about not having access to specialist emergency care for their child whilst abroad" (host_summary) [Ep 81 · 0:37](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=37)
- "ERNICA has developed an online map tool to identify specialist centers across Europe that are able to administer TPN and meet particular criteria" (host_summary) [Ep 81 · 0:46](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=46)
- "The ERNICA map tool is accessible from the publicly available ERNICA website" (host_summary) [Ep 81 · 0:58](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=58)
- "Users can search for specialist centers per country and access detailed information on each center through the tool" (host_summary) [Ep 81 · 1:04](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=64)
- "A holiday checklist document is available for download on the ERNICA website" (host_summary) [Ep 81 · 1:11](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=71)
- "Templates are available for local healthcare providers to provide a written record of the child's medical history and clinical precautions" (host_summary) [Ep 81 · 1:18](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=78)
- "Older patients (ages 8-16) who experience volvulus can lose 90+% of their bowel." — Michael Helmrath (clinical) [Ep 80 · 1:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=71)
- "The benefit and curse in older patients with bowel loss is that they already know how to eat and have established that behavior." — Paul Wales (clinical) [Ep 80 · 1:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=84)
- "In older children, normal feeding behavior is important in many social aspects of life, not just nutrition." — Cecilia Gigena (host_summary) [Ep 80 · 1:30](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=90)
- "Even if you cannot cure the patient and get them off TPN, it is important to make compromises to optimize quality of life." — Paul Wales (opinion) [Ep 80 · 1:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=110)
- "The general strategy is to push the macronutrient modules of protein and fat, which are well tolerated." — Paul Wales (clinical) [Ep 80 · 2:14](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=134)
- "Most patients with short bowel do not tolerate simple sugars very well." — Paul Wales (clinical) [Ep 80 · 2:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=141)
- "The general concept of pushing solids and minimizing fluid intake helps prevent dumping." — Paul Wales (clinical) [Ep 80 · 2:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=145)
- "Smaller meals more frequently of solids separated from liquids, with minimization of simple sugars, reduces dumping tendency." — Paul Wales (clinical) [Ep 80 · 2:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=151)
- "Patients who have transitioned off TPN often come back with problems when diet history reveals they have gotten loose with diet choices, particularly increased sugars." — Paul Wales (clinical) [Ep 80 · 2:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=172)
- "Minimizing sugars reduces symptoms related to bacterial overgrowth, making patients less bloated and gassy." — Paul Wales (clinical) [Ep 80 · 3:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=211)
- "In older children with fluid losses (by stoma or other source), if they are on parenteral support, some fluid can be replaced IV." — Paul Wales (clinical) [Ep 80 · 3:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=228)
- "As you try to get patients off IV support, keeping them hydrated by replenishing losses through enteral replacements is important." — Paul Wales (clinical) [Ep 80 · 4:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=241)
- "Transport requires sodium and glucose, so the rehydration solution must contain some glucose and some salt." — Paul Wales (clinical) [Ep 80 · 4:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=251)
- "There are homemade recipes for oral rehydration solutions and over-the-counter preparations available." — Paul Wales (clinical) [Ep 80 · 4:39](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=279)
- "Gatorade does not always work well for rehydration because it has too much sugar in it." — Paul Wales (clinical) [Ep 80 · 4:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=288)
- "Some patients can come off TPN but still need a central line for IV fluids; without IV fluids they end up sleeping most of the day and lack energy." — Michael Helmrath (clinical) [Ep 80 · 4:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=295)
- "Being in a hydrated state is extremely important to making the bowel work well." — Michael Helmrath (clinical) [Ep 80 · 5:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=308)
- "Sometimes patients cannot drink rehydration solution, but the GI tract can use it (via G-tube)." — Michael Helmrath (clinical) [Ep 80 · 5:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=331)
- "Energy use goes up dramatically during puberty." — Michael Helmrath (clinical) [Ep 80 · 5:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=351)
- "Children who are doing well often hit the wall when they start puberty because their energy needs overcome their nutrient input." — Michael Helmrath (clinical) [Ep 80 · 6:10](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=370)
- "The goal is always healthy growth, and it is important to be proactive, add supplements, and hope they will take extra nutritional support." — Michael Helmrath (opinion) [Ep 80 · 6:10](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=370)
- "It is all about normal growth parameters and getting patients through puberty." — Paul Wales (opinion) [Ep 80 · 6:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=383)
- "Some kids end up back on parenteral support to get through puberty." — Paul Wales (clinical) [Ep 80 · 6:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=388)
- "When patients are not growing anymore as adults, borderline or marginal gut function is often enough to sustain them." — Paul Wales (clinical) [Ep 80 · 6:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=393)
- "Clinicians should look at the growth chart for both weight and height, and not accept a 3rd percentile." — Michael Helmrath (opinion) [Ep 80 · 6:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=417)
- "There are very few conditions with intestinal failure that have restricted growth." — Michael Helmrath (clinical) [Ep 80 · 7:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=426)
- "Patients need to be monitored for micronutrient deficiencies after getting off TPN, as this is when they often get into trouble." — Paul Wales (clinical) [Ep 80 · 7:22](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=442)
- "Long-term growth and outcome need to be followed, highlighting the importance of multidisciplinary teams." — Paul Wales (opinion) [Ep 80 · 7:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=451)
- "Weight is tracked as a major metric for growth, but it has to be balanced with height." — Paul Wales (clinical) [Ep 80 · 8:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=531)
- "What is commonly seen in this population is round babies where their weight for height is elevated." — Paul Wales (clinical) [Ep 80 · 8:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=537)
- "There is increasing data looking at quality of weight: how much is fat weight versus lean body mass." — Paul Wales (clinical) [Ep 80 · 9:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=541)
- "For any child not meeting growth potential, numerous other diagnoses can be responsible, ranging from endocrine issues to pancreatic insufficiency to micronutrient issues." — Michael Helmrath (clinical) [Ep 80 · 9:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=574)
- "The concept is that patients are capable of having normal growth, and as you address issues and improve something, you need reasonable follow-up time on the order of weeks, not months." — Michael Helmrath (opinion) [Ep 80 · 9:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=588)
- "Much of the growth monitoring can be done remotely; patients do not need to travel for assessment, but you cannot wait until the next appointment." — Michael Helmrath (opinion) [Ep 80 · 10:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=615)
- "Gastroschisis occurs when the front of a baby's belly does not form properly during early pregnancy, resulting in an opening on the right side of the belly button through which the intestines pass." (host_summary) [Ep 82 · 0:06](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=6)
- "Gastroschisis is classed as a rare birth defect." (host_summary) [Ep 82 · 0:19](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=19)
- "The cause of gastroschisis is unknown." (host_summary) [Ep 82 · 0:24](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=24)
- "Gastroschisis may mean that the intestines are not able to work properly." (host_summary) [Ep 82 · 0:27](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=27)
- "Gastroschisis is not usually associated with other malformations." (host_summary) [Ep 82 · 0:32](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=32)
- "A diagnosis of gastroschisis can be made before birth using ultrasound." (host_summary) [Ep 82 · 0:36](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=36)
- "Many babies with gastroschisis are born prematurely (before 37 weeks)." (host_summary) [Ep 82 · 0:45](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=45)
- "Ongoing care for babies with gastroschisis should be provided at a specialist center by a dedicated team of professionals with knowledge and experience of the condition." (host_summary) [Ep 82 · 0:51](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=51)
- "Gastroschisis is a serious condition and can be life threatening for the baby before and after birth as a newborn." (host_summary) [Ep 82 · 1:03](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=63)
- "Most babies with gastroschisis do survive." (host_summary) [Ep 82 · 1:10](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=70)
- "Some babies with gastroschisis may be transferred to a dedicated intensive care unit if they are born prematurely." (host_summary) [Ep 82 · 1:18](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=78)
- "After birth, the baby's intestines are wrapped in a sterile bag to avoid damage." (host_summary) [Ep 82 · 1:24](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=84)
- "Babies with gastroschisis receive the fluid they need via a tube that delivers it through a vein." (host_summary) [Ep 82 · 1:24](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=84)
- "When the baby is stable, surgery is performed to place the intestines back in the belly and close the opening." (host_summary) [Ep 82 · 1:33](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=93)
- "Surgical repair can be done in one operation (primary repair) or in several steps (staged repair), depending on the baby's circumstances and severity of gastroschisis." (host_summary) [Ep 82 · 1:41](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=101)
- "Further surgery may be needed if other malformations are also present." (host_summary) [Ep 82 · 1:54](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=114)
- "While the intestines recover, the baby receives feed through a tube that delivers it through a vein, a method called parenteral nutrition." (host_summary) [Ep 82 · 1:59](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=119)
- "Hospital stay duration differs depending on the severity of gastroschisis, any complications, and how well the baby responds to treatment, often ranging between 2 to 10 weeks but may be longer." (host_summary) [Ep 82 · 2:10](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=130)
- "Follow-up care by a multidisciplinary team (MDT) of different clinical specialists is required to monitor the baby's growth and development." (host_summary) [Ep 82 · 2:25](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=145)
- "Some babies may experience ongoing difficulties that require different types and levels of care." (host_summary) [Ep 82 · 2:37](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=157)
- "Identifying any complications or difficulties early is very important." (host_summary) [Ep 82 · 2:43](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=163)
- "Some babies may require parenteral nutrition for a longer period to promote continued growth." (host_summary) [Ep 82 · 2:49](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=169)
- "Peer support can be accessed through patient and family support groups." (host_summary) [Ep 82 · 2:55](https://qa.library.globalcastmd.com/watch/what-is-gastroschisis-an-ernica-animation-for-parents-and-families-7812?t=175)
- "One goal in intestinal failure management is to establish normal feeding habits that promote gut function and optimize quality of life including social aspects of eating." — Paul Wales (clinical) [Ep 79 · 0:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=57)
- "Factors to consider when refeeding include poor gastric emptying, poor gastric function, high stoma outputs versus high stooling output, and the age of the child at the time of intestinal damage." — Michael Helmrath (clinical) [Ep 79 · 1:27](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=87)
- "When initiating feeds in patients with high stoma output, losses increase initially, but this must be pushed through in a hospital setting where volume replacement is available." — Paul Wales (clinical) [Ep 79 · 2:22](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=142)
- "Damaged bowel is in a secretory phase even when not fed, but feeding stimulates the bowel into an absorptive state through luminal nutrition, eventually reducing stoma volume output." — Michael Helmrath (clinical) [Ep 79 · 2:37](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=157)
- "Mother's breast milk is the ideal feeding choice due to nutritional value and immunomodulatory and growth-healing effects not present in typical formulas." — Michael Helmrath (clinical) [Ep 79 · 3:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=220)
- "Donor breast milk is the second choice when mother's breast milk is unavailable." — Michael Helmrath (clinical) [Ep 79 · 4:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=248)
- "Breast milk has lower protein levels than desired and likely requires supplementation." — Cecilia Gigena (host_summary) [Ep 79 · 4:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=261)
- "In short bowel syndrome, protein absorption is fairly well preserved, so the benefit of completely broken-down protein formulas (free amino acids or hydrolysates) is primarily from an allergy perspective." — Paul Wales (clinical) [Ep 79 · 4:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=274)
- "Many formulas have moved from predominant long-chain fat to increasing MCT components, but long-chain fat is a stronger driver for adaptation." — Paul Wales (clinical) [Ep 79 · 5:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=304)
- "Long-chain fatty acids have developmental and immune properties." — Michael Helmrath (clinical) [Ep 79 · 5:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=321)
- "It is a common mistake to increase enteral feeds by the same volume that TPN is decreased, assuming the child will absorb all those calories, which results in stunted growth." — Michael Helmrath (clinical) [Ep 79 · 5:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=351)
- "One milliliter of parenteral nutrition is not isocaloric with one milliliter of formula, and advancing beyond 100-120 per kilo creates problems with not only calories and protein but also sodium and calcium due to compositional differences." — Paul Wales (clinical) [Ep 79 · 6:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=366)
- "At some point during feeding advancement, fortification is necessary." — Paul Wales (clinical) [Ep 79 · 6:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=388)
- "If the child tolerates it and does not have lung issues, the total daily volume can be expanded from 140 to 160, 170, or occasionally even 180 per kilogram." — Michael Helmrath (clinical) [Ep 79 · 6:44](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=404)
- "Feeding options include bolus (oral or gastric via tube), continuous (post-pyloric tube or surgical J-tube), or a hybrid model with gastric bolus component plus continuous component (gastric or post-pyloric)." — Paul Wales (clinical) [Ep 79 · 7:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=441)
- "Bolus feeds are preferred as the default approach; patients should fail bolus feeds before being placed on continuous feeds as the sole delivery method." — Paul Wales (opinion) [Ep 79 · 8:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=485)
- "Continuous feeds can be used as a supplemental approach, with bolus feeds during the day and continuous supplementation overnight." — Paul Wales (clinical) [Ep 79 · 8:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=497)
- "Even when oral feeding is non-nutritive, it is important for skill development; children who never learn to suck, swallow, and process food by mouth will not eat solids later and will remain dependent on tube feeding." — Paul Wales (clinical) [Ep 79 · 8:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=520)
- "The stomach is the most complicated part of the GI tract because it must coordinate both back-and-forth sloshing and coordinated squeezing with pyloric relaxation several times per minute to induce gastric emptying." — Michael Helmrath (clinical) [Ep 79 · 9:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=568)
- "When children have not been fed and have had an injury, gastric coordination is commonly completely disrupted." — Michael Helmrath (clinical) [Ep 79 · 9:43](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=583)
- "Most gastric dysmotility requires time and stimulation; the way to provide time when the rest of the GI tract works is to place a tube beyond the stomach for feeding." — Michael Helmrath (clinical) [Ep 79 · 10:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=602)
- "In a baby, the best way to achieve distal feeding is through an NJ tube with a G-tube decompressing the stomach, allowing feeding outside the stomach while simultaneously decompressing it." — Michael Helmrath (clinical) [Ep 79 · 10:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=615)
- "Distal feeding stimulates the distal small bowel and colon to produce hormones that signal the stomach to start functioning, breaking the dysmotility cycle." — Michael Helmrath (clinical) [Ep 79 · 10:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=633)
- "Post-pyloric refeeding can be done as a bolus or over a pump; bolus is preferred, but at Cincinnati a protocol of running feeds over a pump for one hour works well, typically starting at 5 then 10 cc per kilogram and advancing based on tolerance." — Michael Helmrath (clinical) [Ep 79 · 11:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=663)
- "Feeding the colon causes stoma output to decrease quickly, reflecting hormonal effects of the distal bowel, and often the stomach will start to work." — Michael Helmrath (clinical) [Ep 79 · 11:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=685)
- "The largest benefit of distal bowel refeeding is that when the two bowel ends are reconnected, the distal bowel has been functionally used, making postoperative feeding easier to initiate." — Michael Helmrath (clinical) [Ep 79 · 11:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=710)
- "The technical benefit of distal feeding is that size discrepancy at anastomosis is significantly improved because the bowel has been used." — Paul Wales (clinical) [Ep 79 · 12:12](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=732)
- "Undigested formula in the colon is a trigger that can cause stress to the bowel and may not be the healthiest approach." — Michael Helmrath (opinion) [Ep 79 · 12:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=754)
- "Placing a feeding tube into the stomach and tacking the stomach up does not commit the child to a lifelong G-tube or even one for the first year; it is no different than another tube and can be directed out of the pylorus into the proximal small bowel." — Michael Helmrath (clinical) [Ep 79 · 12:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=773)
- "When children with G-tubes do well, the tube can be removed and the hole heals like any other in these patients." — Michael Helmrath (clinical) [Ep 79 · 13:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=804)
- "The hole from a removed G-tube closes very quickly." — Paul Wales (clinical) [Ep 79 · 13:43](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=823)
- "A G-tube provides versatility for nutrition supplementation, medication delivery, and venting for gassy or bloated children to improve enteral tolerance." — Paul Wales (clinical) [Ep 79 · 13:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=831)
- "The morbidity from a G-tube is extremely low and the benefit can be very high." — Michael Helmrath (clinical) [Ep 79 · 14:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=845)
- "McMaster University team performed a retrospective review of infants born between 2014 and 2022 with uncomplicated gastroschisis examining feeding outcomes." — Alex Halpern (host_summary) [Ep 84 · 0:13](https://qa.library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=13)
- "Infants with exclusive breast milk intake and those with supplemental or exclusive formula intake had similar outcomes in uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 84 · 0:24](https://qa.library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=24)
- "No significant differences were found between exclusive breast milk and formula groups in time to reach full enteral feeds in infants with uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 84 · 0:24](https://qa.library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=24)
- "No significant differences were found between exclusive breast milk and formula groups in duration of parenteral nutrition in infants with uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 84 · 0:24](https://qa.library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=24)
- "No significant differences were found between exclusive breast milk and formula groups in rates of necrotizing enterocolitis in infants with uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 84 · 0:24](https://qa.library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=24)
- "No significant differences were found between exclusive breast milk and formula groups in length of hospital stay in infants with uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 84 · 0:24](https://qa.library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=24)
- "Formula intake versus exclusive breast milk intake does not appear to affect outcomes in uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 84 · 0:44](https://qa.library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=44)
- "Young infants, babies, and young children have tremendous gut growth potential, with the gut growing for the first several years of life." — Paul Well (clinical) [Ep 83 · 0:49](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=49)
- "A term baby will have 160 centimeters of small bowel, and by age 5 years it almost triples to about 425 to 450 centimeters." — Paul Well (clinical) [Ep 83 · 1:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=77)
- "Residual bowel should be discussed as a percentage of what is normal for a child of that age, not in absolute centimeters." — Paul Well (clinical) [Ep 83 · 1:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=62)
- "You can have as low as 10% expected gut length and still achieve enteral autonomy if you have the majority of your colon in continuity." — Paul Well (clinical) [Ep 83 · 1:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=111)
- "The more important factor than the ileocecal valve is the presence or absence of the distal small bowel (ileum) and right colon that can act as a site for bile reclamation and enterohepatic circulation." — Michael Helmrath (clinical) [Ep 83 · 2:30](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=150)
- "The distal ileum produces hormones and incretins including GLP-2, GLP-1, and PYY." — Michael Helmrath (clinical) [Ep 83 · 2:43](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=163)
- "The importance is not the ileocecal valve itself but the distal ileum and proximal colon where bilioenteric circulation occurs and where hormones and peptides that help intestinal growth and absorption are produced." (host_summary) [Ep 83 · 3:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=181)
- "The surgical strategy at the first operation should provide a pathway forward that allows early interval feeding." — Michael Helmrath (clinical) [Ep 83 · 3:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=209)
- "It is sometimes better to stage reconstruction with the plan to restore bowel continuity under more controlled conditions." — Michael Helmrath (opinion) [Ep 83 · 3:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=218)
- "In situations of overwhelming intestinal loss, the strategy is to provide proximal control that allows feeding to occur without the enteral stream going through, and to leave questionable bowel segments that have potential to heal and can make a huge difference in the child's lifetime." — Michael Helmrath (clinical) [Ep 83 · 3:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=233)
- "As long as you can divert proximally and the baby is stable, you can leave questionable bowel for potential use at later secondary reconstructive procedures." (clinical) [Ep 83 · 4:26](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=266)
- "The overarching principle is to deliver adequate nutrition to have normal growth within normal parameters, ideally enterally." — Paul Well (clinical) [Ep 83 · 5:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=308)
- "As much as possible, the goal is to establish normal feeding behavior, recognizing that enteral nutrition is more than just nutrition." — Paul Well (clinical) [Ep 83 · 5:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=328)
- "If a patient needs tube support from the beginning, bolus feeding should be tried rather than defaulting to continuous feeding." — Paul Well (clinical) [Ep 83 · 5:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=352)
- "If the child fails a gastric approach (both bolus and continuous), the strategy is to feed beyond the stomach and decompress the stomach through an NG tube." — Paul Well (clinical) [Ep 83 · 6:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=375)
- "Breast milk is the formula of choice, not only for its nutritional benefits but for all the other beneficial components within breast milk." — Paul Well (clinical) [Ep 83 · 6:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=402)
- "Starting at the single amino acid level for protein is the generalized preference, ensuring patients are not having high stool output, high fluid losses, wound breakdown, rashes, or emesis." — Michael Helmrath (clinical) [Ep 83 · 7:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=448)
- "Long-chain fat is the preferred fat module rather than MCT fat, especially in the setting of short bowel syndrome." — Paul Well (clinical) [Ep 83 · 7:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=477)
- "Long-chain fat is a much stronger stimulus for GLP-2 release compared to MCT, which is important when trying to drive intestinal adaptation." — Paul Well (clinical) [Ep 83 · 8:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=495)
- "Not every child needs to be on SMOF lipids." — Paul Well (opinion) [Ep 83 · 9:00](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=540)
- "For preterm babies, SMOF is not the ideal lipid emulsion but is the best currently available." — Paul Well (clinical) [Ep 83 · 9:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=543)
- "SMOF lipids do not have enough arachidonic acid, which is important for brain development." — Paul Well (clinical) [Ep 83 · 9:16](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=556)
- "Two strategies exist to treat cholestasis: reduce the total amount of fat, or change the composition to introduce SMOF lipids or Omegaven." (clinical) [Ep 83 · 9:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=574)
- "Lipid restrictions that reduce lipid dose to 1 g per kg per day can reverse cholestasis but result in reduced calorie delivery that can impair growth and potentially impact neurocognitive development." (clinical) [Ep 83 · 9:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=590)
- "Omegaven is essentially pure fish oil with omega-3 and is dosed at 1 g/kg, so babies take a calorie hit." (clinical) [Ep 83 · 10:07](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=607)
- "SMOF lipids are a better choice as they are a more well-balanced emulsion with an omega-3 and omega-6 ratio of 2.5 to 1, are less inflammatory than Intralipid, and promote bile flow." (clinical) [Ep 83 · 10:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=628)
- "SMOF lipids should not be restricted and can be given at no less than 2 or 2.5 g per kg per day." (clinical) [Ep 83 · 10:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=628)
- "MMP-7 (matrix metalloproteinase 7) are proteolytic peptidases that break down peptide bonds for amino acids and are part of tissue remodeling processes, playing roles in tissue repair, arthritis, metastasis, and cirrhosis" — Em Gootee (host_summary) [Ep 85 · 1:25](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=85)
- "Higher levels of MMP-7 are associated with the diagnosis of biliary atresia" — Em Gootee (host_summary) [Ep 85 · 1:43](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=103)
- "In a cohort of 329 biliary atresia cases from July 2020 to December 2022, 40 were classified as low MMP-7" — Em Gootee (host_summary) [Ep 85 · 1:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=116)
- "Low levels of MMP-7 in biliary atresia patients are associated with low levels of preoperative GGT (gamma glutamyl transpeptidase) and direct bilirubin" — Em Gootee (host_summary) [Ep 85 · 2:36](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=156)
- "GGT (gamma glutamyl transpeptidase) is an enzyme found in high levels in liver, kidney, pancreas, heart, and brain, and blood GGT levels are used to detect diseases of the liver and bile ducts" — Em Gootee (host_summary) [Ep 85 · 3:02](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=182)
- "Biliary atresia has variable outcomes even within one center, with patients who anatomically look similar having dramatically different outcomes" — Em Gootee (host_summary) [Ep 85 · 3:19](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=199)
- "Having lower MMP-7 levels within the cohort of biliary atresia patients is associated with worse prognosis" — Em Gootee (host_summary) [Ep 85 · 4:09](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=249)
- "The mechanism of why low MMP-7 levels in biliary atresia patients leads to worse prognosis is unknown" — Em Gootee (host_summary) [Ep 85 · 4:41](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=281)
- "In a Canadian cohort of 411 infants with gastroschisis treated at CAPSNET centers from 2014 to 2022, 144 were excluded due to gestational age, birth weight, other congenital anomalies, or complicated gastroschisis, leaving 267 participants" — Em Gootee (host_summary) [Ep 85 · 7:02](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=422)
- "Of 267 uncomplicated gastroschisis patients, 78% received exclusive breast milk in the first 28 days of life and 22% received supplemental or exclusive formula" — Em Gootee (host_summary) [Ep 85 · 7:43](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=463)
- "Patients with uncomplicated gastroschisis who had some exposure to formula in the first 28 days of life did not have increased risk of necrotizing enterocolitis or major differences in reaching full enteral feeds" — Mike Livingston (clinical) [Ep 85 · 8:12](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=492)
- "There were no significant differences between exclusive breast milk and formula groups in time to reach full enteral feeds, duration of parenteral nutrition, or length of stay in uncomplicated gastroschisis" — Em Gootee (host_summary) [Ep 85 · 8:27](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=507)
- "Patients with uncomplicated gastroschisis who received some formula appeared to have slightly faster time getting to full feeds, likely related to timing of closure rather than feeding type" — Mike Livingston (clinical) [Ep 85 · 8:34](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=514)
- "Patients with uncomplicated gastroschisis who received exclusive breast milk in the first 28 days were far more likely to transition to exclusive breastfeeding: 73% compared to 11% in those with formula exposure" — Em Gootee (host_summary) [Ep 85 · 8:53](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=533)
- "A systematic review on transition from pediatric to adult care for colorectal conditions included 8 studies with patient, parent, and clinician perspectives, focusing on patients aged 10-30 years with anorectal malformation or Hirschsprung disease" — Em Gootee (host_summary) [Ep 85 · 12:46](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=766)
- "There is a group of colorectal patients discharged from care in late childhood around age 10 years, and another group that remains in pediatric care way beyond the normal age of transfer to adult care (around 25 years)" — Em Gootee (host_summary) [Ep 85 · 13:16](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=796)
- "The life course progression of anorectal malformation and Hirschsprung disease is not well understood" — Em Gootee (opinion) [Ep 85 · 13:30](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=810)
- "Barriers and enablers of successful transition for surgical colorectal patients showed agreement with those for medical patients that existing guidelines were based on" — Sebastian King (clinical) [Ep 85 · 13:42](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=822)
- "Patients felt that clinicians did not always understand the need for transitioning their child's care from pediatric to adult settings, including the reasons, processes, and how to make transitions smooth" — Sebastian King (clinical) [Ep 85 · 13:42](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=822)
- "There was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner" — Whit Holcomb (clinical) [Ep 85 · 14:22](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=862)
- "No models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review" — Whit Holcomb (clinical) [Ep 85 · 14:38](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-2nd-quarter-2024-9154?t=878)
- "The curation process filters approximately 1200 articles per month from 33 pediatric and general surgical journals plus 3 top clinical journals (NEJM, Lancet, JAMA) down to 25-50 relevant pediatric surgery articles, then further narrows to 10-15 through specialty filtering, quality ranking, methodology assessment, and popularity polling among general surgeons." — Todd Ponsky (host_summary) [Ep 56 · 1:53](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=113)
- "Upper GI contrast study is operator-dependent and requires direct communication with radiologist, readily available at high-volume centers but requires more coordination at community hospitals." — Todd Ponsky (clinical) [Ep 56 · 5:30](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=330)
- "Ultrasound for malrotation diagnosis is very dependent on the person who performs the ultrasound, making it less reliable than upper GI contrast study." (opinion) [Ep 56 · 8:08](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=488)
- "Reversal of vessels at the root of the mesentery on ultrasound is not a very reliable way to make the diagnosis of malrotation." (clinical) [Ep 56 · 8:35](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=515)
- "In the Annals of Surgery 5-year follow-up study of non-operative appendicitis management, 46% of patients randomized to non-surgical management required appendectomy during follow-up, while the surgical group had no complications or readmissions." — Todd Ponsky (host_summary) [Ep 56 · 11:52](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=712)
- "Half of the non-surgical appendicitis management group presented to the emergency room during 5-year follow-up." — Todd Ponsky (host_summary) [Ep 56 · 12:08](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=728)
- "The presence of an appendicolith in appendicitis has about a 50% failure rate with non-operative management, making it a contraindication for non-surgical treatment." — Todd Ponsky (clinical) [Ep 56 · 10:22](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=622)
- "In the Journal of Clinical Oncology study of 1,531 patients with stage 4 high-risk neuroblastoma, 5-year event-free survival and overall survival were significantly higher with complete resection compared to incomplete microscopic resection." (host_summary) [Ep 56 · 14:20](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=860)
- "Local progression in stage 4 neuroblastoma was lower with complete resection when compared with incomplete resection." (host_summary) [Ep 56 · 14:36](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=876)
- "In the New England Journal of Medicine randomized controlled trial of 80 women carrying fetuses with severe isolated left-sided congenital diaphragmatic hernia, fetal endoscopic tracheal occlusion (FETO) at 27-29 weeks resulted in 40% survival to discharge versus 15% with expectant care." (host_summary) [Ep 56 · 16:30](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=990)
- "At 6 months of age, survival was the same between FETO and expectant care groups in severe CDH." (host_summary) [Ep 56 · 16:44](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1004)
- "FETO was associated with an increased risk of pre-labor rupture of membranes and preterm labor." (host_summary) [Ep 56 · 16:47](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1007)
- "In the Journal of Trauma study of 135 children aged 1-17 years who received whole blood as adjunct to component therapy, matched to 270 children receiving only component therapy, the whole blood group had decreased transfusion volume at 24 hours and required fewer ventilation days, though mortality, length of stay, and major complications were the same." — Todd Ponsky (host_summary) [Ep 56 · 18:16](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1096)
- "Current ATLS protocols recommend initial bolus with normal saline or crystalloid solution before moving to blood products in pediatric trauma." — Todd Ponsky (guideline) [Ep 56 · 19:40](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1180)
- "Nationwide in adults, ambulance rigs are starting to travel with whole blood capabilities and people are using whole blood even earlier in trauma resuscitation." — Todd Ponsky (clinical) [Ep 56 · 19:40](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1180)
- "The challenge for whole blood in pediatrics is availability, and thankfully for children, we don't use a lot of massive transfusion protocols compared to adults." — Todd Ponsky (clinical) [Ep 56 · 20:28](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1228)
- "Some centers are limiting whole blood use to males and some to children older than 15, depending on institutional protocols and blood bank partnerships." — Todd Ponsky (clinical) [Ep 56 · 21:13](https://qa.library.globalcastmd.com/watch/update-course-2021-top-publications-in-non-ped-surg-journals-5404?t=1273)
- "MMP7 could be used to distinguish biliary atresia from other cholestatic diseases." (host_summary) [Ep 57 · 3:47](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=227)
- "Intraoperative ICG can be used to determine biliary flow or identify a transaction in biliary atresia surgery." (host_summary) [Ep 57 · 3:47](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=227)
- "26% of respondents use intraoperative ICG to visualize the biliary tree, 23% use it in select patients, and 51% do not use it." — Todd Ponsky (epidemiological) [Ep 57 · 4:45](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=285)
- "MMP7 is a send-out test at many non-freestanding children's hospitals, limiting its clinical utility for time-sensitive biliary atresia diagnosis in children presenting at five weeks of age." (clinical) [Ep 57 · 5:48](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=348)
- "For a hypotensive, tachycardic pediatric blunt trauma patient who has received 20 cc/kg crystalloid, the next steps should be early blood therapy and potentially massive transfusion protocol with balanced resuscitation, consistent with ATLS guidelines." (guideline) [Ep 57 · 8:30](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=510)
- "There is currently no great definition of what constitutes a massive transfusion protocol (MTP) in pediatric patients; approximately 40 cc/kg blood triggers consideration of balanced resuscitation." (clinical) [Ep 57 · 8:30](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=510)
- "For rectal prolapse sclerotherapy, 46% of respondents use hypertonic saline, while 10-16% use phenol, ethyl alcohol, or dextrose in water." (epidemiological) [Ep 57 · 10:35](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=635)
- "Getting phenol into the operating room for sclerotherapy is not always easy due to institutional and pharmacy restrictions." — Todd Ponsky (clinical) [Ep 57 · 10:50](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=650)
- "There are case reports showing mucosal sloughing with phenol sclerotherapy." — Todd Ponsky (host_summary) [Ep 57 · 10:50](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=650)
- "3% sotradecal is used as a sclerotherapy agent for rectal prolapse." (clinical) [Ep 57 · 11:48](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=708)
- "D50 (dextrose 50% from the code cart) is used as a hypertonic sclerotherapy agent and may be easier to acquire in the operating room than 3% saline." (clinical) [Ep 57 · 11:56](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=716)
- "Deflux, a compound used by urology for vesicoureteral reflux, has been reported in case reports for rectal prolapse sclerotherapy." — Todd Ponsky (host_summary) [Ep 57 · 10:50](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=650)
- "Approximately 50% of respondents always use sutureless abdominal closure for large abdominal wall defects, 40% use it in select patients, and only 11% do not use it." — Todd Ponsky (epidemiological) [Ep 57 · 12:23](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=743)
- "The adoption of sutureless closure for abdominal wall defects represents a major practice change over nine years, with 90% now using it always or selectively compared to much lower rates previously." — Todd Ponsky (epidemiological) [Ep 57 · 12:23](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=743)
- "ERAS (Enhanced Recovery After Surgery) is a bundle of interventions to help patients get through the hospital faster with less pain and fewer narcotics, including early mobilization." (clinical) [Ep 57 · 15:59](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=959)
- "ERAS protocols include giving patients a carbohydrate drink two hours before surgery, replacing traditional NPO requirements." (clinical) [Ep 57 · 16:14](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=974)
- "Implementing ERAS requires team buy-in, particularly from anesthesiologists, because of practice changes like allowing oral intake two hours preoperatively." — Todd Ponsky (clinical) [Ep 57 · 16:42](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1002)
- "ERAS protocols are difficult to implement because they require the whole hospital to adopt a different culture and philosophy, unlike single-procedure changes like sutureless gastroschisis closure." (opinion) [Ep 57 · 17:55](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1075)
- "Starting ERAS implementation with surgical pathways standardizes care and has led to decreased cost, antibiotic utilization, and length of stay; hospitalists and pediatric residents use surgical pathways more than other pathways." (clinical) [Ep 57 · 19:09](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1149)
- "A strategy for ERAS implementation is to chip away at individual components (such as decreasing opioid use intraoperatively and perioperatively) before building a larger protocol." (clinical) [Ep 57 · 19:42](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1182)
- "For bleeding from a pulmonary vessel during thoracoscopic lobectomy, start with an energy/sealing device (effective in low-pressure systems), then escalate to clips or sutures if needed." (clinical) [Ep 57 · 21:18](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1278)
- "Multiple hemostasis options (energy, clips, sutures) should be available during thoracoscopic procedures." (clinical) [Ep 57 · 21:38](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1298)
- "Most institutions are either taking steps to address social determinants of health or working on it; few report no action." — Todd Ponsky (epidemiological) [Ep 57 · 21:50](https://qa.library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1310)
- "Ziegler et al. performed a prospective study in 10 patients with giant omphalocele and 6 with complicated gastroschisis evaluating a vertical traction device." — Alex Halpern (host_summary) [Ep 87 · 0:14](https://qa.library.globalcastmd.com/watch/use-of-a-new-vertical-traction-device-for-early-traction-assisted-staged-closure-of-congenital-abdominal-wall-defects-a-prospective-series-of-16-patients-9436?t=14)
- "The study utilized Fascia Tenses Pediatric, a traction-assisted abdominal wall closure device." — Alex Halpern (host_summary) [Ep 87 · 0:24](https://qa.library.globalcastmd.com/watch/use-of-a-new-vertical-traction-device-for-early-traction-assisted-staged-closure-of-congenital-abdominal-wall-defects-a-prospective-series-of-16-patients-9436?t=24)
- "Complete fascial closure was achieved after a median time of 7 days in children with giant omphalocele." — Alex Halpern (host_summary) [Ep 87 · 0:29](https://qa.library.globalcastmd.com/watch/use-of-a-new-vertical-traction-device-for-early-traction-assisted-staged-closure-of-congenital-abdominal-wall-defects-a-prospective-series-of-16-patients-9436?t=29)
- "Complete fascial closure was achieved after a median time of 5 days in children with complicated gastroschisis." — Alex Halpern (host_summary) [Ep 87 · 0:36](https://qa.library.globalcastmd.com/watch/use-of-a-new-vertical-traction-device-for-early-traction-assisted-staged-closure-of-congenital-abdominal-wall-defects-a-prospective-series-of-16-patients-9436?t=36)
- "No patients developed abdominal compartment syndrome in the study." — Alex Halpern (host_summary) [Ep 87 · 0:39](https://qa.library.globalcastmd.com/watch/use-of-a-new-vertical-traction-device-for-early-traction-assisted-staged-closure-of-congenital-abdominal-wall-defects-a-prospective-series-of-16-patients-9436?t=39)
- "No ventral hernias occurred after a median follow-up of 12 months." — Alex Halpern (host_summary) [Ep 87 · 0:39](https://qa.library.globalcastmd.com/watch/use-of-a-new-vertical-traction-device-for-early-traction-assisted-staged-closure-of-congenital-abdominal-wall-defects-a-prospective-series-of-16-patients-9436?t=39)
- "Fascia Tenses Pediatric helps facilitate early fascial closure in patients with congenital abdominal wall defects." — Alex Halpern (host_summary) [Ep 87 · 0:46](https://qa.library.globalcastmd.com/watch/use-of-a-new-vertical-traction-device-for-early-traction-assisted-staged-closure-of-congenital-abdominal-wall-defects-a-prospective-series-of-16-patients-9436?t=46)
- "The ABSA Outcomes and Evidence-based Practice Committee performed a systematic review on optimal initial management of gastroschisis." — Alex Halpern (host_summary) [Ep 90 · 0:10](https://qa.library.globalcastmd.com/watch/management-of-gastroschisis-timing-of-delivery-antibiotic-usage-and-closure-considerations-9626?t=10)
- "Delivery after 37 weeks is optimal for infants with gastroschisis." — Alex Halpern (host_summary) [Ep 90 · 0:17](https://qa.library.globalcastmd.com/watch/management-of-gastroschisis-timing-of-delivery-antibiotic-usage-and-closure-considerations-9626?t=17)
- "Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until closure in gastroschisis." — Alex Halpern (host_summary) [Ep 90 · 0:21](https://qa.library.globalcastmd.com/watch/management-of-gastroschisis-timing-of-delivery-antibiotic-usage-and-closure-considerations-9626?t=21)
- "Studies support primary fascial repair for gastroschisis as long as hemodynamics and abdominal domain permit." — Alex Halpern (host_summary) [Ep 90 · 0:27](https://qa.library.globalcastmd.com/watch/management-of-gastroschisis-timing-of-delivery-antibiotic-usage-and-closure-considerations-9626?t=27)
- "Sutureless repair for gastroschisis is safe and effective." — Alex Halpern (host_summary) [Ep 90 · 0:27](https://qa.library.globalcastmd.com/watch/management-of-gastroschisis-timing-of-delivery-antibiotic-usage-and-closure-considerations-9626?t=27)
- "Sutureless repair does not delay feeding or increase length of stay in gastroschisis patients." — Alex Halpern (host_summary) [Ep 90 · 0:37](https://qa.library.globalcastmd.com/watch/management-of-gastroschisis-timing-of-delivery-antibiotic-usage-and-closure-considerations-9626?t=37)
- "There is a need for high quality randomized controlled trials to help provide evidence-based care for infants with gastroschisis." — Alex Halpern (host_summary) [Ep 90 · 0:41](https://qa.library.globalcastmd.com/watch/management-of-gastroschisis-timing-of-delivery-antibiotic-usage-and-closure-considerations-9626?t=41)
- "A retrospective review by Men et al examined all patients who underwent conservative management of modified Bell stage 2A or greater NEC at a single institution from 2011 to 2022." — Alex Halpern (host_summary) [Ep 92 · 0:13](https://qa.library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=13)
- "126 patients underwent conservative management of NEC in the study period." — Alex Halpern (host_summary) [Ep 92 · 0:27](https://qa.library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=27)
- "24 of 126 patients (19%) who underwent conservative management of NEC eventually required surgery for a post-NEC stricture." — Alex Halpern (host_summary) [Ep 92 · 0:27](https://qa.library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=27)
- "Primary resection and anastomosis was performed in all cases of post-NEC stricture requiring surgery." — Alex Halpern (host_summary) [Ep 92 · 0:36](https://qa.library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=36)
- "Post-NEC strictures are a common occurrence after conservative management of NEC." — Alex Halpern (host_summary) [Ep 92 · 0:40](https://qa.library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=40)
- "Connecticut Children's Medical Center implemented an algorithm for managing esophageal button batteries in 2019 that includes activating the critical airway response team." — Eleanor Cisco (host_summary) [Ep 91 · 1:00](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=60)
- "The Brent et al. study compared patients presenting with esophageal button batteries before algorithm implementation (2015-2019) to those after implementation (2019-2022)." — Eleanor Cisco (host_summary) [Ep 91 · 1:12](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=72)
- "There was a significant reduction in time from chest X-ray to OR for button battery removal after implementing the new algorithm at Connecticut Children's." — Eleanor Cisco (host_summary) [Ep 91 · 1:25](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=85)
- "The McMaster University team performed a retrospective review of infants born between 2014 and 2022 with uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 91 · 2:08](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=128)
- "Infants with uncomplicated gastroschisis who received exclusive breast milk had similar outcomes to those with supplemental or exclusive formula intake." — Alex Halpern (host_summary) [Ep 91 · 2:17](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=137)
- "In uncomplicated gastroschisis, there were no significant differences between exclusive breast milk and formula groups in time to reach full enteral feeds, duration of parenteral nutrition, rates of necrotizing enterocolitis, and length of hospital stay." — Alex Halpern (host_summary) [Ep 91 · 2:17](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=137)
- "The Phoenix study by Lie et al. was a retrospective single institution study from 2017 to 2021 comparing patients who underwent Nuss procedure with cryoanalgesia in the first quarter versus the fourth quarter of their experience." — Cecilia Jenna (host_summary) [Ep 91 · 3:08](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=188)
- "The Phoenix study included 350 patients who underwent Nuss procedure with cryoanalgesia." — Cecilia Jenna (host_summary) [Ep 91 · 3:27](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=207)
- "Patients in the last quarter of the Phoenix cryoablation experience were discharged 1.3 days earlier than patients in the first quarter." — Cecilia Jenna (host_summary) [Ep 91 · 3:32](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=212)
- "Patients in the last quarter of the Phoenix cryoablation experience required 74% less opioids than those in the first quarter." — Cecilia Jenna (host_summary) [Ep 91 · 3:32](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=212)
- "Experience plays a role in outcomes when using cryoanalgesia for Nuss procedures." — Cecilia Jenna (opinion) [Ep 91 · 3:44](https://qa.library.globalcastmd.com/watch/quick-literature-updates-episode-16-9732?t=224)
- "This retrospective study examined 64 pediatric patients with short bowel syndrome managed by a multidisciplinary intestinal rehab program between 2001 and 2022." — Lizzie Lee (host_summary) [Ep 93 · 0:10](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=10)
- "89% of patients with short bowel syndrome in the study survived." — Lizzie Lee (host_summary) [Ep 93 · 0:22](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=22)
- "78% of patients with short bowel syndrome were able to wean off parenteral nutrition." — Lizzie Lee (host_summary) [Ep 93 · 0:22](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=22)
- "Survival rates of children with short bowel syndrome improved over time in the study period." — Lizzie Lee (host_summary) [Ep 93 · 0:22](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=22)
- "Introduction of fish oil-based parenteral nutrition in 2007 improved survival in pediatric short bowel syndrome patients." — Lizzie Lee (host_summary) [Ep 93 · 0:31](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=31)
- "Presence of intestinal failure associated liver disease affected survival in pediatric short bowel syndrome patients." — Lizzie Lee (host_summary) [Ep 93 · 0:31](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=31)
- "The umbilical cord contains two umbilical arteries and one umbilical vein surrounded by Wharton's jelly (a gelatin-like extracellular matrix)." — Em Gootee (host_summary) [Ep 89 · 0:34](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=34)
- "Umbilical cords usually fall off at 2 to 3 weeks after birth." — Em Gootee (host_summary) [Ep 89 · 0:50](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=50)
- "Delayed umbilical cord separation can be a manifestation of an immune deficiency." — Em Gootee (host_summary) [Ep 89 · 0:50](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=50)
- "Omphalitis is bacterial colonization of the umbilical stump, most commonly due to staph and strep from skin flora." — Rebecca Brown (clinical) [Ep 89 · 1:12](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=72)
- "Mild omphalitis cases (inflammation of the belly button) may be treated with alcohol drying, ampicillin, or amoxicillin with follow-up every 24 hours." — Em Gootee (host_summary) [Ep 89 · 1:20](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=80)
- "In advanced omphalitis cases, patients need hospital admission and pediatric surgery consultation." — Rebecca Brown (clinical) [Ep 89 · 1:30](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=90)
- "16% of patients admitted with omphalitis develop necrotizing fasciitis." — Em Gootee (host_summary) [Ep 89 · 1:40](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=100)
- "Necrotizing fasciitis from omphalitis presents with rapidly progressive umbilical edema, erythema, drainage, and has a high mortality rate." — Em Gootee (host_summary) [Ep 89 · 1:46](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=106)
- "Umbilical hernias are more common in African Americans, low birth weight infants, and premature infants." — Rebecca Brown (epidemiological) [Ep 89 · 2:17](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=137)
- "Umbilical hernias can be associated with trisomy 13, 18, and 21." — Em Gootee (host_summary) [Ep 89 · 2:27](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=147)
- "Dr. Brown mentioned that if the fascial opening in an umbilical hernia is larger than 1.5 centimeters, it may not close by itself." — Em Gootee (host_summary) [Ep 89 · 2:47](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=167)
- "In Walker's studies, 96% of very small umbilical hernias (less than 0.5 centimeters) closed by six years, but no hernia greater than 1.5 centimeters closed by six years of age." — Em Gootee (host_summary) [Ep 89 · 2:55](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=175)
- "Incarceration with umbilical hernias is rare, occurring in less than 0.2% of cases, and is more common with smaller defects." — Rebecca Brown (epidemiological) [Ep 89 · 3:21](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=201)
- "In Tiffany Zinz's study of 308 umbilical hernia repairs, there was a higher incidence of complications if patients were less than 4 years of age versus greater than 4 years of age." — Rebecca Brown (epidemiological) [Ep 89 · 3:42](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=222)
- "A literature review of 787 manuscripts (28 meeting quality criteria) showed that early surgical repair of umbilical hernias before age 4 was not indicated regardless of defect size." — Rebecca Brown (guideline) [Ep 89 · 4:06](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=246)
- "In a 2020 study of 9,809 patients, the 3-year recurrence rate after umbilical hernia repair was twice as high in children less than 4 years of age versus those greater than 4 years of age." — Rebecca Brown (epidemiological) [Ep 89 · 4:40](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=280)
- "Unplanned emergency department returns within 30 days after umbilical hernia repair occurred at 2.5%, with rates twice as high for patients younger than 4 years old." — Em Gootee (host_summary) [Ep 89 · 4:54](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=294)
- "Asymptomatic umbilical hernia repair should be delayed until greater than 4 years of age." — Em Gootee (host_summary) [Ep 89 · 5:10](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=310)
- "In Rangel's study of 167,000 patients at 68 pediatricians' offices, 4,486 had umbilical hernia diagnosis at a median age of 1.6 months, with spontaneous closure occurring in 89% by age 5." — Em Gootee (host_summary) [Ep 89 · 5:18](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=318)
- "In Rangel's study, closure rates for smaller hernias (≤1 cm) were nearly 90%, while for larger hernias they were around 80%." — Em Gootee (host_summary) [Ep 89 · 5:53](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=353)
- "If an umbilical hernia persisted at age 3, spontaneous closure occurred in 20% by age 4 and 35% by age 5." — Rebecca Brown (epidemiological) [Ep 89 · 6:03](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=363)
- "Rangel's study concluded that umbilical hernia repair should be delayed until age 5 years given the high incidence of spontaneous closure." — Em Gootee (host_summary) [Ep 89 · 6:12](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=372)
- "Dr. Brown's opinion is that hernias with a huge defect that are proboscoid are probably not going to close spontaneously." — Rebecca Brown (opinion) [Ep 89 · 6:34](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=394)
- "Indications for umbilical hernia repair include persistence after 5 years of age, signs or symptoms of incarceration, and consideration for large proboscoid hernias in patients about to start school." — Rebecca Brown (guideline) [Ep 89 · 6:43](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=403)
- "Proboscoid hernia occurs when the skin above the hernia grows and pushes through the opening in the abdominal wall." — Em Gootee (host_summary) [Ep 89 · 6:56](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=416)
- "It is recommended to correct proboscoid hernias before school age to avoid psychological issues for the child." — Em Gootee (host_summary) [Ep 89 · 7:05](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=425)
- "Dr. Brown's approach is to repair umbilical hernias at 5 years regardless of size if they haven't closed, or earlier if the patient is having symptoms." — Rebecca Brown (opinion) [Ep 89 · 7:11](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=431)
- "Umbilical hernia repair technique involves dissecting around the hernia sac, dividing it, trimming excess sac, closing the fascia with interrupted absorbable sutures (such as Vicryl), and recreating the umbilicus." — Rebecca Brown (clinical) [Ep 89 · 7:22](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=442)
- "Dr. Brown prefers to perform umbilicoplasty in umbilical hernia repairs, excising excess skin and using a 4-0 monocryl purse-string suture close to the skin surface to create a cosmetically appealing umbilicus." — Em Gootee (host_summary) [Ep 89 · 8:00](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=480)
- "Umbilical granulomas are the most common umbilical masses in newborns." — Rebecca Brown (epidemiological) [Ep 89 · 8:52](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=532)
- "Umbilical granulomas are usually moist but commonly dry up and fall off spontaneously over time." — Em Gootee (host_summary) [Ep 89 · 8:55](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=535)
- "Umbilical granulomas often respond to silver nitrate treatment." — Em Gootee (host_summary) [Ep 89 · 9:00](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=540)
- "Dr. Brown recommends neutralizing silver nitrate burns by applying water after silver nitrate application to prevent skin damage and keep it from spreading." — Rebecca Brown (clinical) [Ep 89 · 9:17](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=557)
- "Bright red, pedunculated umbilical lesions that bleed easily are more difficult to treat and may represent polyps rather than simple granulomas." — Rebecca Brown (clinical) [Ep 89 · 9:40](https://qa.library.globalcastmd.com/watch/umbilical-disorders-with-dr-rebeccah-brown-9616?t=580)
- "Necrotizing enterocolitis is a devastating gastrointestinal disease impacting premature infants whose pathophysiology is driven by complex pathways that are not completely understood" — Colleen Nofi (clinical) [Ep 94 · 0:39](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=39)
- "NEC has limited treatment options and an unacceptably high morbidity and mortality risk" — Colleen Nofi (clinical) [Ep 94 · 0:52](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=52)
- "Under biologic conditions, CIRP is found inside the cell where it acts as an RNA chaperone protein" — Colleen Nofi (clinical) [Ep 94 · 1:06](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=66)
- "In states of cellular stress such as sepsis, CIRP escapes outside the cell" — Colleen Nofi (clinical) [Ep 94 · 1:12](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=72)
- "Once released from the cell, extracellular CIRP acts as a DAMP by enhancing the release of cytokines and chemokines and amplifying the inflammatory cascade" — Colleen Nofi (clinical) [Ep 94 · 1:19](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=79)
- "MOP3 (MFGE8 derived oligopeptide 3) is an eCIRP scavenging peptide that removes eCIRP from circulation to reduce inflammation" — Colleen Nofi (clinical) [Ep 94 · 1:33](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=93)
- "CIRP knockout protected pups from NEC severity with preservation of intestinal villi architecture" — Colleen Nofi (clinical) [Ep 94 · 2:30](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=150)
- "CIRP knockout mice subjected to NEC showed reduced intestinal inflammation as measured by mRNA levels of IL-6 and TNF-alpha in the small bowel" — Colleen Nofi (clinical) [Ep 94 · 2:59](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=179)
- "CIRP knockout pups had reduced fluorescent dextran leakage indicating preserved intestinal barrier function compared to wild-type NEC pups" — Colleen Nofi (clinical) [Ep 94 · 3:36](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=216)
- "CIRP knockout pups subjected to NEC had 100% survival whereas wild-type pups had only 65% survival in the same model under the same conditions" — Colleen Nofi (clinical) [Ep 94 · 3:57](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=237)
- "MOP3 treatment reduced circulating eCIRP levels in NEC pups compared to vehicle" — Colleen Nofi (clinical) [Ep 94 · 4:18](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=258)
- "Reduction in eCIRP with MOP3 treatment correlated with reduction in systemic inflammatory markers including IL-6 and TNF-alpha" — Colleen Nofi (clinical) [Ep 94 · 4:27](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=267)
- "MOP3 treatment protected against NEC severity with preservation of intestinal villi" — Colleen Nofi (clinical) [Ep 94 · 4:37](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=277)
- "MOP3 treatment reduced intestinal inflammation in NEC as measured by mRNA levels of IL-6 and TNF-alpha" — Colleen Nofi (clinical) [Ep 94 · 4:55](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=295)
- "MOP3-treated pups had significantly reduced fluorescence intensity indicating protection of the intestinal barrier compared to vehicle-treated NEC pups" — Colleen Nofi (clinical) [Ep 94 · 5:05](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=305)
- "Murine pups subjected to NEC and treated with MOP3 had 80% survival compared to only 50% survival in vehicle-treated pups" — Colleen Nofi (clinical) [Ep 94 · 5:22](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=322)
- "eCIRP exacerbates NEC pathogenesis by increasing inflammation and intestinal injury" — Colleen Nofi (clinical) [Ep 94 · 5:42](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=342)
- "MOP3 protects against NEC pathogenesis by scavenging eCIRP and preventing deleterious downstream impacts" — Colleen Nofi (clinical) [Ep 94 · 5:42](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=342)
- "The murine NEC model uses a 4-day protocol with continuous stressors including LPS, formula gavage, and hypoxia" — Colleen Nofi (clinical) [Ep 94 · 7:34](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=454)
- "MOP3 treatment was administered once per day at the beginning of the model, ongoing with the NEC insult" — Colleen Nofi (clinical) [Ep 94 · 7:49](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=469)
- "MOP3 is effective in other models of ischemia-reperfusion injury in the gut" — Colleen Nofi (clinical) [Ep 94 · 6:53](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=413)
- "The therapeutic benefit of MOP3 is not at the same level as complete CIRP knockdown" — Colleen Nofi (clinical) [Ep 94 · 7:00](https://qa.library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=420)
- "RIC has been shown to decrease rates of necrotizing enterocolitis in a rat model." — Alex Halpern (host_summary) [Ep 95 · 0:00](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=0)
- "Gadal used an established piglet NEC model to test RIC." — Alex Halpern (host_summary) [Ep 95 · 0:16](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=16)
- "Piglets were randomly assigned to receive RIC or serve as controls." — Alex Halpern (host_summary) [Ep 95 · 0:20](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=20)
- "RIC was initiated at 24 hours of life and consisted of 4 cycles of 4 minutes of arterial occlusion followed by reperfusion." — Alex Halpern (host_summary) [Ep 95 · 0:24](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=24)
- "Cycles were repeated every 24 hours in the low frequency group and every 12 hours in the high frequency group." — Alex Halpern (host_summary) [Ep 95 · 0:31](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=31)
- "38 piglets were randomized into the control group, 26 into the low frequency group, and 22 into the high frequency group." — Alex Halpern (host_summary) [Ep 95 · 0:37](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=37)
- "High frequency RIC significantly reduced the incidence of NEC when compared to controls." — Alex Halpern (host_summary) [Ep 95 · 0:45](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=45)
- "Low frequency RIC did not significantly reduce the incidence of NEC." — Alex Halpern (host_summary) [Ep 95 · 0:50](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=50)
- "High frequency RIC protects against NEC in a piglet model." — Alex Halpern (host_summary) [Ep 95 · 0:53](https://qa.library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=53)
- "The STAT trial was a randomized controlled trial in 12 centers worldwide." — Lizzie Lee (host_summary) [Ep 96 · 0:13](https://qa.library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=13)
- "The STAT trial looked at newborns who underwent laparotomy for necrotizing enterocolitis requiring intestinal resection from 2010 to 2020." — Lizzie Lee (host_summary) [Ep 96 · 0:13](https://qa.library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=13)
- "Infants were randomized to two surgical approaches: either anastomosis or stoma formation." — Lizzie Lee (host_summary) [Ep 96 · 0:26](https://qa.library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=26)
- "Infants undergoing primary anastomosis had a significantly less duration of requiring parenteral nutrition compared to those with stoma formation." — Lizzie Lee (host_summary) [Ep 96 · 0:31](https://qa.library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=31)
- "There was no difference in mortality between primary anastomosis and stoma formation groups." — Lizzie Lee (host_summary) [Ep 96 · 0:31](https://qa.library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=31)
- "There was no difference in unplanned surgeries between primary anastomosis and stoma formation groups." — Lizzie Lee (host_summary) [Ep 96 · 0:31](https://qa.library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=31)
- "Primary anastomosis is superior for enhancing recovery from necrotizing enterocolitis in infants and does not increase adverse outcomes." — Lizzie Lee (host_summary) [Ep 96 · 0:43](https://qa.library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=43)
- "This is a retrospective study using educational data from children born between 1991 and 2022." — Lizzie Lee (host_summary) [Ep 97 · 0:11](https://qa.library.globalcastmd.com/watch/educational-outcomes-in-school-aged-children-with-a-history-of-simple-and-complex-gastroschisis-are-poor-compared-to-controls-10437?t=11)
- "Researchers used odds ratio and subgroup analysis to compare school performance using the Early Development Instrument or EDI and grade level assessments between 208 children with gastroschisis and over 2000 age-matched controls." — Lizzie Lee (host_summary) [Ep 97 · 0:18](https://qa.library.globalcastmd.com/watch/educational-outcomes-in-school-aged-children-with-a-history-of-simple-and-complex-gastroschisis-are-poor-compared-to-controls-10437?t=18)
- "Children with gastroschisis, even those with the simpler form, were significantly more likely to fail middle school assessments." — Lizzie Lee (host_summary) [Ep 97 · 0:33](https://qa.library.globalcastmd.com/watch/educational-outcomes-in-school-aged-children-with-a-history-of-simple-and-complex-gastroschisis-are-poor-compared-to-controls-10437?t=33)
- "Children with gastroschisis may face long-term learning challenges and could benefit from early educational support." — Lizzie Lee (host_summary) [Ep 97 · 0:41](https://qa.library.globalcastmd.com/watch/educational-outcomes-in-school-aged-children-with-a-history-of-simple-and-complex-gastroschisis-are-poor-compared-to-controls-10437?t=41)
- "The Beotti et al. prospective study on postoperative calibrations in Hirschsprung disease took place 2021 to 2023 and included 33 patients under six months old who underwent endorectal pull-through surgeries." — Lizzie Lee (host_summary) [Ep 99 · 1:03](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=63)
- "In the Beotti study, patients were assigned to a new non-dilation protocol group or a traditional dilation group." — Lizzie Lee (host_summary) [Ep 99 · 1:14](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=74)
- "The Beotti study primary outcomes were anastomotic complications, enterocolitis, and constipation." — Lizzie Lee (host_summary) [Ep 99 · 1:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=80)
- "In the Beotti study, there was no significant difference in anastomotic complications between the two groups, but the non-dilation group had less enterocolitis and less constipation." — Lizzie Lee (host_summary) [Ep 99 · 1:27](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=87)
- "Choosing not to do postoperative anal dilations after Hirschsprung pull-through may be a good alternative with benefits like lower constipation and enterocolitis." — Lizzie Lee (host_summary) [Ep 99 · 1:36](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=96)
- "The APSA Outcomes and Evidence-based Practice Committee systematic review by Slidell et al. found that delivery after 37 weeks is optimal for gastroschisis." — Alex Halpern (host_summary) [Ep 99 · 2:11](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=131)
- "For gastroschisis, prophylactic antibiotics covering skin flora are adequate to reduce infection risk until closure." — Alex Halpern (host_summary) [Ep 99 · 2:21](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=141)
- "Studies support primary fascial repair for gastroschisis as long as hemodynamics and abdominal domain permit." — Alex Halpern (host_summary) [Ep 99 · 2:28](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=148)
- "Sutureless repair for gastroschisis is safe, effective, and does not delay feeding or increase length of stay." — Alex Halpern (host_summary) [Ep 99 · 2:28](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=148)
- "The APSA systematic review concluded that there is a need for high quality randomized controlled trials to help provide evidence-based care for gastroschisis infants." — Alex Halpern (host_summary) [Ep 99 · 2:42](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=162)
- "The Pefer et al. study is a retrospective study done in Texas using a state hospital database examining CDH outcomes by center volume." — Cecilia Gigena (host_summary) [Ep 99 · 3:16](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=196)
- "The Pefer study identified 1,314 CDH patients: 728 from high volume centers, 9 from mid-volume centers, and 79 from low volume centers." — Cecilia Gigena (host_summary) [Ep 99 · 3:32](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=212)
- "High volume centers had significantly lower mortality rates for CDH, even though they have significantly sicker patients." — Cecilia Gigena (host_summary) [Ep 99 · 3:46](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=226)
- "High volume centers had significantly shorter length of stay for CDH patients." — Cecilia Gigena (host_summary) [Ep 99 · 3:46](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=226)
- "High volume centers had better outcomes for patients with CDH." — Cecilia Gigena (host_summary) [Ep 99 · 4:00](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-22-11118?t=240)
- "A subset of children after esophageal atresia repair experience severe airway collapse, leaving them ventilator dependent or suffering repeated cyanotic spells" — Em Gootee (host_summary) [Ep 98 · 1:41](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=101)
- "80 patients with severe airway collapse after esophageal atresia is a huge number; most pediatric surgeons won't see 10 such patients in their career, and many wouldn't see 5" — George W. Holcomb III (epidemiological) [Ep 98 · 2:17](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=137)
- "90% of patients showed complete airway collapse on dynamic bronchoscopy" — George W. Holcomb III (host_summary) [Ep 98 · 2:34](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=154)
- "Three-quarters of tracheobronchopexy procedures used a posterior approach" — George W. Holcomb III (host_summary) [Ep 98 · 2:40](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=160)
- "Tracheobronchopexy was performed on thoracic trachea alone in over half the patients, but had to be extended onto the bronchi in 40%" — George W. Holcomb III (host_summary) [Ep 98 · 2:44](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=164)
- "94% of patients avoided tracheostomy with a mortality rate of 5%, and the procedure significantly reduced pressure ventilation and ventilator dependence" — George W. Holcomb III (host_summary) [Ep 98 · 2:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=177)
- "In experienced hands who have done numerous or hundreds of these procedures, tracheobronchopexy can have very good outcomes for patients with severe airway collapse symptoms" — George W. Holcomb III (opinion) [Ep 98 · 3:14](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=194)
- "Canada is the second largest country in the world geographically, though population-wise smaller than California" — Eric Skarsgard (epidemiological) [Ep 98 · 5:28](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=328)
- "The majority of Canada's population lives within 200 kilometers of the US border, but there are definitely lots of children in remote communities where it is not easy to access care" — Eric Skarsgard (epidemiological) [Ep 98 · 5:38](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=338)
- "Outreach services were present in only 7 out of 10 provinces, and only 8 out of 18 children's hospitals (44%) provided outreach services" — Preet Bir (epidemiological) [Ep 98 · 6:43](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=403)
- "A significant number of outreach services are located within 50 kilometers of a children's hospital, leaving vast regions without access to pediatric surgical care" — Em Gootee (host_summary) [Ep 98 · 6:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=417)
- "In most places in Canada, no one would transfer a 16 or 17 year old with appendicitis to a children's hospital for surgery; physiologically and every other way they're an adult and do not need the expertise of a pediatric surgeon" — Eric Skarsgard (clinical) [Ep 98 · 7:36](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=456)
- "It's a misconception that the Canadian healthcare system ensures timely care; it actually doesn't, and children wait for surgery beyond their wait time target" — Eric Skarsgard (clinical) [Ep 98 · 8:01](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=481)
- "Newfoundland and Labrador has the best outreach setup with only two pediatric surgeons who have established outreach clinics all over the province, serving as a model to others" — Eric Skarsgard (clinical) [Ep 98 · 8:16](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=496)
- "The population of Newfoundland and Labrador is really rural and spread out, and weather-wise it can be impossible sometimes to access care or financially devastating" — Eric Skarsgard (epidemiological) [Ep 98 · 8:31](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=511)
- "There are measurable costs of living remote to accessible high-quality care in terms of time required to be seen and actual clinical outcomes" — Eric Skarsgard (clinical) [Ep 98 · 9:01](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=541)
- "In the NSQIP database, 5% of all pediatric procedures were G-tube, which is a pretty sizable percent" — Sean Kunisaki (epidemiological) [Ep 98 · 11:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=716)
- "The study examined 4,612 G-tube placements from 71 NSQIP-Pediatric hospitals in 2023" — Em Gootee (host_summary) [Ep 98 · 12:38](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=758)
- "77% of G-tube cases were first-time G-tubes as opposed to redos" (epidemiological) [Ep 98 · 12:46](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=766)
- "Upper GI studies were obtained in 45% of first-time G-tube cases with substantial interhospital variability from 0 to 99%" — Em Gootee (host_summary) [Ep 98 · 13:04](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=784)
- "The heterogeneity in use of preoperative upper GIs was extremely broad with no real reason, indicating a potential teaching moment" — Sean Kunisaki (opinion) [Ep 98 · 13:20](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=800)
- "14% of G-tube cases resulted in an ED visit within 0 to 30 days" — Em Gootee (host_summary) [Ep 98 · 13:45](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=825)
- "5.2% of G-tube cases involved dislodgement within 0 to 30 days" — Em Gootee (host_summary) [Ep 98 · 13:45](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=825)
- "An additional 5.5% of G-tubes were dislodged in the 31 to 60 day period" (clinical) [Ep 98 · 13:55](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=835)
- "Dislodgement rates are higher than rates of readmissions or IR interventions, making dislodgements a great QI target" (opinion) [Ep 98 · 13:55](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=835)
- "If you can get dislodgements down, ED visits go down; when dislodgements happen early, patients are told to come back to the ED" (clinical) [Ep 98 · 14:15](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-1st-quarter-2025-10484?t=855)
- "Van Haal et al. conducted a retrospective cohort study in the Netherlands that included 79 patients who had rigid tracheobronchoscopy done before and after esophageal atresia surgery." — Lizzie Lee (host_summary) [Ep 100 · 1:04](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=64)
- "Preoperative tracheobronchoscopy for the presence of post-operative tracheomalacia had a sensitivity of 50% and a specificity of 67%." — Lizzie Lee (host_summary) [Ep 100 · 1:24](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=84)
- "Preoperative tracheobronchoscopy, though routine, has limited predictive value for post-operative tracheomalacia in esophageal atresia patients." — Lizzie Lee (host_summary) [Ep 100 · 1:34](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=94)
- "Mina et al. performed a retrospective review of all patients who underwent conservative management of modified Bell stage 2A or greater necrotizing enterocolitis at a single institution from 2011 to 2022." — Alex Halpern (host_summary) [Ep 100 · 2:05](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=125)
- "126 patients underwent conservative management of necrotizing enterocolitis, and 24 of those patients eventually underwent surgery for a post-NEC stricture." — Alex Halpern (host_summary) [Ep 100 · 2:20](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=140)
- "Primary resection and anastomosis was performed in all cases of post-NEC stricture requiring surgery." — Alex Halpern (host_summary) [Ep 100 · 2:29](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=149)
- "Post-NEC strictures are a common occurrence after conservative management of necrotizing enterocolitis." — Alex Halpern (host_summary) [Ep 100 · 2:33](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=153)
- "Huncheid et al. conducted a multi-center non-inferiority trial that compared preterm infants treated with expectant management versus early ibuprofen for patent ductus arteriosus." — Cecilia Gigena (host_summary) [Ep 100 · 3:04](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=184)
- "The trial included 273 infants: 136 treated with expectant management and 137 with early ibuprofen." — Cecilia Gigena (host_summary) [Ep 100 · 3:14](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=194)
- "In the expectant management group for PDA, there was 17.6% necrotizing enterocolitis, 33% bronchopulmonary dysplasia, and 14% death rates." — Cecilia Gigena (host_summary) [Ep 100 · 3:24](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=204)
- "In the ibuprofen group for PDA, there was 15.4% necrotizing enterocolitis, 50% bronchopulmonary dysplasia, and 80% death rates." — Cecilia Gigena (host_summary) [Ep 100 · 3:36](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=216)
- "Expectant management is not inferior to early ibuprofen in preterm patients with patent ductus arteriosus." — Cecilia Gigena (host_summary) [Ep 100 · 3:53](https://qa.library.globalcastmd.com/watch/quick-literature-updates-ep-27-11580?t=233)
- "Advances in medicine have dramatically improved survival rates for children with intestinal failure" — Julian Goddard (host_summary) [Ep 101 · 0:00](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=0)
- "Cincinnati Children's intestinal rehabilitation team tracked 46 patients who turned 20 to examine outcomes when they transitioned to adult healthcare centers or continued pediatric care" — Julian Goddard (epidemiological) [Ep 101 · 0:13](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=13)
- "59% of patients transitioned to adult focused programs while the rest continued receiving care at Cincinnati Children's" — Julian Goddard (epidemiological) [Ep 101 · 0:23](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=23)
- "Patients who transitioned to adult care had a significantly higher mortality rate of 33% compared to 5% among those who stayed in pediatric care" — Julian Goddard (epidemiological) [Ep 101 · 0:29](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=29)
- "Patients who transitioned to adult care showed no obvious differences in medical complexity or disease burden compared to those who remained in pediatric care" — Julian Goddard (epidemiological) [Ep 101 · 0:29](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=29)
- "The median time from transition to death was approximately 12 months" — Julian Goddard (epidemiological) [Ep 101 · 0:42](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=42)
- "Young adults with a history of intestinal failure aging out of pediatric care remain a critically vulnerable population in need of greater attention and support until structured transition programs are developed and widely implemented" — Julian Goddard (opinion) [Ep 101 · 0:46](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=46)
- "A 12-year-old female presented with a three-month history of intermittent pain and weight loss with acute worsening of symptoms." (host_summary) [Ep 103 · 0:08](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=8)
- "CT scan showed evidence of midgut volvulus." (host_summary) [Ep 103 · 0:15](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=15)
- "Patient was positioned in dorsal lithotomy position with surgeon positioned between patient's legs." (host_summary) [Ep 103 · 0:18](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=18)
- "5 millimeter ports were used for the procedure." (host_summary) [Ep 103 · 0:29](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=29)
- "Upon entering abdomen, there was clear disorientation of the bowel with an internal hernia and complete twist of the bowel." (host_summary) [Ep 103 · 0:36](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=36)
- "The anatomy was confusing because of 360-degree twist of the bowel as well as the internal hernia." (host_summary) [Ep 103 · 2:38](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=158)
- "The key to this operation is to operate in front of the camera and run the bowel in front of the camera instead of chasing the bowel around the abdomen, which prevents disorientation and allows the surgeon to keep a clear view." (opinion) [Ep 103 · 2:52](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=172)
- "The superior mesenteric vessels were engorged because they had been twisted." (host_summary) [Ep 103 · 3:13](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=193)
- "It is critical that the bowel be completely run from the duodenojejunal junction all the way to the ileocecal valve to ensure that all bands have been released." (opinion) [Ep 103 · 4:00](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=240)
- "The key to this operation is making sure that the mesentery has been broadly widened to prevent a twist in the future." (opinion) [Ep 103 · 6:29](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=389)
- "One should be able to see the superior mesenteric artery and vein coming straight down into the middle of the abdomen with no twists or obstruction." (opinion) [Ep 103 · 6:39](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=399)
- "Running the bowel from proximal to distal places all the small bowel on the patient's right and the colon on the patient's left." (host_summary) [Ep 103 · 7:11](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=431)
- "Using a 5mm stapler for appendix division allows keeping all ports at 5mm and not upsizing to a 12mm port for a larger stapler." (host_summary) [Ep 103 · 7:37](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=457)
- "The operation took approximately 90 minutes and the patient did well." (host_summary) [Ep 103 · 7:58](https://qa.library.globalcastmd.com/watch/malrotation-and-volvulus-with-trinity-11941?t=478)
- "The infant presented with repetitive bilious vomiting." (host_summary) [Ep 102 · 0:00](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=0)
- "An upper GI series showed a redundant duodenum which did not cross the midline." (host_summary) [Ep 102 · 0:09](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=9)
- "The surgeon is positioned at the end of the table with the baby brought down to the foot of the table to allow the surgeon to be in line with the foregut." (host_summary) [Ep 102 · 0:16](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=16)
- "A 4 or 5 millimeter port is placed in the umbilicus, and right and left hand operating ports are placed either side of the umbilicus." (host_summary) [Ep 102 · 0:28](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=28)
- "In a small infant, the right hand port is placed above the umbilicus so that the right hand does not conflict with the scope." (host_summary) [Ep 102 · 0:36](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=36)
- "The 3 millimeter sealer can be used to safely grasp the bowel and act as a forceps which is atraumatic to the bowel." (clinical) [Ep 102 · 1:00](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=60)
- "The first portion of the duodenum is extremely dilated." (clinical) [Ep 102 · 1:22](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=82)
- "Dense adhesions to the proximal duodenum can be safely taken down using the sealer by dissecting them off the bowel and then sealing and gently tearing them off the surface of the duodenum." (clinical) [Ep 102 · 1:33](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=93)
- "Because of the minimal energy spread of the sealer, it is very safe to dissect in this fashion." (clinical) [Ep 102 · 1:51](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=111)
- "The bowel can be grasped immediately after the sealer is activated without any evidence of any heat injury to the bowel." (clinical) [Ep 102 · 1:58](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=118)
- "The sealer is found to be much more useful than using a hook, which had significant energy spread and also could not be used to grasp the bowel." (opinion) [Ep 102 · 2:10](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=130)
- "As is common in these cases, the duodenum goes towards the retroperitoneum, and this is the most difficult part to mobilize." (clinical) [Ep 102 · 3:13](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=193)
- "Adhesions between the transverse colon and the duodenum, some of which are consistent with Ladd bands, can be extremely thick and dense and difficult to take down." (clinical) [Ep 102 · 3:35](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=215)
- "Complete mobilization of the transverse and proximal or ascending colon is necessary because of the posterior attachments." (clinical) [Ep 102 · 4:08](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=248)
- "The minimal energy spread from the sealer allows this device to be used in close proximity to the small bowel without any risk of injury to it." (clinical) [Ep 102 · 5:19](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=319)
- "Ladd bands can traverse across the duodenum causing proximal obstruction." (clinical) [Ep 102 · 5:35](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=335)
- "The posterior retroperitoneal attachment of the duodenum cannot be reached until the Ladd bands have been completely divided." (clinical) [Ep 102 · 7:01](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=421)
- "The bowel is run from proximal to distal to completely derotate the bowel and eliminate the risk of volvulus in the future." (clinical) [Ep 102 · 6:50](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=410)
- "The sealer can act as an atraumatic bowel grasper during bowel running, though the jaws are not quite as large as the 3 millimeter bowel grasper." (clinical) [Ep 102 · 7:39](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=459)
- "The sealer is used during bowel running because other bands are often encountered, and this allows immediate sealing and division." (clinical) [Ep 102 · 7:56](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=476)
- "Enlarged lymph nodes in the mesentery and the chylous appearance within the bowel show evidence of chronic mild obstruction." (clinical) [Ep 102 · 8:29](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=509)
- "At the completion of the Ladd procedure, all of the colon is on the left and the small bowel is on the right." (clinical) [Ep 102 · 8:56](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=536)
- "In a small infant with a small appendix, the appendix can be brought out through the right trocar site and amputated extracorporeally." (clinical) [Ep 102 · 9:06](https://qa.library.globalcastmd.com/watch/malrotation-infant-11940?t=546)
- "Bowel ultrasound is becoming an important tool for diagnosing necrotizing enterocolitis (NEC)." — Lizzie Lee (host_summary) [Ep 106 · 0:08](https://qa.library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=8)
- "A national survey included more than 100 neonatologists, surgeons, and radiologists from 42 children's hospitals." — Lizzie Lee (host_summary) [Ep 106 · 0:19](https://qa.library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=19)
- "Bowel ultrasound was available in 83% of level 4 NICUs." — Lizzie Lee (host_summary) [Ep 106 · 0:26](https://qa.library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=26)
- "Clinicians reported using bowel ultrasound inconsistently, most often only when X-rays were inconclusive." — Lizzie Lee (host_summary) [Ep 106 · 0:26](https://qa.library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=26)
- "The biggest barriers to bowel ultrasound use were lack of standardized protocols, limited provider training, and uncertainty about how bowel ultrasound should guide treatment decisions." — Lizzie Lee (host_summary) [Ep 106 · 0:36](https://qa.library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=36)
- "Wider adoption of bowel ultrasound for NEC will depend on better evidence, standardized guidelines, and improved clinician training." — Lizzie Lee (host_summary) [Ep 106 · 0:46](https://qa.library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=46)
- "Giant omphalocele is typically defined as five centimeters or greater or liver in the sac" (clinical) [Ep 105 · 0:36](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=36)
- "In a two-center retrospective study encompassing 20 years with 97 survivors of giant omphalocele, patients had greater time to full feeds, required more TPN, had more chromosomal anomalies, and had higher incidence of respiratory insufficiency" (epidemiological) [Ep 105 · 0:36](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=36)
- "56 patients of 97 giant omphalocele survivors were identified as having pulmonary hypertension, most diagnosed within the first week of life" (epidemiological) [Ep 105 · 1:14](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=74)
- "Five patients out of 56 with pulmonary hypertension had no signs in their first echo within the first seven days of life, then subsequently developed severe pulmonary hypertension after an episode of sepsis; two died and one required pulmonary vasodilator for more than a year" (clinical) [Ep 105 · 1:14](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=74)
- "Even in omphalocele patients without signs of respiratory compromise early, sepsis later puts these patients at high risk for pulmonary hypertension" (clinical) [Ep 105 · 1:14](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=74)
- "Dr. Miguel Guelfand uses hydrocolloid dressing to make a silo for giant omphalocele without painting the sac, achieving closure in 97% within 30 days and 92% within 15 days in 40 patients" (clinical) [Ep 105 · 3:46](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=226)
- "For hydrocolloid dressing technique, the dressing should be placed within the first 24 hours so the sac doesn't get very stiff, and the hydrocolloid makes the sac very smooth and hydrated" (clinical) [Ep 105 · 4:26](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=266)
- "Dr. Guelfand's team keeps all giant omphalocele patients in ICU ventilated and completely paralyzed during active reduction" (clinical) [Ep 105 · 4:20](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=260)
- "For ruptured omphalocele, Dr. Guelfand's team sutures the omphalocele and then applies the hydrocolloid dressing; they have treated three such patients" (clinical) [Ep 105 · 4:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=285)
- "The risk of midgut volvulus was higher in patients with omphalocele compared to gastroschisis, and there was increased risk of adhesive bowel obstruction with gastroschisis" (epidemiological) [Ep 105 · 5:17](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=317)
- "If exposing the intestines in omphalocele patients, it is worthwhile doing a Ladd procedure at the time because these patients have non-rotation or mal-rotation, and non-rotation does not exclude the possibility of having anatomy with a narrow base of mesentery" (clinical) [Ep 105 · 5:17](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=317)
- "Dr. Guelfand uses proline mesh for huge gastroschisis or omphalocele cases when there is no place for hydrocolloid, protecting it with a plastic bag within the bowel; this technique has been used for 15 years" (clinical) [Ep 105 · 8:18](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=498)
- "When a Bentec spring-loaded silo is placed for giant abdominal wall defect and pushed down, the forces go out and actually make the defect much bigger over time" (clinical) [Ep 105 · 8:49](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=529)
- "Dr. Islam's team used biologic mesh as a scaffold for a large abdominal wall defect, which sticks to the bowel and creates a scaffold to allow skin to epithelialize, then used circumcision skin as a graft, followed by plastic surgery tissue expanders and flaps for coverage" (clinical) [Ep 105 · 9:14](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=554)
- "Component separation technique involves separating tissue at the external oblique about a centimeter beyond the rectus sheath on both sides, dissecting between external and internal oblique, and optionally making an incision on the anterior rectus sheath for another centimeter of space" — Ellen Encisco (host_summary) [Ep 105 · 10:26](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=626)
- "A Texas report described component separation use in nine children aged seven days to 10 years, mostly for omphaloceles and giant defects, achieving fascial closure in the vast majority with some mesh use for bridging" — Ellen Encisco (host_summary) [Ep 105 · 10:26](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=626)
- "Complex gastroschisis is almost a different disease from simple variety; everything is worse including hospital length of stay, requirement for further operations, and sepsis rates" (clinical) [Ep 105 · 12:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=745)
- "In sutureless gastroschisis closure, the silo is placed or bowel is tucked in with occlusive dressing, changed at five days, and mostly closed by the next change, then simple dressings can be used" (clinical) [Ep 105 · 12:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=745)
- "Comparing sutured versus sutureless gastroschisis closure, there was no difference in time to full feeds, TPN use, or duration of hospital stay, but sutureless had fewer anesthetics, less frequent antibiotic use, and fewer infections and septic events" (epidemiological) [Ep 105 · 12:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=745)
- "A randomized trial of over 50 gastroschisis patients found no difference between immediate closure and silo placement" (epidemiological) [Ep 105 · 12:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=745)
- "The finding of no difference between silo and immediate closure paved the way for studying sutureless closure, because it established that immediate closure was not superior before moving to sutureless technique" (opinion) [Ep 105 · 12:25](https://qa.library.globalcastmd.com/watch/update-course-rewind-omphalocele-gastroschisis-2020-13507?t=745)
- "Abdominal X-rays for NEC have high specificity but very low sensitivity, with studies showing sensitivity between 13 and 25%" — Augusto Zani (clinical) [Ep 107 · 1:56](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=116)
- "For every 10 babies with surgical NEC, an X-ray might only catch one or two in the early stages (based on 13% sensitivity)" — Lizzie Lee (host_summary) [Ep 107 · 2:06](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=126)
- "A 2023 study in Pediatric Radiology suggests ultrasound can detect bowel wall thinning, perfusion abnormalities, and silent fluid collections that X-ray misses" — Lizzie Lee (host_summary) [Ep 107 · 2:15](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=135)
- "Ultrasound can assess bowel wall thickening, thinning, perfusion, peristalsis, intra-abdominal contents, peritoneum, and liver" — Augusto Zani (clinical) [Ep 107 · 2:30](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=150)
- "High-risk ultrasound findings for bowel perforation include pneumoperitoneum, focal fluid collections, and complex fluid" — Augusto Zani (clinical) [Ep 107 · 2:59](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=179)
- "Intermediate-risk ultrasound findings include increased bowel wall echogenicity, absent perfusion, portal venous gas, and bowel thinning and thickening" — Augusto Zani (clinical) [Ep 107 · 3:07](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=187)
- "The majority of surgeons would perform laparotomy rather than drain placement for perforated NEC" — Augusto Zani (opinion) [Ep 107 · 3:56](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=236)
- "Babies are sick post-operatively whether you perform anastomosis or not" — Todd Ponsky (clinical) [Ep 107 · 4:18](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=258)
- "In NEC, diseased bowel is a symptom or result of the illness, not the cause of the illness" — Todd Ponsky (clinical) [Ep 107 · 4:28](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=268)
- "The disease still progresses even after resection, which is the problem of operating too early" — Todd Ponsky (clinical) [Ep 107 · 4:34](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=274)
- "In stable babies where approximately 10 cm of necrotic segment is removed for source control, they do not necessarily do poorly afterwards and there is long-term benefit" — Augusto Zani (clinical) [Ep 107 · 4:47](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=287)
- "The benefit of primary anastomosis may not be seen in immediate survival but appears in the long run" — Lizzie Lee (host_summary) [Ep 107 · 5:00](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=300)
- "Data shows primary anastomosis is better than stoma in appropriate cases" — Todd Ponsky (clinical) [Ep 107 · 5:06](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=306)
- "In clip-and-drop technique, surgeon removes necrotic segment, staples the ends, and returns in 24-48 hours to check gut hemodynamics before committing to stoma or anastomosis" — Lizzie Lee (host_summary) [Ep 107 · 5:18](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=318)
- "Hemodynamic markers to guide second-look decisions include lactate correction, thrombocytopenia correction, and weaning off inotropes" — Todd Ponsky (clinical) [Ep 107 · 5:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=345)
- "The SAT trial was a randomized controlled trial where final eligibility decision was made by the surgeon during laparotomy based on hemodynamic stability" — Simon Eaton (clinical) [Ep 107 · 6:19](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=379)
- "In the SAT trial, mortality was similar between primary anastomosis and stoma groups" — Lizzie Lee (host_summary) [Ep 107 · 6:55](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=415)
- "Babies who received primary anastomosis got off parenteral nutrition significantly sooner than those with stoma" — Lizzie Lee (host_summary) [Ep 107 · 6:56](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=416)
- "Babies with primary anastomosis were able to return to enteral feeds more quickly and had fewer intestinal complications than those with stoma" — Lizzie Lee (host_summary) [Ep 107 · 7:06](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=426)
- "Mucous fistula refeeding involves recycling upper stoma output into the lower bowel to keep it healthy" — Lizzie Lee (host_summary) [Ep 107 · 7:52](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=472)
- "A systematic review and meta-analysis by Bonnie Jasani from Toronto Sick Kids shows the evidence for mucous fistula refeeding is not strong so far" — Simon Eaton (clinical) [Ep 107 · 8:10](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=490)
- "There is an ongoing randomized controlled trial of mucous fistula refeeding measuring time to full enteral feeds" — Simon Eaton (clinical) [Ep 107 · 8:21](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=501)
- "A recent paper in Journal of Surgical Research shows early stoma closure (before 8 weeks) appears to be safe" — Simon Eaton (clinical) [Ep 107 · 8:41](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=521)
- "The early stoma closure study was very underpowered, and in the less-than-8-weeks group there were 2 infants who had repeat episodes of NEC" — Simon Eaton (clinical) [Ep 107 · 8:54](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=534)
- "There is an ongoing preparation for a randomized trial on stoma closure timing in the UK (SKIN mixed methods study)" — Simon Eaton (clinical) [Ep 107 · 9:06](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=546)
- "Surgeons need to be prepared to have some negative laparotomies when clinical suspicion is high despite equivocal imaging" — Augusto Zani (opinion) [Ep 107 · 9:45](https://qa.library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=585)
- "This was a retrospective cohort study of children with short bowel syndrome in an intestinal rehabilitation program, followed from 2006 to 2019." — Lizzie Lee (host_summary) [Ep 109 · 0:07](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=7)
- "The study asked whether social determinants of health predict outcomes like bloodstream infections, liver disease, and achieving enteral autonomy." — Lizzie Lee (host_summary) [Ep 109 · 0:16](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=16)
- "Social determinants of health do predict outcomes in pediatric short bowel syndrome in real ways." — Lizzie Lee (host_summary) [Ep 109 · 0:24](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=24)
- "Distance from the hospital was associated with higher risks of serious complications in children with short bowel syndrome." — Lizzie Lee (host_summary) [Ep 109 · 0:27](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=27)
- "Parental education was linked with fewer central line infections in children with short bowel syndrome." — Lizzie Lee (host_summary) [Ep 109 · 0:33](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=33)
- "Social determinants need to be considered to support families of children with short bowel syndrome better." — Lizzie Lee (host_summary) [Ep 109 · 0:37](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=37)
- "Most umbilical hernias will close spontaneously in the first year and some in the second year." — Kenneth Azarow (clinical) [Ep 38 · 2:58](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=178)
- "Age 2 is the earliest Dr. Azarow would consider umbilical hernia repair, and only after extensive counseling; optimal timing is before school entry (age 4–5)." — Kenneth Azarow (opinion) [Ep 38 · 3:05](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=185)
- "A long proboscis does not affect the decision to operate early on an umbilical hernia." — Kenneth Azarow (opinion) [Ep 38 · 3:47](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=227)
- "Larger umbilical defects (>1 cm) are less likely to close spontaneously, but this does not justify early surgery." — Kenneth Azarow (clinical) [Ep 38 · 4:12](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=252)
- "Race or ethnicity of the child does not affect the decision on timing of umbilical hernia repair." — Kenneth Azarow (opinion) [Ep 38 · 4:40](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=280)
- "Emerging anesthesia data suggesting risks of operating before age 2–3 provides additional support for delaying umbilical hernia repair." — Todd Ponsky (host_summary) [Ep 38 · 4:54](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=294)
- "True incarcerated umbilical hernias requiring emergency surgery must present with bowel obstruction symptoms (vomiting, inability to feed)." — Kenneth Azarow (clinical) [Ep 38 · 5:38](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=338)
- "Red, tender umbilical lumps in children are usually incarcerated omentum, preperitoneal fat, or infected urachal cysts—not incarcerated bowel." — Kenneth Azarow (clinical) [Ep 38 · 5:49](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=349)
- "Incarcerated omentum or fat at the umbilicus can be treated with NSAIDs; infected urachal cysts with antibiotics." — Kenneth Azarow (clinical) [Ep 38 · 6:09](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=369)
- "Dr. Azarow cannot recall ever performing emergency surgery for an incarcerated umbilical hernia." — Kenneth Azarow (opinion) [Ep 38 · 6:19](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=379)
- "LMA anesthesia can be used for umbilical hernia repair if adequate abdominal wall relaxation is achieved, but this is anesthesiologist-dependent." — Kenneth Azarow (clinical) [Ep 38 · 7:47](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=467)
- "PDS or Maxon suture is preferred for umbilical hernia repair because it lasts twice as long as Vicryl and is non-braided (lower infection risk in semi-contaminated field)." — Kenneth Azarow (clinical) [Ep 38 · 8:26](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=506)
- "Dr. Azarow uses prophylactic antibiotics for umbilical hernia repair but acknowledges this is anecdotal practice." — Kenneth Azarow (opinion) [Ep 38 · 8:51](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=531)
- "Umbilicoplasty (excision of redundant skin) should be performed during umbilical hernia repair to achieve a flat, cosmetically acceptable result." — Kenneth Azarow (opinion) [Ep 38 · 10:19](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=619)
- "Umbilicoplasty technique involves creating a pedicled skin flap with blood supply from above or below, avoiding complete circumferential incision." — Kenneth Azarow (clinical) [Ep 38 · 10:37](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=637)
- "Tacking the undersurface of umbilical skin to the fascia with braided suture (Vicryl) promotes inflammatory adhesion and prevents recurrent proboscis." — Kenneth Azarow (clinical) [Ep 38 · 11:42](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=702)
- "A pressure dressing should remain in place for 3 days after umbilical hernia repair." — Kenneth Azarow (clinical) [Ep 38 · 12:22](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=742)
- "Gastroschisis is actually an umbilical ring defect, not a paraumbilical defect, because the natural history is for the hole to close spontaneously (which only occurs at the umbilical ring)." — Kenneth Azarow (clinical) [Ep 38 · 12:37](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=757)
- "Over half of gastroschisis patients closed with sutureless technique develop large umbilical hernias, but most close spontaneously over 2–3 years." — Kenneth Azarow (clinical) [Ep 38 · 13:24](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=804)
- "A Canadian study by Dr. Baird's group showed that gastroschisis patients closed with sutures had higher rates of subsequent umbilical hernia repair compared to sutureless closure." — Todd Ponsky (host_summary) [Ep 38 · 13:45](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=825)
- "Suturing the gastroschisis defect makes the umbilical ring edge ischemic and destroys its integrity, leading to hernias that won't close spontaneously." — Kenneth Azarow (clinical) [Ep 38 · 14:13](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=853)
- "Omphalocele repair should be delayed as long as possible to allow abdominal domain expansion; operating too early is a mistake." — Kenneth Azarow (opinion) [Ep 38 · 15:00](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=900)
- "Parents should watch for the child's flanks bulging when lying flat—this indicates the abdominal girth is expanding and primary closure may be achievable." — Kenneth Azarow (clinical) [Ep 38 · 15:34](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=934)
- "If mesh placement seems inevitable for omphalocele, wait longer—many can be primarily closed if given sufficient time." — Kenneth Azarow (opinion) [Ep 38 · 15:13](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=913)
- "For large umbilical hernias in older teenagers, laparoscopic repair with mesh can be considered if primary closure seems unlikely." — Kenneth Azarow (clinical) [Ep 38 · 16:48](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1008)
- "A 5 mm umbilical defect very rarely causes intestinal incarceration; small pieces of fat may get caught and cause discomfort." — Kenneth Azarow (clinical) [Ep 38 · 17:23](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1043)
- "Repair of small asymptomatic umbilical hernias is not absolutely indicated and can be watched indefinitely if the child has no symptoms." — Kenneth Azarow (opinion) [Ep 38 · 17:17](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1037)
- "A Nebraska study showed that operating on umbilical drainage in the first 3 months increases complication rates; many resolve spontaneously by 6 months." — Kenneth Azarow (epidemiological) [Ep 38 · 19:17](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1157)
- "Infants with tiny drops of clear or whitish umbilical drainage should be watched for 6 months before considering surgery." — Kenneth Azarow (opinion) [Ep 38 · 19:08](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1148)
- "Dr. Azarow has stopped operating in the first 6 months for minor umbilical drainage or granulomas." — Kenneth Azarow (opinion) [Ep 38 · 19:29](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1169)
- "Umbilical granulomas can be treated with silver nitrate application; many resolve without surgery." — Kenneth Azarow (clinical) [Ep 38 · 20:59](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1259)
- "Office ligation of umbilical granulomas is not recommended unless the stalk is very narrow; they often don't fall off easily." — Kenneth Azarow (opinion) [Ep 38 · 21:11](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1271)
- "A prospective trial at Dr. Ponsky's institution found triamcinolone (Kenalog) cream superior to silver nitrate for umbilical granulomas, with such a drastic difference the study was stopped early." — Todd Ponsky (epidemiological) [Ep 38 · 21:33](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1293)
- "Steroid cream works better than silver nitrate for granulation tissue at gastrostomy sites, so the same principle applies to umbilical granulomas." — Kenneth Azarow (clinical) [Ep 38 · 21:49](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1309)
- "For persistent umbilical drainage at 6–12 months, perform umbilical exploration through a hernia repair incision, divide the fascia inferiorly to visualize the urachal track, and bluntly dissect to the bladder dome." — Kenneth Azarow (clinical) [Ep 38 · 22:10](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1330)
- "The distal epithelialized portion of the urachal remnant must be excised from the umbilical skin, taking care not to devascularize the umbilicus." — Kenneth Azarow (clinical) [Ep 38 · 22:32](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1352)
- "A Nebraska study found no VCUG or ultrasound findings that changed management of urachal remnants, so Dr. Azarow does not perform preoperative imaging." — Kenneth Azarow (epidemiological) [Ep 38 · 24:05](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1445)
- "Infected urachal cysts can usually be treated with antibiotics alone; true abscesses require percutaneous drainage by interventional radiology." — Kenneth Azarow (clinical) [Ep 38 · 24:52](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1492)
- "After cooling down an infected urachal cyst, the entire congenital remnant should be excised electively to prevent recurrent abscess." — Kenneth Azarow (clinical) [Ep 38 · 25:01](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1501)
- "Elective urachal remnant excision is performed laparoscopically with a supraumbilical port and a 12 mm lateral port for stapling across the bladder dome." — Kenneth Azarow (clinical) [Ep 38 · 25:31](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1531)
- "Patent omphalomesenteric duct with stool draining from the umbilicus will not close spontaneously and requires surgery before hospital discharge." — Kenneth Azarow (clinical) [Ep 38 · 26:23](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1583)
- "Patent omphalomesenteric duct poses risk of volvulus from small bowel wrapping around the fistula tract." — Kenneth Azarow (clinical) [Ep 38 · 26:36](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1596)
- "Patent omphalomesenteric duct is approached through umbilical exploration; laparoscopy can assist if bowel is already twisted around the tract." — Kenneth Azarow (clinical) [Ep 38 · 26:56](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1616)
- "Epigastric hernias (epiploceles) are purely elective and should only be repaired if causing discomfort; they are preperitoneal fat through a pinhole defect, not true hernias." — Kenneth Azarow (clinical) [Ep 38 · 28:06](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1686)
- "The fascial defect in epigastric hernias is typically only 1 millimeter in diameter." — Kenneth Azarow (clinical) [Ep 38 · 28:46](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1726)
- "Analysis of PHIS (Pediatric Health Information System) data showed the mean age for umbilical hernia repair across U.S. children's hospitals is 4 years." — Todd Ponsky (epidemiological) [Ep 38 · 29:22](https://qa.library.globalcastmd.com/watch/umbilical-cord-defects-with-dr-kenneth-azarow-298?t=1762)
- "Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding" — Brad Warner (clinical) [Ep 34 · 1:42](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=102)
- "The intestine of a newborn or fetus doubles in length in the last trimester of gestation" — Brad Warner (clinical) [Ep 34 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=183)
- "A 24-25 week premature infant with 20-25 cm of bowel will likely increase to at least 50 cm just on the basis of growth alone" — Brad Warner (clinical) [Ep 34 · 3:13](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=193)
- "For a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability" — Brad Warner (clinical) [Ep 34 · 4:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=243)
- "Without the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate" — Brad Warner (clinical) [Ep 34 · 4:37](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=277)
- "In adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years" — Brad Warner (epidemiological) [Ep 34 · 4:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=291)
- "According to Pediatric Intestinal Failure Research Consortium data, of children on TPN for more than several months due to short gut syndrome: 25% die, 25% need transplant, and 50% can wean off TPN" — Brad Warner (epidemiological) [Ep 34 · 6:38](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=398)
- "Common causes of death in intestinal failure include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access" — Brad Warner (clinical) [Ep 34 · 7:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=431)
- "Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection" — Brad Warner (clinical) [Ep 34 · 7:49](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=469)
- "The goal of management is to wean TPN and push enteral feeding, accepting stool outputs of up to 40 cc per kilo per day as the limit" — Brad Warner (clinical) [Ep 34 · 8:19](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=499)
- "The most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias" — Brad Warner (epidemiological) [Ep 34 · 9:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=562)
- "For TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein" — Brad Warner (clinical) [Ep 34 · 10:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=622)
- "Shoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN" — Brad Warner (clinical) [Ep 34 · 10:45](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=645)
- "Begin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip" — Brad Warner (clinical) [Ep 34 · 11:06](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=666)
- "With continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous" — Brad Warner (opinion) [Ep 34 · 11:23](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=683)
- "Want a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn" — Brad Warner (clinical) [Ep 34 · 12:05](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=725)
- "Lipid reduction strategy takes fat from 2-3 g per kilo per day given daily down to about 1 g per kilo per day delivered twice or 3 times a week, which has been effective in reducing TPN-associated cholestasis" — Brad Warner (clinical) [Ep 34 · 12:53](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=773)
- "Omegaven is a fish oil-based fat containing primarily omega-3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega-6 fatty acids that are pro-inflammatory" — Brad Warner (clinical) [Ep 34 · 14:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=843)
- "When fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels" — Brad Warner (clinical) [Ep 34 · 14:38](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=878)
- "SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has recently been FDA approved in the United States" — Brad Warner (clinical) [Ep 34 · 15:08](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=908)
- "Breast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation" — Brad Warner (opinion) [Ep 34 · 18:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1091)
- "Complex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent" — Brad Warner (opinion) [Ep 34 · 19:26](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1166)
- "There is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, with 90% enteral feeding having far less risk of TPN-related cholestasis than 10% enteral" — Brad Warner (clinical) [Ep 34 · 21:19](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1279)
- "Time to consider surgical intervention is when enteral tolerance plateaus and then declines (going backward rather than forward), or with multiple sepsis episodes plus abdominal distention and dilated bowel loops, or when child starts getting jaundiced" — Brad Warner (clinical) [Ep 34 · 22:33](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1353)
- "Dilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function" — Brad Warner (clinical) [Ep 34 · 23:28](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1408)
- "More than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention" — Brad Warner (clinical) [Ep 34 · 25:43](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1543)
- "If a child has over 100 centimeters of intestine, less than 5-10% should require TPN, suggesting there may be an underlying motility or mucosal problem" — Brad Warner (clinical) [Ep 34 · 27:53](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1673)
- "For bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated" — Brad Warner (clinical) [Ep 34 · 28:37](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1717)
- "The STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation" — Brad Warner (epidemiological) [Ep 34 · 29:31](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1771)
- "The Bianchi procedure takes advantage of the V-shaped blood supply bifurcation before reaching the bowel wall, allowing creation of two tubes each supplied by one arm of the V" — Brad Warner (clinical) [Ep 34 · 30:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1800)
- "STEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles" — Brad Warner (clinical) [Ep 34 · 32:30](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1950)
- "STEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo" — Brad Warner (clinical) [Ep 34 · 32:54](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1974)
- "You can do a Bianchi and then later do a STEP on top of it, but you cannot do a Bianchi once a STEP has been done" — Brad Warner (clinical) [Ep 34 · 33:26](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2006)
- "In a case where a STEP was acting as a brake causing dysmotility, removing the distal stepped bowel allowed the patient to completely wean off TPN" — Brad Warner (clinical) [Ep 34 · 35:04](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2104)
- "Would taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length" — Brad Warner (clinical) [Ep 34 · 38:23](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2303)
- "Strategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds" — Brad Warner (clinical) [Ep 34 · 39:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2340)
- "Dan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work" — Brad Warner (clinical) [Ep 34 · 39:23](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2363)
- "Dilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver" — Brad Warner (clinical) [Ep 34 · 39:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2391)
- "Medical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation" — Brad Warner (clinical) [Ep 34 · 40:26](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2426)
- "The gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion" — Brad Warner (clinical) [Ep 34 · 41:54](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2514)
- "In mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection" — Brad Warner (clinical) [Ep 34 · 42:19](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2539)
- "Teduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week" — Brad Warner (clinical) [Ep 34 · 43:57](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2637)
- "Teduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation" — Brad Warner (clinical) [Ep 34 · 44:34](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2674)
- "Growth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine" — Brad Warner (clinical) [Ep 34 · 45:13](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2713)
- "Growth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive" — Brad Warner (clinical) [Ep 34 · 45:46](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2746)
- "Survival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%" — Brad Warner (epidemiological) [Ep 34 · 46:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2811)
- "The intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression" — Brad Warner (clinical) [Ep 34 · 47:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2831)
- "Ethanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters" — Brad Warner (clinical) [Ep 34 · 49:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2962)
- "Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival in intestinal failure patients, as demonstrated in series from Boston, Michigan, and Texas" — Brad Warner (clinical) [Ep 34 · 51:20](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=3080)
- "The three major causes of LUTO are urethral atresia (complete obstruction with no communication from bladder neck through urethra), posterior urethral valves (flap of tissue in proximal urethra), and mid-urethral hypoplasia (significant tapering and narrowing that becomes progressive obstruction as pelvic anatomy matures)." — Mark (clinical) [Ep 9 · 0:44](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=44)
- "In complete urethral obstruction, progressive oligohydramnios leads to anhydramnios, causing physical deformations (joint contractures, ear flattening, Potter's phenotype), pulmonary hypoplasia due to inability to expand and contract chest, and severe hydronephrosis with progressive renal fibrocystic dysplasia resulting in renal failure after birth." — Mark (clinical) [Ep 9 · 1:41](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=101)
- "In the sheep model, early ureteral ligation produced the same fibrocystic dysplasia seen in humans, with earlier obstruction and longer duration causing greater kidney damage." — Mark (host_summary) [Ep 9 · 3:00](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=180)
- "Early mid-gestational reversal of obstruction in the sheep model prevented progressive dysplastic changes to the kidneys and preserved kidney function, giving rise to the concept of in utero shunting." — Mark (host_summary) [Ep 9 · 3:35](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=215)
- "The stepwise approach to identifying fetuses for possible shunt therapy involves: (1) high-resolution ultrasound to evaluate anatomy and rule out associated anomalies like myelomeningocele and cardiac disease, (2) karyotype confirmation to rule out chromosomal abnormalities and confirm male sex, and (3) renal function evaluation by serial bladder drainage." — Mark (guideline) [Ep 9 · 4:44](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=284)
- "Amnioinfusion is sometimes necessary when sonographic evaluation is difficult due to oligohydramnios, to expand the amniotic fluid space and restore the fluid interface for better ultrasound imaging." — Mark (clinical) [Ep 9 · 5:31](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=331)
- "Female fetuses with large bladder-like structures usually have cloacal abnormalities and do not benefit from shunting because it is a completely different process and underlying pathophysiology." — Mark (clinical) [Ep 9 · 6:04](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=364)
- "Renal function evaluation involves draining the bladder completely on several occasions and analyzing sodium, chloride, calcium, osmolarity, total proteins, and beta-2 microglobulin as reflections of proximal tubular injury and possible direct injury to the glomerular apparatus." — Mark (clinical) [Ep 9 · 6:27](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=387)
- "Characteristic early LUTO ultrasound findings include large fluid-filled bladder with markedly thickened and echogenic walls due to smooth muscle hypertrophy and hyperplasia from pressure, dilated kidneys with increased echogenicity, and dilation of the intrarenal collecting system." — Mark (clinical) [Ep 9 · 7:07](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=427)
- "Increased renal echogenicity is evidence of compression of the renal parenchyma rather than a poor prognostic sign per se; following serial bladder drainages and allowing kidneys to drain, re-expansion of parenchyma occurs with more normal echogenicity." — Mark (clinical) [Ep 9 · 8:21](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=501)
- "The pathophysiology of hydronephrosis involves the collecting system (like a balloon) expanding within the kidney (like a sponge in a glass fishbowl), compressing the parenchyma against the serosa, impairing delicate vasculature, resulting in cell death, progressive fibrosis, and eventually cystic dysplasia." — Mark (clinical) [Ep 9 · 9:01](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=541)
- "The presence of discrete cortical cysts indicates irreversible kidney damage and means the kidney is not amenable to any kind of in utero therapy because of the severity of underlying injury." — Mark (clinical) [Ep 9 · 10:29](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=629)
- "Obstructing ureteroceles from ectopic insertion of a duplicated collecting system upper pole can cause bladder outlet obstruction and obstructive uropathy, and these are amenable to therapy." — Mark (clinical) [Ep 9 · 10:59](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=659)
- "Patent urachus (a tract from the dome of the bladder to the umbilical cord insertion) can open back up with early obstruction and high bladder pressure, draining urine into the amniotic fluid space, which is one underlying etiology for obstructive uropathy with normal amniotic fluid volume." — Mark (clinical) [Ep 9 · 12:53](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=773)
- "In megacystis-microcolon-hypoperistalsis syndrome (more common in females but seen in at least six dozen male cases), there is a neurologic defect in bladder and ureteral muscles preventing bladder contraction and emptying, with massively distended bladder but normal amniotic fluid; most do not survive more than a few years." — Mark (clinical) [Ep 9 · 14:58](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=898)
- "In megacystis-microcolon-hypoperistalsis syndrome, after bladder drainage the bladder wall remains very thin because it does not develop the hyperplasia or thickening typically seen in complete obstruction, and amniotic fluid flows into the amniotic cavity through a completely patent urethra." — Mark (clinical) [Ep 9 · 15:34](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=934)
- "Severe congenital reflux can present with normal amniotic fluid, thickened but normal-sized bladder, patency through the urethra, massively dilated kidneys with severe hydronephrosis and huge megaureters, with the bladder refluxing back up to the kidneys." — Mark (host_summary) [Ep 9 · 16:15](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=975)
- "With new technology, particularly FISH, vesicocentesis can be used to screen and confirm male karyotype and rule out major aneuploidies when amniocentesis is difficult due to anhydramnios or severe oligohydramnios." — Mark (clinical) [Ep 9 · 17:01](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1021)
- "Good prognostic urinary values for potential survival with successful shunt placement are: sodium <100, chloride <90, osmolarity <210, calcium <8, beta-2 microglobulin <6, and total protein <20 (units not specified in transcript)." — Mark (clinical) [Ep 9 · 18:12](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1092)
- "Values above the cutoff thresholds indicate significant underlying renal injury and fibrotic changes; histologic examination of fetuses with values not much higher than these levels showed pretty significant fibrotic injury to the kidneys." — Mark (clinical) [Ep 9 · 18:35](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1115)
- "The first urine specimen from bladder tap is not predictive or reliable because it has been exposed to degradation products and osmotic gradients that change electrolyte composition; serial taps are necessary." — Mark (clinical) [Ep 9 · 19:16](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1156)
- "The second bladder tap (2 days after first) samples urine that was in the ureters and intrarenal collecting system; the third tap (2 days after second) samples freshly produced urine by the kidney and has much higher predictive value for detecting significant underlying injury." — Mark (clinical) [Ep 9 · 20:01](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1201)
- "Improving urinary values across serial taps (e.g., sodium initially poor but dropping after second and third taps) indicates an excellent candidate with reasonably good prognosis with successful shunting; worsening values indicate ongoing irreversible damage that shunting won't benefit." — Mark (clinical) [Ep 9 · 20:29](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1229)
- "After complete bladder drainage and refill, urethral atresia cases show symmetric, very thick, universal bladder wall thickening with a typical keyhole; posterior urethral valve cases show elongated bladder shape with more proximal than distal thickening; mid-urethral hypoplasia (prune belly/triad) cases show a 'snowman appearance' with typical keyhole but unusual three-part bladder shape." — Mark (clinical) [Ep 9 · 21:21](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1281)
- "In mid-urethral hypoplasia cases, histologic study showed typical hypertrophy and thickening in the lower bladder wall, but significant smooth muscle deficiency and abnormal composition in the upper bladder (more like a hernia sac), with abnormal smooth muscle from proximal ureters to renal pelvis and severe abnormalities in the bladder dome." — Mark (clinical) [Ep 9 · 22:18](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1338)
- "All urinary electrolyte cutoff thresholds are based on urine analyzed between 18 to 22 weeks of gestation and cannot be reliably used before 18 weeks or after 22 weeks without adjustment." — Mark (clinical) [Ep 9 · 26:26](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1586)
- "For fetuses at 17 weeks, the cutoff value would be extrapolated to be a bit higher; for 24 or 26 week fetuses, cutoff thresholds would be extrapolated to be much lower due to maturation and increasing kidney function with advancing gestational age." — Mark (clinical) [Ep 9 · 27:00](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1620)
- "There is no good data that allows prediction of renal injury at gestational ages of 26 or 28 weeks using the established electrolyte cutoffs." — Mark (opinion) [Ep 9 · 27:51](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1671)
- "The primary goal of fetal bladder shunting is to prevent pulmonary hypoplasia secondary to oligohydramnios; secondary goals are preservation of renal function and bladder function." (clinical) [Ep 9 · 28:52](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1732)
- "The Rocket shunt is a double-tailed silastic pigtail catheter inserted with coils in different directions; theoretically the flat end outside the baby's abdomen cannot be grabbed and pulled out, and the other end is inside the bladder." (clinical) [Ep 9 · 29:27](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1767)
- "Shunt procedures are done as outpatient with IV remifentanyl and if necessary propofol, local anesthetic, antibiotic, a dose of indomethacin, and possibly nifedipine immediately afterwards; the mother usually goes home a couple of hours later." (clinical) [Ep 9 · 29:54](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1794)
- "Amnioinfusion before shunt placement is the most important step because without good fluid volume around the fetus, the external end of the shunt (the trickiest part of the procedure) cannot be deposited properly." (clinical) [Ep 9 · 30:18](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1818)
- "Shunt placement inferior to the bladder is preferred; the higher the shunt placement, the greater the risk that when the bladder deflates, some holes in the shunt will be in the peritoneal cavity, potentially causing urine leakage and fetal urinary ascites." (clinical) [Ep 9 · 31:16](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1876)
- "The Birmingham group's meta-analysis showed that in the good prognosis group (based on urinary electrolytes), there appeared to be some benefit to drainage, and in the poor prognosis group, drainage appeared to have an even better result." (host_summary) [Ep 9 · 31:48](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1908)
- "In the PLUTO trial, babies were randomized only when the physician was uncertain whether to shunt; if certain, patients were entered into a registry. Karyotype and urinalysis were not mandatory for trial entry, and amniotic fluid volume was not used as a prognostic evaluator." (host_summary) [Ep 9 · 32:59](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=1979)
- "The PLUTO trial was designed to collect 150 patients over approximately 4 years but by the end of 4 years only 31 patients had been randomized (20% of planned patients), and the trial was stopped early due to poor recruitment." (host_summary) [Ep 9 · 33:53](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2033)
- "In the PLUTO trial, fetuses that were shunted had about a 3-fold increase in survival compared to those not shunted, but the numbers were very small and the size and direction of the effect is uncertain, so the benefit is unproven." (host_summary) [Ep 9 · 34:33](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2073)
- "In the PLUTO trial, all 12 deaths were from pulmonary hypoplasia, suggesting improved survival was probably related to decreased lung hypoplasia; only 7 of 12 live-born shunted babies were alive at age 2, and only 2 of the shunted survivors had normal renal function." (host_summary) [Ep 9 · 34:48](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2088)
- "Difficulties in fetal therapy trials include: rare conditions, many undetected prenatally, many parents choosing termination when faced with outcome realities, delay in accepting new therapy reflecting clinician and patient bias based on small heterogeneous observational studies, and loss of clinical equipoise." (opinion) [Ep 9 · 35:18](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2118)
- "Six studies report long-term outcomes of shunted babies with consistent results across studies: approximately 40-50% of survivors have normal renal function, and approximately one-third end up requiring either dialysis or transplant." (host_summary) [Ep 9 · 36:17](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2177)
- "In the Canadian population, when parents look at the outcome studies showing that only 40-50% have normal renal function and one-third need dialysis or transplant, many parents opt for termination of pregnancy rather than shunting." (epidemiological) [Ep 9 · 37:25](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2245)
- "Some LUTO cases can resolve spontaneously, as demonstrated by a case where a baby diagnosed at 14 weeks with anhydramnios at 17 weeks was observed peeing and filling its sac at 19 weeks, with recollection of amniotic fluid by 23 weeks with no intervention." (clinical) [Ep 9 · 37:35](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2255)
- "Spontaneous bladder decompression can occur through asymmetrical hydronephrosis or urinary ascites from bladder rupture; spontaneous rupture is unusual but very commonly happens after bladder drainage and always resolves after a few days." (clinical) [Ep 9 · 38:06](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2286)
- "Megacystis-microcolon-hypoperistalsis syndrome presents with very large bladder in a female fetus with normal amniotic fluid volume; these are cases where shunting is not advocated." (clinical) [Ep 9 · 38:38](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2318)
- "Massively enlarged bladder secondary to cloacal dysgenesis is a case where there is no role whatsoever for intervention." (clinical) [Ep 9 · 39:03](https://qa.library.globalcastmd.com/watch/overview-of-prenatal-diagnosis-cincinnati-fetal-center-743?t=2343)
- "Despite 6 decades of research, we don't know exactly what causes NEC and are still quite some ways from finding an absolute cure." — Gail Besner (clinical) [Ep 16 · 2:11](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=131)
- "Indomethacin predisposes babies to both isolated ileal perforation and necrotizing enterocolitis." — Gail Besner (clinical) [Ep 16 · 4:14](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=254)
- "PPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; you don't want to neutralize gastric acid." — Gail Besner (clinical) [Ep 16 · 4:44](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=284)
- "In premature babies with NEC, intestinal contents can leak into the scrotum through a patent processus vaginalis, causing scrotal swelling and discoloration." — Gail Besner (clinical) [Ep 16 · 5:29](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=329)
- "Neutropenia (low white blood cell count) is more worrisome than elevated WBC in NEC because it suggests overwhelming sepsis that the patient is not compensating for." — Gail Besner (clinical) [Ep 16 · 7:17](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=437)
- "Thrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and knowledge of platelet count is important for optimizing patient condition prior to surgery." — Gail Besner (clinical) [Ep 16 · 7:33](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=453)
- "There is no single test that shows whether you have ischemic or necrotic bowel, but taking all tests in combination gives a sense of how sick the patient is." — Gail Besner (clinical) [Ep 16 · 8:33](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=513)
- "For imaging in suspected NEC, you need plain film plus either cross-table lateral or lateral decubitus film because free air can be quite subtle and you don't want to miss it." — Gail Besner (clinical) [Ep 16 · 8:50](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=530)
- "Free air on imaging is an absolute indication for surgical intervention (either drain or laparotomy)." — Gail Besner (clinical) [Ep 16 · 9:38](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=578)
- "Clinical deterioration in the face of maximum medical management is an indication for surgery." — Gail Besner (clinical) [Ep 16 · 9:54](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=594)
- "Fixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not going in the right direction." — Gail Besner (clinical) [Ep 16 · 10:02](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=602)
- "Portal venous air is a concerning and worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation." — Gail Besner (clinical) [Ep 16 · 10:16](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=616)
- "Medical management of NEC includes: withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotics, and performing serial abdominal exams, labs, and X-rays." — Gail Besner (clinical) [Ep 16 · 10:58](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=658)
- "Small French feeding tubes are not adequate for gastric decompression in NEC; they should be replaced with an orogastric tube." — Gail Besner (clinical) [Ep 16 · 12:05](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=725)
- "There is tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization of the ICU environment." — Gail Besner (epidemiological) [Ep 16 · 12:43](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=763)
- "For serial X-rays in NEC, obtaining them every 8 hours is reasonable; getting them too frequently makes no sense, but waiting 12-24 hours is too long." — Gail Besner (opinion) [Ep 16 · 13:37](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=817)
- "Patients with NEC should be kept NPO with NG decompression and antibiotics for at least 1 week to 10 days (preferably a week and a half) before starting feeds." — Gail Besner (clinical) [Ep 16 · 14:15](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=855)
- "Some babies have repeated episodes of necrotizing enterocolitis." — Gail Besner (clinical) [Ep 16 · 14:29](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=869)
- "Stricture formation is a complication of medical NEC that should be suspected in babies not tolerating feeds post-NEC; strictures typically occur in the colon, usually near the splenic flexure, but can occur anywhere." — Gail Besner (clinical) [Ep 16 · 14:40](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=880)
- "For suspected stricture post-NEC, starting with contrast enema is preferred over upper GI with small bowel follow-through because strictures are more common in the colon and contrast from above takes long to transit, especially if partially obstructed." — Gail Besner (opinion) [Ep 16 · 15:17](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=917)
- "Serial abdominal exams are critical for determining when to operate on NEC patients without absolute indications; worsening distention, peritoneal signs, hemodynamic instability with increasing pressor needs, and renal shutdown build up like building blocks to indicate need for surgery." — Gail Besner (clinical) [Ep 16 · 16:23](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=983)
- "Two surgical options for NEC are exploratory laparotomy and peritoneal drain placement." — Gail Besner (clinical) [Ep 16 · 18:16](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1096)
- "The ongoing NEST trial (necrotizing enterocolitis surgery trial) is concluding and will provide results in the next 1-2 years comparing peritoneal drainage versus laparotomy." — Gail Besner (clinical) [Ep 16 · 18:22](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1102)
- "Mortality difference between peritoneal drainage and laparotomy for NEC is indecipherable; survival chance is about the same with either procedure." — Gail Besner (clinical) [Ep 16 · 18:39](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1119)
- "At a NEC conference in London, 100% of surgeons polled do laparotomy and no one puts in a drain in Europe." — Gail Besner (epidemiological) [Ep 16 · 19:10](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1150)
- "The MOSS trial (United States) and PIERO trial (Europe) showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC, but these studies looked at early endpoints rather than delayed neurological outcomes." — Gail Besner (clinical) [Ep 16 · 19:44](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1184)
- "Babies who have peritoneal drains instead of laparotomy may do worse neurologically if you look at outcomes 1-2 years after recovery from NEC." — Gail Besner (clinical) [Ep 16 · 20:14](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1214)
- "The NEST trial will randomize 300 babies to peritoneal drainage versus laparotomy and assess neurological outcomes at 18-22 months after NEC recovery with detailed neurological assessments." — Gail Besner (clinical) [Ep 16 · 20:34](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1234)
- "Dr. Besner predicts that in the next 1-2 years practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes likely better in babies who undergo laparotomy with removal of inflammatory necrotic tissue." — Gail Besner (opinion) [Ep 16 · 21:44](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1304)
- "When peritoneal drains are placed and babies subsequently undergo laparotomy, the degree of dead bowel actually present is often quite striking and it's inconceivable the baby could get over that insult." — Gail Besner (clinical) [Ep 16 · 22:09](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1329)
- "There are no criteria that help decide between laparotomy or drain for NEC; with current information you can't be faulted for doing either one." — Gail Besner (opinion) [Ep 16 · 22:58](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1378)
- "You can get just as sick and hemodynamically unstable from systemic inflammatory response syndrome with an isolated intestinal perforation as from necrotizing enterocolitis." — Gail Besner (clinical) [Ep 16 · 24:15](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1455)
- "Peritoneal drain placement is a bedside procedure with tiny amount of local anesthesia, using a small transverse incision in the right lower quadrant for a 1/4 inch Penrose drain." — Gail Besner (clinical) [Ep 16 · 26:15](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1575)
- "If the incision for peritoneal drain is made too big, it's a problem because the patient can get a hernia once the drain is out." — Gail Besner (clinical) [Ep 16 · 26:34](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1594)
- "When placing peritoneal drain, pass it several times gently without forcing to avoid bleeding; it's hard to achieve the drain curving to all four quadrants as shown in published pictures." — Gail Besner (clinical) [Ep 16 · 27:01](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1621)
- "After peritoneal drain placement, if baby continues producing stool from drain for weeks and you convert to laparotomy, you may be forced to operate at the wrong time when inflammatory process is at its worst, resulting in extensive adhesions and serosal tears." — Gail Besner (clinical) [Ep 16 · 28:43](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1723)
- "One of the smartest surgical decisions is knowing when to get out and stop; if you're getting serosal tears and making the situation worse during difficult NEC laparotomy, it's time to stop." — Gail Besner (opinion) [Ep 16 · 29:03](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1743)
- "In difficult NEC laparotomy with extensive adhesions, try to make a proximal diverting stoma to control the area of perforation, but don't keep going if making multiple enterotomies and serosal injuries." — Gail Besner (clinical) [Ep 16 · 29:13](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1753)
- "For successful peritoneal drain management, advance the drain out over several days starting at 7-10 days post-operation rather than withdrawing it all at once." — Gail Besner (clinical) [Ep 16 · 29:48](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1788)
- "Don't advance peritoneal drain out if there's continual leakage of stool at the drain site; this suggests ongoing area of leakage." — Gail Besner (clinical) [Ep 16 · 30:09](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1809)
- "There is difference of opinion about whether to get upper GI small bowel follow-through before removing peritoneal drain; it should be considered if there's ongoing stool leakage." — Gail Besner (opinion) [Ep 16 · 30:22](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1822)
- "If baby does well after drain removal without contrast study but doesn't tolerate feeds, then contrast study is compelled to ensure everything is OK." — Gail Besner (clinical) [Ep 16 · 30:49](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1849)
- "For NEC laparotomy, if baby is hemodynamically unstable or on very high oscillator settings and can't be safely moved to OR, bring the OR to bedside and operate in the ICU." — Gail Besner (clinical) [Ep 16 · 31:19](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1879)
- "For NEC laparotomy, make supraumbilical transverse incision; skin is extraordinarily thin so be careful entering abdomen, especially with underlying dilated bowel loops." — Gail Besner (clinical) [Ep 16 · 31:43](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1903)
- "For NEC laparotomy, have blood products available (packed RBCs, platelets, fresh frozen plasma) and partially correct platelet and coagulation abnormalities preoperatively." — Gail Besner (clinical) [Ep 16 · 32:08](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1928)
- "In premature babies undergoing NEC laparotomy, it's incredibly important not to hurt the liver or spleen; even looking at or touching the liver wrong can cause subcapsular hematoma that a baby can exsanguinate from." — Gail Besner (clinical) [Ep 16 · 32:27](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1947)
- "Liver and spleen injuries can occur with peritoneal drain insertion as well." — Gail Besner (clinical) [Ep 16 · 32:53](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1973)
- "Spontaneous intestinal perforation (SIP) is one small localized area of perforation; NEC is more diffuse disease with pneumatosis involving more than one tiny area. These can be hard to differentiate preoperatively." — Gail Besner (clinical) [Ep 16 · 33:21](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2001)
- "Some surgeons around the world resect limited NEC and do primary anastomosis; this is less common in the United States where surgeons typically make stomas due to concern about anastomotic healing." — Gail Besner (epidemiological) [Ep 16 · 34:04](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2044)
- "For NEC stomas, bring functional end and mucous fistula out through the laparotomy incision close to each other (facilitating later closure), tack to fascia without maturation." — Gail Besner (clinical) [Ep 16 · 35:07](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2107)
- "No matter how carefully NEC stomas are made, sometimes the distal end will slough off, so leave a little distal end sticking out so it doesn't recede under the fascia." — Gail Besner (clinical) [Ep 16 · 35:50](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2150)
- "High-quality enterostomal therapists can manage stomas brought out through the incision; the problem gets more complicated if the wound opens." — Gail Besner (opinion) [Ep 16 · 36:19](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2179)
- "For indeterminate bowel viability during NEC laparotomy (injured but not necrotic, diffusely the same appearance), it's acceptable to not resect, leave abdomen open to avoid pressure compromising blood flow, and return for second-look operation in 24-48 hours." — Gail Besner (clinical) [Ep 16 · 37:12](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2232)
- "For multiple skip lesions in NEC, if very close together and can resect without creating short bowel syndrome, do that rather than multiple anastomoses; otherwise do multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion." — Gail Besner (clinical) [Ep 16 · 38:07](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2287)
- "Clip-and-drop technique (resect dead bowel, clip ends, put back in, return another day) can be life-saving in very unstable NEC patients without time for multiple anastomoses." — Gail Besner (clinical) [Ep 16 · 38:46](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2326)
- "The 'putting green' approach (bringing out multiple stomas throughout abdomen) can get really confusing and messy; try to avoid if possible." — Gail Besner (opinion) [Ep 16 · 39:15](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2355)
- "For stoma reversal timing, typically wait until baby is stable, well, hopefully being fed, and about 2000g (anastomosis is easier when baby is bigger); go in sooner if TPN-induced cholestasis develops or can't nourish baby due to very high stoma." — Gail Besner (clinical) [Ep 16 · 39:32](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2372)
- "Stoma reversal timing is more about weight gain, clinical appearance, and TPN sequelae than a mandatory 2-month waiting period." — Gail Besner (opinion) [Ep 16 · 40:21](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2421)
- "Refeeding mucous fistula is done selectively (not routinely) for very high-output stomas where any nourishment given comes right out the stoma." — Gail Besner (clinical) [Ep 16 · 40:48](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2448)
- "A recent Journal of Pediatric Surgery article showed substantial decrease in TPN use with mucous fistula refeeding." — Todd Ponsky (host_summary) [Ep 16 · 41:06](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2466)
- "Mucous fistulas often stricture and you lose the opportunity to refeed; if serious about refeeding (e.g., massive resection, very high stoma), consider leaving a small soft catheter in the mucous fistula post-op to maintain access." — Gail Besner (clinical) [Ep 16 · 41:22](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2482)
- "NEC totalis is one of the most tragic findings on exploratory laparotomy for NEC; the chance of a baby with true NEC totalis living to be old enough for small bowel-liver transplant is very close to zero." — Gail Besner (clinical) [Ep 16 · 42:15](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2535)
- "For very small premature baby with NEC totalis, we don't have the technology to get that baby through this devastating problem; no one would be criticized for explaining severity to parents and closing abdomen with comfort care." — Gail Besner (opinion) [Ep 16 · 42:56](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2576)
- "For NEC totalis, the chance of the baby living through months to years of required TPN will irreversibly injure their liver, and even if they live to be big enough, results of small bowel transplant are still suboptimal." — Gail Besner (clinical) [Ep 16 · 43:42](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2622)
- "There is a very small subset of premature patients with horrible lung disease who get pneumothorax that dissects through the diaphragm into the abdomen, presenting as free air; make sure the problem is in the abdomen and not in the chest." — Gail Besner (clinical) [Ep 16 · 44:28](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2668)
- "For hemodynamically unstable baby with free air and abdominal distention, put an angiocatheter through the abdominal wall to release pneumoperitoneum as a temporizing maneuver while mobilizing for surgery." — Gail Besner (clinical) [Ep 16 · 45:06](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2706)
- "The frequency and incidence of abdominal wall defects appears to be increasing" (host_summary) [Ep 17 · 0:00](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=0)
- "Most gastroschisis patients don't have any other associated anomalies, and it's rare to have abnormal chromosomes with gastroschisis" — Jack Langer (clinical) [Ep 17 · 4:46](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=286)
- "Early papers showed benefit to cesarean section for gastroschisis, but those cesarean sections were usually done early at 36 or 37 weeks, raising the question of whether timing rather than cesarean section itself gave the benefit" — Jack Langer (clinical) [Ep 17 · 5:46](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=346)
- "Many studies have failed to show an advantage to cesarean section for gastroschisis, and most people nowadays would not do routine cesarean section" — Jack Langer (clinical) [Ep 17 · 6:13](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=373)
- "There has not been any large randomized trial looking specifically at the issue of early delivery for gastroschisis" — Jack Langer (clinical) [Ep 17 · 6:29](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=389)
- "Toronto's approach is to deliver gastroschisis patients at around 37 weeks unless they've already gone into spontaneous labor" — Jack Langer (clinical) [Ep 17 · 6:58](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=418)
- "The mean gestational age of onset of labor is earlier in gastroschisis pregnancies, possibly because of inflammatory mediators produced by the inflamed bowel" — Jack Langer (clinical) [Ep 17 · 7:07](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=427)
- "Labor induction at 37 weeks is successful most of the time in gastroschisis pregnancies, unlike regular pregnancies" — Jack Langer (clinical) [Ep 17 · 7:30](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=450)
- "Most evidence, including from the CapsNet database, suggests that delivery in a perinatal center is beneficial for gastroschisis" — Jack Langer (clinical) [Ep 17 · 8:36](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=516)
- "During transport, gastroschisis babies should be nursed on their side, usually right side down, to prevent kinking of the mesentery and ischemia of the bowel" — Jack Langer (clinical) [Ep 17 · 10:01](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=601)
- "Adrian Bianchi first described bedside closure for gastroschisis" — Jack Langer (clinical) [Ep 17 · 11:21](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=681)
- "Using forceps at the bedside to push bowel back in can damage the bowel in a squiggling baby" — Jack Langer (clinical) [Ep 17 · 11:29](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=689)
- "Current technique uses pre-formed silos with fentanyl or morphine sedation without intubation in awake babies, slowly pushing bowel in while monitoring intraabdominal pressure to keep it below 20" — Jack Langer (clinical) [Ep 17 · 11:47](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=707)
- "If reduction is successful with good pressure and perfusion, the silo can be removed immediately and the umbilical cord stump used to cover the hole with a Duoderm dressing left for about 5 days" — Jack Langer (clinical) [Ep 17 · 12:27](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=747)
- "Anthony Sandler championed the sutureless plastic closure approach after training in Toronto" — Jack Langer (clinical) [Ep 17 · 13:40](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=820)
- "Dr. Baird published a paper in JPS showing that patients with flap closure did better in every way than those with sutured fascial closure, including lower rates of umbilical hernia repair" — Todd Ponsky (host_summary) [Ep 17 · 14:19](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=859)
- "Some gastroschisis patients become tachypneic with bluish legs after reduction and require intubation by neonatologists an hour or two later" — Jack Langer (clinical) [Ep 17 · 16:12](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=972)
- "Leaving a silo on for 24-48 hours causes the abdominal wall defect to stretch and get bigger, taking longer to close with plastic closure" — Jack Langer (clinical) [Ep 17 · 17:25](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1045)
- "Spring-loaded silos (Bentech) create outward pressure forces as you push down, making the defect larger over time" — Todd Ponsky (clinical) [Ep 17 · 18:10](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1090)
- "The incidence of intestinal atresia in gastroschisis is between 5 and 10%" — Jack Langer (epidemiological) [Ep 17 · 18:51](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1131)
- "There are two types of intestinal atresia in gastroschisis: early-onset atresia with dilated but not thick-walled bowel, and late atresia from a constricting defect causing ischemia and potentially vanishing gastroschisis" — Jack Langer (clinical) [Ep 17 · 19:01](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1141)
- "The prognosis for short bowel syndrome has improved dramatically over the last 10-15 years due to intestinal failure centers, better TPN that doesn't damage the liver, and improved sepsis control" — Jack Langer (clinical) [Ep 17 · 20:15](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1215)
- "Three management options for atresia in gastroschisis: repair at time of closure, bring out stomas, or reduce everything and repair atresia in a couple months" — Jack Langer (clinical) [Ep 17 · 20:54](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1254)
- "There is no good evidence for optimal management of atresia in gastroschisis because it's rare, so approach should be individualized" — Jack Langer (opinion) [Ep 17 · 21:15](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1275)
- "If bowel looks good without much peel, repair the atresia and reduce at the same sitting; if concerning, drop it back in without repair" — Jack Langer (clinical) [Ep 17 · 21:35](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1295)
- "Stomas are only brought out when there's necrotic bowel requiring resection and the bowel is not healthy enough to anastomose" — Jack Langer (clinical) [Ep 17 · 22:01](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1321)
- "The umbilicus is the preferred site for neonatal stomas; prolapse occurs regardless of location" — Jack Langer (clinical) [Ep 17 · 22:50](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1370)
- "Three weeks is average time to bowel function in gastroschisis, so investigations typically aren't started until 4 weeks" — Jack Langer (clinical) [Ep 17 · 24:27](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1467)
- "Metoclopramide (Reglan) can be given intravenously as a prokinetic agent in gastroschisis patients with hypomotility" — Jack Langer (clinical) [Ep 17 · 24:55](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1495)
- "A UK study showed cisapride shortened time to bowel function, but cisapride is no longer available" — Jack Langer (clinical) [Ep 17 · 25:02](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1502)
- "Toronto is conducting a randomized prospective trial to determine if intravenous metoclopramide can shorten the period of hypomotility in gastroschisis" — Jack Langer (clinical) [Ep 17 · 25:37](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1537)
- "At 4 weeks without bowel function, start with contrast enema to look for mechanical obstruction, can also do upper GI" — Jack Langer (clinical) [Ep 17 · 25:57](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1557)
- "If still no resolution at 6 weeks, laparotomy is usually performed; sometimes mechanical obstruction is found, sometimes just adhesions" — Jack Langer (clinical) [Ep 17 · 26:44](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1604)
- "Going in too early on gastroschisis patients with prolonged ileus is a mistake" — Jack Langer (opinion) [Ep 17 · 27:21](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1641)
- "Undescended testis (usually right) in gastroschisis is directed down into the pelvis during reduction; in about half the cases it finds its way to the scrotum" — Jack Langer (clinical) [Ep 17 · 28:03](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1683)
- "Omphalocele has a much higher incidence of associated anomalies and chromosomal abnormalities compared to gastroschisis" — Jack Langer (clinical) [Ep 17 · 28:43](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1723)
- "Karyotype analysis and testing for Beckwith-Wiedemann syndrome are routinely done for omphalocele patients" — Jack Langer (clinical) [Ep 17 · 28:59](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1739)
- "Small omphaloceles without liver are counterintuitively more likely to be associated with abnormal chromosomes than large omphaloceles" — Jack Langer (clinical) [Ep 17 · 29:47](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1787)
- "There is no rationale for routine cesarean section, delivery at a perinatal center, or preterm delivery for small omphaloceles" — Jack Langer (clinical) [Ep 17 · 30:05](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1805)
- "Small omphaloceles are simple to repair surgically" — Jack Langer (clinical) [Ep 17 · 30:23](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1823)
- "For giant omphaloceles (with significant liver), most recommend cesarean section, though this is not evidence-based" — Jack Langer (clinical) [Ep 17 · 31:04](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1864)
- "Giant omphaloceles should be delivered at a perinatal center due to need for pediatric surgeon and experienced neonatologists" — Jack Langer (clinical) [Ep 17 · 31:42](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1902)
- "Pulmonary hypoplasia is associated with giant omphaloceles but is very difficult to diagnose prenatally; some patients require early intubation and respiratory support" — Jack Langer (clinical) [Ep 17 · 31:55](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=1915)
- "Stuart Lacy established intraabdominal pressure guideline of 20 mmHg based on rabbit studies in the 1980s, then validated in prospective study in children showing improved outcomes" — Jack Langer (clinical) [Ep 17 · 33:28](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2008)
- "Lacy also described increase in central venous pressure of more than 4 as a concerning threshold" — Jack Langer (clinical) [Ep 17 · 33:56](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2036)
- "Intraabdominal pressure can be measured through nasogastric tube or Foley catheter (intravesical pressure); the trend is more important than absolute number" — Jack Langer (clinical) [Ep 17 · 34:02](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2042)
- "Primary closure is attempted for full-term omphalocele patients without significant cardiac disease, respiratory issues, or pulmonary hypoplasia" — Jack Langer (clinical) [Ep 17 · 34:43](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2083)
- "The Montreal group described using the omphalocele sac as a silo, sequentially ligating it over days to allow abdominal wall stretching before definitive closure" — Jack Langer (clinical) [Ep 17 · 35:07](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2107)
- "Sequential sac ligation requires a thick enough sac and umbilical cord coming off the top rather than the side" — Jack Langer (clinical) [Ep 17 · 35:44](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2144)
- "Cristobal Abello in Colombia uses Duoderm over the sac to compress and reduce omphaloceles over time" — Todd Ponsky (host_summary) [Ep 17 · 37:22](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2242)
- "Duoderm compression appears to achieve reduction more quickly than sac ligation and doesn't require a sac amenable to ligation" — Jack Langer (clinical) [Ep 17 · 37:43](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2263)
- "Indications for escharotic therapy include prematurity, bad cardiac disease, pulmonary hypoplasia, multiple anomalies, abnormal chromosomes, or omphalocele too giant to reduce" — Jack Langer (clinical) [Ep 17 · 38:15](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2295)
- "Mushroom-shaped omphaloceles (small abdominal wall defect with large amount of viscera out) are impossible to reduce primarily" — Jack Langer (clinical) [Ep 17 · 38:49](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2329)
- "Sigy Ein used silver sulfadiazine (Silvadene) for escharotic therapy in omphaloceles for many years; Toronto published long-term follow-up" — Jack Langer (clinical) [Ep 17 · 39:26](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2366)
- "Timing of delayed omphalocele repair depends on patient specifics; some can be repaired at 6-8 months if defect reduces spontaneously, others require waiting 3-4 years for cardiac or pulmonary optimization" — Jack Langer (clinical) [Ep 17 · 40:19](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2419)
- "Mushroom-shaped omphaloceles never reduce spontaneously and stay large" — Jack Langer (clinical) [Ep 17 · 41:10](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2470)
- "For mushroom-shaped omphaloceles, the abdominal wall defect can be enlarged as a first step by incising the lower edge fascia, closing skin, and allowing more spontaneous reduction before definitive repair" — Jack Langer (clinical) [Ep 17 · 41:20](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2480)
- "Phil Gazzetta described the 'flip flop' technique (modification of component separation) for omphalocele closure: lateral incision of anterior sheath only, folding over while attached to posterior sheath, creating single posterior layer" — Todd Ponsky (clinical) [Ep 17 · 42:03](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2523)
- "Formal adult-style component separation in small children carries risk of devascularization and worsening the situation" — Jack Langer (clinical) [Ep 17 · 43:06](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2586)
- "In omphaloceles extending to the costal margin, the upper defect cannot be closed, so inferior defect is closed and a patch placed superiorly" — Jack Langer (clinical) [Ep 17 · 43:35](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2615)
- "Surgisis patch fails about 50% of the time in omphalocele closure; can be replaced with non-absorbable prolene mesh" — Jack Langer (clinical) [Ep 17 · 44:01](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2641)
- "Stratus is being used more recently for patches but long-term follow-up is not yet available to compare with Surgisis" — Jack Langer (clinical) [Ep 17 · 44:19](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2659)
- "Omphaloceles can be part of pentalogy of Cantrell, often with missing pericardium or Morgagni hernia; these tend to be more superiorly placed" — Jack Langer (clinical) [Ep 17 · 44:44](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2684)
- "For pentalogy of Cantrell patients, escharotic therapy is used due to cardiac problems; cardiac surgeons can patch the diaphragm from above through sternotomy, then abdominal wall is repaired later after cardiac optimization" — Jack Langer (clinical) [Ep 17 · 45:24](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2724)
- "Reflux is very common in omphalocele patients, especially those with bad hearts or pulmonary hypoplasia who don't eat normally" — Jack Langer (clinical) [Ep 17 · 46:08](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2768)
- "Interventional radiologists can place G-tubes under fluoroscopy in giant omphalocele patients by finding a window lateral to the defect, then convert to GJ tube after maturation" — Jack Langer (clinical) [Ep 17 · 46:30](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2790)
- "Fundoplication in a child with a large omphalocele defect is extremely difficult because the liver is midline and accessing the hiatus is nearly impossible, especially with cardiac disease and congested liver" — Jack Langer (clinical) [Ep 17 · 47:15](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2835)
- "GJ tube is a better short-term solution for reflux in omphalocele; fundoplication can be performed when fixing the abdominal wall defect after medical optimization" — Jack Langer (clinical) [Ep 17 · 47:42](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2862)
- "In large omphaloceles with midline liver, the liver can put pressure on the duodenum or pylorus causing mechanical gastric outlet obstruction that worsens reflux" — Jack Langer (clinical) [Ep 17 · 48:08](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2888)
- "Non-rotation in omphalocele is not a problem because it's not associated with risk of midgut volvulus, unlike malrotation" — Jack Langer (clinical) [Ep 17 · 48:49](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2929)
- "Inversion appendectomy during Ladd procedure makes sense if the appendix is encountered, as several omphalocele patients have developed perforated appendicitis with delayed diagnosis due to abnormal appendix location" — Jack Langer (clinical) [Ep 17 · 49:06](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2946)
- "If a child has renal abnormality requiring potential Mitrofanoff, the appendix should be preserved" — Jack Langer (clinical) [Ep 17 · 49:44](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=2984)
- "Hepatic veins in omphalocele are very superficial and can be injured during fascial dissection if not careful" — Jack Langer (clinical) [Ep 17 · 50:10](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=3010)
- "Kinking of hepatic veins during reduction has not been a problem when using intraabdominal pressure monitoring and not being too aggressive with pressures above 20" — Jack Langer (clinical) [Ep 17 · 50:31](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=3031)
- "In immediate omphalocele reduction, fascial edges can usually be approximated at the bottom but often not at the top, requiring patch placement" — Jack Langer (clinical) [Ep 17 · 50:56](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=3056)
- "For partial reductions with liver still protruding superiorly, Gore-Tex or silastic can be sewn on, skin closed over it, then removed in 1-2 weeks after stretching allows fascial closure" — Jack Langer (clinical) [Ep 17 · 51:09](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=3069)
- "97% of bilateral kidney tumors in children are Wilms tumor, with only a small percentage being other diagnoses" — Tony Sandler (epidemiological) [Ep 19 · 9:12](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=552)
- "Current standard for bilateral Wilms tumor is to start chemotherapy without biopsy, typically 2 cycles, and continue until tumor shrinkage plateaus (defined as less than 50% size reduction)" — Tony Sandler (guideline) [Ep 19 · 1:32](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=92)
- "When Wilms tumors stop shrinking with chemotherapy, it is usually due to mesenchymal differentiation rather than anaplastic transformation" — Tony Sandler (clinical) [Ep 19 · 4:19](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=259)
- "Bilateral nephron-sparing surgery is feasible even in large bilateral Wilms tumors by placing kidneys on ice, clamping vessels, and performing sharp dissection" — Tony Sandler (clinical) [Ep 19 · 4:44](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=284)
- "Wilms tumors are heterogeneous and biopsy may miss foci of anaplasia" — Dan (clinical) [Ep 19 · 3:27](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=207)
- "Recurrence of anaplastic Wilms tumor portends a very bad outcome and salvage is difficult despite chemotherapy" — Dan (clinical) [Ep 19 · 6:48](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=408)
- "Multifocal Wilms tumors raise concern about underlying embryologic abnormalities of the kidney and risk of developing additional tumors" — Dan (clinical) [Ep 19 · 8:15](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=495)
- "Most pathologists believe anaplasia in Wilms tumor is present primarily rather than induced by chemotherapy" — Tony Sandler (opinion) [Ep 19 · 7:56](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=476)
- "For gastroschisis with inflamed bowel, bedside reduction without intubation is feasible using rectal Tylenol and minimal fentanyl" — Todd Ponsky (clinical) [Ep 19 · 9:58](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=598)
- "Tegaderm closure of gastroschisis without fascial closure allows cicatrization over 3 days to 8 weeks, with feeding started when bowel function returns rather than waiting for complete closure" — Tony Sandler (clinical) [Ep 19 · 14:52](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=892)
- "When gastroschisis defect dilates during silo reduction attempts, Tegaderm closure alone can still achieve successful cicatrization without fascial closure" — Tony Sandler (clinical) [Ep 19 · 15:32](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=932)
- "Umbilical hernias after gastroschisis closure will close spontaneously if no fascia was cut; if fascia is cut, a permanent defect results" — Tony Sandler (clinical) [Ep 19 · 12:54](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=774)
- "Spring-loaded Bianchi silos may enlarge the fascial defect because the outward forces from the compressed ring push laterally" — Todd Ponsky (opinion) [Ep 19 · 14:27](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=867)
- "In gastroschisis with intestinal atresia and pristine bowel, creating an ostomy through the umbilical fascial ring is technically favorable because the bowel size matches the ring and provides good tissue for suturing" (clinical) [Ep 19 · 17:49](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=1069)
- "Primary anastomosis in gastroschisis with atresia is risky because the proximal bowel is massively dilated and distal bowel is decompressed, creating a tenuous anastomosis in bowel that has been outside the abdomen" (clinical) [Ep 19 · 18:36](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=1116)
- "In vanishing gastroschisis with markedly inflamed bowel, it is impossible to determine bowel viability or the extent of remaining intra-abdominal bowel from external examination" — Tony Sandler (clinical) [Ep 19 · 21:01](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=1261)
- "Re-exploration at 2 weeks after gastroschisis closure (rather than the traditional 4-6 weeks) can reveal that inflamed gastroschisis bowel has transformed into functional intestine suitable for anastomosis" — Tony Sandler (clinical) [Ep 19 · 22:07](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=1327)
- "The STEP registry discourages performing STEP procedures in the perinatal period due to difficult outcomes at best" — Greg (host_summary) [Ep 19 · 26:24](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=1584)
- "STEP procedures in patients with gastroschisis are not particularly beneficial due to underlying motility disorders" — Greg (host_summary) [Ep 19 · 26:33](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=1593)
- "Bianchi procedure is preferred over STEP for bowel lengthening because a patient can undergo Bianchi followed by STEP if needed, but once STEP is performed, lengthening options are limited" — Greg (opinion) [Ep 19 · 26:46](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=1606)
- "In neonatal ileal atresia with dilated proximal bowel, plication is preferred over tapering to preserve bowel length for potential future lengthening procedures" — Tony Sandler (clinical) [Ep 19 · 28:10](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=1690)
- "Plication of dilated bowel in ileal atresia usually unravels with time, allowing the bowel to be used later for lengthening procedures" — Tony Sandler (clinical) [Ep 19 · 26:13](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=1573)
- "In many centers, high-risk obstetric teams deliver gastroschisis cases early by C-section, resulting in less thick and matted bowel at birth" (clinical) [Ep 19 · 11:11](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=671)
- "For gastroschisis reduction at bedside, babies are intubated and paralyzed, a stitch is placed in the fascia with cord left as a biological patch, and Opsite dressing is applied; patients are kept paralyzed for 1-2 days" (clinical) [Ep 19 · 11:53](https://qa.library.globalcastmd.com/watch/compiled-sandler-rapid-fire-sessions-update-course-2015-992?t=713)
- "The abdominal wall forms around the 4th week of gestation, well before most women know they are pregnant." — Joyce (clinical) [Ep 24 · 0:31](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=31)
- "During the 6th week of gestation, rapid growth of intestines and liver expansion causes herniation of the midgut into the umbilical cord." — Joyce (clinical) [Ep 24 · 0:40](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=40)
- "Around the 10th week of gestation, herniated bowel loops return to the abdominal cavity and the small bowel and colon assume a fixed position." — Joyce (clinical) [Ep 24 · 0:50](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=50)
- "In gastroschisis, the umbilical cord is located to the left of the defect; in omphalocele it is in the center." — Joyce (clinical) [Ep 24 · 1:24](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=84)
- "With gastroschisis, bowel is exposed in utero causing it to be thickened, matted, and inflamed; with omphalocele the bowel is covered and remains normal." — Joyce (clinical) [Ep 24 · 1:32](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=92)
- "Associated anomalies occur in around 10% of gastroschisis cases but 60-75% of omphalocele cases, correlating with increased mortality in omphalocele." — Joyce (epidemiological) [Ep 24 · 1:52](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=112)
- "Gastroschisis is herniation of intestinal loops through a full-thickness defect in the anterior abdominal wall, usually lateral to the umbilicus on the right more than the left, around 4 cm in size, with no covering sac." — Joyce (clinical) [Ep 24 · 2:14](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=134)
- "The etiology of gastroschisis remains unknown. Leading theories propose a vascular event involving the right umbilical vein or right omphalomesenteric artery causing necrosis and abdominal wall weakening." — Joyce (clinical) [Ep 24 · 2:40](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=160)
- "The incidence of gastroschisis has risen over the last 20 years to as high as 5 per 10,000 live births." — Joyce (epidemiological) [Ep 24 · 3:06](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=186)
- "Gastroschisis is associated with young maternal age, prematurity, and low birth weight." — Joyce (epidemiological) [Ep 24 · 3:16](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=196)
- "Risk factors for gastroschisis are multifactorial but include young maternal age (<20 years), smoking, and use of vasoconstrictive medications." — Joyce (epidemiological) [Ep 24 · 3:37](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=217)
- "Around 90% of gastroschisis cases are diagnosed prenatally on routine ultrasound." — Joyce (epidemiological) [Ep 24 · 3:51](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=231)
- "There is no evidence in the literature to support either C-section or vaginal delivery in regards to outcome for gastroschisis." — Joyce (clinical) [Ep 24 · 4:48](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=288)
- "Initial delivery room management focuses on supporting the infant and keeping the bowel warm and moist: assess airway/breathing/circulation, assess bowel viability, place bowel and lower extremities in bowel bag with intestines central to decrease kinking risk." — Joyce (guideline) [Ep 24 · 5:01](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=301)
- "Gastroschisis infants experience excessive fluid losses from exposed bowel and require maintenance of temperature >36°C to decrease stress." — Joyce (clinical) [Ep 24 · 5:35](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=335)
- "An NG or OG tube is placed to decompress the stomach and prevent further intestinal distention in gastroschisis." — Joyce (guideline) [Ep 24 · 5:51](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=351)
- "There is about a 10% associated occurrence of intestinal atresia with gastroschisis." — Joyce (epidemiological) [Ep 24 · 7:10](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=430)
- "Intestinal atresia in gastroschisis can be treated at time of abdominal wall closure with resection and primary anastomosis, or the bowel can be reduced with atresia intact and repaired 4-12 weeks later, possibly requiring temporary ostomy especially with distal atresia." — Joyce (clinical) [Ep 24 · 7:22](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=442)
- "Surgical management of gastroschisis focuses on safe viscera reduction, identifying and treating associated defects (atresia, perforation), closure of the defect, early recognition of complications, and nutritional support." — Joyce (guideline) [Ep 24 · 7:47](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=467)
- "Closure is accomplished through either primary surgical closure or staged reduction with silo. Defect size, intestinal condition, and abdominal cavity size impact the decision." — Joyce (clinical) [Ep 24 · 8:14](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=494)
- "Staged closure with silo is accomplished gradually over 1 to 14 days, then surgically closed either at bedside or in the OR." — Joyce (clinical) [Ep 24 · 8:40](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=520)
- "At Cincinnati Children's, out of 41 gastroschisis patients in the last 3 years, almost all had staged closures with silos; only a handful with small defects were closed primarily." — Joyce (clinical) [Ep 24 · 8:52](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=532)
- "Lucille Packard Children's Hospital uses a sutureless technique: silo reduction followed by covering the remaining defect with Mepilex and Tegaderm dressings until fully healed (about 6 weeks), leaving an umbilical hernia that may need later repair." — Joyce (clinical) [Ep 24 · 9:37](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=577)
- "Todd Ponsky has done only non-sutured gastroschisis repair for the last 6 years and has never had a ventral hernia. He reports 10-20% umbilical hernia rate, most resolving by age 3-5 years, with perfect cosmetic results." — Todd Ponsky (clinical) [Ep 24 · 10:22](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=622)
- "In a pediatric surgery event poll, about 75% of surgeons reported doing non-sutured (Tegaderm) gastroschisis repair." — Todd Ponsky (epidemiological) [Ep 24 · 11:03](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=663)
- "For non-sutured closure, Todd Ponsky places a silo on all patients, reduces at bedside, and if everything reduces he closes it by tying the umbilical cord with suture, laying it in a circle over the hole, applying gauze and Tegaderm, waiting 4 days, then changing dressing every 4 days until sealed (usually 2 weeks)." — Todd Ponsky (clinical) [Ep 24 · 11:53](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=713)
- "Complications of primary gastroschisis closure stem mainly from increased abdominal pressure leading to decreased venous return and possible abdominal compartment syndrome with ischemic injury." — Joyce (clinical) [Ep 24 · 13:06](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=786)
- "It is important to monitor intra-abdominal pressure during and post gastroschisis closure using bladder pressures, frequent physical exam, urine output monitoring, and assessment of respiratory support requirements." — Joyce (guideline) [Ep 24 · 13:22](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=802)
- "Literature review shows debate about gastroschisis closure method: some groups report earlier feeding and decreased length of stay with primary closure, others report decreased ventilator time, shorter stay, and lower cost with silo reduction. Overall survival is >95% regardless of closure type." — Joyce (epidemiological) [Ep 24 · 15:06](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=906)
- "Post-silo placement nursing care focuses on quick complication recognition: support silo and bowel to avoid kinking/twisting, bowel should be pink with serous (not stool-containing) fluid in bag, monitor lower extremity perfusion, urine output, edema, oxygen requirement, respiratory difficulty, and temperature." — Joyce (guideline) [Ep 24 · 15:38](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=938)
- "Gastroschisis patients may require as much as 140-150 mL/kg/day of fluids to manage losses." — Joyce (clinical) [Ep 24 · 16:54](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=1014)
- "At Cincinnati Children's, Betadine-soaked gauze is used around the silo base and changed twice daily." — Joyce (clinical) [Ep 24 · 17:24](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=1044)
- "Todd Ponsky does not use bladder pressures for gastroschisis monitoring, finding them not terribly accurate in this patient size. He uses peak airway pressures as primary assessment during reduction, watching them to decide when to stop reducing, and looks at overall baby appearance and urine output." — Todd Ponsky (opinion) [Ep 24 · 29:22](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=1762)
- "Dean agrees that bladder pressures are not routinely used; peak airway pressures are very good, or in pressure-control ventilation watch for significant tidal volume changes, plus good physical exam of the belly for tightness." — Dean (opinion) [Ep 24 · 30:13](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=1813)
- "Jenny emphasizes that in Seattle the majority of gastroschisis care is done by advanced practitioners: non-surgical closure, kids out of ICU within days, then weeks on floors managed by nurse practitioners doing fluid management, feeding advancement, and wound care." — Jenny (clinical) [Ep 24 · 30:59](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=1859)
- "Of all potential gastroschisis complications, dysmotility is the most universal." — Joyce (clinical) [Ep 24 · 19:56](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=1196)
- "Gastroschisis prognosis is mainly dependent on severity of associated problems (prematurity, initial post-op complications) and degree of dysmotility, all impacting course and length of stay." — Joyce (clinical) [Ep 24 · 20:08](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=1208)
- "NEC is reported in about 5-10% of gastroschisis patients, tends to occur later in the course, should be treated same as isolated NEC, and shows no correlation with type of closure performed." — Joyce (clinical) [Ep 24 · 20:30](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=1230)
- "Cincinnati feeding protocol: enteral feedings start 24 hours after NG tube removal (when NG output <20 mL/kg/day for 24 hours), begin at 1 mL/hr, increase by 1 mL/hr daily until day 5, then BID increases, then q8h increases by day 8 if tolerated. PO feedings introduced with windows off tube feeds as tolerated, TPN gradually dialed down." — Joyce (guideline) [Ep 24 · 33:46](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2026)
- "Cincinnati is enrolling gastroschisis patients in a feeding study randomizing to either the enteral feeding protocol arm or PO ad-lib feedings arm." — Joyce (clinical) [Ep 24 · 34:33](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2073)
- "Cincinnati data 2010-present: 36 gastroschisis patients required long-term TPN (>30 days). Simple gastroschisis (n=22) averaged 35 days TPN with 3 still on TPN at 1 year. Complex with atresia (n=4) averaged 146 days TPN but all were off TPN on enteral feeds within 10 months." — Joyce (epidemiological) [Ep 24 · 36:31](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2191)
- "Studies show about 1/3 of gastroschisis children are below 10th percentile for weight at 1 year but without neurodevelopmental delays at time of evaluation." — Joyce (host_summary) [Ep 24 · 37:24](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2244)
- "Fallon et al 2012 retrospective review reported that gestational age <37 weeks and development of cholestasis were independently linked to poor growth in gastroschisis, whereas small-for-gestational-age or low birth weight was not." — Joyce (host_summary) [Ep 24 · 38:06](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2286)
- "Cincinnati group 2010 outcomes for 71 gastroschisis infants (6 complex) treated with standardized nutritional protocol (2006-2009): enteral feedings started around day 16, median length of stay 42 days, 6 patients discharged on TPN, 24% on tube feedings, rest on oral feeding." — Joyce (host_summary) [Ep 24 · 38:30](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2310)
- "Cincinnati 2006-2008 readmission data (n=58, 21% primary closure, remainder silo): 40% readmitted at least once within first year, >25% of readmissions directly gastroschisis-related. Most common reasons: bowel obstruction, abdominal pain/distention." — Joyce (host_summary) [Ep 24 · 39:25](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2365)
- "Cincinnati readmission analysis found no relationship with place of birth, bowel resection requirement, complex vs simple gastroschisis, small-for-gestational-age, delivery mode, feeding timing, TPN duration, length of stay, gender, maternal age, or prenatal diagnosis." — Joyce (host_summary) [Ep 24 · 40:07](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2407)
- "Cincinnati data showed interesting trend (not statistically significant): 67% of primary closure patients readmitted vs 20% of silo patients; bowel obstruction occurred in 17% of primary closure group vs 7% of silo group." — Joyce (host_summary) [Ep 24 · 40:50](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2450)
- "Holland 2010 article 'Gastroschisis: An Update' summarized that there is a need for multi-center prospective studies (due to small numbers at individual centers) and focus on improved evaluation of long-term nutritional and neurodevelopmental outcomes in these relatively well-doing patients." — Joyce (host_summary) [Ep 24 · 41:19](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2479)
- "For gastroschisis monitoring, the volume of NG output matters less than the color: even high-volume clear/spitty output may allow feeding, but any bilious output (regardless of volume) means the patient is not ready to feed." — Todd Ponsky (clinical) [Ep 24 · 42:18](https://qa.library.globalcastmd.com/watch/gastroschisis-advanced-practice-providers-1049?t=2538)
- "Jejunostomy chimney technique involves dividing bowel 2-3 cm distal to ligament of Treitz, bringing distal limb up as chimney over splenic flexure with side-to-end anastomosis, allowing Mickey button placement without luminal obstruction" (clinical) [Ep 20 · 3:00](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=180)
- "Placing balloon catheter directly in jejunal lumen creates obstruction; chimney technique avoids this by creating separate access limb" (clinical) [Ep 20 · 4:21](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=261)
- "Distal feeding can be provided through 3-4 French feeding tube placed in distal bowel and brought out as stent rather than matured mucous fistula, allowing easy refeeding without catheter access issues" (clinical) [Ep 20 · 0:57](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=57)
- "Refeeding distal bowel provides significant benefit for fluid/electrolyte absorption and allows bowel to dilate and mature, potentially decreasing technical problems at takedown" (clinical) [Ep 20 · 1:45](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=105)
- "When proximal and distal stomas are placed close together, takedown is less stressful on patient and surgeon than complete laparotomy to find and reconnect distant bowel segments" (opinion) [Ep 20 · 8:02](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=482)
- "Gastrostomy tubes in very small premature infants (700 grams) can be deferred by placing 3 French feeding tube coiled in stomach, then later dilating tract with wire and interventional radiology to place primary tube without second surgery" (clinical) [Ep 20 · 14:46](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=886)
- "Gastrostomy tube placement has costs including leakage issues if placed against costal margin in small infants; timing and location require careful consideration" (clinical) [Ep 20 · 20:41](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1241)
- "Prolapsed gastrostomy tubes can cause significant formula loss during feeds; removing dysfunctional gastrostomy allows some children to thrive better" (clinical) [Ep 20 · 22:46](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1366)
- "In 2-month-old with jejunal atresia unable to advance feeds beyond 20 mL/kg, if anastomosis appears patent at reoperation, would still revise it rather than leave it alone" (clinical) [Ep 20 · 24:16](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1456)
- "At end of intestinal failure operation, must ensure no kinking, restriction, or potential problems remain - cannot tolerate leaving anything that 'could be a problem but is probably all right'" (clinical) [Ep 20 · 25:29](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1529)
- "STEP procedure in first year of life, especially in infant who has not progressed with enteral feeds, is not beneficial unless specifically avoiding line infections and bacterial overgrowth" (clinical) [Ep 20 · 29:20](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1760)
- "Dysmotile bowel does not become motile because you did a STEP procedure on it; if bowel hasn't been fed and isn't functioning, STEP won't make it work" (clinical) [Ep 20 · 29:32](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1772)
- "The one thing that makes bowel adapt is feeding the bowel; procedures causing problems reinitiating feeds cause damage to patient" (clinical) [Ep 20 · 30:06](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1806)
- "In patient with 50% estimated bowel length, expectation is they will come off parenteral nutrition; should not overtry to salvage bad bowel when good bowel exists" (clinical) [Ep 20 · 28:07](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1687)
- "STEP registry paper showing procedures can be done safely in early neonatal period found only 3 patients came off parenteral nutrition, whereas natural data shows 80-90% of such patients off TPN at 12 months just by being fed" (epidemiological) [Ep 20 · 31:18](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1878)
- "Kids who had early STEP procedures have often redilated, undergone second STEPs, and had mechanical obstructions very detrimental to feeding ability" (clinical) [Ep 20 · 31:43](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1903)
- "Indication for lengthening procedure is complications from bacterial overgrowth (d-lactic acidosis) or ultra-short bowel with very dilated segment where tapering doesn't make sense - generally not decisions made at 2-3 months old but after first birthday" (clinical) [Ep 20 · 33:21](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2001)
- "Expectation of going from 10 mL/kg enteral feeds to off TPN in 3 months after STEP is a fairy tale that doesn't exist" (opinion) [Ep 20 · 34:06](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2046)
- "Surgical techniques for intestinal failure are not out of realm of any pediatric surgeon, but outcomes differ when done in isolation without multidisciplinary team consideration" (opinion) [Ep 20 · 34:46](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2086)
- "Since maturing multidisciplinary program, transplant candidates declined by 75% and internal transplants almost non-existent" (epidemiological) [Ep 20 · 40:47](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2447)
- "Patients should be referred to intestinal rehabilitation programs as soon as identified as needing comprehensive approach, not when complications exhausted local knowledge" (opinion) [Ep 20 · 44:23](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2663)
- "Programs do far better with children who do not already have complications of their disease than patients who come already suffering from current management" (clinical) [Ep 20 · 44:34](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2674)
- "In gastroschisis and surgical necrotizing enterocolitis, significant benefit to time to wean off parenteral nutrition based solely on breast milk (fortified or not) versus formula only" (clinical) [Ep 20 · 59:42](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3582)
- "Breast milk is not just formula but really a therapy with components that are anti-inflammatory and promotile" (clinical) [Ep 20 · 60:19](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3619)
- "Benefit to kids with spontaneous intestinal perforation is not seen with breast milk, suggesting specific anti-inflammatory and promotile components important for other conditions" (clinical) [Ep 20 · 60:20](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3620)
- "Donor breast milk is less advantageous than maternal breast milk; usually taken from mothers 10-14 months postpartum before weaning, has lower caloric density and protein, and freezing may inactivate trophic factors" (clinical) [Ep 20 · 62:25](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3745)
- "Express maternal breast milk is favorite approach; when patient predicted to do badly, go to elemental formulas as second line" (clinical) [Ep 20 · 63:19](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3799)
- "Free amino acid formulas are relatively hyperosmolar at 20 kcal/oz (osmolarity around 350-360); going higher increases osmolarity, so tend to avoid high caloric density formulas in very young infants" (clinical) [Ep 20 · 64:20](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3860)
- "In study by Joly et al in French adult cohort, hyperphagic adults with short bowel had 60% absorption coefficient with ad lib eating, 85% with continuous drip feeds, and 75% with half calories by mouth during day plus overnight drip feeds" (host_summary) [Ep 20 · 17:01](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1021)
- "Continuous drip feeding improves absorptive index, but combining daytime oral intake with nighttime drip feeds may offer best of both approaches" (host_summary) [Ep 20 · 17:40](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1060)
- "Prefer isotonic formulas (15-17 cal/oz) because digestion changes osmolarity in jejunum, and most bad kids don't have ileum so jejunum has no ability to absorb against concentration gradient" (clinical) [Ep 20 · 65:20](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3920)
- "Kids without upper GI dysmotility handle volume much better than concentration, so keep concentration low and advance volume" (clinical) [Ep 20 · 65:55](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3955)
- "Introduction of baby foods, meats, and vegetables remarkably helpful in adaptation process once kids get older" (clinical) [Ep 20 · 66:03](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3963)
- "TPN panel includes renal panel, liver panel, calcium/phosphorus/magnesium; no longer follow prealbumin or RBP as money-saving strategy, follow albumin instead for chronic changes" (clinical) [Ep 20 · 70:04](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4204)
- "Follow essential fatty acids monthly or every other month if on low lipid TPN; iron, ferritin, TIBC every 2-3 months; zinc, copper, ceruloplasmin every 3-6 months; selenium every 6 months" (clinical) [Ep 20 · 70:43](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4243)
- "About 60% of patients weaned off TPN have deficiencies in one micronutrient or another" (epidemiological) [Ep 20 · 71:36](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4296)
- "Follow B12 annually plus methylmalonic acid and homocysteine as more sensitive surrogate markers, since B12 can be synthesized by bacteria or falsely elevated with liver disease" (clinical) [Ep 20 · 72:03](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4323)
- "Breast milk has non-nutrient oligosaccharides (2FL, 3FL) that are not nutrient source to humans but affect microflora and dysbiosis; 80% of secretor mothers make 2FL which is immunomodulatory" (clinical) [Ep 20 · 85:56](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5156)
- "Dysbiosis in intestinal failure patients is profound and furthered by H2 blockers and antibiotics; how this affects adaptive process not well understood" (clinical) [Ep 20 · 86:24](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5184)
- "Older patient recommends prebiotics more and antibiotics less; almost all patients with substantial resection and lost ileocecal valve have element of small bowel contamination with colonic flora" (opinion) [Ep 20 · 83:13](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4993)
- "Want to encourage right flora (anaerobes) and discourage wrong flora (putrefactive bacteria like E. coli, Klebsiella); too many antibiotics kill bacteria you want present to break down starches into butyric acid" (clinical) [Ep 20 · 83:59](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5039)
- "Use antibiotics selectively: for d-lactic acidosis, hyperammonemia, or older child no longer thriving on previously adequate caloric intake; if used, finite period 2-3 weeks, and abandon if no improved growth velocity" (clinical) [Ep 20 · 85:06](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5106)
- "In recent data, probably 2/3 of bloodstream infections seen in patients on prophylactic Flagyl, because knocking out anaerobes facilitates aerobic overgrowth and presumably translocation" (clinical) [Ep 20 · 90:33](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5433)
- "Metronidazole has limited spectrum, knocks off anaerobes, facilitates growth of aerobes - absolutely the wrong choice for bacterial overgrowth" (opinion) [Ep 20 · 91:56](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5516)
- "If desperate for antibiotics, might use selective decontamination with non-absorbable aminoglycoside (Tobramycin) and Colistin" (clinical) [Ep 20 · 92:16](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5536)
- "Rifaximin may have role but not well studied in bacterial overgrowth, appropriate dose unknown, and no stable suspension available" (clinical) [Ep 20 · 92:37](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5557)
- "Use metronidazole to promote motility by decreasing overgrowth, improving mucosal quality, decreasing inflammation, and increasing tolerance and absorption - not to prevent bacterial infection" (clinical) [Ep 20 · 93:26](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5606)
- "When culture most bacteria causing overgrowth, get anaerobes qualitatively, which is reason for metronidazole use" (clinical) [Ep 20 · 94:29](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5669)
- "Lack of knowledge about microbiome in children with intestinal failure; tend to use antibiotics based on clinical findings - gram negatives or cholestasis suggests non-absorbable aminoglycoside; sudden distension with frothy diarrhea or lactic acidosis suggests Flagyl" (clinical) [Ep 20 · 95:24](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5724)
- "Patients seem to advance well once on solid food, likely due to more physiological exposure to complex proteins and oligosaccharides, but can't identify single causative factor yet" (clinical) [Ep 20 · 96:45](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5805)
- "Use antibiotics and not probiotics, only when forced to (d-lactic acidosis, stalling feeds with distension); metronidazole used because anaerobes are gas producers and cause lactic acidosis" (clinical) [Ep 20 · 97:56](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5876)
- "Metronidazole doesn't work for everyone; with lactic acidosis, very specific antibiotics seem to work and must find best one; try not to cycle, use once and see how long before recurrence" (clinical) [Ep 20 · 98:47](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5927)
- "Worry about probiotics getting in central lines through external contamination more than translocation; lactobacillus species extremely hard to clear, may require line removal" (clinical) [Ep 20 · 99:41](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5981)
- "One case established blood infection with same genotype as lactobacillus given as probiotic, which turned program away from probiotics in all kids with central lines" (clinical) [Ep 20 · 100:06](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6006)
- "First consideration with increased output is whether overfeeding and overtaxing gut, providing elements for osmotic diarrhea" (clinical) [Ep 20 · 101:17](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6077)
- "Reanastomosing colon helps with output; when colon involved, anti-motility drugs like loperamide become helpful" (clinical) [Ep 20 · 101:51](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6111)
- "Use soluble fibers to decrease high output; have tried octreotide but not found very useful and worry about chronic use with growth hormone suppression" (clinical) [Ep 20 · 102:20](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6140)
- "For patients with lot of gastric output, might use proton pump inhibitor to decrease gastric secretions, but must balance with potential medication risks" (clinical) [Ep 20 · 103:12](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6192)
- "Documented inflammation found on endoscopy in some kids; using anti-inflammatory agents (5-ASA products) seems to have impact, sometimes steroid-based enemas helpful depending on location" (clinical) [Ep 20 · 103:50](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6230)
- "Anti-inflammatories really helpful in challenging Hirschsprung's patients with dysbiosis and high stool frequency not well managed with other interventions" (clinical) [Ep 20 · 104:29](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6269)
- "Successfully managed some Hirschsprung's patients (8-9 years old, stooling 12 times daily, not responding to antibiotic cycling or prebiotics/formulas) with long-term anti-inflammatories and 5-ASA with remarkable success" (clinical) [Ep 20 · 104:49](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6289)
- "Avoid cholestyramine as much as possible; doses effective in firming stool usually bind nutrients, fat-soluble vitamins, and fats; slight risk for hyperchloremic acidosis and cholestyramine bezos" (clinical) [Ep 20 · 105:42](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6342)
- "Encountered patients on almost homeopathic cholestyramine doses whose parents/physicians believed stools looked better, but not sure stool volume actually declined" (clinical) [Ep 20 · 106:30](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6390)
- "Ursodiol in child with very short gut can contribute to diarrhea due to osmotic component with no real benefit preventing cholestasis" (clinical) [Ep 20 · 107:10](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6430)
- "Pancreatic enzymes not physiologic in humans until 5-7 months of age; worry about enzymes in dysmotile bowel areas especially with stomas - have seen strictures/stoma problems related to enzymes sitting in stenotic areas" (clinical) [Ep 20 · 108:12](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6492)
- "Only pancreatic enzyme present in adult quantities in young infants are proteases; amylases don't appear until 6-12 months, lipase doesn't reach adult levels until end of first year" (clinical) [Ep 20 · 109:23](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6563)
- "Short gut patients have high trypsinogen levels because they don't have enough enterokinase, but formal pancreatic stimulation shows proteases do appear" (clinical) [Ep 20 · 109:52](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6592)
- "Problem with pancreatic enzymes in short gut is they go through before releasing" (clinical) [Ep 20 · 110:47](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6647)
- "No upper number for acceptable stoma output that is hard and fast; have many patients with 40-50 cc/kg stoma output who continue feeding based on electrolyte profile" (clinical) [Ep 20 · 111:14](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6674)
- "Don't want patients acidotic (CO2 dropping to teens despite maximizing acetate) - that's the limit, not volume; electrolytes and acidosis drive decision, not volume" (clinical) [Ep 20 · 111:29](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6689)
- "Knee-jerk reactions to volume of output (unless otherwise sick with acidosis/abnormal electrolytes) should not be made; using nurse-callable number for output leads to variable feeding over longer time, very detrimental to weaning program" (opinion) [Ep 20 · 111:45](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6705)
- "Stoma output or stool output more relevant in guiding fluid and electrolyte replacement than making decisions about stopping or decreasing feeds" (clinical) [Ep 20 · 112:36](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6756)
- "Patients receiving GLP-2 analog therapies have dramatically decreased stomal output with benefit in fluid and electrolytes, though whether this gives sustainable benefit and whether use in kids is indicated not yet determined" (clinical) [Ep 20 · 113:12](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6792)
- "Adult GLP-2 analog studies suggest it is beneficial: can reduce fecal output in 60-70% of patients allowing 20% TPN reduction, and in extension study 20% of patients totally emancipated from TPN" (host_summary) [Ep 20 · 113:45](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6825)
- "Some patients do fine on GLP-2 analog while on it but regress when they come off, so jury still out" (clinical) [Ep 20 · 114:35](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6875)
- "Studies waiting until children have late intestinal failure not likely to give needed insight; multi-institutional trials following patients in areas where they can be monitored will provide better outcomes and insight for next 5-10 years" (opinion) [Ep 20 · 114:53](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6893)
- "Major advancements made in intestinal failure field in last 5-6 years not fully recognized; trajectory suggests remarkably different treatment paradigm in very short time" (opinion) [Ep 20 · 115:31](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6931)
- "When patients on long-term TPN, must monitor not just growth (weight and length) but micronutrient status - impacts neurodevelopmental/cognitive outcome and bone health" (clinical) [Ep 20 · 116:10](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6970)
- "Most of the damage to the intestine in gastroschisis occurs in the last few weeks of pregnancy, based on animal studies and clinical studies" (clinical) [Ep 23 · 2:45](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=165)
- "The age at spontaneous onset of labor for gastroschisis pregnancy is 3 weeks earlier than the general population" (epidemiological) [Ep 23 · 3:44](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=224)
- "About half of gastroschisis pregnancies go into labor spontaneously before 37 weeks" (epidemiological) [Ep 23 · 3:56](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=236)
- "No perinatal center in Canada was doing routine cesarean sections for gastroschisis based on a national survey" (epidemiological) [Ep 23 · 4:37](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=277)
- "15 or 20 years ago, routine cesarean section for gastroschisis was pretty much the standard of care" (clinical) [Ep 23 · 4:49](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=289)
- "Using a pre-formed silo allows gentle reduction of gastroschisis bowel without trauma, and in about a third of cases the bowel can be reduced immediately and the silo removed" (clinical) [Ep 23 · 8:27](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=507)
- "Waiting for gastroschisis babies to lose their first 10% of body weight reduces bowel edema and makes reduction easier" (clinical) [Ep 23 · 9:05](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=545)
- "Leaving a silo on for more than a day causes the fascial defect to get much bigger" (clinical) [Ep 23 · 9:41](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=581)
- "Using plastic closure (non-surgical closure) for gastroschisis gives extremely good results, often with a small umbilical hernia that closes by age 2" (clinical) [Ep 23 · 11:37](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=697)
- "There are two kinds of intestinal atresia in gastroschisis: early-developing atresia not always associated with bowel thickening, and late-occurring atresia from a very small abdominal wall defect" (clinical) [Ep 23 · 15:55](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=955)
- "Bringing an ostomy out through the umbilicus avoids additional scars and makes subsequent closure easier" (clinical) [Ep 23 · 16:13](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=973)
- "Gord Cameron in Hamilton in the 1980s was the first to describe umbilical ostomies" (clinical) [Ep 23 · 17:53](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1073)
- "At 4 weeks post-gastroschisis repair with feeding intolerance, waiting longer is reasonable as the bowel may still be recovering from motility disorder" (opinion) [Ep 23 · 20:04](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1204)
- "At 8 weeks post-repair with persistent feeding intolerance, exploration is warranted to rule out mechanical obstruction" (opinion) [Ep 23 · 20:46](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1246)
- "For large omphalocele, attempting to remove the sac and close primarily can lead to inability to achieve closure and need for prosthetic patch" (clinical) [Ep 23 · 22:13](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1333)
- "The Schuster repair uses mesh sutured to fascia over intact omphalocele sac with gradual closure, eventually allowing primary repair" (clinical) [Ep 23 · 22:31](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1351)
- "For large omphalocele, patch covered by skin or skin coverage alone is better than paint-and-wait which takes months" (opinion) [Ep 23 · 23:11](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1391)
- "Lateral component separation makes it easier to bring fascial edges together in omphalocele repair" (clinical) [Ep 23 · 23:32](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1412)
- "Antibiotic ointment on omphalocele sac keeps it supple, and using 4x4s with Ace wrap compression can gradually reduce the defect" (clinical) [Ep 23 · 23:53](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1433)
- "Dr. Abello uses Duoderm wrapped around omphalocele and tightens it daily to achieve gradual reduction" (host_summary) [Ep 23 · 24:37](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1477)
- "Botox has been used successfully by adult hernia surgeons to relax muscle and facilitate closure of large ventral hernias" (host_summary) [Ep 23 · 24:57](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1497)
- "Intragastric pressure monitoring via NG tube is easy to perform in the OR and provides useful guidance, with 20 as a suggested threshold" (clinical) [Ep 23 · 29:56](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1796)
- "Bladder pressure measurement in tiny newborns is unreliable and cannot be trusted consistently" (opinion) [Ep 23 · 29:00](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1740)
- "Ventilatory parameters are the most reliable measure for assessing safe closure tension" (opinion) [Ep 23 · 28:04](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=1684)
- "For giant omphalocele in older children, enlarging the fascial defect and allowing staged closure over time without forcing reduction prevents abdominal compartment syndrome" (clinical) [Ep 23 · 36:14](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=2174)
- "In older children with giant omphalocele, the abdomen does not expand as rapidly as in newborns and requires more time between stages" (clinical) [Ep 23 · 36:40](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=2200)
- "When opening the fascial ring in giant omphalocele, opening inferiorly avoids encountering hepatic veins at the superior aspect" (clinical) [Ep 23 · 36:58](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-update-course-2013-1059?t=2218)
- "Restrictive transfusion protocols using a target hemoglobin of 7 instead of 8, 9, or 10 showed no difference in mortality" — Alex Gibbons (host_summary) [Ep 31 · 0:26](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=26)
- "Exception to restrictive transfusion is sickle cell disease where hematocrit needs to be around 30 or HbSS below 50%" (clinical) [Ep 31 · 1:45](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=105)
- "Early enteral feeding in pancreatitis decreases morbidity, infectious complications, and overall mortality" (host_summary) [Ep 31 · 2:20](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=140)
- "Nasogastric feeding is equal to nasojejunal feeding in pancreatitis and is equally tolerated" (host_summary) [Ep 31 · 2:20](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=140)
- "In ovarian torsion, even if the ovary looks black and dead after detorsion, leave it in place because ovaries can still have recovery afterwards and it helps preserve fertility" (host_summary) [Ep 31 · 3:29](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=209)
- "Ultrasound is not a great tool for diagnosis of ovarian torsion; clinical judgment should not be based primarily on ultrasound findings" (host_summary) [Ep 31 · 3:29](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=209)
- "For low bleeding risk trauma patients, VTE prophylaxis should include SCDs and low molecular weight heparin" (host_summary) [Ep 31 · 4:05](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=245)
- "For high bleeding risk trauma patients, use SCDs until ambulatory, then do screening ultrasound on ICU day 7" (host_summary) [Ep 31 · 4:05](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=245)
- "At our institution, VTE prophylaxis policy is for patients 12 years and over" (clinical) [Ep 31 · 4:53](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=293)
- "High risk for VTE includes femur fractures, cervical spine fracture, and intubated patients" (clinical) [Ep 31 · 4:53](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=293)
- "Kids with IBD are probably the most at-risk group for deep venous thromboses" (clinical) [Ep 31 · 5:50](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=350)
- "Burnout directly impacts patient care and outcomes" (host_summary) [Ep 31 · 6:02](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=362)
- "Support systems for physician wellness need to be established proactively during education and practice because burnt out surgeons are not likely to seek help" (host_summary) [Ep 31 · 6:02](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=362)
- "Physicians should talk to patients about whether there's a firearm in the home and if there is, whether it's safely stored" (host_summary) [Ep 31 · 8:23](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=503)
- "Isotonic fluids should be continued throughout hospitalization instead of switching to hypotonic fluids for maintenance, which decreases the risk of hyponatremia with similar morbidity and mortality" (host_summary) [Ep 31 · 11:27](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=687)
- "In Wilms tumor operations, failure to remove lymph nodes automatically upstages the patient" — Liz Byerly (host_summary) [Ep 31 · 14:30](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=870)
- "Pulmonary metastasis in Wilms tumor doesn't preclude doing a primary nephrectomy" — Liz Byerly (host_summary) [Ep 31 · 14:30](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=870)
- "It is important to take lymph nodes in Wilms tumor regardless of whether the patient has lung metastases because you treat the local disease and it has an impact on treatment for abdominal disease" — Dan (clinical) [Ep 31 · 15:37](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=937)
- "Non-operative management of uncomplicated appendicitis has decreased days of hospitalization, decreased days of disability, and equal outcome measures" (host_summary) [Ep 31 · 16:41](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1001)
- "The important point in non-operative appendicitis management is not whether it's effective for six months or a year, but what happens 10, 20, or 40 years down the road regarding appendix scarring and future obstruction" — Todd Ponsky (host_summary) [Ep 31 · 17:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1036)
- "In the APAC trial (adult study), at five years, 41% of the non-operative appendicitis group underwent an appendectomy" — Todd Ponsky (host_summary) [Ep 31 · 17:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1036)
- "Parents surveyed for PCORI-funded study said if there was a 50% chance of non-operative appendicitis management being successful, they would enroll in the study" — Todd Ponsky (host_summary) [Ep 31 · 17:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1036)
- "For Wilms tumor lymph node sampling, there are data to show that nine nodes or seven nodes are probably adequate, but plucking nodes from the mesentery or pelvis is not helpful just to get a number" — Dan (clinical) [Ep 31 · 22:01](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1321)
- "For Wilms tumor, you should take nodes from both sides of the cava and the aorta, but you don't have to dive into the renal hilum on the other side or open Gerota's fascia" (clinical) [Ep 31 · 23:01](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1381)
- "Recommendations for opioid crisis management include reducing total amount of opioids prescribed, using non-opioid analgesia and non-pharmacological approaches, and educating on disposal of unused opioids" (host_summary) [Ep 31 · 23:29](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1409)
- "Enhanced recovery after surgery protocols have been great at reducing opioids both in the inpatient setting and at time of discharge" — Todd Ponsky (host_summary) [Ep 31 · 23:29](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1409)
- "For well-appearing neonates with intact omphalocele and no maternal fever or chorioamnionitis, preoperative antibiotic given one hour before incision and discontinued within 72 hours is most appropriate" (host_summary) [Ep 31 · 26:19](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1579)
- "Babies don't need antibiotics just because they showed up in the NICU; they only need standard prophylactic antibiotics when going to the OR" (clinical) [Ep 31 · 28:02](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1682)
- "Based on AAP and neonatology recommendations, as long as the baby is well and mother has no signs of sepsis or chorioamnionitis, you don't need to give antibiotics for children that don't have an open abdomen" (host_summary) [Ep 31 · 28:02](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1682)
- "Children with ruptured omphalocele or gastroschisis have an open abdomen and probably should receive antibiotics" (clinical) [Ep 31 · 28:02](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1682)
- "Children with duodenal atresia probably don't need antibiotics if they're going to the operating room within the next 24 to 48 hours" (clinical) [Ep 31 · 28:02](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1682)
- "For intact omphalocele managed with paint and wait, no antibiotics are needed as long as mom didn't have chorioamnionitis and baby doesn't have fever" (clinical) [Ep 31 · 28:02](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1682)
- "According to Surviving Sepsis Campaign guidelines, give 20 cc per kilo boluses of isotonic fluid up to 60 ml per kilo total, with goal of perfusion improvement" — Stephen Lee (host_summary) [Ep 31 · 33:01](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1981)
- "Stop fluid boluses if you see over-perfusion such as rales on auscultation or enlarged liver" — Stephen Lee (host_summary) [Ep 31 · 33:01](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1981)
- "Must start broad-spectrum antibiotics in sepsis; data shows in adults that if you wait over three hours to start antibiotics in a septic patient, survival goes down" — Stephen Lee (host_summary) [Ep 31 · 33:01](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1981)
- "If hematocrit or hemoglobin is less than 10 in septic patient, transfusion may be indicated" — Stephen Lee (host_summary) [Ep 31 · 33:01](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1981)
- "For pediatric sepsis, epinephrine is the vasopressor of choice; two randomized trials showed mortality was better with epi in one study and epi had better improvement in systolic blood pressure in the other compared to dopamine" — Stephen Lee (host_summary) [Ep 31 · 33:01](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1981)
- "Hydrocortisone has a role in sepsis for patients who are vasopressor refractory, meaning vasopressors were started and systolic blood pressure remains low" — Stephen Lee (host_summary) [Ep 31 · 33:01](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=1981)
- "Broad-spectrum antimicrobial therapy for sepsis means extended-spectrum penicillin like piperacillin-tazobactam or ampicillin-sulbactam to cover everything empirically" — Stephen Lee (clinical) [Ep 31 · 36:49](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2209)
- "Draw blood for lactate level and cultures just prior to starting antibiotics in sepsis, but don't delay starting antibiotics while waiting" — Stephen Lee (host_summary) [Ep 31 · 36:49](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2209)
- "Antibiotic stewardship in sepsis means following cultures and titrating antibiotics down or stopping them altogether if in three or four days patients have improved and it's no longer an infectious issue" — Stephen Lee (host_summary) [Ep 31 · 36:49](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2209)
- "The odds ratio for not starting antibiotics within three hours in children with sepsis was 3.92 for mortality - almost four times more likely to die" — Salim Islam (host_summary) [Ep 31 · 36:49](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2209)
- "ECMO survival for patients with severe sepsis and recalcitrant hypotension is about 46% overall, which is better than zero" — Salim Islam (epidemiological) [Ep 31 · 36:49](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2209)
- "Updated APSA blunt liver-spleen injury guidelines recommend treating based on patients' hemodynamic status, not injury grade" (host_summary) [Ep 31 · 43:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2596)
- "Modified shock index for pediatrics (heart rate over systolic blood pressure) can determine if patient is still bleeding; if so, recommend ICU admission" (host_summary) [Ep 31 · 43:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2596)
- "If patient with solid organ injury has responded to normal saline bolus and remains hemodynamically stable, they just need to be observed on the ward" (host_summary) [Ep 31 · 43:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2596)
- "For ward admission with solid organ injury, patient needs only another hemoglobin check in six hours, can have regular diet, and no activity restrictions needed" (host_summary) [Ep 31 · 43:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2596)
- "After first 20 ml per kilo normal saline bolus in trauma, if patient still requires additional fluids, give blood (10 cc per kilo)" (host_summary) [Ep 31 · 43:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2596)
- "Angioembolization in stable patients with solid organ injury does not need to be done even with contrast blush, particularly in splenic injuries which have been shown not to continue bleeding" (host_summary) [Ep 31 · 43:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2596)
- "If there's evidence of ongoing bleeding in solid organ injury, then angioembolization should be performed" (host_summary) [Ep 31 · 43:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2596)
- "Based on ATOMIC protocol, 40 mLs per kilogram of packed red blood cells is the threshold; when you need more than 40 cc per kilo, you should go to the operating room" (host_summary) [Ep 31 · 43:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2596)
- "ATOMIC was started in 2010 as a group of level one pediatric trauma centers (Arkansas, Texas, Oklahoma, Memphis, Arizona) coming together to study vital trauma questions prospectively" (host_summary) [Ep 31 · 43:16](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=2596)
- "Cervical spine injury is about 1 to 2% of all pediatric traumas" — Meera Kotagal (host_summary) [Ep 31 · 59:25](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=3565)
- "In older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns" — Meera Kotagal (host_summary) [Ep 31 · 59:25](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=3565)
- "In younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA" — Meera Kotagal (host_summary) [Ep 31 · 59:25](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=3565)
- "60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults" — Meera Kotagal (host_summary) [Ep 31 · 59:25](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=3565)
- "AAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years" — Meera Kotagal (host_summary) [Ep 31 · 59:25](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=3565)
- "Patients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging" — Meera Kotagal (host_summary) [Ep 31 · 59:25](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=3565)
- "For cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony" — Meera Kotagal (host_summary) [Ep 31 · 59:25](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=3565)
- "46% of institutions don't have a protocol for cervical spine clearance in children" — Meera Kotagal (host_summary) [Ep 31 · 59:25](https://qa.library.globalcastmd.com/watch/7th-annual-pediatric-surgery-update-course-2019-full-show-2797?t=3565)
- "The case patient is a 10-year-old male with chronic constipation, soiling, poor appetite, and a water-soluble contrast enema showing a tortuous, redundant, dilated colon full of stool." — Amanda Jensen (host_summary) [Ep 42 · 0:35](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=35)
- "Anorectal manometry in this patient showed an absent rectoanal inhibitory reflex (RAIR)." (host_summary) [Ep 42 · 1:03](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=63)
- "Colonic transit and colonic function must be assessed in this patient; it is not purely a sphincter issue." — Anil Darbari (clinical) [Ep 42 · 1:45](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=105)
- "The massively dilated colon is a result of colonic dysfunction, with dilatation predominantly in the rectosigmoid." — Anil Darbari (clinical) [Ep 42 · 2:04](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=124)
- "A Sitz marker study is recommended to assess colonic transit." — Kahleb Graham (clinical) [Ep 42 · 2:24](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=144)
- "Anorectal manometry should assess resting pressure; high resting pressure may indicate a patient amenable to anal Botox." — Kahleb Graham (clinical) [Ep 42 · 2:35](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=155)
- "Conscious rectal sensitivity threshold is tested by gradually inflating a balloon to determine when the patient has a sensation to defecate." — Kahleb Graham (clinical) [Ep 42 · 2:49](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=169)
- "Normal defecation physiology involves pushing from the belly (increasing intraabdominal pressure) and relaxing the anal sphincter, creating a positive pressure gradient." — Kahleb Graham (clinical) [Ep 42 · 3:00](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=180)
- "Motility disorder patients may have a negative pressure gradient during defecation, termed dyssynergia, and may benefit from pelvic floor physical therapy or biofeedback." — Kahleb Graham (clinical) [Ep 42 · 3:09](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=189)
- "Sitz marker study is performed by having the patient ingest markers and obtaining an X-ray at day 5." — Kahleb Graham (clinical) [Ep 42 · 3:39](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=219)
- "Sitz marker study is used as a screening test; if markers are scattered throughout the colon or predominantly on the right side, colonic manometry may be indicated." — Kahleb Graham (clinical) [Ep 42 · 3:48](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=228)
- "If all Sitz markers are at the bottom of the colon, it suggests an outlet issue rather than a transit problem." (host_summary) [Ep 42 · 4:07](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=247)
- "If all Sitz markers have disappeared on day-5 X-ray, the patient has stooled, even if they report not having done so; the markers do not dissolve." — Kahleb Graham (clinical) [Ep 42 · 4:13](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=253)
- "Sitz marker study should be available in most settings worldwide." — Marc Levitt (opinion) [Ep 42 · 4:35](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=275)
- "Colonic manometry is not available everywhere in the world." — Marc Levitt (epidemiological) [Ep 42 · 4:45](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=285)
- "Sitz markers can be used as a colonic transit study by obtaining X-rays at days 0, 1, 2, and 4 to visualize marker transit through the colon." — Anil Darbari (clinical) [Ep 42 · 4:51](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=291)
- "Sitz marker study is not a replacement for colonic manometry." — Amanda Jensen (host_summary) [Ep 42 · 5:17](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=317)
- "Nuclear scintigraphy is an alternative to colonic manometry in centers without manometry capability but with nuclear medicine capacity." — Marc Levitt (clinical) [Ep 42 · 5:32](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=332)
- "From a surgeon's perspective, three colonic motility scenarios must be distinguished: (1) diffusely slow but functional, (2) normal motility with a segmental problem, and (3) severely slow throughout." — Marc Levitt (clinical) [Ep 42 · 5:40](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=340)
- "Anorectal manometry is the gold standard for diagnosing motility disorders, but it is expensive and not available everywhere." (host_summary) [Ep 42 · 6:34](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=394)
- "Colonic manometry provides information on peristaltic activity, specifically the motion of the colon." — Anil Darbari (clinical) [Ep 42 · 7:07](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=427)
- "Normal colonic physiology includes two strong contractions per day, called high-amplitude propagating contractions (HAPCs)." — Anil Darbari (clinical) [Ep 42 · 7:21](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=441)
- "HAPCs start in the cecum and progress distally in a coordinated manner." — Anil Darbari (clinical) [Ep 42 · 7:32](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=452)
- "Presence of two HAPCs during an 18- or 24-hour colonic manometry study rules out colonic dysmotility." — Anil Darbari (clinical) [Ep 42 · 7:45](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=465)
- "Many patients undergoing colonic manometry have normal results, meaning they have slow transit but normal HAPCs." — Jason Frischer (clinical) [Ep 42 · 8:02](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=482)
- "If HAPCs are present throughout the colon, antegrade flush therapy is likely to work well." — Marc Levitt (clinical) [Ep 42 · 8:22](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=502)
- "Some patients have a true outlet issue with a normal colon on manometry." — Kahleb Graham (clinical) [Ep 42 · 8:38](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=518)
- "Colonic manometry can characterize whether contractions are well coordinated (neuropathic problem) or low amplitude (myopathic problem)." — Kahleb Graham (clinical) [Ep 42 · 8:47](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=527)
- "Contractions should propagate from the right colon to the rectum; the rectum does not have the same contractions as the colon." — Kahleb Graham (clinical) [Ep 42 · 9:03](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=543)
- "In Hirschsprung patients status post pull-through, the rectosigmoid brake is removed, and contractions may be seen extending from the right colon all the way to the sphincters." — Kahleb Graham (clinical) [Ep 42 · 9:12](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=552)
- "Even if HAPCs are present and colonic motility appears normal, absence of response to stimulants on manometry indicates abnormal colonic motility." — Anil Darbari (clinical) [Ep 42 · 9:36](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=576)
- "In this case, the team concluded the patient did not have Hirschsprung disease; the absent RAIR was a sampling error, and calretinin staining was positive." — Marc Levitt (clinical) [Ep 42 · 10:11](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=611)
- "Anorectal manometry showed the colon was diffusely slow, and the problem was primarily the sphincter." (host_summary) [Ep 42 · 10:26](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=626)
- "The patient was offered a Malone antegrade continence enema (MACE) for antegrade flushes, in combination with Botox and biofeedback physiotherapy." (host_summary) [Ep 42 · 10:38](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=638)
- "Over time, the colon may rehabilitate, and the patient may eventually need only laxatives, but mechanical emptying of the colon is a perfectly acceptable endpoint." — Marc Levitt (opinion) [Ep 42 · 10:50](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=650)
- "Enemas from below or from above (via Malone or cecostomy) are acceptable management; failure of this conservative therapy may then require resection." — Marc Levitt (clinical) [Ep 42 · 11:11](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=671)
- "Patients who fail conservative management are those with slow transit throughout or segmental disease." (host_summary) [Ep 42 · 11:24](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=684)
- "The vast majority of patients with segmental disease respond to antegrade enemas only and do not need resection." — Marc Levitt (clinical) [Ep 42 · 11:32](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=692)
- "Historically, colons were resected in patients who, in retrospect, likely had only motility disorders and did not need surgery." (host_summary) [Ep 42 · 12:03](https://qa.library.globalcastmd.com/watch/the-colorectal-quiz-episode-9-motility-disorders-part-2-3888?t=723)
- "In Toronto, ultra-short gut is classified as less than 20% of expected bowel length for age; in a term baby that corresponds to 20–30 centimeters." — Paul Wales (clinical) [Ep 49 · 1:37](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=97)
- "Overall survival in the ultra-short gut population in the current era of management is over 90%, actually 90–95%." — Paul Wales (epidemiological) [Ep 49 · 1:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=112)
- "Ultra-short gut patients in the current era do not die of liver failure anymore and are rarely transplanted." (host_summary) [Ep 49 · 2:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=123)
- "Ultra-short gut patients who reached enteral autonomy required multiple nutritional supplements but were able to grow within normal parameters." — Paul Wales (clinical) [Ep 49 · 2:07](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=127)
- "Long-term risks of death from liver disease or sepsis in ultra-short gut patients have been transformed in the current era of management." — Paul Wales (clinical) [Ep 49 · 2:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=133)
- "Ultra-short gut patients who did better tended to have some remnant ileum and longer colonic remnants." — Paul Wales (clinical) [Ep 49 · 2:26](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=146)
- "The ileum reclaims bile, tells the liver what to do, and produces hormones like GLP-2, PYY, and others that slow motility and signal the jejunum to reabsorb fluid." — Michael Helmrath (clinical) [Ep 49 · 2:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=175)
- "The colon can account for one-third to one-half of the caloric needs of these babies when exposed to undigested nutrients." — Michael Helmrath (clinical) [Ep 49 · 3:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=195)
- "These children with overwhelming intestinal catastrophe are largely neurologically fine—they are running and playing—and their life expectancy is not associated with lifelong care needs that most parents would not want." — Michael Helmrath (clinical) [Ep 49 · 3:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=204)
- "The child should be the one driving the care, not the surgeon's expectations or lack thereof; without changing that early paradigm, nothing else can improve in this population." — Michael Helmrath (opinion) [Ep 49 · 3:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=228)
- "Bowel removed is bowel never to be used; the fear that delayed surgery drives neurocognitive harm needs to be supported with data." — Michael Helmrath (opinion) [Ep 49 · 4:26](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=266)
- "NEC totalis in NEC patients is fairly rare; most NEC patients do not have overwhelming totalis." — Michael Helmrath (epidemiological) [Ep 49 · 4:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=288)
- "A dozen or more children with NEC totalis at Cincinnati have survived, are off TPN, and have done remarkably well; the comparative group is dead children who have no neurological function." — Michael Helmrath (clinical) [Ep 49 · 4:54](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=294)
- "Once these patients survive the acute phase, the opportunities to rehabilitate the bowel and the new tools that will be developed in the next decade are going to be profound." — Michael Helmrath (opinion) [Ep 49 · 5:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=325)
- "The opportunity given to the child is made at the time the surgeon opens the belly and sees catastrophe; removing all bowel eliminates all future potential based on clinical acumen that the outcome will be bad." — Michael Helmrath (opinion) [Ep 49 · 5:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=334)
- "The first team that must be convinced of this approach is the neonatology team, because historically they are the ones who removed breathing tubes and allowed these babies to pass." — Michael Helmrath (clinical) [Ep 49 · 5:49](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=349)
- "Neonatologists see some of the survivors—ex-premature infants with intestinal failure—return to their follow-up clinics, which informs their perspective." — Paul Wales (clinical) [Ep 49 · 5:59](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=359)
- "Not every child needs to die with a laparotomy decision; the data will tell whether the unoperated septic/inflammatory response leads to negative outcomes." — Paul Wales (opinion) [Ep 49 · 6:10](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=370)
- "Long-term neurocognitive tracking of this population is part of the program's responsibility and is beneficial to patients." — Paul Wales (opinion) [Ep 49 · 6:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=389)
- "If you see protein growth, linear growth, and head growth in the baby, that is brain growth; a baby will not grow well with an unhealthy liver or poor management." — Michael Helmrath (clinical) [Ep 49 · 6:47](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=407)
- "An unhealthy liver does not provide the protein necessary for neurocognitive development; liver health is the number one priority early in management." — Michael Helmrath (clinical) [Ep 49 · 6:59](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=419)
- "Lipid restriction as a way of controlling liver disease was never a practice subscribed to by the speakers." — Paul Wales (opinion) [Ep 49 · 7:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=440)
- "Babies, especially premature babies in the first year of life, have caloric needs of 80–120 kcal/kg because they are growing and developing; when critically ill they are no longer growing and their livers are catabolic, so feeding 150 kcal/kg will not result in growth." — Michael Helmrath (clinical) [Ep 49 · 7:43](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=463)
- "For a 30-week baby with extensive NEC and a long segment of dead bowel, the surgeon knows the baby will need multiple operations, so a transverse incision is used because it causes the least problems over time." — Michael Helmrath (clinical) [Ep 49 · 8:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=501)
- "The surgeon finds a segment of bowel just beyond what is expected to heal (1–2 cm margin) and brings in an 8 or 10 French Blake drain, often from the left lower quadrant if normally rotated, placing it through bowel that is not expected to do well and advancing it retrograde to the pylorus." — Michael Helmrath (clinical) [Ep 49 · 8:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=511)
- "A loose tie is placed around the most healthy part of the bowel around the drain to control secretions, and a purse-string is placed at the insertion site and secured to the skin, essentially stemming the bowel to the abdominal wall; this takes minutes." — Michael Helmrath (clinical) [Ep 49 · 8:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=533)
- "If the stomach is visible, a purse-string is placed in the stomach and a 5–7 French feeding tube is inserted into the proximal bowel and tied, taking one to two minutes; this avoids having to access the left upper quadrant later for a G-tube." — Michael Helmrath (clinical) [Ep 49 · 9:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=569)
- "The surgeon tries to close the abdomen primarily, but if there is concern about dead bowel, Alloderm is placed; if very worried, a drain is placed in the abdomen to allow drainage." — Michael Helmrath (clinical) [Ep 49 · 9:54](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=594)
- "The surgeon tries to avoid significant dissection of the distal ileum to preserve blood supply and allow collateralization to recover as much proximal bowel as possible." — Michael Helmrath (clinical) [Ep 49 · 10:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=608)
- "If the distal diverted bowel is baggy and filled with bloody enteric fluid, and there are distal perforations with patchy necrosis, the surgeon may place stitches distal to proximal to bring the bowel together to preserve muscle, planning to manage it later." — Michael Helmrath (clinical) [Ep 49 · 10:30](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=630)
- "A refeeding tube is placed in the distal bowel to allow refeeding and let the intermediate bowel hang out and heal; this depends on the amount of proximal bowel and whether feeding is feasible." — Michael Helmrath (clinical) [Ep 49 · 10:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=653)
- "In one current case with 40 cm of proximal bowel, refeeding is allowing the surgeon to wait longer for intervening bowel to heal, and the baby's liver is fine, buying time because the fluid output from injured bowel is very high." — Michael Helmrath (clinical) [Ep 49 · 11:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=666)
- "When damaged bowel weeps and secretes fluids, the volume of output is high; as it heals and regenerates the ability to reabsorb fluid, the drain output will decrease, signaling that the bowel is healing." (host_summary) [Ep 49 · 11:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=685)
- "The surgeon's intraoperative decisions—what is done and what is not done—have a lifelong impact and are critically important; these decisions can determine whether the child stays on or gets off TPN or whether they survive." — Paul Wales (opinion) [Ep 49 · 11:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=713)
- "These conversations about approach need to be had with neonatologists and dietitians in the room, not just surgical colleagues, because they must be on board." — Michael Helmrath (opinion) [Ep 49 · 12:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=753)
- "Families are not able to make decisions in these situations; once the family is told that the baby is the one driving decisions moving forward, it makes things easier for them when outcomes are bad." — Michael Helmrath (opinion) [Ep 49 · 12:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=765)
- "Many babies taken to the OR are not as critically sick as believed; once proximal bowel is controlled and everything is decompressed, many will slowly improve." — Michael Helmrath (clinical) [Ep 49 · 13:22](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=802)
- "Traditional teaching is to remove obviously dead and infarcted bowel, leave suspicious or questionable bowel, and return in 24–48 hours to let it demarcate; the approach described is a departure from that teaching." — Paul Wales (clinical) [Ep 49 · 13:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=832)
- "Some of these children look worse over the next 24–36 hours, then start to stabilize—they may not get better, but they stop getting worse." — Paul Wales (clinical) [Ep 49 · 14:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=860)
- "Long-term, if all bowel is removed, many patients will heal but there is no opportunity for rehabilitation; that experiment has been done." — Michael Helmrath (opinion) [Ep 49 · 14:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=871)
- "Blake tubes have linear cuts on the outside so they do not get obstructed when secretions accumulate; they are soft and do not put pressure on damaged bowel; they can be connected to a bulb syringe and cut to size." — Michael Helmrath (clinical) [Ep 49 · 14:47](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=887)
- "The downside of Blake tubes is that they cannot be changed over a wire like JP drains with side holes; the ideal tube would be a Blake with a central hole for wire passage." — Michael Helmrath (opinion) [Ep 49 · 14:59](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=899)
- "Adaptation is defined as developing and strengthening gut function, occurring naturally in infants during in utero development and the first few years of life, or as a regenerative response to damage in older children." — Michael Helmrath (clinical) [Ep 52 · 0:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=55)
- "Adaptation generally takes months and years, not weeks and days, and requires enteral nutrition in all situations." — Michael Helmrath (clinical) [Ep 52 · 1:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=85)
- "In short gut syndrome, residual intestine undergoes adaptation to compensate and reestablish function to absorb enough nutrients and fluids to maintain survival." — Paul Wales (clinical) [Ep 52 · 2:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=122)
- "The adaptive process is driven by the presence of intraluminal nutrients and their interaction with gut secretions (pancreatic, biliary) and trophic gut peptides." — Paul Wales (clinical) [Ep 52 · 2:16](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=136)
- "Structural changes during adaptation include mucosal hypertrophy (increased villous length), increased blood supply through angiogenesis, bowel dilation, and in younger children, gut lengthening—all increasing surface area for nutrient absorption." — Paul Wales (clinical) [Ep 52 · 2:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=162)
- "Functional changes during adaptation include slowed motility to allow more contact time and up-regulation of enterocyte transporters to move nutrients across cells more efficiently." — Paul Wales (clinical) [Ep 52 · 3:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=184)
- "The duodenum senses caloric intake, monitors sugars, receives hepatobiliary secretions, takes up iron, and functions as an endocrine engine recognizing meal initiation." — Michael Helmrath (clinical) [Ep 52 · 3:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=214)
- "The jejunum is largely a source of fluid secretion needed for digestion, with random back-and-forth sloshing motion like a washing machine." — Michael Helmrath (clinical) [Ep 52 · 3:54](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=234)
- "The ileum secretes different hormones including the incretins GLP-2, GLP-1, and PYY, which stop gastric emptying and slow motility when excess liquid is detected in the distal bowel and proximal colon." — Michael Helmrath (clinical) [Ep 52 · 4:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=246)
- "The distal ileum's ability to take up bile sends a signal to the liver, the metabolic engine that helps regulate the whole metabolism of the patient." — Michael Helmrath (clinical) [Ep 52 · 4:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=271)
- "In short gut patients, the colon becomes a source of energy uptake when exposed to free fatty acids, which requires the presence of bacteria." — Michael Helmrath (clinical) [Ep 52 · 4:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=290)
- "Colonic adaptation does not occur in most normal patients because energy is already reclaimed before reaching the colon." — Michael Helmrath (clinical) [Ep 52 · 5:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=301)
- "Adaptation is highly influenced by modifiable factors including formula type, H2 blockers, antibiotics, illness episodes, and motility changes." — Michael Helmrath (clinical) [Ep 52 · 5:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=313)
- "Until very recently, there was no standardized definition for enteral autonomy, and most intestinal failure outcomes have poor definitions." — Paul Wales (clinical) [Ep 52 · 5:35](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=335)
- "The current ASPEN guidelines define enteral autonomy as independence from parenteral support for 12 weeks with maintenance of adequate growth and hydration during that time period." — Paul Wales (guideline) [Ep 52 · 6:39](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=399)
- "A patient is not truly off TPN unless they can actually grow off TPN; stopping TPN without achieving growth is a mistake." — Paul Wales (clinical) [Ep 52 · 6:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=413)
- "Healthy growth is the underlying driver of successful TPN weaning, not time off TPN." — Michael Helmrath (clinical) [Ep 52 · 7:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=426)
- "The last thing a patient needs to come off TPN is fluid; without adequate hydration, the baby will not grow and will not efficiently absorb nutrition, losing energy and decreasing their growth trajectory." — Michael Helmrath (clinical) [Ep 52 · 7:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=433)
- "In the 2012 Squires/PIFCO paper, 50% of patients achieved enteral autonomy over 5-6 years, 25% died, and 25% received transplants." — Paul Wales (epidemiological) [Ep 52 · 7:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=477)
- "Recent papers from the last 5-6 years show that 60-80% of patients now achieve enteral autonomy, representing improved outcomes compared to historical data." — Paul Wales (epidemiological) [Ep 52 · 8:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=505)
- "Higher proportions of patients are now surviving to have the ability to reach enteral autonomy due to better management of TPN complications such as line infections, liver disease, and vascular thrombosis." — Paul Wales (clinical) [Ep 52 · 6:10](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=370)
- "In the past, patients were lost to complications such as liver disease before they could reach their adaptive potential; current management is much better at preventing these complications." — Paul Wales (clinical) [Ep 52 · 6:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=380)
- "Small bowel length is an independently significant variable predicting adaptive capacity, which is intuitive since the majority of nutrient digestion and fluid absorption occurs in the small bowel." — Paul Wales (clinical) [Ep 52 · 9:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=595)
- "The ileum has a much greater capacity to adapt than the jejunum; patients with predominant ileal anatomy do better than those with predominant jejunal anatomy." — Paul Wales (clinical) [Ep 52 · 10:18](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=618)
- "A full-term baby is born with approximately 160 centimeters of small bowel, which grows to about 425 centimeters by age 5 years, with the steepest growth rate between 35 weeks gestation and 6 months postnatal." — Paul Wales (clinical) [Ep 52 · 10:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=634)
- "The presence or absence of the ileocecal valve is a predictor of adaptation, though the valve itself may not be the important factor; rather, loss of the valve typically accompanies loss of the terminal ileum, which is the bigger factor affecting adaptive potential." — Paul Wales (opinion) [Ep 52 · 11:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=673)
- "When a patient has the majority of their small bowel, it almost does not matter how much colon they have—probability of enteral autonomy is 85-100%." — Paul Wales (clinical) [Ep 52 · 11:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=713)
- "When small bowel remnant is less than 50% of expected length, the colon becomes vitally important, assuming an increasing role in energy absorption from short-chain fatty acids and fluid/salt absorption." — Paul Wales (clinical) [Ep 52 · 12:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=726)
- "Lab data from Cincinnati shows a shift in microbiota to more acid-producing bacteria in an acidotic state, with increased bile due to lack of reclamation." — Michael Helmrath (clinical) [Ep 52 · 12:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=760)
- "Bacterial colonization differences from normal are part of the adaptive response and should not automatically be considered pathological; they need to be studied and taken into context." — Michael Helmrath (opinion) [Ep 52 · 13:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=786)
- "NEC is an acquired condition; infants are born, start eating (often reaching near-full feeds), then have an incident usually at 2-3 weeks of life, meaning they have not been using their gut during the critical 35-week-to-6-months adaptive window." — Michael Helmrath (clinical) [Ep 52 · 13:26](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=806)
- "Whether a child has been fed before makes them different from one who has never been fed, affecting their adaptive potential." — Michael Helmrath (clinical) [Ep 52 · 13:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=825)
- "Surgical planning for short gut patients is like a game of chess requiring consideration of the second, third, and fourth steps ahead." — Michael Helmrath (opinion) [Ep 52 · 13:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=838)
- "The sooner a child can be fed safely and bowel access achieved without exposing them to surgical risk, the more the adaptive process can be leveraged." — Michael Helmrath (clinical) [Ep 52 · 14:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=849)
- "Cincinnati strategies were developed to take advantage of the easiest, safest way to use the bowel early without needing to return immediately to surgery." — Michael Helmrath (clinical) [Ep 52 · 14:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=863)
- "Surgery puts children in harm's way regardless of surgeon talent, so balancing surgical intervention with optimization of adaptation has led to improved outcomes." — Michael Helmrath (opinion) [Ep 52 · 14:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=888)
- "Nutritional choices including elemental versus semi-elemental versus intact macronutrient diet selection are guided by residual anatomy and functional status" — Wales (clinical) [Ep 53 · 1:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=69)
- "Inadequate caloric support results in poor growth, impaired healing, and diminished adaptive response" — Wales (clinical) [Ep 53 · 1:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=98)
- "Implementation of a feeding protocol is associated with achieving full enteral autonomy in a shorter time period, based on literature from Chris Duggan's group at Boston" — Rod (host_summary) [Ep 53 · 1:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=115)
- "Bowel heals with adhesions which bring blood supply to the bowel and help it heal" — Helmuth (clinical) [Ep 53 · 2:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=165)
- "Placing a tube beyond the pylorus at time of surgery while allowing NG decompression of the stomach, later changed to gastrostomy tube, has been beneficial at Cincinnati Children's" — Helmuth (clinical) [Ep 53 · 3:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=185)
- "Refeeding through a tube is done best and allows standardized nursing feeding practices" — Helmuth (opinion) [Ep 53 · 3:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=201)
- "High ostomy outputs without feeding are an indication to feed, as long as the child can be hydrated, though this presents a clinical challenge" — Helmuth (clinical) [Ep 53 · 3:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=236)
- "After massive bowel resection, patients can be hypergastrinemic with elevated acid secretion for 6 to 12 months due to loss of distal bowel and hormonal feedback" — Wales (clinical) [Ep 53 · 4:35](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=275)
- "Acid blockade (H2 blocker or PPI) can decrease gastric volume in the short term" — Wales (clinical) [Ep 53 · 4:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=297)
- "Acid blockade carries risk of bacterial overgrowth by losing the acid barrier" — Wales (clinical) [Ep 53 · 5:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=311)
- "Prokinetic therapy options include intravenous agents (metoclopramide, erythromycin) or enteral agents (domperidone, cisapride) to improve gastric emptying and motility" — Wales (clinical) [Ep 53 · 5:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=320)
- "Increased secretions result from thick, leaky mucosa which requires delivery of luminal nutrients to heal" — Wales (clinical) [Ep 53 · 5:59](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=359)
- "Serum bicarbonate above 20 indicates feeding is generally safe even with high ostomy outputs (40-60 cc/kg), and acetate can be added to TPN for hydration support" — Helmuth (clinical) [Ep 53 · 6:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=377)
- "Enteral antibiotics are often cycled for bacterial overgrowth treatment in an empiric and ad hoc manner" — Wales (clinical) [Ep 53 · 6:49](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=409)
- "Anti-secretory or anti-diarrheal medications to decrease losses include octreotide, clonidine, and loperamide" — Wales (clinical) [Ep 53 · 6:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=417)
- "Antibiotic treatment should have defined endpoints and duration rather than empiric two-week courses when the child is not showing clinical signs of illness" — Helmuth (opinion) [Ep 53 · 7:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=458)
- "Surgical procedures to promote adaptation fall into three categories: restoring continuity, affecting motility, and lengthening the bowel" — Wales (clinical) [Ep 53 · 7:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=478)
- "Closing a stoma immediately recruits more bowel" — Wales (clinical) [Ep 53 · 7:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=478)
- "As bowel becomes increasingly dilated, its motility becomes impaired" — Wales (clinical) [Ep 53 · 8:36](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=516)
- "Dilated bowel with impaired motility leads to stool stasis, mucosal inflammation, barrier damage allowing bacterial translocation, potential sepsis, and malabsorption" — Rod (host_summary) [Ep 53 · 8:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=521)
- "Restoring bowel caliber to normal improves motility, clearance, decreases bacterial overgrowth, allows mucosal healing, and improves absorption" — Wales (clinical) [Ep 53 · 9:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=541)
- "Bowel tapering can be performed on the anti-mesenteric side or the dilated segment can be resected if the patient has adequate length" — Wales (clinical) [Ep 53 · 9:14](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=554)
- "Bowel lengthening procedures include the Bianchi procedure (longitudinal intestinal lengthening, available since 1980) and the serial transverse enteroplasty (STEP)" — Wales (clinical) [Ep 53 · 9:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=573)
- "The most important factor for efficacy of both Bianchi and STEP procedures is that they taper the bowel" — Wales (clinical) [Ep 53 · 9:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=585)
- "STEP differs from anti-mesenteric tapering or resection by preserving all available mucosa without removing any" — Wales (clinical) [Ep 53 · 9:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=591)
- "In patients who are shorter with dilated bowel segments where resection is undesirable, STEP or Bianchi become options to preserve all mucosa while addressing dilatation" — Wales (clinical) [Ep 53 · 10:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=601)
- "Bowel lengthening procedures redistribute rather than increase surface area; ongoing dilatation and bowel growth in infants and young children eventually result in more surface area through downstream adaptive responses" — Wales (clinical) [Ep 53 · 10:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=638)
- "It takes approximately 6 months to see changes in absorption after bowel lengthening procedures, as demonstrated in published absorption studies measuring fecal fat, alpha-1 antitrypsin clearance, xylose, and citrulline" — Wales (clinical) [Ep 53 · 11:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=665)
- "An upper GI study can rule in a problem but does not rule out a problem; a normal upper GI does not exclude an anatomical problem" — Helmuth (clinical) [Ep 53 · 11:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=694)
- "The new ASPEN guidelines define enteral autonomy as independence from parenteral support for 12 weeks" — Ellen (host_summary) [Ep 53 · 12:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=725)
- "Despite six decades of research, the exact cause of necrotizing enterocolitis remains unknown and there is no absolute cure." — Gail Besner (clinical) [Ep 55 · 1:53](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=113)
- "Indomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis." — Gail Besner (clinical) [Ep 55 · 3:21](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=201)
- "Acid suppression medications (PPIs, H2 blockers) should be avoided in at-risk neonates because neutralizing gastric acid may increase NEC risk." — Gail Besner (clinical) [Ep 55 · 4:46](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=286)
- "In premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration." — Gail Besner (clinical) [Ep 55 · 5:24](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=324)
- "Neutropenia (low white blood cell count) in a baby with suspected NEC is more concerning than leukocytosis because it may indicate overwhelming sepsis that the baby cannot compensate for." — Gail Besner (clinical) [Ep 55 · 7:14](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=434)
- "Thrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and platelet count is important to know before surgery to optimize the patient's condition." — Gail Besner (clinical) [Ep 55 · 7:14](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=434)
- "Cross-table lateral or lateral decubitus films are essential in addition to plain films because free air can be quite subtle and easily missed." — Gail Besner (clinical) [Ep 55 · 8:48](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=528)
- "Free air on imaging is an absolute indication for surgical intervention (either drain or laparotomy) in NEC." — Gail Besner (clinical) [Ep 55 · 9:24](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=564)
- "Fixed loops of intestine on serial x-rays are not an absolute indication for surgery but are a concerning sign that the patient is not improving." — Gail Besner (opinion) [Ep 55 · 9:50](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=590)
- "Portal venous air is a worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management." — Gail Besner (clinical) [Ep 55 · 10:25](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=625)
- "Medical management of NEC includes withholding feeds, orogastric tube decompression, broad-spectrum antibiotics, and serial monitoring (exams, labs, x-rays)." — Gail Besner (guideline) [Ep 55 · 11:01](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=661)
- "Small French feeding tubes are inadequate for gastric decompression in NEC; they should be replaced with larger orogastric tubes." — Gail Besner (clinical) [Ep 55 · 11:46](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=706)
- "There is likely tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization patterns in individual ICU environments." — Gail Besner (opinion) [Ep 55 · 12:35](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=755)
- "Abdominal x-rays should be obtained at regular intervals (approximately every 8 hours) during medical NEC management, not waiting 12-24 hours between films." — Gail Besner (opinion) [Ep 55 · 13:39](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=819)
- "Babies should remain NPO for at least 7-10 days (preferably a week and a half) after medical NEC treatment before attempting to restart feeds." — Gail Besner (opinion) [Ep 55 · 14:16](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=856)
- "Stricture formation after medical NEC typically occurs in the colon, usually near the splenic flexure, but can occur anywhere." — Gail Besner (clinical) [Ep 55 · 14:45](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=885)
- "When evaluating for post-NEC stricture, contrast enema should be performed before upper GI with small bowel follow-through because strictures are more common in the colon and waiting for contrast to pass through obstructed small bowel is time-consuming." — Gail Besner (clinical) [Ep 55 · 15:18](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=918)
- "Serial abdominal examinations over time are more valuable than a single examination for determining need for surgery in NEC without absolute indications." — Gail Besner (opinion) [Ep 55 · 16:22](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=982)
- "The MOSS and PIERO randomized controlled trials showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC." — Gail Besner (epidemiological) [Ep 55 · 19:42](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1182)
- "Babies who receive peritoneal drains instead of laparotomy may have worse neurological outcomes at 1-2 years post-NEC, though early mortality is similar." — Gail Besner (epidemiological) [Ep 55 · 20:20](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1220)
- "The NEST trial randomized 300 babies to peritoneal drainage versus laparotomy and will assess neurological outcomes at 18-22 months, with results expected in 1-2 years (from 2017)." — Gail Besner (epidemiological) [Ep 55 · 21:00](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1260)
- "At a recent NEC conference in London, 100% of European surgeons reported performing laparotomy for NEC; none use peritoneal drainage." — Gail Besner (epidemiological) [Ep 55 · 19:29](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1169)
- "Spontaneous intestinal perforation (SIP) can cause hemodynamic instability similar to NEC through systemic inflammatory response syndrome, making clinical differentiation difficult." — Gail Besner (clinical) [Ep 55 · 24:07](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1447)
- "Peritoneal drain placement can be performed at bedside with local anesthesia through a small right lower quadrant transverse incision using a quarter-inch Penrose drain." — Gail Besner (clinical) [Ep 55 · 26:17](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1577)
- "Making the drain incision too large can lead to hernia formation after drain removal." — Gail Besner (clinical) [Ep 55 · 27:00](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1620)
- "Some babies with peritoneal drains continue to produce stool from the drain for weeks, and if this persists for approximately two weeks, conversion to laparotomy should be considered." — Todd Ponsky (clinical) [Ep 55 · 28:14](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1694)
- "When operating on a baby with extensive adhesions after drain placement, surgeons should know when to stop if causing multiple serosal tears and enterotomies, as continuing may worsen the outcome." — Gail Besner (opinion) [Ep 55 · 28:38](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1718)
- "Creating a proximal diverting stoma is helpful when extensive adhesions prevent safe complete exploration, as it controls the perforation and diverts the fecal stream." — Gail Besner (clinical) [Ep 55 · 29:20](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1760)
- "Peritoneal drains should be advanced out gradually over several days starting at 7-10 days post-placement, rather than removing all at once." — Gail Besner (opinion) [Ep 55 · 29:50](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1790)
- "For laparotomy in NEC, a supraumbilical transverse incision is used, with extreme care required to avoid liver and spleen injury in premature infants." — Gail Besner (clinical) [Ep 55 · 31:18](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1878)
- "Even minimal trauma to the liver in premature babies can cause subcapsular hematomas that can lead to exsanguination." — Gail Besner (clinical) [Ep 55 · 32:00](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1920)
- "NEC is differentiated from SIP intraoperatively: SIP presents as one small localized perforation, while NEC shows more diffuse disease with pneumatosis involving more than one area." — Gail Besner (clinical) [Ep 55 · 33:10](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1990)
- "Some surgeons internationally perform primary anastomosis after NEC resection, but many US surgeons create stomas due to concern about anastomotic healing in critically ill premature infants." — Gail Besner (clinical) [Ep 55 · 34:00](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2040)
- "Bringing stoma and mucous fistula out close together through the main incision allows for more limited reoperation at stoma closure compared to separate sites." — Gail Besner (clinical) [Ep 55 · 35:03](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2103)
- "Stomas should be tacked to fascia (not matured) and a small distal end should protrude to prevent recession under the fascia, though sloughing of the distal end can still occur." — Gail Besner (clinical) [Ep 55 · 35:45](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2145)
- "When bowel appears injured but not clearly necrotic (thin-walled, brownish, with pneumatosis but diffusely similar), it may be appropriate to not resect, leave the abdomen open to reduce pressure, and return for second-look operation in 24-48 hours." — Gail Besner (opinion) [Ep 55 · 37:13](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2233)
- "For multiple skip lesions in NEC, if they are close together and can be resected without creating short bowel syndrome, resecting all may be preferable to multiple anastomoses." — Gail Besner (opinion) [Ep 55 · 38:06](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2286)
- "Multiple anastomoses can be performed with proximal diversion so that if one anastomosis fails to heal, it is distal to the diversion and less problematic." — Gail Besner (clinical) [Ep 55 · 38:30](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2310)
- "Clip-and-drop technique (resecting dead bowel, clipping ends, replacing in abdomen for later definitive surgery) can be lifesaving in very unstable patients when time does not permit multiple anastomoses." — Gail Besner (clinical) [Ep 55 · 38:48](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2328)
- "Stoma reversal is typically performed when the baby reaches approximately 2000 grams, though earlier reversal is indicated for TPN-induced cholestasis or inability to nourish due to high stoma output." — Gail Besner (opinion) [Ep 55 · 39:28](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2368)
- "Refeeding through mucous fistula is done selectively (not routinely), primarily for very high-output stomas where most nutrition is lost through the stoma." — Gail Besner (opinion) [Ep 55 · 40:41](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2441)
- "A recent Journal of Pediatric Surgery article showed substantial decrease in TPN use with mucous fistula refeeding." — Todd Ponsky (host_summary) [Ep 55 · 41:06](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2466)
- "Mucous fistulas often stricture, preventing refeeding access; leaving a small soft catheter in the mucous fistula post-operatively can maintain access for refeeding." — Gail Besner (clinical) [Ep 55 · 41:23](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2483)
- "The chance of a premature baby with NEC totalis surviving long enough to receive small bowel-liver transplant is very close to zero." — Gail Besner (clinical) [Ep 55 · 42:06](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2526)
- "Babies with NEC totalis who survive on TPN for months to years will develop irreversible liver injury, and even if they reach transplant size, small bowel transplant outcomes remain suboptimal." — Gail Besner (clinical) [Ep 55 · 43:39](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2619)
- "Pneumothorax can dissect through the diaphragm into the abdomen in premature babies with severe lung disease, mimicking intra-abdominal free air; this must be ruled out before attributing pneumoperitoneum to bowel perforation." — Gail Besner (clinical) [Ep 55 · 44:22](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2662)
- "In a hemodynamically unstable baby with pneumoperitoneum, inserting an angiocatheter through the abdominal wall to release pressure is a useful temporizing measure while mobilizing the OR." — Gail Besner (clinical) [Ep 55 · 45:00](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2700)
- "The NEST trial results published in fall 2021 showed no overall difference in death or neurodevelopmental impairment between laparotomy and drainage groups." — Rod Gerardo (host_summary) [Ep 55 · 46:18](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2778)
- "In the NEST trial, neonates with a preoperative diagnosis of necrotizing enterocolitis (versus isolated intestinal perforation) had approximately 20% decrease in death rate with laparotomy compared to drainage." — Rod Gerardo (host_summary) [Ep 55 · 47:00](https://qa.library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2820)
- "Microaggressions are verbal, nonverbal, environmental slights, snubs, invalidations, or insults that send hostile, derogatory, or negative messages to individuals based solely on their marginalized group membership" — Craig Lillehei (clinical) [Ep 60 · 3:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=210)
- "Microaggressions have a cumulative impact causing isolation and self-doubt despite being termed 'micro'" — Craig Lillehei (clinical) [Ep 60 · 4:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=240)
- "Bystanders who do not speak up compound the harm of microaggressions even if they address the issue later" — Craig Lillehei (opinion) [Ep 60 · 4:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=270)
- "In the TOTAL trial for severe CDH, FETO significantly improved survival" — Craig Lillehei (host_summary) [Ep 60 · 10:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=600)
- "In the TOTAL trial for moderate CDH, FETO showed some improvement in survival but did not approach statistical significance" — Craig Lillehei (host_summary) [Ep 60 · 10:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=630)
- "The TOTAL trial was conducted over an 11-year period at multiple centers with variable CDH management protocols" — Craig Lillehei (host_summary) [Ep 60 · 11:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=660)
- "Prematurity and premature rupture of membranes are significant complications of FETO" — Craig Lillehei (clinical) [Ep 60 · 11:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=690)
- "NPO guidelines for children are based on very poor evidence and vary considerably between institutions" (clinical) [Ep 60 · 15:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=900)
- "Pulmonary aspiration is very scary but very rare, usually occurring in emergency surgeries in high-risk children rather than elective procedures" (clinical) [Ep 60 · 15:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=930)
- "Studies suggest clear liquids containing carbohydrates empty the stomach very quickly regardless of age" (host_summary) [Ep 60 · 16:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=960)
- "British and Irish consensus recommends one hour NPO for clear liquids, four hours for breast milk, six hours for solid foods in children under 17" (host_summary) [Ep 60 · 16:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=990)
- "ASA currently recommends two hours for clear liquids, four hours for breast milk, six hours for non-human milk and light meals, eight hours for heavy meals" (host_summary) [Ep 60 · 17:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1020)
- "European Society of Anesthesia recommends one hour for clear liquids, three hours for breast milk, four hours for formula, six hours for everything else" (host_summary) [Ep 60 · 17:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1050)
- "Prolonged NPO periods generate ketone bodies, cause hypoglycemia, and make children irritable preoperatively" (clinical) [Ep 60 · 18:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1080)
- "In C-arm fluoroscopy, the x-ray source is conventionally placed below the table with the image intensifier above" (clinical) [Ep 60 · 25:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1500)
- "Placing radiation shields on top of the patient does nothing to protect them because radiation comes from below the table" (clinical) [Ep 60 · 25:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1530)
- "If a shield is in the fluoroscopy field, automatic brightness control increases x-ray energy to compensate, increasing patient exposure" (clinical) [Ep 60 · 26:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1560)
- "Collimation focuses the x-ray beam to a specific area, increasing detail and clarity while decreasing total patient dose and room exposure" (clinical) [Ep 60 · 27:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1620)
- "Pulse mode fluoroscopy is feasible for most pediatric surgery applications and does not require the temporal resolution of continuous fluoroscopy" (clinical) [Ep 60 · 28:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1680)
- "Using magnification setting on fluoroscopy significantly increases radiation dose to both patient and room" (clinical) [Ep 60 · 28:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=1710)
- "In a study of 521 primary lung lesions from 11 children's hospitals, none of the prenatally diagnosed lesions were malignant" (host_summary) [Ep 60 · 40:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2400)
- "Approximately 10% of postnatally diagnosed lung lesions were malignant in the Midwest consortium study" (host_summary) [Ep 60 · 40:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2430)
- "About half of malignant lung lesions were associated with DICER1 mutation" (host_summary) [Ep 60 · 41:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2460)
- "No malignant lung lesion had a systemic feeding vessel in the consortium study" (host_summary) [Ep 60 · 41:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2490)
- "CT scan sensitivity and specificity for detecting pleuropulmonary blastoma was poor, with poor inter-rater reliability among nine radiologists" (host_summary) [Ep 60 · 42:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2520)
- "In a series of approximately 600 patients with prenatal lung lesion diagnosis, the chance of pleuropulmonary blastoma is close to zero" (host_summary) [Ep 60 · 44:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2640)
- "In the IMPACT study, piperacillin-tazobactam had significantly lower postoperative abscess rate, ER visit rate, and postoperative CT scan rate compared to ceftriaxone-metronidazole for perforated appendicitis" (host_summary) [Ep 60 · 48:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2880)
- "A NSQIP study by Sean Rangel of 654 patients showed opposite results, suggesting ceftriaxone-metronidazole were preferred over piperacillin-tazobactam" (host_summary) [Ep 60 · 48:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2910)
- "The IMPACT study was multi-institutional but 75% of patients were at one institution and 25% at another" (host_summary) [Ep 60 · 49:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=2940)
- "Mechanical bowel preparation has no effect on surgical site infection rates" — Paul Yzotrak (host_summary) [Ep 60 · 51:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3060)
- "Some data suggests mechanical bowel preparation actually increases surgical site infections" — Paul Yzotrak (host_summary) [Ep 60 · 51:30](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3090)
- "The strongest data for preventing surgical site infection is appropriate timing of preoperative intravenous antibiotics" — Paul Yzotrak (clinical) [Ep 60 · 52:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3120)
- "The NEST trial showed neurodevelopmental outcomes are improved with laparotomy compared to peritoneal drainage for NEC" — Paul Yzotrak (host_summary) [Ep 60 · 55:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3300)
- "The NEST trial used approximately one kilogram as the cutoff weight for laparotomy" — Paul Yzotrak (host_summary) [Ep 60 · 54:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3240)
- "For NEC survival in the first 24-48 hours, it is unclear whether there is a survival advantage or disadvantage for drain versus laparotomy" (opinion) [Ep 60 · 58:00](https://qa.library.globalcastmd.com/watch/update-course-2022-apsa-pdc-updates-mary-edwards-paul-jeziorczak-craig-lillehei-and-charles-snyder-5820?t=3480)
- "The PCPLC multi-institutional registry includes a number of institutions throughout the United States." — Em Gootee (host_summary) [Ep 86 · 1:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=116)
- "The study included 679 patients diagnosed with Hirschsprung's disease." — Colin Martin (clinical) [Ep 86 · 2:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=176)
- "85% of Hirschsprung patients were diagnosed at less than 1 year of age." — Em Gootee (host_summary) [Ep 86 · 3:20](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=200)
- "Kids with shorter segment disease (rectosigmoid or very small portion of aganglionic bowel) were more likely to be diagnosed at a later age." — Em Gootee (host_summary) [Ep 86 · 3:45](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=225)
- "Children with long segment Hirschsprung disease typically present at birth with classic symptoms such as failure to pass meconium." — Em Gootee (host_summary) [Ep 86 · 3:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=237)
- "Delayed diagnosis of Hirschsprung's disease does not impact postoperative outcomes nor the need for revision surgery of the pull-through, but is associated with increased need for fecal diversion after pull through." — Colin Martin (clinical) [Ep 86 · 4:12](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=252)
- "Approximately one-third of neonates and 50% of infants, toddlers, and children had diverting ostomies performed prior to pull-through." — Em Gootee (host_summary) [Ep 86 · 4:26](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=266)
- "There was no difference in overall rates of redo pull-throughs across age groups." — Em Gootee (host_summary) [Ep 86 · 5:01](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=301)
- "Older children were more likely to need a redo pull-through due to an anastomotic leak." — Em Gootee (host_summary) [Ep 86 · 5:07](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=307)
- "Higher rates of diverting ostomy post pull-through were suspected to be a treatment for post pull-through leak or anastomotic leak." — Em Gootee (host_summary) [Ep 86 · 5:13](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=313)
- "The only outcome difference seen was nighttime soiling or incontinence in the older patient population." — Em Gootee (host_summary) [Ep 86 · 5:24](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=324)
- "The systematic review on gastroschisis included 28 high quality manuscripts." — Em Gootee (host_summary) [Ep 86 · 8:09](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=489)
- "Two randomized controlled trials on gastroschisis had been started but both ended prematurely and were underpowered." — Em Gootee (host_summary) [Ep 86 · 8:15](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=495)
- "There is significant practice variation regarding the optimal timing of delivery for infants with gastroschisis." — Mark Slidell (clinical) [Ep 86 · 9:22](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=562)
- "Currently there's no evidence to suggest that earlier delivery prior to 37 weeks is justified for gastroschisis." — Casey Culkins (clinical) [Ep 86 · 9:39](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=579)
- "Planned delivery before 37 weeks gestational age for gastroschisis is probably not beneficial and may in fact be harmful." — Mark Slidell (clinical) [Ep 86 · 9:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=596)
- "Early delivery of gastroschisis may promote complications of prematurity." — Mark Slidell (clinical) [Ep 86 · 10:04](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=604)
- "Delivery of infants with gastroschisis after 37 weeks post-conception seems to be preferable." — Mark Slidell (clinical) [Ep 86 · 10:04](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=604)
- "Clinical practice suggests that skin organisms are most commonly identified in infections among infants with gastroschisis." — Em Gootee (host_summary) [Ep 86 · 10:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=637)
- "Gastroschisis infants have a fairly high rate of wound infection." — Em Gootee (host_summary) [Ep 86 · 10:44](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=644)
- "Silo closures have a higher rate of infection than other closure methods for gastroschisis." — Em Gootee (host_summary) [Ep 86 · 10:50](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=650)
- "Sutureless closure has the lowest rate of infection for gastroschisis." — Em Gootee (host_summary) [Ep 86 · 10:50](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=650)
- "The recommendation for gastroschisis is to provide antibiotic coverage for skin flora until the defect is closed and potentially for an additional 24 hours thereafter if the infant is clinically stable." — Em Gootee (host_summary) [Ep 86 · 10:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=657)
- "Once the gastroschisis defect is closed, antibiotics can be safely stopped unless there's some other reason to continue." — Casey Culkins (guideline) [Ep 86 · 11:11](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=671)
- "Stable gastroschisis infants with sufficient abdominal capacity for sutureless closure tend to have the best outcomes." — Em Gootee (host_summary) [Ep 86 · 12:22](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=742)
- "Minimizing fluids and paralytics in gastroschisis infants improves their results." — Em Gootee (host_summary) [Ep 86 · 12:29](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=749)
- "Gastroschisis patients with sutureless closure have shorter length of stay and achieve feeding sooner." — Em Gootee (host_summary) [Ep 86 · 12:35](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=755)
- "Sutureless repair for gastroschisis is safe and effective and associated with a clear decrease in the need for mechanical ventilation." — Casey Culkins (clinical) [Ep 86 · 13:05](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=785)
- "The literature on gastroschisis suffers from a lack of level 1 randomized controlled trials or high level comparative studies." — Mark Slidell (opinion) [Ep 86 · 13:17](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=797)
- "There was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system." — Whit Holcomb (clinical) [Ep 86 · 14:30](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=870)
- "The Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population." — Whit Holcomb (clinical) [Ep 86 · 14:30](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=870)
- "The benefits of the Clavien-Dindo classification reported from adult surgical literature were not transferrable into pediatric surgery." — Omid Madadi-Sanjani (clinical) [Ep 86 · 14:43](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=883)
- "The Clavien-Madadi classification scale consists of several grades from 1 to 5 based on the type of therapy needed to correct the complication." — Em Gootee (host_summary) [Ep 86 · 15:11](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=911)
- "The validation process circulated up to 20 case scenarios of unexpected events within the ERNICA Network (European Reference Network for inherited and congenital anomalies)." — Em Gootee (host_summary) [Ep 86 · 15:46](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=946)
- "An unexpected event includes any event with a subsequent deviation from the planned pre-intra and post-operative course of children." — Omid Madadi-Sanjani (clinical) [Ep 86 · 16:01](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=961)
- "59 surgeons from 12 European countries completed the Clavien-Madadi validation questionnaire." — Em Gootee (host_summary) [Ep 86 · 16:34](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=994)
- "The Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification." — Whit Holcomb (clinical) [Ep 86 · 16:39](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=999)
- "The Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification." — Whit Holcomb (clinical) [Ep 86 · 16:53](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=1013)
- "43% of pediatric surgeons preferred the Clavien-Madadi classification compared to 12% for the Clavien-Dindo classification." — Em Gootee (host_summary) [Ep 86 · 17:04](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=1024)
- "Nearly 82% of surgeons affirmed advantages of the Clavien-Madadi classification." — Em Gootee (host_summary) [Ep 86 · 17:04](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-3rd-quarter-2024-9308?t=1024)
- "Felipe Glu is a colorectal research fellow at Children's National Hospital" — Felipe Glu (clinical) [Ep 88 · 0:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=11)
- "Chris Geyer runs a colorectal program at Children's Hospital Los Angeles" (clinical) [Ep 88 · 0:41](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=41)
- "Hirschsprung's disease is a very anatomically fixable problem and with a good operation you should get a good result" (clinical) [Ep 88 · 1:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=98)
- "About one-third of Hirschsprung patients are constipated and need to be proactively and aggressively managed to avoid trouble" (epidemiological) [Ep 88 · 1:47](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=107)
- "Surgeons might leave behind the dilated segment right above the aganglionic segment as an anatomic reason for decompensation" (clinical) [Ep 88 · 2:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=131)
- "The most relevant reason for decompensation is that the patient never figured out how to successfully empty their sphincters and the pull-through decompensates" (clinical) [Ep 88 · 2:22](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=142)
- "Normal calretinin staining is expected because calretinin hangs out with ganglion cells" (clinical) [Ep 88 · 3:14](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=194)
- "In younger children age less than 3 or so, hypertrophic nerves are defined as greater than 40 microns in diameter" (clinical) [Ep 88 · 3:47](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=227)
- "The definition of hypertrophic nerve is more gray in older patients and in patients who have chronic constipation issues" (clinical) [Ep 88 · 4:01](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=241)
- "If there are no ganglion cells and no calretinin staining, that is a retained Hirschsprung's and that patient needs a redo to a higher level" (clinical) [Ep 88 · 4:27](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=267)
- "If there are good ganglion cells with abundant ganglion cells and normal calretinin, the nerve hypertrophy could represent transition zone or could represent that the bowel has decompensated over time because it hasn't emptied and gotten dilated" (clinical) [Ep 88 · 4:38](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=278)
- "An absent rectal anal inhibitory reflex means that the internal anal sphincter doesn't relax when the rectum is distended, which can contribute to constipation" — Felipe Glu (host_summary) [Ep 88 · 6:35](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=395)
- "The anorectal manometry is expected to be abnormal in Hirschsprung patients and many patients are going to have an abnormal amen but they're OK" (clinical) [Ep 88 · 6:46](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=406)
- "One of the things done with Botox is to try to get patients to learn to overcome non-relaxing sphincters by other maneuvers like pushing on their abdominal wall" (clinical) [Ep 88 · 6:56](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=416)
- "There are many patients that are completely asymptomatic doing great with Hirschsprung's that have residual absent RAIR" (clinical) [Ep 88 · 7:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=431)
- "In Hirschsprung patients with sphincter problems, the colon is not the problem; the problem usually is the sphincters or the pelvic floor" (clinical) [Ep 88 · 7:39](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=459)
- "If you get an awake anorectal manometry in a cooperative patient and you get a normal RAIR and can detect the resting pressure, the kid goes home with no anesthesia and no procedure" (clinical) [Ep 88 · 8:14](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=494)
- "If the RAIR is absent, you're obligated to do a biopsy and give Botox" (clinical) [Ep 88 · 8:29](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=509)
- "Botox is given if the resting pressure of the external sphincter is also high" (clinical) [Ep 88 · 8:36](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=516)
- "Pelvic floor dysynergia can be detected on anorectal manometry and is a good indication that pelvic floor physical therapy is going to help that patient" (clinical) [Ep 88 · 8:41](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=521)
- "HAPCs (high amplitude propagating contractions) aid in the transfer of colonic contents over long distance and often precede emptying" — Felipe Glu (host_summary) [Ep 88 · 11:17](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=677)
- "Colonic manometry should not be done in Hirschsprung patients who have obstructive symptoms because it's not the colon but the distal pull-through that's the problem" (clinical) [Ep 88 · 9:55](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=595)
- "You must rule out anatomic and pathologic causes before any colonic manometry is considered" (clinical) [Ep 88 · 10:11](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=611)
- "You must get rid of the distal obstruction, which is why colonic manometry in a patient with distal obstruction is the wrong test" (clinical) [Ep 88 · 10:18](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=618)
- "Once distal obstruction is ruled out or fixed and the colon is still not working, then you have a problem and that would be a case for colonic manometry" (clinical) [Ep 88 · 10:31](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=631)
- "The rule of thumb is if there's a segment less than 30 centimeters of inadequate HAPCs, they are not super aggressive about it; over 30 centimeters is definitely more of a red flag" (clinical) [Ep 88 · 11:01](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=661)
- "In a PCPLC Consortium study of close to 100 patients with functional constipation and segmental dysmotility of the sigmoid, 97% successfully responded to Malone only and never needed a resection" (epidemiological) [Ep 88 · 11:54](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=714)
- "Five years ago, surgeons were taking sigmoids out of patients with segmental dysmotility, but the new data shows this is not necessary" (clinical) [Ep 88 · 12:28](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=748)
- "A Malone procedure is a route for medical treatment that gives antegrade access to the colon for the gastroenterologist to give better medical treatment" (clinical) [Ep 88 · 13:24](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=804)
- "While surgery can correct the underlying anatomical problem in Hirschsprung disease, many other factors can contribute to constipation including motility disorders, pelvic floor dysfunction, and behavioral issues" — Felipe Glu (host_summary) [Ep 88 · 14:15](https://qa.library.globalcastmd.com/watch/colorectal-quiz-episode-42-hd-constipation-9506?t=855)
- "Despite 6 decades of research, the exact cause of necrotizing enterocolitis is unknown and there is no absolute cure for the disease." — Gail Besner (clinical) [Ep 36 · 2:11](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=131)
- "Indomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis." — Gail Besner (clinical) [Ep 36 · 3:53](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=233)
- "PPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; gastric acid neutralization should be avoided." — Gail Besner (clinical) [Ep 36 · 4:44](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=284)
- "In premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration." — Gail Besner (clinical) [Ep 36 · 5:29](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=329)
- "Neutropenia and low white blood cell count are more concerning than elevated white count in NEC, suggesting overwhelming sepsis that the patient is not compensating for." — Gail Besner (clinical) [Ep 36 · 7:17](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=437)
- "Thrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC; low platelet count is important to know before surgery to optimize patient condition." — Gail Besner (clinical) [Ep 36 · 7:33](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=453)
- "Cross-table lateral or lateral decubitus X-ray films are essential in addition to plain films because free air can be quite subtle and easily missed." — Gail Besner (clinical) [Ep 36 · 8:50](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=530)
- "Pneumoperitoneum (free air) is an absolute indication for surgical intervention, either drain placement or laparotomy." — Gail Besner (clinical) [Ep 36 · 9:38](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=578)
- "Clinical deterioration in the face of maximum medical management is an indication for surgery." — Gail Besner (clinical) [Ep 36 · 9:54](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=594)
- "Fixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not improving." — Gail Besner (clinical) [Ep 36 · 10:02](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=602)
- "Portal venous air is a concerning and worrisome sign, but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation." — Gail Besner (clinical) [Ep 36 · 10:16](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=616)
- "Medical management of NEC includes withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotic therapy, and performing serial abdominal exams, labs, and X-rays." — Gail Besner (clinical) [Ep 36 · 10:58](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=658)
- "Small French feeding tubes are not adequate for gastric decompression in NEC; feeding tube should be removed and replaced with orogastric tube." — Gail Besner (clinical) [Ep 36 · 12:05](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=725)
- "There is tremendous diversity in antibiotic regimens for NEC across the United States; broad-spectrum coverage is critical but specific regimen may depend on bacterial colonization of the intensive care unit environment." — Gail Besner (clinical) [Ep 36 · 12:33](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=753)
- "At Nationwide Children's Hospital, abdominal X-rays are obtained at intervals (approximately every 8 hours) rather than waiting 12-24 hours between films." — Gail Besner (clinical) [Ep 36 · 13:37](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=817)
- "Medical management (NPO, decompression, antibiotics) should continue for at least 1 week to 10 days, preferably a week and a half, before starting feeds." — Gail Besner (clinical) [Ep 36 · 14:15](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=855)
- "Some babies have repeated episodes of necrotizing enterocolitis." — Gail Besner (clinical) [Ep 36 · 14:29](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=869)
- "Post-NEC stricture formation typically occurs in the colon, usually near the splenic flexure in the left colon, but can occur anywhere." — Gail Besner (clinical) [Ep 36 · 14:40](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=880)
- "For suspected post-NEC stricture, contrast enema is preferred as initial study over upper GI with small bowel follow-through because strictures are more common in colon and contrast from below avoids long wait time if patient is partially obstructed." — Gail Besner (clinical) [Ep 36 · 15:17](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=917)
- "Serial abdominal exams are important for surgical decision-making; worsening distention, signs of peritoneal irritation, hemodynamic instability with increasing pressor support, and renal shutdown with no urine production build up to indicate need for surgery." — Gail Besner (clinical) [Ep 36 · 16:23](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=983)
- "Two randomized controlled trials (MOSS trial in US and PIERO trial in Europe) of peritoneal drainage versus laparotomy showed no difference in overall mortality." — Gail Besner (clinical) [Ep 36 · 19:44](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1184)
- "MOSS and PIERO trials looked at early endpoints rather than delayed endpoints of neurological recovery." — Gail Besner (clinical) [Ep 36 · 20:04](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1204)
- "Babies who have peritoneal drains instead of laparotomy may do worse from neurological standpoint if neurological outcomes are examined 1-2 years after recovery from NEC." — Gail Besner (clinical) [Ep 36 · 20:14](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1214)
- "The ongoing NEST trial (necrotizing enterocolitis surgery trial) in the United States has randomized 300 babies to peritoneal drainage versus laparotomy and will examine neurological outcomes at 18-22 months after recovery from NEC with detailed neurological assessments." — Gail Besner (clinical) [Ep 36 · 20:34](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1234)
- "Dr. Besner predicts that in the next 1-2 years, practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes expected to be better in babies who undergo laparotomy with removal of inflammatory necrotic tissue." — Gail Besner (opinion) [Ep 36 · 21:44](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1304)
- "Babies with peritoneal drains can have striking degree of dead bowel remaining in abdomen, as seen when some drain patients subsequently undergo laparotomy." — Gail Besner (clinical) [Ep 36 · 22:09](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1329)
- "Systemic inflammatory response syndrome can make patients just as sick and hemodynamically unstable from isolated intestinal perforation as from necrotizing enterocolitis." — Gail Besner (clinical) [Ep 36 · 24:15](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1455)
- "Peritoneal drain placement is a bedside procedure performed with small amount of local anesthesia using small transverse incision in right lower quadrant; incision must not be too large to prevent subsequent hernia." — Gail Besner (clinical) [Ep 36 · 26:15](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1575)
- "Quarter-inch Penrose drain is used for peritoneal drainage; drain is passed gently multiple times without forcing to avoid bleeding, then sutured in place." — Gail Besner (clinical) [Ep 36 · 26:41](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1601)
- "After peritoneal drain placement, significant proportion of patients continue to decline and require subsequent laparotomy." — Gail Besner (clinical) [Ep 36 · 25:46](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1546)
- "Operating during peak inflammatory process (e.g., 2 weeks after drain with ongoing stool output) can result in severe adhesions, serosal tears, and enterotomies; sometimes smartest decision is to stop operation, create proximal diverting stoma if possible, and avoid making situation worse." — Gail Besner (clinical) [Ep 36 · 28:43](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1723)
- "After successful drain placement with patient recovery, drain should be advanced out over several days starting at 7-10 days post-operation rather than withdrawing all at once." — Gail Besner (clinical) [Ep 36 · 29:48](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1788)
- "Continual leakage of stool at drain site is concerning; upper GI small bowel follow-through should be considered before drain removal if ongoing stool leakage present." — Gail Besner (clinical) [Ep 36 · 30:09](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1809)
- "If feeds are started after drain removal without contrast study and patient doesn't tolerate feeds, contrast study becomes mandatory to ensure everything is intact." — Gail Besner (clinical) [Ep 36 · 30:49](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1849)
- "For laparotomy, if baby is too hemodynamically unstable or on very high oscillator settings to safely transport to OR, operation can be performed at bedside in ICU with surgical team and anesthesiologists." — Gail Besner (clinical) [Ep 36 · 31:24](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1884)
- "Laparotomy uses supraumbilical transverse incision; extreme care needed due to thin skin and underlying dilated bowel to avoid immediate enterotomy." — Gail Besner (clinical) [Ep 36 · 31:43](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1903)
- "Patient should be resuscitated preoperatively with at least partial correction of platelet and coagulation abnormalities; blood products (packed red blood cells, platelets, fresh frozen plasma) must be available for operation." — Gail Besner (clinical) [Ep 36 · 32:05](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1925)
- "It is critically important not to injure liver or spleen in premature babies during laparotomy; even minimal trauma can cause subcapsular hematoma that baby can exsanguinate from." — Gail Besner (clinical) [Ep 36 · 32:27](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1947)
- "Spontaneous intestinal perforation (SIP) presents as one small localized area of perforation, while NEC is more diffuse disease with pneumatosis involving more than one tiny area; differentiation can be difficult preoperatively." — Gail Besner (clinical) [Ep 36 · 33:21](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2001)
- "Some surgeons worldwide perform primary anastomosis after limited NEC resection; in the United States, surgeons are less likely to do primary anastomosis due to concern about anastomotic healing in these patients." — Gail Besner (clinical) [Ep 36 · 34:04](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2044)
- "Dr. Besner typically performs resection with stoma and mucous fistula rather than primary anastomosis, with stoma closure when patient is bigger (at least 2000g) and stable." — Gail Besner (clinical) [Ep 36 · 34:20](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2060)
- "Stomas are brought out through laparotomy incision with functional end and mucous fistula positioned close together to facilitate limited reoperation for closure; stomas are tacked to fascia but not matured." — Gail Besner (clinical) [Ep 36 · 35:07](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2107)
- "Distal end of stoma must protrude slightly because it can slough off; leaving small distal end prevents recession under fascia." — Gail Besner (clinical) [Ep 36 · 35:50](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2150)
- "When bowel appears injured but not clearly necrotic (thin-walled, brownish discoloration, pneumatosis but not dead), acceptable approach is to not resect and perform second-look operation in 24-48 hours." — Gail Besner (clinical) [Ep 36 · 37:12](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2232)
- "Abdomen may be left open if there are many dilated loops of bowel to avoid adding pressure that may compromise blood flow." — Gail Besner (clinical) [Ep 36 · 37:35](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2255)
- "For multiple skip lesions that are very close together, can resect all without creating short bowel syndrome rather than having multiple anastomoses." — Gail Besner (clinical) [Ep 36 · 38:07](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2287)
- "For separated skip lesions, can perform multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion; if anastomotic healing problem occurs, it won't be major issue because of proximal diversion." — Gail Besner (clinical) [Ep 36 · 38:19](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2299)
- "Clip and drop technique (resecting dead bowel, clipping ends, replacing in abdomen, returning for anastomosis when baby more stable) can be life-saving maneuver in very unstable patients without time for multiple anastomoses." — Gail Besner (clinical) [Ep 36 · 38:46](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2326)
- "Stoma reversal typically performed when baby is stable, well, hopefully feeding, and approximately 2000g in size; anastomosis is easier when baby is bigger." — Gail Besner (clinical) [Ep 36 · 39:32](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2372)
- "Earlier stoma reversal is indicated if baby develops TPN-induced cholestasis or cannot be nourished due to very high stoma output." — Gail Besner (clinical) [Ep 36 · 39:56](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2396)
- "Mucous fistula refeeding is done selectively rather than routinely, particularly for very high output stomas where any nourishment given comes directly out the stoma." — Gail Besner (clinical) [Ep 36 · 40:48](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2448)
- "Recent Journal of Pediatric Surgery article showed substantial decrease in TPN use with mucous fistula refeeding." — Todd Ponsky (host_summary) [Ep 36 · 41:06](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2466)
- "Mucous fistula often strictures post-operatively, losing opportunity for refeeding; if serious about refeeding (e.g., after massive resection with very high stoma), consider leaving small soft catheter in mucous fistula post-op to maintain access." — Gail Besner (clinical) [Ep 36 · 41:22](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2482)
- "NEC totalis is one of most tragic findings on exploratory laparotomy for NEC; chance of baby living to be old enough for small bowel-liver transplant is very close to zero." — Gail Besner (clinical) [Ep 36 · 42:15](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2535)
- "For very small premature baby with NEC totalis, current technology cannot get baby through this devastating problem; no one would be criticized for explaining severity to parents and providing comfort care after closing abdomen." — Gail Besner (opinion) [Ep 36 · 42:56](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2576)
- "In Dr. Besner's experience, chance of baby with NEC totalis surviving months-to-years of required TPN is very low; TPN will irreversibly injure liver, and even if baby lives to transplant size, small bowel transplant results remain suboptimal." — Gail Besner (opinion) [Ep 36 · 43:42](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2622)
- "Small subset of premature patients with severe lung disease can develop pneumothorax that dissects through diaphragm into abdomen, causing pneumoperitoneum; must confirm problem is in abdomen rather than chest." — Gail Besner (clinical) [Ep 36 · 44:28](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2668)
- "For extremely unstable patient (e.g., 800g on jet ventilation and pressors) with pneumoperitoneum and severe distention, angiocatheter can be inserted through abdominal wall to release pneumoperitoneum as temporizing maneuver while mobilizing for definitive operation." — Gail Besner (clinical) [Ep 36 · 45:06](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2706)
- "At London NEC conference, 100% of European surgeons polled perform laparotomy for NEC and no one places peritoneal drains." — Gail Besner (epidemiological) [Ep 36 · 19:10](https://qa.library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1150)

## Common questions
### How is teduglutide dosed and monitored?
Teduglutide is given once daily by subcutaneous injection. It is a GLP-2 analog with a 2-hour half-life. Monitoring guidance is limited: the FDA recommends checking electrolytes and complete blood counts to screen for anemia, though no formal long-term monitoring protocol exists from major organizations. Clinical outcomes tracked include reduction in TPN requirements—approximately 1–2 liters per week in adults, or 40% reduction in fluid and calorie needs over 6 months.
### What did Paul Wales say about intestinal failure?
Dr. Wales defined intestinal failure as a functional problem where gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth. He noted that until recently there was no standardized definition for the condition. Patients presenting to intestinal rehabilitation programs have intestinal failure, which can be divided into three categories of causes. Some patients present with elements of two or all three categories simultaneously.
### What did Todd Ponsky say about Intestinal Rehab?
Todd Ponsky hosted the intestinal rehabilitation series at Cincinnati Children's Hospital alongside Rod Gerardo and Ellen Encisco, beginning in 2021. He and Brian Modi noted that children with intestinal failure might be slightly short statured but are not severely undersized compared to the general population, while also observing a high incidence of short stature in chronic intestinal failure.
### Where do experts disagree?
Experts disagree on management of atresia in gastroschisis: whether to repair at initial closure, create stomas, or delay repair. Evidence for mucous fistula refeeding is not strong. Additionally, there is disagreement on bowel resection philosophy: some experts advocate resecting all damaged bowel, while intestinal rehabilitation specialists at Cincinnati Children's challenge this, arguing that understanding physiology may allow bowel regeneration and recovery without complete resection.

## Changelog
- Sep 9: Summaries and takeaways published for 4 audiences
- Sep 7: Audit reverted — short clips unhidden
- Aug 31: 112 doctors auto-found from episode dossiers
- Aug 30: 92 doctors auto-found from episode dossiers
- Aug 30: 82 doctors auto-found from episode dossiers
- Aug 30: Members-only episodes removed from this collection
- Aug 29: 96 doctors auto-found from episode dossiers
- Aug 29: 98 doctors auto-found from episode dossiers
- Aug 29: Collection generated from campaign corpus: 132 items, 96 dossiers, summaries for 4 audience(s)
- Aug 29: Collection reviewed and published
- Aug 29: Collection generated from campaign corpus: 86 items, 83 dossiers, summaries for 1 audience(s)
- Aug 29: Collection generated from campaign corpus: 86 items, 83 dossiers, summaries for 2 audience(s)
- Aug 29: Collection generated from campaign corpus: 86 items, 83 dossiers, summaries for 1 audience(s)

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