# Single Ventricle / HLHS — GCMD Library living collection

Also covered as: cloaca · anorectal malformation · tethered cord · pulmonary hypoplasia · scoliosis · hypoplastic left heart syndrome · urogenital sinus · pulmonary hypertension

Experts: Dr. Todd Ponsky, Dr. Ian Glenn, Dr. Marc Levitt, Dr. Dr. Veldman

Updated: n/a · 35 episodes · 1189 cited statements

## Episodes
### Fundamentals
- [How Does the Blood Go Round in Single Ventricles and Fontans? New Horizons in...](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896) — video · 24:58 · [machine version](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896.md)

### Diagnosis & Workup
- [Case Review Dynamic Assessment of the Fontan Part II: New Horizons in Medical...](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894) — video · 14:38 · [machine version](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894.md)
- [Case Review Dynamic Assessment of the Fontan Part I: New Horizons in Medical...](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895) — video · 22:46 · [machine version](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895.md)
- [Advanced Imaging of the Fontan, What is Driving Fontan Failure: New Horizons...](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892) — video · 24:44 · [machine version](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892.md)

### Medical Management
- [How do we manage thrombogenicity and thrombosis in the Fontan? New Horizons...](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886) — video · 16:51 · [machine version](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886.md)
- [The Role of Trans-Catheter Arrhythmia Management - Patient Based Decision...](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890) — video · 20:55 · [machine version](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890.md)

### Surgical Management
- [Update on Surgical Practice and Current State on Fontan Conversion Surgery:...](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889) — video · 25:00 · [machine version](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889.md)
- [Transplantation and Ventricular Assist Devices: New Horizons in Medical and...](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891) — video · 23:13 · [machine version](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891.md)
- [Trans-Catheter Interventions: New Horizons in Medical and Surgical Fontan...](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893) — video · 17:26 · [machine version](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893.md)
- [Ovarian Torsion with Dr. Jennifer Dietrich](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949) — podcast · 47:22 · [machine version](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949.md)
- [Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957) — podcast · 43:47 · [machine version](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957.md)
- [Neonatal Lung Lesions with Dr. Steven Rothenberg](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948) — podcast · 66:58 · [machine version](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948.md)
- [Chest Wall Deformities with Dr. Robert Kelly](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950) — podcast · 46:50 · [machine version](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950.md)
- [Neonatal Lung Lesions with Dr. Steven Rothenberg](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307) — podcast · 66:58 · [machine version](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307.md)
- [Ovarian Torsion with Dr. Jennifer Dietrich](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306) — podcast · 47:22 · [machine version](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306.md)
- [Chest Wall Deformities with Dr. Robert Kelly](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305) — podcast · 46:50 · [machine version](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305.md)
- [Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299) — podcast · 43:47 · [machine version](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299.md)

### Complications
- [Complications of Anorectal Malformations with Dr. Marc Levitt](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951) — podcast · 48:09 · [machine version](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951.md)
- [Management of Retained Central Venous Catheters](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330) — video · 3:41 · [machine version](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330.md)
- [Complications of Anorectal Malformations with Dr. Marc Levitt](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304) — podcast · 48:09 · [machine version](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304.md)

### Evidence & Research
- [Posterior Tracheopexy For Severe Tracheomalacia](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320) — video · 2:17 · [machine version](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320.md)
- [Posterior Tracheopexy For Severe Tracheomalacia](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375) — video · 2:18 · [machine version](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375.md)
- [Esophagogastric Dissociation for GERD in Severe Neurodisability](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563) — video · 2:49 · [machine version](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563.md)
- [Esophagogastric Dissociation for GERD in Severe Neurodisability](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962) — video · 2:49 · [machine version](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962.md)
- [Do we need Bowel Prep](https://qa.library.globalcastmd.com/watch/do-we-need-bowel-prep-1331) — video · 1:15 · [machine version](https://qa.library.globalcastmd.com/watch/do-we-need-bowel-prep-1331.md)
- [Outcomes of Fontan Patients Undergoing Combined Heart - Liver Transplantation in Pediatric Hospitals Across the U.S.](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307) — video · 0:59 · [machine version](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307.md)
- [Pancreas, Muscle, and Subcutaneous Fat Atrophy in Patients Undergoing Radiation for Neuroblastoma](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866) — video · 1:10 · [machine version](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866.md)

### Case-Based Learning
- [Intussusception - Soft Tissue Abscess - Pilonidal Cyst - Bleeding Meckel's...](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678) — video · 19:53 · [machine version](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678.md)
- [Pregnancy in a Fontan Patient:  New Horizons in Medical and Surgical Fontan...](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887) — video · 18:27 · [machine version](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887.md)
- [Pilonidal Cyst Case Presentation: Update Course 2015](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982) — video · 5:08 · [machine version](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982.md)

### In-Depth Reviews
- [Congenital Diaphragmatic Hernia with Dr. Charlie Stolar](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952) — podcast · 82:05 · [machine version](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952.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)
- [Congenital Diaphragmatic Hernia with Dr. Charlie Stolar](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303) — podcast · 82:05 · [machine version](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303.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)

### Long-Term Care
- [Psychosocial Outcomes: New Horizons in Medical and Surgical Fontan Management...](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888) — video · 22:39 · [machine version](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=0) Prenatal Counseling and Diagnosis (Ep 31)
- [7:14](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=434) Initial Neonatal Management and Respiratory Strategy (Ep 31)
- [17:48](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1068) ECMO Indications and Contraindications (Ep 31)
- [29:21](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1761) ECMO Technical Considerations (Ep 31)
- [36:24](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2184) Timing of Surgical Repair (Ep 31)
- [46:40](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2800) Surgical Approach: Open vs Thoracoscopic (Ep 31)
- [53:56](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3236) Technical Aspects of Repair (Ep 31)
- [59:19](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3559) Postoperative Management and Chest Tubes (Ep 31)
- [69:28](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4168) Long-term Complications and Follow-up (Ep 31)
- [74:54](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4494) Recurrence and Right-sided Hernias (Ep 31)
- [0:00](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=0) Introduction and Missed Diagnoses in the Newborn Period (Ep 30)
- [2:57](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=177) Perineal Fistula in Males: Diagnosis and Management (Ep 30)
- [7:33](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=453) Perineal Fistula in Females: Diagnostic Challenges (Ep 30)
- [10:11](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=611) Examination Techniques and Missed Cloaca (Ep 30)
- [15:13](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=913) Colostomy Technique and Common Errors (Ep 30)
- [19:51](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1191) Anoplasty Placement and Stimulator Use (Ep 30)
- [23:17](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1397) Distal Colostogram Interpretation (Ep 30)
- [26:36](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1596) Avoiding Urinary Tract Injury During Dissection (Ep 30)
- [29:41](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1781) Choosing Between Posterior Sagittal and Laparoscopic Approach (Ep 30)
- [33:36](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2016) Preventing and Managing Perineal Body Dehiscence (Ep 30)
- [38:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2305) Complications Specific to Laparoscopic and PSARP Approaches (Ep 30)
- [40:51](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2451) Managing the Soiling 4-Year-Old and Indications for Redo (Ep 30)
- [0:00](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=0) Introduction and Initial Evaluation of Lower Abdominal Pain (Ep 28)
- [3:23](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=203) Ultrasound Interpretation and Blood Flow Assessment (Ep 28)
- [7:04](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=424) Imaging Findings and Risk Factors for Torsion (Ep 28)
- [11:12](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=672) Malignancy Evaluation and Advanced Imaging (Ep 28)
- [15:00](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=900) Clinical Diagnosis and Timing of Intervention (Ep 28)
- [19:40](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1180) Differential Diagnosis: Hemorrhagic Cysts (Ep 28)
- [22:51](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1371) Surgical Management: Detorsion and Cystectomy (Ep 28)
- [27:51](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1671) Ovarian Bivalving and Debulking Procedures (Ep 28)
- [30:17](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1817) Oophoropexy Techniques and Indications (Ep 28)
- [34:50](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2090) Management of Tubal-Ovarian Abscess and Ectopic Pregnancy (Ep 28)
- [39:57](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2397) Endometriosis Recognition and Management (Ep 28)
- [42:22](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2542) Postoperative Management and Surveillance (Ep 28)
- [0:00](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=0) Introduction and Study Context (Ep 35)
- [0:13](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=13) Study Design and Pancreatic Findings (Ep 35)
- [0:43](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=43) Body Composition Changes and Clinical Implications (Ep 35)
- [0:00](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=0) Introduction and Guest Presentation (Ep 29)
- [1:23](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=83) Patient Selection and Initial Evaluation for Pectus Excavatum (Ep 29)
- [7:20](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=440) Diagnostic Workup and Objective Criteria (Ep 29)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies" — Charlie Stolar (epidemiological) [Ep 31 · 2:45](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=165)
- "CDH diagnosis is typically made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart" — Charlie Stolar (clinical) [Ep 31 · 3:37](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=217)
- "CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side" — Charlie Stolar (clinical) [Ep 31 · 4:14](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=254)
- "At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation" — Charlie Stolar (clinical) [Ep 31 · 4:23](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=263)
- "CDH is a field defect; the most common neonatal comorbidity is foregut motility difficulty" — Charlie Stolar (clinical) [Ep 31 · 4:39](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=279)
- "CDH is a medical physiologic emergency but not a surgical emergency" — Charlie Stolar (clinical) [Ep 31 · 5:00](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=300)
- "The diagnosis of CDH alone is not an indication for cesarean section; elective spontaneous vaginal delivery is recommended assuming no obstetric issues" — Charlie Stolar (guideline) [Ep 31 · 5:24](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=324)
- "Antenatal interventions for CDH are no better than investigational and experimental at best" — Charlie Stolar (opinion) [Ep 31 · 6:35](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=395)
- "Babies with CDH should be born at a full-service children's facility with ECMO capability; maybe 10-15% will benefit from ECMO" — Charlie Stolar (guideline) [Ep 31 · 7:23](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=443)
- "In single-center experiences, presence of liver in the chest or stomach in the chest is of no prognostic value" — Charlie Stolar (clinical) [Ep 31 · 8:31](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=511)
- "Lung-to-head ratio is of limited prognostic value except when very low (less than 0.8), where prognosis is concerning" — Charlie Stolar (clinical) [Ep 31 · 8:42](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=522)
- "Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis" — Charlie Stolar (clinical) [Ep 31 · 9:07](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=547)
- "If shown 100 children with CDH, 80-85% will survive to become teenagers" — Charlie Stolar (epidemiological) [Ep 31 · 10:13](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=613)
- "Antenatal steroids have tremendous value for preterm labor under 35 weeks but most CDH babies are near-term (37-39 weeks) where steroid role is arguable" — Charlie Stolar (clinical) [Ep 31 · 10:37](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=637)
- "Exit to ECMO for CDH is nonsense; it moves the goalposts on almost certainly non-viable babies" — Charlie Stolar (opinion) [Ep 31 · 12:06](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=726)
- "We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth" — Charlie Stolar (clinical) [Ep 31 · 13:00](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=780)
- "Initial evaluation of newborn with CDH includes looking for morphology, associated anomalies, respiratory distress, pre- and post-ductal oxygen gradients, and early cardiac echo for right heart function" — Charlie Stolar (clinical) [Ep 31 · 14:45](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=885)
- "Not every baby with CDH needs or is a candidate for ECMO; approximately 5% have insufficient lung to support life based on inability to saturate preductal blood" — Charlie Stolar (clinical) [Ep 31 · 15:55](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=955)
- "ECMO is a drug delivery system for oxygen; indication is when end organs aren't getting enough oxygen despite best care" — Charlie Stolar (clinical) [Ep 31 · 17:06](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1026)
- "The best way to assess end-organ function is urine output" — Charlie Stolar (clinical) [Ep 31 · 17:44](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1064)
- "ECMO indication is typically oxygenation index in excess of 40 for 4 hours or more" — Charlie Stolar (guideline) [Ep 31 · 18:21](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1101)
- "All therapy is guided by preductal oximetry, not postductal; if preductal saturation is 90% (PaO2 ~65 torr), the brain is doing fine with fetal hemoglobin" — Charlie Stolar (clinical) [Ep 31 · 19:06](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1146)
- "When managing dropping preductal saturation, first ensure adequate hemoglobin and circulating volume, then increase FiO2 or ventilator pressure, but avoid trying to control PCO2 as this will destroy the lungs" — Charlie Stolar (clinical) [Ep 31 · 20:25](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1225)
- "Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today" — Charlie Stolar (opinion) [Ep 31 · 21:38](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1298)
- "CDH babies are not paralyzed during ventilation; minimal sedation is used and babies should be awake and breathing spontaneously" — Charlie Stolar (clinical) [Ep 31 · 21:56](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1316)
- "Initial conventional ventilator settings (IMV rate ~40, peak pressure 25-28, PEEP ~5) are not tolerated by most CDH babies" — Charlie Stolar (clinical) [Ep 31 · 22:15](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1335)
- "Unconventional ventilation mode for CDH uses high rate (100 breaths/min), low peak pressure (turned down to zero due to stacking), and high gas flow rate with permissive hypercapnia" — Charlie Stolar (clinical) [Ep 31 · 22:53](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1373)
- "High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO; when they get out the oscillator, it's time to prime an ECMO circuit" — Charlie Stolar (clinical) [Ep 31 · 24:30](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1470)
- "Nitric oxide is a waste of money for CDH; it's terrific for premature babies with immature lung disease but of no value in CDH" — Charlie Stolar (opinion) [Ep 31 · 25:45](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1545)
- "The best drug for CDH is oxygen" — Charlie Stolar (opinion) [Ep 31 · 26:07](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1567)
- "ECMO gestational age limit has been pushed from 36 weeks down to 35, maybe 34 weeks; below 32 weeks the intracranial hemorrhage rate takes off and neurologic outcomes become poor" — Charlie Stolar (clinical) [Ep 31 · 26:22](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1582)
- "The smallest ECMO arterial cannula is about 8 French; getting adequate flow out of small cannulas is problematic due to resistance related to both length and diameter" — Charlie Stolar (clinical) [Ep 31 · 27:40](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1660)
- "For ECMO candidacy, it's the gestational age that matters for intracranial hemorrhage risk (germinal matrix), not the size; size becomes an issue only when cannulas don't fit" — Charlie Stolar (clinical) [Ep 31 · 28:15](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1695)
- "The broad principle for ECMO candidacy is: do you have a reversible condition? Can you get out with reasonable confidence once you start?" — Charlie Stolar (clinical) [Ep 31 · 28:45](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1725)
- "VV ECMO is terrific if the heart works but problematic in CDH because heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum" — Charlie Stolar (clinical) [Ep 31 · 30:27](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1827)
- "VV ECMO is for less sick patients who aren't in extremis; most CDH babies are sicker and do better on VA ECMO" — Charlie Stolar (clinical) [Ep 31 · 31:00](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1860)
- "VA bypass is basically dialing in a PaO2; VV has mixing issues, cannula position concerns, and is more annoying to manage" — Charlie Stolar (clinical) [Ep 31 · 31:53](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1913)
- "Echo guidance during ECMO cannulation is really helpful with the shifted mediastinum; the arterial cannula can go out the subclavian artery or the venous cannula into the innominate vein" — Charlie Stolar (clinical) [Ep 31 · 32:17](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1937)
- "If the arterial cannula goes out the subclavian artery, you'll have a well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen" — Charlie Stolar (clinical) [Ep 31 · 33:01](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1981)
- "Using a guide wire to position the venous cannula into the right atrium is helpful when the mediastinum is distorted" — Charlie Stolar (clinical) [Ep 31 · 33:23](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2003)
- "Use 3 stay sutures (5-0 Prolene, rubber-shod) to lift the venotomy and arteriotomy open to avoid shearing off the intima and creating a false passage" — Charlie Stolar (clinical) [Ep 31 · 33:55](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2035)
- "In the first hours on ECMO, hyperkalemia can cause cardiac arrest if blood isn't washed; just perfuse through it and give calcium" — Charlie Stolar (clinical) [Ep 31 · 34:47](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2087)
- "ECMO flow must be increased slowly over 45-90 minutes to reduce intracranial hemorrhage incidence" — Charlie Stolar (clinical) [Ep 31 · 34:55](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2095)
- "Target VA ECMO flow is 100-125 cc/kg/min, which is about 80% of cardiac output assuming an open duct" — Charlie Stolar (clinical) [Ep 31 · 35:10](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2110)
- "At target ECMO flow, preductal saturation will be good and mixed venous (from venous drainage) will come up to 65-70%" — Charlie Stolar (clinical) [Ep 31 · 35:29](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2129)
- "Regular cardiac echos during ECMO weaning are important to assess right heart function, dilation, tricuspid regurgitation, and pulmonary outflow tract jet" — Charlie Stolar (clinical) [Ep 31 · 36:12](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2172)
- "The hyperoxia test (turning ventilator FiO2 up to 1.0) demonstrates if the baby can use their lungs; if PaO2 rises, it gives courage to begin weaning ECMO" — Charlie Stolar (clinical) [Ep 31 · 36:34](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2194)
- "For babies unweanable from ECMO after 2+ weeks at high flow, ensure they are maximally dried out (bone dry, eyes sucked into head), making good urine, with good labs and chest X-ray before considering on-ECMO repair" — Charlie Stolar (clinical) [Ep 31 · 38:18](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2298)
- "Repairing the hernia on ECMO is unusual to get you out of trouble; the problem is lung growth arrest at 14-15 weeks gestation, not that bowel is in the chest" — Charlie Stolar (clinical) [Ep 31 · 39:05](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2345)
- "Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) are making clot; platelet thrombus lifespan is 48-72 hours" — Charlie Stolar (clinical) [Ep 31 · 40:40](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2440)
- "If operating on ECMO, you have about 48-72 hours to decannulate before bleeding starts; operate when nearly weanable (20 cc/kg/min), expect 1 day of post-op deterioration, then 2-3 days to get off" — Charlie Stolar (clinical) [Ep 31 · 41:07](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2467)
- "Operating off ECMO means the baby will get stiff post-operatively, pulmonary hypertension may relapse, and you risk needing a second ECMO run" — Charlie Stolar (clinical) [Ep 31 · 41:51](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2511)
- "When operating on ECMO, load with Amicar preoperatively, do abdominal approach, use low threshold for patch to avoid tension, place Jackson-Pratt drain under patch, and place chest tube" — Charlie Stolar (clinical) [Ep 31 · 42:39](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2559)
- "Futility on ECMO begins to rear its head after 2-3 weeks; it becomes easier to discuss withdrawal if there's been a CNS event like intracranial hemorrhage" — Charlie Stolar (clinical) [Ep 31 · 44:11](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2651)
- "For non-ECMO babies, repair timing is when they're on minimal ventilator settings (FiO2 0.4, conventional settings), which typically takes 3-4 days" — Charlie Stolar (clinical) [Ep 31 · 45:42](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2742)
- "Use the infant ventilator instead of anesthesia machine intraoperatively; infant anesthesia machines have high dead space and aren't very compliant" — Charlie Stolar (clinical) [Ep 31 · 46:07](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2767)
- "Anesthesia can be all intravenous (muscle relaxants and narcotics); you don't need an anesthesia machine" — Charlie Stolar (clinical) [Ep 31 · 46:28](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2788)
- "Pre-repair assessment includes pre/post-ductal gradient, echo showing RV not dilated, RV pressure no more than systemic (not super-systemic), acceptable tricuspid regurgitation, and acceptable pulmonary outflow tract acceleration times" — Charlie Stolar (clinical) [Ep 31 · 46:47](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2807)
- "Perioperative antibiotics (typically ampicillin-gentamicin) are given because a patch may be placed in a newborn" — Charlie Stolar (clinical) [Ep 31 · 47:57](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2877)
- "The thoracoscopic approach provides a gorgeous view and often the bowel reduces with chest insufflation, but only rock-stable kids are candidates because you're creating a tension pneumothorax in a potentially hypercapnic baby" — Charlie Stolar (clinical) [Ep 31 · 48:32](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2912)
- "In Dr. Stolar's series of 35 thoracoscopic CDH repairs in stable babies, recurrence rate was about 25% in under a year; APSA outcomes committee meta-analysis reached similar conclusions" — Charlie Stolar (clinical) [Ep 31 · 49:37](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2977)
- "Laparoscopic CDH repair is problematic because the scaphoid abdomen has loss of abdominal domain; insufflating just puts air up in the chest" — Charlie Stolar (opinion) [Ep 31 · 50:21](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3021)
- "For open repair, key is adequate subcostal incision (not a small two-finger incision); rotate liver out of chest and abdomen to see the defect" — Charlie Stolar (clinical) [Ep 31 · 54:58](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3298)
- "Critical repair points are all medial where structures with names are located; mobilize posterior leaflet by unrolling it like a window shade down to the body wall until you feel rib" — Charlie Stolar (clinical) [Ep 31 · 55:31](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3331)
- "The medial repair is hardest because sometimes the esophagus or aorta hangs out with nothing to sew to; use an upside-down U-shaped pericardial flap rotated down to where the diaphragm would be to begin the repair" — Charlie Stolar (clinical) [Ep 31 · 56:11](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3371)
- "Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike braided suture like Vicryl" — Charlie Stolar (opinion) [Ep 31 · 57:16](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3436)
- "For patches, favor non-biologic material like 1mm Gore-Tex; laterally, anchor the patch to the ribs by getting a needle around the rib and into the patch" — Charlie Stolar (clinical) [Ep 31 · 57:59](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3479)
- "Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out with a deep breath; over time it gets incorporated into fibrous tissue" — Charlie Stolar (clinical) [Ep 31 · 58:43](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3523)
- "For thoracoscopic repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and reduce spleen last as it obturates the hole and keeps bowel in the belly" — Charlie Stolar (clinical) [Ep 31 · 60:23](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3623)
- "Thoracoscopically, mobilizing the posterior leaflet is difficult because it's rolled into the abdomen and hard to see around the corner" — Charlie Stolar (clinical) [Ep 31 · 61:35](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3695)
- "For thoracoscopic patch placement, use extracorporeal-intracorporeal suture technique: come from outside through skin around rib into patch and back out, tie externally, and bury the knot under the skin" — Charlie Stolar (clinical) [Ep 31 · 62:03](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3723)
- "If you can see through the diaphragm (it's just pleura and peritoneum with no muscle), resect it back to something that looks like muscle; plication of see-through tissue will fail" — Charlie Stolar (clinical) [Ep 31 · 64:16](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3856)
- "The ipsilateral lung is small and not as big as the pleural space; that's how God made this lung. You won't inflate the lung to fill the chest" — Charlie Stolar (clinical) [Ep 31 · 66:47](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4007)
- "The pleural space will be obliterated either slowly by lung growth over 3-4 years or by filling with fluid; it's not a pneumothorax under pressure, it's pneumothorax ex vacuo" — Charlie Stolar (clinical) [Ep 31 · 67:01](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4021)
- "Chest tube on water-seal suction will distort the mediastinum and precipitate a pulmonary hypertensive crisis; there's no reason to put in a chest tube unless there's active air leak or bleeding" — Charlie Stolar (clinical) [Ep 31 · 67:18](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4038)
- "Typical stable post-op CDH baby will be unstable for about a day with increased ventilator requirements, then improve and get extubated in 4-5 days" — Charlie Stolar (clinical) [Ep 31 · 68:53](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4133)
- "CDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz; these kids have disordered motility throughout" — Charlie Stolar (clinical) [Ep 31 · 69:34](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4174)
- "All CDH patients should have a GI series showing dilated, ectatic, abnormal esophagus; manometry and impedance show abnormal esophageal and gastric motility and emptying" — Charlie Stolar (clinical) [Ep 31 · 69:51](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4191)
- "The foregut problem is not really reflux; calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture" — Charlie Stolar (opinion) [Ep 31 · 70:09](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4209)
- "CDH babies do well with continuous feedings slowly condensed to bolus; surgical intervention for foregut issues is unusual and should be approached as palliation" — Charlie Stolar (clinical) [Ep 31 · 70:28](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4228)
- "Nissen fundoplication is a poor operation for CDH kids (like for esophageal atresia) because their motility is abnormal; if surgery is needed, use a partial wrap with gastrostomy and real drainage procedure (Jaboulay-Finney type, not Heineke-Mikulicz)" — Charlie Stolar (opinion) [Ep 31 · 70:40](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4240)
- "Dr. Stolar's multidisciplinary CDH clinic follows 450-500 patients for life, addressing heart, lung, foregut, nutrition, neurodevelopmental, and axial skeleton issues that emerge over time" — Charlie Stolar (clinical) [Ep 31 · 72:11](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4331)
- "Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis; he recommends lifelong proton pump inhibitors and regular endoscopic surveillance" — Charlie Stolar (clinical) [Ep 31 · 73:18](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4398)
- "CDH patients have increased incidence of attention deficit disorders and autism; early intervention for neuropsychiatric issues is recommended" — Charlie Stolar (clinical) [Ep 31 · 73:57](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4437)
- "As a field defect, CDH causes asymmetric chest growth leading to pectus-like distortion; some patients need Nuss-type operations to rebuild chest wall" — Charlie Stolar (clinical) [Ep 31 · 74:09](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4449)
- "Some CDH girls have no breast development on the hernia side as teenagers; combined Nuss operation and breast implant procedures have been performed" — Charlie Stolar (clinical) [Ep 31 · 74:29](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4469)
- "CDH patients develop thoracolumbar scoliosis (not idiopathic scoliosis, as it's mostly in boys); early bracing programs help minimize this" — Charlie Stolar (clinical) [Ep 31 · 74:34](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4474)
- "CDH recurrence is related to tension on tissues and tissue quality; it's a tough problem whether tissue-to-tissue or prosthetic repair" — Charlie Stolar (clinical) [Ep 31 · 75:16](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4516)
- "Recurrence is more common with left-sided CDH than right because the liver plugs up the hole on the right" — Charlie Stolar (clinical) [Ep 31 · 77:35](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4655)
- "For right-sided CDH, the most important consideration is determining where hepatic veins drain; not infrequently they enter directly into the right atrium, not the suprahepatic IVC" — Charlie Stolar (clinical) [Ep 31 · 77:51](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4671)
- "If hepatic veins enter the right atrium directly, attempting to reduce the liver into the abdomen will cause a troublesome moment; you should not try to put that liver in the abdomen" — Charlie Stolar (clinical) [Ep 31 · 78:09](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4689)
- "Hepatopulmonary fusion actually exists in right-sided CDH; the liver and lung are fused and cannot be separated surgically" — Charlie Stolar (clinical) [Ep 31 · 78:29](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4709)
- "Most patients with hepatopulmonary fusion don't survive; they often have associated severe congenital heart disease and IVC interruption with azygous continuation" — Charlie Stolar (clinical) [Ep 31 · 79:11](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4751)
- "For right-sided CDH, prep the baby for both thoracic and abdominal incisions; often need to be on both sides to figure out what's going on because the liver is in the way" — Charlie Stolar (clinical) [Ep 31 · 79:48](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4788)
- "For right-sided CDH, can put a scope through an open thoracotomy to see around corners where the liver might come up against the heart" — Charlie Stolar (clinical) [Ep 31 · 80:12](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4812)
- "Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period." — Marc Levitt (clinical) [Ep 30 · 2:57](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=177)
- "Male babies with perineal fistula may pass meconium and no one notices anything wrong with their anorectal anatomy, typically presenting in the first year of life with severe constipation." — Marc Levitt (clinical) [Ep 30 · 3:06](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=186)
- "A newborn anus should accept a size 12 Hagar dilator and a 1-year-old should accept a size 15." — Marc Levitt (clinical) [Ep 30 · 6:13](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=373)
- "Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation; patients will inherently have some constipation requiring aggressive treatment." — Marc Levitt (clinical) [Ep 30 · 4:54](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=294)
- "If a perineal fistula is not centered in the sphincter, patients with loose stool will soil, and athletic activity will cause soiling because sphincter squeeze cannot completely close the hole." — Marc Levitt (clinical) [Ep 30 · 5:38](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=338)
- "In females, diagnostic criteria for perineal fistula are: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter." — Marc Levitt (clinical) [Ep 30 · 8:02](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=482)
- "If a female's anal opening is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed; the perineal body will lengthen with growth." — Marc Levitt (clinical) [Ep 30 · 8:47](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=527)
- "The standard practice of checking temperature on forehead or ear rather than rectally makes it easier to miss anorectal malformations in newborns." — Marc Levitt (opinion) [Ep 30 · 4:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=265)
- "An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 stimulators for identifying sphincter muscles." — Marc Levitt (clinical) [Ep 30 · 11:06](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=666)
- "The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula." — Marc Levitt (clinical) [Ep 30 · 17:18](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1038)
- "Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections." — Marc Levitt (clinical) [Ep 30 · 17:45](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1065)
- "With transverse colostomy and large rectourethral fistula, the left colon absorbs urine which doesn't exit the mucous fistula, potentially causing acidosis from urine absorption." — Marc Levitt (clinical) [Ep 30 · 18:38](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1118)
- "Prolapse risk depends on colostomy location: mid-transverse allows bilateral prolapse, hepatic flexure allows only distal prolapse, proximal sigmoid allows only distal prolapse because left colon is fixed to retroperitoneum." — Marc Levitt (clinical) [Ep 30 · 19:58](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1198)
- "Marking the sphincter ellipse on skin surface before making any incision prevents confusion from muscle stimulation after dissection is open, avoiding misplaced anoplasty." — Marc Levitt (clinical) [Ep 30 · 21:30](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1290)
- "A distal colostogram showing flattening of the rectum corresponding to the pubococcygeal line indicates insufficient contrast or pressure; more pressure is needed to overcome the sphincters and reveal the true rectal position and fistula." — Marc Levitt (clinical) [Ep 30 · 24:26](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1466)
- "Fistula level is determined by viewing the urethra as a reverse C or elbow: fistula at or below the elbow is bulbar, above the elbow is prostatic, at bladder neck is bladder neck fistula." — Marc Levitt (clinical) [Ep 30 · 25:23](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1523)
- "Bulbous rectum on colostogram may be reachable posterior sagittally and difficult laparoscopically; tapered rectum is better approached laparoscopically." — Marc Levitt (clinical) [Ep 30 · 25:55](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1555)
- "Opening posterior sagittally without knowing exact rectal location risks finding and potentially mobilizing bladder neck instead of rectum." — Marc Levitt (clinical) [Ep 30 · 27:00](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1620)
- "Bulbar and low prostatic fistulas with bulbous rectum are best approached posterior sagittally; high prostatic with tapered rectum and bladder neck fistulas are best approached laparoscopically." — Marc Levitt (clinical) [Ep 30 · 30:09](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1809)
- "Attempting laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level risks leaving behind a remnant of the original fistula (roof) if the surgeon is timid." — Marc Levitt (clinical) [Ep 30 · 30:43](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1843)
- "Laparoscopy replaces laparotomy, not PSARP; a mini-PSARP during laparoscopy allows safe entry through peritoneal reflection and tacking rectum to posterior muscle complex to prevent prolapse." — Marc Levitt (opinion) [Ep 30 · 31:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=1908)
- "Rectal prolapse occurs in about 3% of cases, particularly in patients without great muscles." — Marc Levitt (epidemiological) [Ep 30 · 33:35](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2015)
- "Rectal prolapse more than 3 millimeters should be treated because it causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential." — Marc Levitt (clinical) [Ep 30 · 34:14](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2054)
- "Circumferential prolapse can be trimmed in two separate ambulatory sessions (half circumference each), avoiding hospitalization and eliminating need for dilation since half the circumference remains untouched." — Marc Levitt (clinical) [Ep 30 · 34:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2088)
- "Perineal body dehiscence is the most common cause of reoperation in female ARM repairs." — Marc Levitt (clinical) [Ep 30 · 36:03](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2163)
- "Complete anterior rectal wall mobilization to the areolar plane between rectum and vagina is essential to avoid tension on the anoplasty that can lead to perineal body dehiscence." — Marc Levitt (clinical) [Ep 30 · 35:41](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2141)
- "Clear liquids only for one week postoperatively prevents hard stool formation while allowing more stool volume, showing good perineal body healing results without traditional 7-day NPO period." — Marc Levitt (clinical) [Ep 30 · 36:45](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2205)
- "If perineal body dehiscence is recognized on days 5-8, taking the patient back to OR to re-suture can salvage the repair; by 3-4 weeks the entire perineal body is dehisced and unsalvageable." — Marc Levitt (clinical) [Ep 30 · 37:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2268)
- "During laparoscopic approach for high rectums, the IMA must be preserved because prior colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on IMA blood supply." — Marc Levitt (clinical) [Ep 30 · 39:33](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2373)
- "Continence potential in ARM patients is predicted by three factors: original malformation type, sacral ratio, and spine quality (ARM continence index). Three A's predicts continence, three C's predicts incontinence." — Marc Levitt (clinical) [Ep 30 · 42:14](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2534)
- "A bulbar fistula with sacral ratio of 1 and normal spine should have bowel control; a bladder neck fistula with sacral ratio of 0.4 and tethered cord or myelomeningocele has no chance of good bowel control." — Marc Levitt (clinical) [Ep 30 · 43:19](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2599)
- "Initial management of soiling 4-year-old with continence potential is bowel management with enemas to achieve cleanliness, then trial of laxatives when older and more mature to attempt voluntary bowel movements." — Marc Levitt (clinical) [Ep 30 · 43:52](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2632)
- "Indications for redo pull-through include any patient with continence potential who has improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum)." — Marc Levitt (clinical) [Ep 30 · 44:39](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2679)
- "The major problem with anorectal malformations is that surgical errors may not become apparent for years; an improperly placed anus appears successful initially but presents with soiling at age 4." — Marc Levitt (opinion) [Ep 30 · 46:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-304?t=2785)
- "In all reproductive age females presenting with lower abdominal pain, a pregnancy test should be checked regardless of sexual history." — Jennifer Dietrich (guideline) [Ep 28 · 2:02](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=122)
- "Ultrasound provides real-time and still pictures with better penetration capabilities regardless of patient BMI, as long as the female has a full bladder." — Jennifer Dietrich (clinical) [Ep 28 · 2:57](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=177)
- "Significant asymmetry between ovaries on ultrasound, particularly enlargement on the side of pain, raises concern for adnexal torsion." — Jennifer Dietrich (clinical) [Ep 28 · 3:31](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=211)
- "Complete absence of blood flow on ultrasound is the most concerning and more reliable finding; presence of blood flow is actually less reliable in diagnosing torsion." — Jennifer Dietrich (clinical) [Ep 28 · 4:33](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=273)
- "Blood flow may be present in ovarian torsion because it could be just a torsed tube, in which case flow to the ovary would still be visible." — Jennifer Dietrich (clinical) [Ep 28 · 5:00](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=300)
- "Intermittent torsion can occur, and if diagnosis is difficult, observation with repeat ultrasound may help if the patient's condition declares itself." — Jennifer Dietrich (clinical) [Ep 28 · 6:14](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=374)
- "When the ovary is edematous with compromised blood supply, follicles become peripheralized to the ovary's periphery due to vascular congestion in the middle." — Jennifer Dietrich (clinical) [Ep 28 · 7:15](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=435)
- "In the literature, cysts around 5 or 6 centimeters in size increase concern for torsion risk in the setting of symptoms, as they make the ovary and tube heavy enough to twist." — Jennifer Dietrich (clinical) [Ep 28 · 8:50](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=530)
- "In prepubertal girls, normal ovaries can torse, and torsion is the most common reason these children undergo surgery for a gynecologic indication." — Jennifer Dietrich (epidemiological) [Ep 28 · 9:31](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=571)
- "There is no specific size cutoff for torsion risk; diagnosis is based on clinical presentation. Prepubertal ovaries are very small (1-1.5 cm), but normal ovaries can still twist." — Jennifer Dietrich (clinical) [Ep 28 · 10:19](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=619)
- "Complex features on ultrasound (partly cystic, partly solid) with hypervascular flow within the lesion and elevated tumor markers raise concern for malignancy." — Jennifer Dietrich (clinical) [Ep 28 · 11:24](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=684)
- "CT is beneficial to distinguish an adnexal lesion from an abscess or appendiceal pathology when infection is a concern." — Jennifer Dietrich (clinical) [Ep 28 · 12:17](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=737)
- "MRI is useful to distinguish torsion from Müllerian anomalies with outflow tract obstruction, where a hematosalpinx may mimic torsion on ultrasound." — Jennifer Dietrich (clinical) [Ep 28 · 12:36](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=756)
- "Pelvic exams in adolescents are typically delayed until later teenage years or until the first Pap smear at age 21, unless specific concerns arise." — Jennifer Dietrich (guideline) [Ep 28 · 13:19](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=799)
- "Tumor markers sent for complex adnexal masses include alpha-fetoprotein, serum beta-HCG quantitative, lactate dehydrogenase, and CA-125." — Jennifer Dietrich (clinical) [Ep 28 · 15:06](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=906)
- "At Texas Children's Hospital, three out of four tumor markers return within an hour to hour and a half, allowing results before OR posting." — Jennifer Dietrich (clinical) [Ep 28 · 15:57](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=957)
- "Studies from Boston Children's show that salvage rates are higher within the first 24 to 72 hours from onset of abdominal pain compared to one week." — Jennifer Dietrich (host_summary) [Ep 28 · 17:26](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1046)
- "It is unpredictable whether a patient has a loose torsion with more time or a tight torsion with rapid ischemia development, so diagnosis should be addressed as soon as possible." — Jennifer Dietrich (clinical) [Ep 28 · 17:52](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1072)
- "Ovarian torsion is a clinical diagnosis; if clinical suspicion is high, surgery should proceed regardless of ultrasound findings including blood flow." — Jennifer Dietrich (guideline) [Ep 28 · 18:16](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1096)
- "If the diagnosis is uncertain, observation for a few hours is reasonable to see if a patient with intermittent torsion declares herself, but the patient should not be sent home." — Jennifer Dietrich (clinical) [Ep 28 · 18:56](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1136)
- "A classic torsion presentation includes acute onset abdominal pain after physical activity (gymnastics, cartwheels), persistent pain unresponsive to over-the-counter measures, nausea and vomiting, and ultrasound showing ovarian asymmetry on the painful side." — Jennifer Dietrich (clinical) [Ep 28 · 19:52](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1192)
- "Hemorrhagic ovarian cysts are more likely in females who are already menstruating, and menstrual history (regularity, timing of last cycle) helps determine risk for hemorrhagic or corpus luteum cysts." — Jennifer Dietrich (clinical) [Ep 28 · 21:22](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1282)
- "Doppler can help differentiate hemorrhagic cysts from torsion: within a hemorrhagic cyst there is no flow, but peripheral to the cyst there is flow." — Jennifer Dietrich (clinical) [Ep 28 · 22:09](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1329)
- "At surgery for torsion, the ovary is detorsed and any lesion (peritubal or ovarian cyst) is removed, as the lesion's weight made the adnexa prone to twisting." — Jennifer Dietrich (clinical) [Ep 28 · 22:51](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1371)
- "Oophorectomy and salpingo-oophorectomy should be avoided at all times; even purple, black and blue ovaries can recover over time after detorsion." — Jennifer Dietrich (guideline) [Ep 28 · 23:35](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1415)
- "For non-ischemic torsion, cystectomy is performed rather than simple drainage unless the cyst is clearly functional." — Jennifer Dietrich (clinical) [Ep 28 · 23:49](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1429)
- "Peritubal cysts will recur if not completely excised; the technique involves opening the mesosalpinx beneath the fallopian tube and shelling out the cyst wall." — Jennifer Dietrich (clinical) [Ep 28 · 24:18](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1458)
- "For expanding hemorrhagic cysts, the cyst should be removed and bleeding areas coagulated; if the cyst wall is not completely removed, the cyst may continue to bleed." — Jennifer Dietrich (clinical) [Ep 28 · 25:04](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1504)
- "Even necrotic-appearing ovaries should be salvaged unless the tissue is literally falling apart during detorsion; ovarian function and follicles can return after a few months." — Jennifer Dietrich (clinical) [Ep 28 · 26:20](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1580)
- "Follow-up studies at Texas Children's Hospital show return of ovarian function and evidence of follicles in patients who had torsed ovaries preserved." — Jennifer Dietrich (clinical) [Ep 28 · 26:47](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1607)
- "Whether to remove the fallopian tube along with a necrotic ovary depends on whether the tube is involved in the torsion and completely devitalized or salvageable." — Jennifer Dietrich (clinical) [Ep 28 · 27:35](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1655)
- "The ovarian bivalving procedure, described at Boston Children's, involves making an incision into the ovarian cortex after detorsion to relieve compartment syndrome-like vascular congestion." — Jennifer Dietrich (host_summary) [Ep 28 · 27:56](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1676)
- "Bivalving may be needed when the ovary remains edematous after detorsion, to debulk the ovary and reduce re-torsion risk, especially when there is no lesion to remove." — Jennifer Dietrich (clinical) [Ep 28 · 28:48](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1728)
- "Energy devices such as harmonic scalpel or monopolar hook can be used for ovarian bivalving and debulking procedures." — Jennifer Dietrich (clinical) [Ep 28 · 29:43](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1783)
- "Oophoropexy is considered when a child has lost one ovary and presents with torsion of the remaining ovary, or in cases of recurrent torsion." — Jennifer Dietrich (clinical) [Ep 28 · 30:53](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1853)
- "Oophoropexy may change future fertility potential, but preserving the ovary is better than losing it; in vitro technologies remain an option for egg retrieval." — Jennifer Dietrich (opinion) [Ep 28 · 31:18](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1878)
- "Absorbable suture material can be used for oophoropexy to hold the adnexa still for 4-6 weeks while inflammation resolves, minimizing near-term re-torsion risk." — Jennifer Dietrich (clinical) [Ep 28 · 31:54](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1914)
- "Clipping the utero-ovarian ligament does not always prevent torsion because torsion can occur on either the utero-ovarian ligament or the infundibulopelvic ligament." — Jennifer Dietrich (clinical) [Ep 28 · 32:37](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1957)
- "Oophoropexy techniques include shortening the utero-ovarian ligament (by suturing it closer together), fixation to the pelvic sidewall (avoiding ureters), or fixation to the back of the uterus." — Jennifer Dietrich (clinical) [Ep 28 · 33:10](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=1990)
- "For tubal-ovarian abscess, antibiotics should be started and the abscess should not be disturbed unless the patient is crashing, to avoid seeding other pelvic structures." — Jennifer Dietrich (clinical) [Ep 28 · 35:14](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2114)
- "Ectopic pregnancy can present similarly to torsion with acute pain and an adnexal mass, and may not be visible on transabdominal ultrasound if beta-HCG levels are below the threshold for visualization." — Jennifer Dietrich (clinical) [Ep 28 · 35:57](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2157)
- "For tubal ectopic pregnancy, a salpingostomy is made, the ectopic pregnancy is removed, hemostasis is ensured, and tissue is submitted for pathology; the tube is not sutured closed." — Jennifer Dietrich (clinical) [Ep 28 · 38:07](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2287)
- "Pelvic structures heal well without suturing; suturing can cause more scar tissue and stricture formation than leaving small incisions to heal on their own." — Jennifer Dietrich (clinical) [Ep 28 · 38:56](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2336)
- "Endometriosis in young adolescents presents with atypical lesions (clear or red) rather than the classic blue or black lesions seen in adults with advanced disease." — Jennifer Dietrich (clinical) [Ep 28 · 39:57](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2397)
- "To identify clear endometriosis lesions, fill the pelvis with crystalloid fluid and examine the cul-de-sac closely with the camera underwater to see blebs pulling away from the peritoneum." — Jennifer Dietrich (clinical) [Ep 28 · 40:55](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2455)
- "Endometriosis lesions can be excised with cold scissors when near the ureter or bowel, or ablated in other locations." — Jennifer Dietrich (clinical) [Ep 28 · 41:52](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2512)
- "Patients can go home within a few hours after laparoscopic surgery if they meet postoperative milestones, with activity limited for 4-6 weeks to allow incision healing and avoid hernia formation." — Jennifer Dietrich (clinical) [Ep 28 · 42:22](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2542)
- "Oral contraceptive pills can prevent recurrence if the torsion was caused by a functional cyst, but will not help with dermoid cysts or peritubal cysts." — Jennifer Dietrich (clinical) [Ep 28 · 43:31](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2611)
- "Surveillance ultrasound is obtained at 3 months post-surgery (allowing time for inflammation to resolve), then at 3-6 months if the ovary is still recovering, then annually." — Jennifer Dietrich (clinical) [Ep 28 · 44:32](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-306?t=2672)
- "Radiation improves survival in high-risk neuroblastoma" — Sophia Schermerhorn (clinical) [Ep 35 · 0:00](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=0)
- "This is a retrospective study of 50 children with high-risk neuroblastoma undergoing abdominal radiation therapy" — Sophia Schermerhorn (clinical) [Ep 35 · 0:13](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=13)
- "The authors use CT and MRI body segmentation to measure pancreatic volume, subcutaneous fat, and muscle area before and after treatment" — Sophia Schermerhorn (clinical) [Ep 35 · 0:19](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=19)
- "There was a significant decrease in pancreatic volume after radiation" — Sophia Schermerhorn (clinical) [Ep 35 · 0:27](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=27)
- "Very few patients developed clinically apparent pancreatic insufficiency" — Sophia Schermerhorn (clinical) [Ep 35 · 0:31](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=31)
- "Pancreatic insufficiency wasn't systematically screened for in this study" — Sophia Schermerhorn (clinical) [Ep 35 · 0:31](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=31)
- "Follow-up may not be long enough to detect pancreatic effects, especially given the young average age of these patients" — Sophia Schermerhorn (opinion) [Ep 35 · 0:31](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=31)
- "Pancreatic dysfunction could be an under-recognized late effect" — Sophia Schermerhorn (opinion) [Ep 35 · 0:43](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=43)
- "Patients had a significant drop in weight percentile with smaller decreases in fat and muscle" — Sophia Schermerhorn (clinical) [Ep 35 · 0:48](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=48)
- "Body composition changes likely reflect the overall impact of cancer therapy overall rather than radiation alone" — Sophia Schermerhorn (opinion) [Ep 35 · 0:48](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=48)
- "These findings highlight the importance of nutritional screening during cancer treatments" — Sophia Schermerhorn (opinion) [Ep 35 · 0:48](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=48)
- "As survival improves, understanding and screening for long-term effects is becoming just as important as curing the cancer itself" — Sophia Schermerhorn (opinion) [Ep 35 · 1:03](https://qa.library.globalcastmd.com/watch/pancreas-muscle-and-subcutaneous-fat-atrophy-in-patients-undergoing-radiation-for-neuroblastoma-11866?t=63)
- "Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest." — Robert Kelly (clinical) [Ep 29 · 1:33](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=93)
- "Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker." — Robert Kelly (clinical) [Ep 29 · 2:55](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=175)
- "In patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration." — Robert Kelly (clinical) [Ep 29 · 4:04](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=244)
- "In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath." — Robert Kelly (clinical) [Ep 29 · 4:29](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=269)
- "In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis." — Robert Kelly (epidemiological) [Ep 29 · 6:15](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=375)
- "When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon." — Robert Kelly (clinical) [Ep 29 · 6:36](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=396)
- "In the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain." — Robert Kelly (epidemiological) [Ep 29 · 8:39](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=519)
- "The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus." — Robert Kelly (clinical) [Ep 29 · 9:44](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=584)
- "The Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant." — Robert Kelly (host_summary) [Ep 29 · 10:09](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=609)
- "Mitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population." — Robert Kelly (epidemiological) [Ep 29 · 12:53](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=773)
- "On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted)." — Robert Kelly (epidemiological) [Ep 29 · 13:37](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=817)
- "In both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery." — Robert Kelly (clinical) [Ep 29 · 14:15](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=855)
- "Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected." — Robert Kelly (clinical) [Ep 29 · 14:37](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=877)
- "Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems." — Robert Kelly (clinical) [Ep 29 · 15:05](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=905)
- "Dr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image." — Robert Kelly (guideline) [Ep 29 · 15:11](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=911)
- "Around the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct." — Robert Kelly (clinical) [Ep 29 · 15:35](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=935)
- "The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that." — Robert Kelly (clinical) [Ep 29 · 16:47](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1007)
- "Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed." — Robert Kelly (clinical) [Ep 29 · 17:02](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1022)
- "Some Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results." — Robert Kelly (host_summary) [Ep 29 · 17:29](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1049)
- "Dr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback." — Robert Kelly (clinical) [Ep 29 · 18:49](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1129)
- "Dr. Kelly's center has not used epidurals for pectus excavatum surgery for several years." — Robert Kelly (clinical) [Ep 29 · 19:39](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1179)
- "Postoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery." — Robert Kelly (clinical) [Ep 29 · 19:47](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1187)
- "For the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest." — Robert Kelly (clinical) [Ep 29 · 20:46](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1246)
- "The Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance." — Robert Kelly (clinical) [Ep 29 · 21:37](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1297)
- "Titanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate." — Robert Kelly (opinion) [Ep 29 · 22:17](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1337)
- "For Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other." — Robert Kelly (guideline) [Ep 29 · 24:43](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1483)
- "Sternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify." — Robert Kelly (clinical) [Ep 29 · 24:57](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1497)
- "The most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low." — Robert Kelly (clinical) [Ep 29 · 26:02](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1562)
- "To prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib." — Robert Kelly (clinical) [Ep 29 · 26:43](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1603)
- "For Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus." — Robert Kelly (clinical) [Ep 29 · 27:32](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1652)
- "In post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient." — Robert Kelly (clinical) [Ep 29 · 27:39](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1659)
- "The bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load." — Robert Kelly (clinical) [Ep 29 · 28:54](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1734)
- "In growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar." — Robert Kelly (clinical) [Ep 29 · 30:07](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1807)
- "Patients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation." — Robert Kelly (clinical) [Ep 29 · 30:39](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1839)
- "The Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities." — Robert Kelly (clinical) [Ep 29 · 31:17](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1877)
- "Postoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines." — Robert Kelly (clinical) [Ep 29 · 32:02](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1922)
- "In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent." — Robert Kelly (host_summary) [Ep 29 · 33:03](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1983)
- "In Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures." — Robert Kelly (epidemiological) [Ep 29 · 33:14](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=1994)
- "Most bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents." — Robert Kelly (clinical) [Ep 29 · 33:43](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2023)
- "Bar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy." — Robert Kelly (epidemiological) [Ep 29 · 34:13](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2053)
- "Wound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle." — Robert Kelly (epidemiological) [Ep 29 · 34:40](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2080)
- "Recurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years." — Robert Kelly (epidemiological) [Ep 29 · 35:07](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2107)
- "Dr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal." — Robert Kelly (clinical) [Ep 29 · 36:33](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2193)
- "The vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients." — Robert Kelly (host_summary) [Ep 29 · 37:19](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2239)
- "Dr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up." — Robert Kelly (clinical) [Ep 29 · 37:49](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2269)
- "In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial." — Robert Kelly (clinical) [Ep 29 · 39:06](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2346)
- "Because brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients." — Robert Kelly (opinion) [Ep 29 · 40:04](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2404)
- "Dr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands." — Robert Kelly (clinical) [Ep 29 · 41:23](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2483)
- "Candidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing." — Robert Kelly (clinical) [Ep 29 · 42:35](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2555)
- "The reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest." — Robert Kelly (clinical) [Ep 29 · 43:13](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2593)
- "There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch." — Robert Kelly (host_summary) [Ep 29 · 43:43](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2623)
- "There is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history." — Robert Kelly (epidemiological) [Ep 29 · 44:52](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-305?t=2692)
- "Serial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks." — Steven Rothenberg (clinical) [Ep 27 · 3:48](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=228)
- "Fetal MRI for lung lesions provides little additional benefit and does not change the management plan." — Steven Rothenberg (opinion) [Ep 27 · 4:11](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=251)
- "Anywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear." — Steven Rothenberg (epidemiological) [Ep 27 · 5:43](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=343)
- "Fetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years." — Steven Rothenberg (epidemiological) [Ep 27 · 6:11](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=371)
- "Fetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality." — Steven Rothenberg (clinical) [Ep 27 · 6:31](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=391)
- "Steroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated." — Steven Rothenberg (clinical) [Ep 27 · 7:13](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=433)
- "A cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention." — Steven Rothenberg (clinical) [Ep 27 · 7:54](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=474)
- "Congenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology." — Steven Rothenberg (clinical) [Ep 27 · 8:52](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=532)
- "Sequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining." — Steven Rothenberg (clinical) [Ep 27 · 9:37](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=577)
- "If a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks." — Steven Rothenberg (clinical) [Ep 27 · 11:43](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=703)
- "A chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required." — Steven Rothenberg (clinical) [Ep 27 · 12:39](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=759)
- "Some children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM." — Steven Rothenberg (clinical) [Ep 27 · 14:44](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=884)
- "Depending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point." — Steven Rothenberg (epidemiological) [Ep 27 · 15:47](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=947)
- "The incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant." — Steven Rothenberg (epidemiological) [Ep 27 · 16:56](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1016)
- "Rothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth." — Steven Rothenberg (opinion) [Ep 27 · 17:49](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1069)
- "In Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg." — Steven Rothenberg (clinical) [Ep 27 · 19:19](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1159)
- "Most infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery." — Steven Rothenberg (clinical) [Ep 27 · 19:46](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1186)
- "Even in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection." — Steven Rothenberg (clinical) [Ep 27 · 18:46](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1126)
- "The key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work." — Steven Rothenberg (clinical) [Ep 27 · 21:13](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1273)
- "Blood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant." — Steven Rothenberg (clinical) [Ep 27 · 22:36](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1356)
- "Most asymptomatic children on room air tolerate single-lung ventilation without problem." — Steven Rothenberg (clinical) [Ep 27 · 23:38](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1418)
- "Single-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided." — Steven Rothenberg (clinical) [Ep 27 · 24:06](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1446)
- "After lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops." — Steven Rothenberg (clinical) [Ep 27 · 26:02](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1562)
- "Anesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung." — Steven Rothenberg (clinical) [Ep 27 · 26:36](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1596)
- "End-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy." — Steven Rothenberg (clinical) [Ep 27 · 27:41](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1661)
- "The surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back." — Steven Rothenberg (clinical) [Ep 27 · 28:59](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1739)
- "The camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles." — Steven Rothenberg (clinical) [Ep 27 · 30:39](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1839)
- "A fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children." — Steven Rothenberg (clinical) [Ep 27 · 32:28](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1948)
- "Rothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference." — Steven Rothenberg (clinical) [Ep 27 · 33:01](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=1981)
- "Low-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space." — Steven Rothenberg (clinical) [Ep 27 · 33:56](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2036)
- "A 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter." — Steven Rothenberg (clinical) [Ep 27 · 35:01](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2101)
- "The dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division." — Steven Rothenberg (clinical) [Ep 27 · 35:15](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2115)
- "Vascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage." — Steven Rothenberg (clinical) [Ep 27 · 35:52](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2152)
- "Clips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping." — Steven Rothenberg (opinion) [Ep 27 · 36:59](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2219)
- "Using energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding." — Steven Rothenberg (opinion) [Ep 27 · 37:46](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2266)
- "Rothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open." — Steven Rothenberg (clinical) [Ep 27 · 39:09](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2349)
- "If using the LigaSure device, do not activate the cutting function; seal, remove the device, and cut with scissors to allow partial division and confirmation of hemostasis." — Todd Ponsky (host_summary) [Ep 27 · 39:28](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2368)
- "The first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein." — Steven Rothenberg (clinical) [Ep 27 · 42:01](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2521)
- "The ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery." — Steven Rothenberg (clinical) [Ep 27 · 42:54](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2574)
- "In a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly." — Steven Rothenberg (clinical) [Ep 27 · 44:06](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2646)
- "The bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery." — Steven Rothenberg (clinical) [Ep 27 · 45:23](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2723)
- "If the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control." — Steven Rothenberg (clinical) [Ep 27 · 45:35](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2735)
- "When using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds." — Steven Rothenberg (clinical) [Ep 27 · 46:25](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2785)
- "Rothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically." — Steven Rothenberg (clinical) [Ep 27 · 47:35](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2855)
- "After dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus." — Steven Rothenberg (clinical) [Ep 27 · 48:04](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2884)
- "In children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice." — Steven Rothenberg (clinical) [Ep 27 · 49:11](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2951)
- "After dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium." — Steven Rothenberg (clinical) [Ep 27 · 49:46](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=2986)
- "If a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control." — Steven Rothenberg (clinical) [Ep 27 · 50:33](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3033)
- "Right lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery." — Steven Rothenberg (clinical) [Ep 27 · 51:03](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3063)
- "For left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first." — Steven Rothenberg (clinical) [Ep 27 · 52:02](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3122)
- "After taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein." — Steven Rothenberg (clinical) [Ep 27 · 53:23](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3203)
- "In left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved." — Steven Rothenberg (clinical) [Ep 27 · 54:06](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3246)
- "Working through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus." — Steven Rothenberg (clinical) [Ep 27 · 54:30](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3270)
- "For right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches." — Steven Rothenberg (clinical) [Ep 27 · 55:47](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3347)
- "If the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure." — Steven Rothenberg (clinical) [Ep 27 · 57:38](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3458)
- "Extralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter." — Steven Rothenberg (clinical) [Ep 27 · 58:40](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3520)
- "For sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm)." — Steven Rothenberg (clinical) [Ep 27 · 58:58](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3538)
- "Never use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding." — Steven Rothenberg (clinical) [Ep 27 · 59:45](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3585)
- "Systemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical." — Steven Rothenberg (clinical) [Ep 27 · 60:43](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3643)
- "Extralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated." — Steven Rothenberg (opinion) [Ep 27 · 61:07](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3667)
- "Rothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up." — Steven Rothenberg (clinical) [Ep 27 · 62:42](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3762)
- "A chest tube is left overnight after lobectomy; if no air leak or drainage, it is removed the morning of postoperative day 1, chest X-ray obtained 2 hours later, and patient discharged that afternoon." — Steven Rothenberg (clinical) [Ep 27 · 64:46](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3886)
- "Average length of stay for lobectomy is 2.5 days; it is shorter (under 2 days) in infants under 5 kg." — Steven Rothenberg (clinical) [Ep 27 · 65:33](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-307?t=3933)
- "The frequency and incidence of abdominal wall defects appears to be increasing" (host_summary) [Ep 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 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 33 · 51:09](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-821?t=3069)
- "The patient underwent coarctation repair and PA banding at 2 days of life via end-to-end anastomotic repair after resection of coarc segment, plus left carotid to left subclavian artery side-to-side anastomosis" — Anisa Chowdhury (clinical) [Ep 7 · 0:46](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=46)
- "The patient underwent right modified Blalock-Thomas-Taussig shunt at 6 weeks of age, bidirectional Glenn at 6 months, and 20mm extracardiac Fontan at 4 years of age" — Anisa Chowdhury (clinical) [Ep 7 · 1:00](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=60)
- "The Fontan fenestration spontaneously closed and patient had transcatheter coil and vascular plugging of veno-venous collaterals at approximately 10 years of age" — Anisa Chowdhury (clinical) [Ep 7 · 1:12](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=72)
- "On 2006 catheterization, Fontan pressures were 12 mmHg and left ventricular end-diastolic pressure was 5 mmHg, both normal" — Anisa Chowdhury (clinical) [Ep 7 · 1:22](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=82)
- "Patient was lost to follow-up from age 16 to 21 years until presenting pregnant in first trimester" — Anisa Chowdhury (clinical) [Ep 7 · 1:41](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=101)
- "Lisinopril is teratogenic and should be stopped in pregnancy" — Anisa Chowdhury (guideline) [Ep 7 · 1:49](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=109)
- "Patient had 3 prior miscarriages and was told to use Depo-Provera contraception but only had 1 injection in past 3-4 years" — Anisa Chowdhury (clinical) [Ep 7 · 1:58](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=118)
- "Patient had baseline NYHA class 2-3 dyspneic symptoms (short of breath climbing one flight of stairs or walking 2 blocks) with no change during first couple trimesters of pregnancy" — Anisa Chowdhury (clinical) [Ep 7 · 2:08](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=128)
- "Patient's oxygen saturation was low-normal at 92% on room air" — Anisa Chowdhury (clinical) [Ep 7 · 2:39](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=159)
- "Echocardiogram showed mildly reduced left ventricular systolic function with estimated LVEF 45-50%" — Anisa Chowdhury (clinical) [Ep 7 · 3:20](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=200)
- "Patient had mild polycythemia with hemoglobin of 17, indicative of probable intermittent desaturations likely from venous collaterals" — Anisa Chowdhury (clinical) [Ep 7 · 4:20](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=260)
- "Patient was classified as WHO class 3 risk, indicating significantly elevated risk of both maternal morbidity and mortality during peripartum period" — Anisa Chowdhury (clinical) [Ep 7 · 4:43](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=283)
- "Management included aspirin 162 mg daily; stronger anticoagulation not pursued given unremarkable thrombophilia profile" — Anisa Chowdhury (clinical) [Ep 7 · 5:06](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=306)
- "Beta blocker was considered if LV function remained depressed on subsequent visits" — Anisa Chowdhury (clinical) [Ep 7 · 5:18](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=318)
- "Normal pregnancy causes decreased systemic vascular resistance, decreased PVR, increased heart rate, drop in blood pressure mid-pregnancy that rises again, and increase in cardiac output by about 50% and blood volume by 25%" — Nicole Brown (clinical) [Ep 7 · 7:11](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=431)
- "Risk of thrombosis is about 6 times normal during pregnancy and as high as 11 times normal in first 6 weeks postpartum" — Nicole Brown (epidemiological) [Ep 7 · 7:33](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=453)
- "During labor without analgesia, cardiac output may increase by about 30% during each contraction; with regional analgesia this is mitigated to some degree" — Nicole Brown (clinical) [Ep 7 · 7:53](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=473)
- "It takes about 6 months for cardiac output to return to non-pregnant levels postpartum" — Nicole Brown (clinical) [Ep 7 · 8:26](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=506)
- "Miscarriage rate among Fontan single ventricle patients is about 46%" — Nicole Brown (epidemiological) [Ep 7 · 8:45](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=525)
- "In a systematic review of about 198 pregnancies in 110 Fontan women, there were no maternal deaths" — Nicole Brown (epidemiological) [Ep 7 · 9:05](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=545)
- "In Fontan pregnancies, SVT occurs in about 8.9% and heart failure in about 5%" — Nicole Brown (epidemiological) [Ep 7 · 9:22](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=562)
- "Most Fontan women deliver between 26 and 36 weeks gestation, not making it to term (37 weeks)" — Nicole Brown (epidemiological) [Ep 7 · 9:40](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=580)
- "Risk of congenital heart disease in fetus of Fontan mother is probably between 3-10%" — Nicole Brown (epidemiological) [Ep 7 · 9:56](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=596)
- "WHO class 3 indicates significantly increased risk of maternal mortality or severe morbidity; in Fontan pregnancy it is more the morbidity that is concerning, not the mortality" — Nicole Brown (clinical) [Ep 7 · 10:23](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=623)
- "Fontan women should be followed in a multidisciplinary care unit with serial echocardiograms" — Nicole Brown (guideline) [Ep 7 · 10:52](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=652)
- "Higher-risk Fontan patients include those with significant NYHA functional class deterioration, residual cyanosis, pulmonary hypertension, arrhythmias, multi-organ failure, or protein-losing enteropathy; these should be classified as class 4 and advised against pregnancy" — Nicole Brown (guideline) [Ep 7 · 11:20](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=680)
- "Warfarin is concerning from aspect of teratogenicity, especially in first trimester" — Nicole Brown (clinical) [Ep 7 · 13:35](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=815)
- "Aspirin seems reasonable for most Fontan pregnant patients" — Nicole Brown (opinion) [Ep 7 · 13:46](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=826)
- "For Fontan patients at higher thrombotic risk (arrhythmias, prior clot, low cardiac output), therapeutic anticoagulation should be considered" — Nicole Brown (guideline) [Ep 7 · 13:51](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=831)
- "Delivery should be at tertiary care center where highest level of cardiac, OB, anesthesia, and neonatal care is available" — Nicole Brown (guideline) [Ep 7 · 14:27](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=867)
- "Left lateral decubitus position improves systemic venous return in pregnant Fontan patients" — Nicole Brown (clinical) [Ep 7 · 14:50](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=890)
- "Fontan patients should be kept adequately hydrated but avoid fluid overload" — Nicole Brown (guideline) [Ep 7 · 14:56](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=896)
- "Vaginal delivery with epidural is the preferred method for most Fontan women from cardiovascular perspective" — Nicole Brown (guideline) [Ep 7 · 15:10](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=910)
- "Oxytocin should be used at lowest effective dose to avoid significant hemodynamic fluctuations" — Nicole Brown (guideline) [Ep 7 · 15:24](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=924)
- "Fontan women should stay in hospital for up to about a week postpartum because that is how long it takes for hemodynamics to settle back out" — Nicole Brown (guideline) [Ep 7 · 15:32](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=932)
- "Estrogen-containing contraceptives should be avoided in Fontan women because of increased thrombogenicity" — Nicole Brown (guideline) [Ep 7 · 15:58](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=958)
- "Pneumoperitoneum required for laparoscopic tubal ligation may be detrimental for Fontan patients" — Nicole Brown (clinical) [Ep 7 · 16:10](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=970)
- "Subdermal contraceptive implants are lowest risk, requiring only local anesthesia" — Nicole Brown (opinion) [Ep 7 · 16:23](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=983)
- "The aspirin dose of 162 mg in this patient was based on aspirin resistance testing" — Veldman (clinical) [Ep 7 · 18:06](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=1086)
- "Many centers use full anticoagulation in pregnant Fontan patients by definition, but this carries risk of antepartum and postpartum hemorrhage" — Veldman (clinical) [Ep 7 · 18:14](https://qa.library.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=1094)
- "Stacey Morrison is a clinical psychologist working in adult congenital heart disease and the Fontan Clinic." (host_summary) [Ep 8 · 0:03](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=3)
- "Psychosocial functioning is the interplay between psychological factors (internal processes including neurocognitive functioning, cognitive and intellectual functioning, executive functioning, mood, anxiety, temperament, and personality factors) and social factors (levels of social support including family supports, school supports for children, employment, social interactions with peers, community involvement, and areas where they may feel productive in their social roles)." — Stacey Morrison (clinical) [Ep 8 · 1:42](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=102)
- "The presence of a congenital heart defect, especially a Fontan, often results in enormous emotional and financial strain on families, with continual effects from ongoing medical care and routine disruptions." — Stacey Morrison (clinical) [Ep 8 · 2:40](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=160)
- "Early life experiences of families with Fontan patients have profound impact and these experiences resonate across a lifetime." — Stacey Morrison (clinical) [Ep 8 · 3:11](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=191)
- "Children with complex CHD are at risk of neurological and cognitive impairment, and Fontan patients may be especially vulnerable." — Stacey Morrison (clinical) [Ep 8 · 3:24](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=204)
- "A multidisciplinary clinic at Children's includes psychology, developmental pediatricians, cardiologists, social work, education consultant, OT, nutrition, and speech and language professionals, focusing on evaluation, consultation, and coordination of care for especially vulnerable children followed into adulthood." — Stacey Morrison (clinical) [Ep 8 · 3:34](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=214)
- "As adults, Fontan patients remain at risk for significant sequelae and face significant and very unique life stressors that place them at increased risk for ongoing distress." — Stacey Morrison (clinical) [Ep 8 · 4:13](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=253)
- "Typical neurodevelopmental issues in Fontan patients include lower IQ, difficulty with math and language-based academic achievement, impairments in expressive and receptive language skills and written expression skills (including organization and planning of expression), executive functioning deficits (behavioral and metacognitive), flexible attention shifting problems (distractibility and hyperfocus), poor planning and organization problems, difficulty with time management, diminished fine and gross motor skills, working memory issues, and slowed processing speed." — Stacey Morrison (clinical) [Ep 8 · 4:32](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=272)
- "A very high number of Fontan patients are left-handed (anecdotal observation)." — Stacey Morrison (clinical) [Ep 8 · 5:44](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=344)
- "Approximately 1 in 3 adults with CHD in North America experience difficulty with depression and/or anxiety." — Stacey Morrison (epidemiological) [Ep 8 · 6:02](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=362)
- "Adolescents with single ventricle congenital heart disease have a 5-fold increase in rates of anxiety disorders as well as ADHD compared with their healthy control peers." — Stacey Morrison (epidemiological) [Ep 8 · 6:13](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=373)
- "Adults with CHD may have significantly higher risk of PTSD than in the general population." — Stacey Morrison (epidemiological) [Ep 8 · 6:29](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=389)
- "The chronic impact over time of disruption contributes to PTSD risk, and parents early on also show signs of PTSD." — Stacey Morrison (clinical) [Ep 8 · 6:50](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=410)
- "Mitigating psychosocial factors for adults with Fontan include differences in body image or perceptions of scarring, perceived health status or severity of disease, poor social support or social anxiety, performance anxiety, tendency to compare themselves and feel different than others with difficulties in social situations, communication skill deficits extending into adulthood, lack of awareness of how these factors impact self-adjustment and ability to interact with others and coping skills, perceived or real lack of independence, impulsivity or poor problem solving, ongoing difficulty maintaining employment for physical or psychological reasons, and contributing financial strain." — Stacey Morrison (clinical) [Ep 8 · 7:07](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=427)
- "The case patient is a 15-year-old female with complex medical history resulting in a Fontan, who had feeding difficulties early on requiring a G-tube in early childhood." — Stacey Morrison (clinical) [Ep 8 · 8:43](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=523)
- "Extra medical requirements such as G-tubes can contribute to changes in parent-child interactions and family dynamics." — Stacey Morrison (clinical) [Ep 8 · 9:06](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=546)
- "The case patient has an extensive medication regimen, could verbalize her medication list, was very aware of all medications, and was reported to take them consistently; on adaptive scales, self-care and health management was really high." — Stacey Morrison (clinical) [Ep 8 · 9:16](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=556)
- "Children and young adults who tend to be anxious do a really nice job of taking care of their healthcare regimen and are very hypervigilant about that area." — Stacey Morrison (clinical) [Ep 8 · 9:39](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=579)
- "The case patient lives in a rural area with her mother and 16-year-old brother; parents are divorced (contentious early on), and she does not have consistent contact with her father." — Stacey Morrison (clinical) [Ep 8 · 10:05](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=605)
- "The case patient had friends in school but recently moved, lost established friends, and her closest friend had moved away with no contact; the family as a whole is pretty isolated and mother is under quite a bit of stress." — Stacey Morrison (clinical) [Ep 8 · 10:21](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=621)
- "The case patient just transitioned into high school with academic concerns surrounding reading comprehension, math reasoning, retention of complex academic information (especially abstract reasoning), and applied skills including written expression." — Stacey Morrison (clinical) [Ep 8 · 11:00](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=660)
- "The case patient missed quite a bit of school for medical reasons (appointments and procedures), and over time there were increased days staying home because she didn't feel good, probably could have gone to school at least part of the day, which played into anxiety and comfort of being home." — Stacey Morrison (clinical) [Ep 8 · 11:09](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=669)
- "Loss of school days results in losing instruction time, piled-up assignments, and missing social interaction and positive social experiences that contribute to sense of satisfaction and competency." — Stacey Morrison (clinical) [Ep 8 · 11:45](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=705)
- "At presentation, the case patient was complaining of fluttering heart and a lot of somatic body pain; she denied anxiety when asked directly, but her mother reported she reported feeling panicky and was panting (significant signs of anxiety)." — Stacey Morrison (clinical) [Ep 8 · 12:05](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=725)
- "The case patient is described as very meek, very self-conscious, and often very keyed up or on edge; at school she would not ask for help and wanted to be under the radar if at all possible." — Stacey Morrison (clinical) [Ep 8 · 12:31](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=751)
- "The case patient worried about missing assignments, which could lead to more procrastination and avoidance of school; she did not view herself as being as capable as peers, and any talk about differences led her to report feeling stupid or not smart." — Stacey Morrison (clinical) [Ep 8 · 12:44](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=764)
- "During evaluation, the case patient presented as extremely polite, arrived a bit late, very cooperative, very soft-spoken, difficult to get her to engage, does not initiate; on verbal components there was a lot of query and exploring needed to get information; if not sure of an answer she was hesitant to take a guess; on nonverbal tasks her approach was disorganized; she seemed anxious and when things became more challenging she tended to shut down and become tearful, appeared embarrassed." — Stacey Morrison (clinical) [Ep 8 · 13:07](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=787)
- "On the WISC-5 (standardized cognitive measure), the case patient's full-scale IQ is 82, which falls in the low average range when compared to other children her age." — Stacey Morrison (clinical) [Ep 8 · 14:18](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=858)
- "The case patient's verbal index was in the average range, nonverbal in the low average range, and her weakest areas of performance were working memory and processing speed." — Stacey Morrison (clinical) [Ep 8 · 14:35](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=875)
- "Academically, the case patient's stronger areas are basic phonetic decoding, reading accuracy, sentence completion, spelling, and numerical sequencing (basic rote skills)." — Stacey Morrison (clinical) [Ep 8 · 14:57](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=897)
- "The case patient has difficulty with higher-level reading comprehension, reading fluency (reads slowly, has to reread for accuracy of understanding), math calculation and reasoning, and listening recall." — Stacey Morrison (clinical) [Ep 8 · 15:10](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=910)
- "In the classroom, the case patient often feels overwhelmed and very anxious, feels like she's behind the eight ball at all times, has difficult time processing what's being instructed (feels it's going too fast), doesn't ask questions, often does not bring home materials needed or actual assignment requirements because she has hard time copying from the board and keeping up with her planner." — Stacey Morrison (clinical) [Ep 8 · 15:27](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=927)
- "Low-level organizational and processing issues contribute to further withdrawal and feeling of inadequacy in the case patient." — Stacey Morrison (clinical) [Ep 8 · 16:00](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=960)
- "The case patient reports a high level of test anxiety, with her mind going blank and difficulty recalling any information." — Stacey Morrison (clinical) [Ep 8 · 16:11](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=971)
- "Diagnostic rating scales (BRIEF - Behavior Rating Inventory of Executive Function) distributed to school personnel, mother, and patient showed significant executive dysfunction in areas of organization, planning, initiating, task persistence, and attention dysregulation." — Stacey Morrison (clinical) [Ep 8 · 16:33](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=993)
- "The case patient met criteria for ADHD, predominantly inattentive presentation (not the hyperactive or impulsive components)." — Stacey Morrison (clinical) [Ep 8 · 17:08](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1028)
- "Additional ratings indicated significant levels of anxiety and somatic or health-related complaints, a lot of dysphoria, and sense of inadequacy, best represented with a diagnosis of generalized anxiety disorder." — Stacey Morrison (clinical) [Ep 8 · 17:17](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1037)
- "The initial care plan included encouragement to pursue ongoing counseling (with the psychologist or options close to home); the family was very closed in and other than medically presenting were not really likely to come in, and despite voicing interest they did not come back for psychotherapy." — Stacey Morrison (clinical) [Ep 8 · 17:46](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1066)
- "The school was willing to accommodate with a shortened school week (3 partial days per week) to allow time for medical planning and appointments while condensing core instruction time, with assistance in core instruction areas so the patient could demonstrate mastery without excessive assignments compiling." — Stacey Morrison (clinical) [Ep 8 · 18:38](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1118)
- "All listed psychosocial factors (limited social support, low self-confidence and performance anxiety, isolation) are contributing factors to patient outcomes, with the relative importance dependent on where the family is at; isolation is a significant part because it plays into low sense of competency and further social withdrawal, not integrating back into the community." — Stacey Morrison (opinion) [Ep 8 · 19:48](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1188)
- "Clinicians should assume that Fontan patients are going to have adjustment issues, which normalizes the challenges and gives credence to them, starting the conversation very early that emotional and mental support is a basic part of the care plan (equal opportunity, not selective for those not doing well)." — Stacey Morrison (opinion) [Ep 8 · 21:08](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1268)
- "Having conversations about mental health very early is important because there is still a lot of misconception about what that represents; conversations should start early with parents as well to normalize that they are juggling a lot and this disrupts work and the entire family." — Stacey Morrison (opinion) [Ep 8 · 21:48](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1308)
- "A solution-focused approach asking 'what is working' taps into patient and family strengths." — Stacey Morrison (opinion) [Ep 8 · 22:12](https://qa.library.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1332)
- "In adult Fontan patients, ventricular function is either moderately or severely dysfunctional but often does not change very much over the years." — Andrew Crean (clinical) [Ep 15 · 2:37](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=157)
- "T1 mapping in adolescent Fontan patients shows fibrosis content is higher than in normal controls and significantly higher in those with systemic right ventricles compared to systemic left ventricles." — Andrew Crean (host_summary) [Ep 15 · 1:51](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=111)
- "A change in ventricular function in a Fontan patient is an indicator to look at the ventricle more carefully, as this is not frequently seen." — Andrew Crean (clinical) [Ep 15 · 2:50](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=170)
- "Embolic ventricular dysfunction is not a common feature of Fontans, but embolic complications are seen roughly once a year in the Toronto center." — Andrew Crean (epidemiological) [Ep 15 · 3:57](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=237)
- "Thrombus imaging in Fontan circuits is generally not done very well, particularly in adult Fontan circulations." — Andrew Crean (opinion) [Ep 15 · 4:11](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=251)
- "Timing is everything in imaging of the Fontan circulation, and usually imaging is performed too quickly, leading to false-positive thrombus diagnoses." — Andrew Crean (clinical) [Ep 15 · 6:07](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=367)
- "Premature contrast timing is a particular problem with on-call PE studies done in the middle of the night." — Andrew Crean (clinical) [Ep 15 · 6:13](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=373)
- "Radiologists imaging the chest typically want to image in the pulmonary arterial phase, which is too early to adequately opacify the IVC portion of Fontan circuits." — Andrew Crean (clinical) [Ep 15 · 7:07](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=427)
- "In large atriopulmonary Fontans, it can take up to 7 minutes for contrast to fully opacify the circuit and confidently exclude thrombus." — Andrew Crean (clinical) [Ep 15 · 8:02](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=482)
- "Late gadolinium enhancement imaging performed 10 minutes after contrast administration is effective for detecting thrombus in Fontan circuits." — Andrew Crean (clinical) [Ep 15 · 10:23](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=623)
- "Both CT and MRI are exquisitely good at looking at the presence of thrombus in Fontan circuits, and CT allows easy volumetric measurement of thrombus over time." — Andrew Crean (clinical) [Ep 15 · 10:40](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=640)
- "The tried and tested approach to managing large atrial thrombus in Fontan patients involves anticoagulation with heparin." — Andrew Crean (clinical) [Ep 15 · 11:16](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=676)
- "Resolution of Glenn shunt thrombus with TPA was associated with normalization of albumin levels, suggesting a link between venous obstruction and protein-losing enteropathy." — Andrew Crean (clinical) [Ep 15 · 12:36](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=756)
- "Fontan patients in their mid-80s oxygen saturation without open fenestrations are unusual and warrant investigation for causes of desaturation." — Andrew Crean (clinical) [Ep 15 · 13:21](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=801)
- "Veno-venous collaterals and arteriovenous malformations are easily seen by CT or MRI angiography but very difficult to detect in any other way." — Andrew Crean (clinical) [Ep 15 · 14:06](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=846)
- "The spatial resolution of cross-sectional imaging, particularly CT, allows detection of very subtle features such as highly stenotic coronary sinus drainage to the left atrium." — Andrew Crean (clinical) [Ep 15 · 14:39](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=879)
- "A Fontan patient presenting with a heart failure phenotype, particularly edema, does not necessarily have pump failure; conduit stenosis can present with anasarca." — Andrew Crean (clinical) [Ep 15 · 16:05](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=965)
- "Plastic bronchitis has not been seen in adult Fontan patients in 10 years at the Toronto center, though it is easy to detect by CT." — Andrew Crean (clinical) [Ep 15 · 17:21](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1041)
- "In adult patients, echocardiography is not adequate for thrombus detection in a Fontan circuit." — Andrew Crean (opinion) [Ep 15 · 18:13](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1093)
- "Transesophageal echo for detecting thrombus in an atriopulmonary Fontan is a waste of time and should not be done prior to cardioversion." — Andrew Crean (opinion) [Ep 15 · 19:47](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1187)
- "It took roughly 10 years and many cases where CT or MR were right and echo was wrong to convert colleagues in Toronto away from routine TEE for Fontan thrombus assessment." — Andrew Crean (clinical) [Ep 15 · 20:03](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1203)
- "Cardiac CT can be obtained within about 1 hour, which is more practical than organizing space on the CCU for a TEE in a sick Fontan patient." — Andrew Crean (clinical) [Ep 15 · 20:13](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1213)
- "The spatial resolution of cardiac CT is at worst 0.5 millimeters isotropic, which is sufficient to detect small thrombi." — Andrew Crean (clinical) [Ep 15 · 20:53](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1253)
- "In 10 years of practice, there have been no cases requiring escalation from CT to echo based on doubt about thrombus detection." — Andrew Crean (clinical) [Ep 15 · 21:25](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1285)
- "There are large series in the adult AF population with outcomes up to about a year suggesting no increased stroke risk when CT is used instead of TEE for pre-cardioversion thrombus assessment." — Andrew Crean (host_summary) [Ep 15 · 24:05](https://qa.library.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1445)
- "Fontan-associated plastic bronchitis occurs in less than 2% of patients with Fontan circulation" — Brian (epidemiological) [Ep 14 · 1:56](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=116)
- "Plastic bronchitis is characterized by proteinaceous lymphatic effluent into the tracheobronchial tree where there are connections between the lymphatic circulation and the airway" — Brian (clinical) [Ep 14 · 2:01](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=121)
- "With evaporation of water content through breathing, characteristic fibrinous airway casts remain and may be expectorated in whole or in part" — Brian (clinical) [Ep 14 · 2:09](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=129)
- "The incidence of fenestration thrombosis or stenosis early after the procedure and in short and mid-term follow-up is very high with bare metal stents, presumably from tissue invagination through the cells of the stent and tissue factor exposure to blood" — Brian (clinical) [Ep 14 · 5:16](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=316)
- "Even on anticoagulation, thrombosis is pretty common with bare metal stents used for fenestration creation" — Brian (clinical) [Ep 14 · 5:34](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=334)
- "Good procedures don't always mean much - one can do a good intervention in a complex population but it doesn't always mean you're going to change the ultimate clinical outcome" — Brian (opinion) [Ep 14 · 5:46](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=346)
- "The Fontan population has a very high incidence of liver-related pathologies" — Brian (epidemiological) [Ep 14 · 6:51](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=411)
- "Having obstruction in the inferior limb of the Fontan can be a real problem as it only serves to augment venous hypertension" — Brian (clinical) [Ep 14 · 7:09](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=429)
- "A resting absence of gradient does not rule out the presence of hemodynamically meaningful obstruction" — Brian (clinical) [Ep 14 · 7:13](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=433)
- "Left innominate vein obstruction can create opportunity for patients to present with either plastic bronchitis or protein-losing enteropathy, two diagnoses associated with very adverse clinical outcomes that have been shown increasingly to be associated with lymphatic pathology, especially by the group from Philadelphia" — Brian (clinical) [Ep 14 · 8:37](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=517)
- "Secondary palliations (palliation of a palliation, the Fontan circuit) have limitations - they may not offer cure, may not even offer substantial benefits" — Brian (opinion) [Ep 14 · 9:47](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=587)
- "Sometimes we're not able to test the hypothesis until we actually perform the intervention" — Brian (opinion) [Ep 14 · 9:57](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=597)
- "The approach to transcatheter interventions must be taken from a multidisciplinary perspective - therapies have both medical and surgical considerations to future therapies, to the need for anticoagulation" — Brian (opinion) [Ep 14 · 10:03](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=603)
- "Everything we do can have sequelae - it's really important to make sure that the multiple disciplines we use to care for these patients all understand and appreciate the implications of decision making and therapies" — Brian (opinion) [Ep 14 · 10:38](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=638)
- "Stent in conduit equals thrombogenic behavior substrate" — Brian (clinical) [Ep 14 · 12:59](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=779)
- "A 12-year-old young man being on Coumadin is not free (not without consequences)" — Brian (opinion) [Ep 14 · 13:05](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=785)
- "Having seen many of these patients grow up and face symptoms increasing through their teenage years, it's worth being aggressive when there's anatomic deficiencies within the circuit" — Brian (opinion) [Ep 14 · 13:18](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=798)
- "The fluid challenge protocol involves giving 15 cc per kilo with no limit of fluid volume rapidly via central access in about 2 minutes, then starting a timer with 5 minutes from the end of fluid challenge until repeat hemodynamic runs are measured" — Brian (clinical) [Ep 14 · 13:59](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=839)
- "Fluid challenge is not performed if patients have overt diastolic dysfunction, defined as baseline EDP at resting EDP of greater than 15" — Brian (clinical) [Ep 14 · 14:19](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=859)
- "Fluid challenge is not performed if patients have baseline Fontan pressure greater than 18 and/or repeated hospitalizations with heart failure to get volume off" — Brian (clinical) [Ep 14 · 14:30](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=870)
- "We can safely take Gore-Tex tubes to at least 110% of their nominal diameter" — Brian (clinical) [Ep 14 · 15:23](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=923)
- "Beyond 110% of nominal diameter, there is a bit of risk, but the risk is probably pretty subtle for moderate dilation (e.g., 18mm tube to 22mm)" — Brian (opinion) [Ep 14 · 15:31](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=931)
- "There is always risk at the anastomosis where it's hard to necessarily cover that should a problem arise because hepatic vein enters very close" — Brian (clinical) [Ep 14 · 15:44](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=944)
- "Gore-Tex tubes can be taken up to about 110% - the stiffness constant is very high and you cannot generate enough pressure in the balloon to stretch the Gore-Tex much more than about 110%" (clinical) [Ep 14 · 16:06](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=966)
- "The risk of rupture is actually very low when dilating Gore-Tex conduits" (opinion) [Ep 14 · 16:17](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=977)
- "There are few patients who have an undersized tube at placement and really require augmentation of the nominal diameter" — Brian (epidemiological) [Ep 14 · 16:32](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=992)
- "Extracardiac conduits are three-dimensional structures that are not circular - if a 22mm tube measures 17mm in the frontal plane, it often measures 25mm in the lateral plane, and the cross-sectional area is just fine" — Brian (clinical) [Ep 14 · 17:01](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=1021)
- "It's important that there's a true stenosis, not just a non-circular shape, for us to want to treat conduit narrowing" — Brian (opinion) [Ep 14 · 17:19](https://qa.library.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=1039)
- "40-50% of cardiac output at baseline in Fontan patients is driven directly by the work of breathing" — Andrew Reddington (clinical) [Ep 13 · 2:43](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=163)
- "Negative mean airway pressure during normal ventilation draws blood into the Fontan circuit" — Andrew Reddington (clinical) [Ep 13 · 3:14](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=194)
- "Valsalva maneuver with mean airway pressure elevated to 20 cm H2O cuts off spontaneous respiratory flow, leaving only tiny flow with ventricular systole" — Andrew Reddington (clinical) [Ep 13 · 3:25](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=205)
- "Low pulmonary vascular resistance is a prerequisite for good Fontan outcome" — Andrew Reddington (clinical) [Ep 13 · 4:01](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=241)
- "In normal individuals, nitric oxide does not reduce pulmonary vascular resistance because the pulmonary vascular bed is maximally vasodilated" — Andrew Reddington (clinical) [Ep 13 · 4:52](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=292)
- "Nitric oxide produced a statistically and physiologically significant fall in pulmonary vascular resistance of about 1 index wood unit in teenage Fontan patients" — Andrew Reddington (clinical) [Ep 13 · 5:01](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=301)
- "Only half of teenage Fontan patients showed benefit from nitric oxide" — Andrew Reddington (clinical) [Ep 13 · 5:39](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=339)
- "If only half of Fontan patients benefit from nitric oxide, they are unlikely to further benefit from PDE5 inhibitors" — Andrew Reddington (opinion) [Ep 13 · 6:00](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=360)
- "CHOP data showed no difference in outcomes in the first 10 years after Fontan between hypoplastic left heart syndrome and systemic left ventricle patients" — Andrew Reddington (host_summary) [Ep 13 · 6:54](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=414)
- "Boston data showed patients born with systemic left ventricle with normally related great vessels or single right ventricle do better than all other diagnoses" — Andrew Reddington (host_summary) [Ep 13 · 7:21](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=441)
- "Melbourne group data showed right ventricular dominance is a risk factor if present at birth, but after surviving the first couple of years post-Fontan, survival curves are essentially identical regardless of ventricular morphology" — Andrew Reddington (host_summary) [Ep 13 · 7:40](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=460)
- "The systemic ventricle in Fontan circulation is hypercontractile to match its increased afterload" — Andrew Reddington (clinical) [Ep 13 · 8:22](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=502)
- "Force-frequency relationships in systemic right and left ventricles in univentricular circulation outperformed normal ventricles" — Andrew Reddington (host_summary) [Ep 13 · 8:37](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=517)
- "End-systolic elastance in Fontan patients is orders of magnitude higher than normals and even greater than in systemic right ventricle of Mustard patients" — Andrew Reddington (host_summary) [Ep 13 · 9:03](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=543)
- "Arterial elastance is high in Fontan patients but relatively well coupled to ventricular elastance" — Andrew Reddington (clinical) [Ep 13 · 9:29](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=569)
- "The primary problem in Fontan ventricles is in diastole, not systole" — Andrew Reddington (clinical) [Ep 13 · 9:29](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=569)
- "In early post-Fontan course, it is early diastole (E wave) that is affected, not late diastole (A wave), with virtual abolishment of early rapid filling" — Andrew Reddington (clinical) [Ep 13 · 10:14](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=614)
- "Time constant of relaxation and isovolumic relaxation time are prolonged in early post-Fontan patients, indicative of impaired relaxation" — Andrew Reddington (clinical) [Ep 13 · 10:43](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=643)
- "Impaired early relaxation is due to incoordinate wall motion during isovolumic relaxation, with post-systolic shortening of one part of the ventricle causing another part to move outward" — Andrew Reddington (clinical) [Ep 13 · 10:56](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=656)
- "MRI tagging showed some segments of Fontan ventricular wall were 180 degrees out of phase with other parts, in systole when rest of ventricle was in diastole" — Andrew Reddington (host_summary) [Ep 13 · 11:58](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=718)
- "Longer isovolumic relaxation time correlates with longer hospital stay immediately after Fontan operation" — Andrew Reddington (clinical) [Ep 13 · 12:23](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=743)
- "Late post-Fontan patients can develop pseudonormalized filling pattern (E > A) due to rising left atrial pressure despite persistent incoordinate relaxation" — Andrew Reddington (clinical) [Ep 13 · 13:03](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=783)
- "In normal individuals, left ventricular end-diastolic pressure rises by about 2 mmHg per decade after age 30" — Andrew Reddington (clinical) [Ep 13 · 13:36](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=816)
- "Eight-year follow-up of Fontan patients showed maintained incoordinate relaxation, shortened IVRT suggesting rising left atrial pressure, and faster E wave deceleration suggesting falling compliance" — Andrew Reddington (host_summary) [Ep 13 · 14:18](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=858)
- "Diastolic compliance of Fontan ventricles (predominantly left ventricles) is highly abnormal, unlike Mustard systemic right ventricles where diastolic compliance is not a problem" — Andrew Reddington (host_summary) [Ep 13 · 14:47](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=887)
- "Fontan patients with high diastolic stiffness may have low end-diastolic pressure because reduced preload causes the ventricle to become smaller and pressure to fall down the pressure-volume curve" — Andrew Reddington (clinical) [Ep 13 · 15:33](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=933)
- "Bench pressing 500 pounds essentially cuts off pulmonary blood flow in Fontan patients" — Andrew Reddington (clinical) [Ep 13 · 17:37](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1057)
- "Sustained Valsalva maneuvers may be particularly disadvantageous in old atrio-pulmonary Fontans due to direct effects on atrial stretch and potential for chronic atrial arrhythmias" — Andrew Reddington (opinion) [Ep 13 · 18:13](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1093)
- "Mayo Clinic series with longer follow-up suggests right ventricular morphology does appear to be a risk factor late after Fontan" (epidemiological) [Ep 13 · 19:32](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1172)
- "PHN data at 10-12 years post-Fontan showed systemic right ventricles had far more patients with increased E/E' ratio (indicating increased stiffness) compared to systemic left ventricles" — Andrew Reddington (host_summary) [Ep 13 · 20:04](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1204)
- "Rise in end-diastolic pressure in normal individuals is more rapid with hypertension, diabetes, other risk factors, and ventricular volume load such as AV valve or aortic regurgitation" — Andrew Reddington (clinical) [Ep 13 · 21:58](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1318)
- "Fontan patients frequently have some degree of volume load and have had volume load for the first few years of life" — Andrew Reddington (clinical) [Ep 13 · 22:33](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1353)
- "All Fontan patients have very raised arterial impedance and systemic vascular resistance" — Andrew Reddington (clinical) [Ep 13 · 22:44](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1364)
- "Recent conductance catheter work from the Netherlands shows a tight relationship between arterial elastance and ventricular end-diastolic pressure" — Andrew Reddington (host_summary) [Ep 13 · 23:01](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1381)
- "There is no evidence-based role for ACE inhibition or arterial vasodilators in short-term Fontan management, as systemic vasodilation drops cardiac output" — Andrew Reddington (opinion) [Ep 13 · 23:18](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1398)
- "Management of left ventricular end-diastolic pressure, fibrosis, and vascular biology have real potential as therapeutic targets in long-term Fontan management" — Andrew Reddington (opinion) [Ep 13 · 23:38](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1418)
- "Understanding the impact of long-term therapies for diastolic dysfunction will require 10-20 years of follow-up" — Andrew Reddington (opinion) [Ep 13 · 23:58](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1438)
- "The difference between 10-15 year outcomes and 20-30 year outcomes is important; abnormalities in diastolic relaxation will likely become clinically manifest later, and 30-year RV vs LV data are not yet available" (opinion) [Ep 13 · 24:38](https://qa.library.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1478)
- "More Fontan patients are surviving into adolescence and adulthood" — Lizzie Lee (epidemiological) [Ep 34 · 0:11](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=11)
- "Liver disease is becoming a rising issue in Fontan patients" — Lizzie Lee (epidemiological) [Ep 34 · 0:11](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=11)
- "Combined heart-liver transplantation is happening more often in Fontan patients" — Lizzie Lee (epidemiological) [Ep 34 · 0:11](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=11)
- "The study examined children and young adults undergoing combined heart-liver transplant at hospitals across the US in the last few years" — Lizzie Lee (clinical) [Ep 34 · 0:21](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=21)
- "Many of the patients in the study had hypoplastic left heart syndrome" — Lizzie Lee (clinical) [Ep 34 · 0:28](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=28)
- "About 85% of patients survived at 1 year after combined heart-liver transplant" — Lizzie Lee (clinical) [Ep 34 · 0:36](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=36)
- "Long-term outcomes after combined heart-liver transplant were excellent" — Lizzie Lee (clinical) [Ep 34 · 0:36](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=36)
- "Three-year survival after combined heart-liver transplant was basically identical to patients who received heart transplant alone" — Lizzie Lee (clinical) [Ep 34 · 0:41](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=41)
- "Combined heart-liver transplant is effective for Fontan patients with advanced liver disease" — Lizzie Lee (clinical) [Ep 34 · 0:48](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=48)
- "Combined heart-liver transplant is increasingly common for Fontan patients with advanced liver disease" — Lizzie Lee (epidemiological) [Ep 34 · 0:48](https://qa.library.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=48)
- "Adult prospective randomized trials show mechanical bowel prep alone does no good or probably harms patients" — Ian Glenn (clinical) [Ep 26 · 0:35](https://qa.library.globalcastmd.com/watch/do-we-need-bowel-prep-1331?t=35)
- "Oral antibiotics that are not absorbed are probably beneficial in adult colorectal surgery" — Ian Glenn (clinical) [Ep 26 · 0:41](https://qa.library.globalcastmd.com/watch/do-we-need-bowel-prep-1331?t=41)
- "One pediatric study showed mechanical bowel prep by itself led to higher infection rates in children" — Ian Glenn (clinical) [Ep 26 · 0:51](https://qa.library.globalcastmd.com/watch/do-we-need-bowel-prep-1331?t=51)
- "One pediatric study showed mechanical bowel prep by itself led to longer hospital stays in children" — Ian Glenn (clinical) [Ep 26 · 0:51](https://qa.library.globalcastmd.com/watch/do-we-need-bowel-prep-1331?t=51)
- "In one pediatric study, addition of antibiotics to mechanical bowel prep did not make any difference in outcomes" — Ian Glenn (clinical) [Ep 26 · 0:51](https://qa.library.globalcastmd.com/watch/do-we-need-bowel-prep-1331?t=51)
- "Another pediatric study showed mechanical bowel prep with oral antibiotics made no difference compared to no prep" — Ian Glenn (clinical) [Ep 26 · 1:01](https://qa.library.globalcastmd.com/watch/do-we-need-bowel-prep-1331?t=61)
- "For pediatric colostomy takedown, it is reasonable to omit both mechanical bowel prep and oral antibiotics" — Ian Glenn (opinion) [Ep 26 · 1:07](https://qa.library.globalcastmd.com/watch/do-we-need-bowel-prep-1331?t=67)
- "Esophagogastric dissociation was historically considered a last resort operation when Nissen fundoplication fails." — Todd Ponsky (host_summary) [Ep 3 · 0:14](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=14)
- "Esophagogastric dissociation is being suggested as an upfront primary operation for a small subset of patients with severe neurologic impairment." — Todd Ponsky (host_summary) [Ep 3 · 0:24](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=24)
- "In the study, operative failure was defined as either recurrence of preoperative reflux symptoms or requirement of additional anti-reflux surgery." — Ian Glenn (host_summary) [Ep 3 · 1:01](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=61)
- "The esophagogastric dissociation group had a 4% operative failure rate." — Ian Glenn (host_summary) [Ep 3 · 1:13](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=73)
- "The Nissen fundoplication group had a 21% operative failure rate." — Ian Glenn (host_summary) [Ep 3 · 1:13](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=73)
- "The difference in operative failure rates between esophagogastric dissociation and Nissen fundoplication was not statistically significant." — Ian Glenn (host_summary) [Ep 3 · 1:21](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=81)
- "17% of patients in the esophagogastric dissociation group continued to require anti-reflux medications after surgery." — Ian Glenn (host_summary) [Ep 3 · 1:23](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=83)
- "54% of patients in the Nissen fundoplication group continued to require anti-reflux medications after surgery." — Ian Glenn (host_summary) [Ep 3 · 1:23](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=83)
- "The difference in continued requirement for anti-reflux medications between groups was statistically significant." — Ian Glenn (host_summary) [Ep 3 · 1:23](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=83)
- "Caregiver-evaluated quality of life and symptom scores were the same between the esophagogastric dissociation and Nissen groups." — Ian Glenn (host_summary) [Ep 3 · 1:39](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=99)
- "The lack of statistical significance in operative failure rates could represent a type 2 error where the sample size was too small to detect an actual difference." — Ian Glenn (host_summary) [Ep 3 · 2:03](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=123)
- "A multi-center study will likely be needed to fully understand the comparative effectiveness of esophagogastric dissociation versus Nissen fundoplication." — Todd Ponsky (opinion) [Ep 3 · 2:12](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=132)
- "Leaks and strictures are the primary concerns that prevent most surgeons from performing esophagogastric dissociation." — Todd Ponsky (opinion) [Ep 3 · 2:15](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=135)
- "The study examined perioperative factors including OR time, length of hospital stay, need for ICU stay, and time to full feeds, finding statistically significant differences following expected trends." — Ian Glenn (host_summary) [Ep 3 · 2:26](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=146)
- "The study did not report on leaks, strictures, or long-term requirement for additional surgeries other than anti-reflux operations." — Ian Glenn (host_summary) [Ep 3 · 2:39](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-563?t=159)
- "Cincinnati changed practice 6-8 months ago to discharge intussusception patients home from the ER after a 4-hour observation period if they tolerate feeds and are hemodynamically stable." — Todd Ponsky (clinical) [Ep 4 · 0:57](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=57)
- "In a series of 48 intussusception patients discharged from the ED, only one recurred within 48 hours and that patient did not require operation, only repeat reduction." — Nick Bruns (host_summary) [Ep 4 · 2:01](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=121)
- "When contrast fills the appendix but does not reflux into small bowel after intussusception reduction, this is attributed to ileocecal edema; the recommendation is to observe and repeat the study in a few hours." — Nick Bruns (host_summary) [Ep 4 · 2:44](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=164)
- "The repeat enema study after initial reduction does not actually reduce the intussusception again; it proves the first reduction was successful because the edema has now resolved." (clinical) [Ep 4 · 3:04](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=184)
- "Ultrasound after intussusception reduction is difficult to interpret due to inflammation, so a contrast enema is preferred for confirmation." — Todd Ponsky (clinical) [Ep 4 · 3:19](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=199)
- "One surgeon previously removed the appendix during operative intussusception reduction but now leaves it in due to concern about appendiceal stump dehiscence if reoperation is needed." — Todd Ponsky (opinion) [Ep 4 · 3:43](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=223)
- "Age over 5 years is the inflection point for pathologic lead point in intussusception, with 30-60% of cases in this age group having a lead point depending on the series." — Nick Bruns (host_summary) [Ep 4 · 5:28](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=328)
- "For intussusception in a 6-year-old, one approach is to attempt radiologic reduction, then work up for lead point electively and perform resection in a non-inflamed setting." — Todd Ponsky (clinical) [Ep 4 · 4:22](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=262)
- "Many soft tissue abscesses are drained in the emergency department by ED physicians with sedation, not in the operating room." — Todd Ponsky (clinical) [Ep 4 · 6:50](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=410)
- "Vessel loops are used as wicks for abscess drainage instead of traditional packing by some surgeons." (clinical) [Ep 4 · 7:41](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=461)
- "A study at ABSA showed that packing abscesses did not make a difference in outcomes, yet surgeons continue to use packing or wicks." — Todd Ponsky (host_summary) [Ep 4 · 7:55](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=475)
- "Admission criteria for soft tissue abscess include cellulitis, fever, and leukocytosis in some combination; if the child appears sick, admission is warranted." — Todd Ponsky (clinical) [Ep 4 · 8:08](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=488)
- "Antibiotics are prescribed for soft tissue abscess only if cellulitis is present; otherwise patients go home without antibiotics." (clinical) [Ep 4 · 8:31](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=511)
- "In a retrospective review of abscess I&D cases discharged same-day from the OR, treatment failure (readmission or repeat I&D within 2 weeks) occurred in only 0.9% of patients." — Nick Bruns (epidemiological) [Ep 4 · 8:44](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=524)
- "Among patients with leukocytosis (white count up to 35), only 2 out of 138 had treatment failure after same-day discharge, and only one febrile patient had treatment failure." — Nick Bruns (epidemiological) [Ep 4 · 9:11](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=551)
- "For pilonidal disease, one surgeon operates after the second recurrence, though tries to delay as long as possible." — Todd Ponsky (opinion) [Ep 4 · 10:27](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=627)
- "The Bascom technique involves excising pits with an 11 blade at skin level under local anesthesia, allowing healing by secondary intention; 70% of patients do not recur, though there is no control group." (host_summary) [Ep 4 · 10:54](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=654)
- "For recurrent pilonidal disease or large draining sinuses, formal excision with off-midline layered closure and drain placement is performed." (clinical) [Ep 4 · 11:37](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=697)
- "Physical exam findings such as deep gluteal fold and excessive hair are high-risk factors that may influence timing and type of pilonidal surgery." — Todd Ponsky (clinical) [Ep 4 · 12:24](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=744)
- "For severe recurrent pilonidal disease, open excision with wet-to-dry dressing changes or wound vac is used." — Todd Ponsky (clinical) [Ep 4 · 12:50](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=770)
- "The Karydakis flap is superior to excision alone for pilonidal disease and comparable to the modified Limberg flap; the modified elliptical rotation flap has comparable short-term results." — Ian Glenn (host_summary) [Ep 4 · 13:04](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=784)
- "The key to preventing pilonidal recurrence is post-operative management: keeping the patient prone on bed rest until the wound heals, as it is primarily a wound healing problem from sitting on the surgical site." — Todd Ponsky (opinion) [Ep 4 · 13:43](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=823)
- "Plastic surgeons perform flap procedures for recurrent pilonidal disease and keep patients prone post-operatively." — Todd Ponsky (clinical) [Ep 4 · 14:02](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=842)
- "One patient reported laser hair removal for pilonidal disease was the most painful thing he had experienced and discontinued treatment after half a session." — Todd Ponsky (host_summary) [Ep 4 · 14:26](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=866)
- "Some surgeons have sent patients for laser hair removal without complaints, though ensuring adequate treatment area and obtaining insurance reimbursement remain challenges." — Todd Ponsky (clinical) [Ep 4 · 14:42](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=882)
- "After a negative Meckel scan in a child with hematochezia, one approach is colonoscopy with intent to proceed to laparoscopy if negative, ideally under the same anesthetic." (clinical) [Ep 4 · 15:34](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=934)
- "Starting a PPI for suspected Meckel diverticulum bleeding will stop the bleeding temporarily; it should never be an emergency operation." (clinical) [Ep 4 · 16:09](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=969)
- "For a bleeding Meckel diverticulum, if there is an ulcer at the base, segmental small bowel resection is performed rather than simple diverticulectomy." — Todd Ponsky (clinical) [Ep 4 · 17:00](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=1020)
- "Bill Gazetta taught at the fellows course that ulcers in Meckel bleeding are in the Meckel diverticulum itself, not in the adjacent small bowel." — Todd Ponsky (host_summary) [Ep 4 · 17:29](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=1049)
- "One position is that stapling off a bleeding Meckel removes the acid source, so the ulcer will heal without needing bowel resection, similar to vagotomy for peptic ulcer disease." (opinion) [Ep 4 · 17:39](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=1059)
- "The ectopic gastric mucosa in Meckel diverticulum is almost always at the tip of the diverticulum." — Todd Ponsky (clinical) [Ep 4 · 18:09](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=1089)
- "When performing Meckel diverticulectomy by pulling the diverticulum out through the umbilicus, marking the bowel edge with a marker while it is relaxed (not under tension) helps avoid narrowing the bowel lumen." — Todd Ponsky (clinical) [Ep 4 · 18:48](https://qa.library.globalcastmd.com/watch/intussusception-soft-tissue-abscess-pilonidal-cyst-bleeding-meckel-s-678?t=1128)
- "Fontan circulation is a profoundly prothrombotic state and thrombosis is a major cause of death in patients with Fontan circulation." — Joe (clinical) [Ep 6 · 1:01](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=61)
- "Many thrombotic events in Fontan patients are subclinical but clinically significant." — Joe (clinical) [Ep 6 · 1:10](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=70)
- "The prevalence of silent pulmonary embolism in adults with Fontan circulation may be as high as 1 in 5 (20%)." — Joe (host_summary) [Ep 6 · 1:23](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=83)
- "In Paul Monagle's study comparing aspirin and warfarin in newer style Fontans, patients had an overall cumulative risk of 22% for thrombotic events." — Joe (host_summary) [Ep 6 · 1:39](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=99)
- "The cumulative hazard risk of thrombotic events in Fontan patients increases over time, with Fontan circulation becoming essentially a freight train of thrombogenicity." — Joe (clinical) [Ep 6 · 2:19](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=139)
- "Fontan circulation's thrombotic risk is comparable to paroxysmal nocturnal hemoglobinuria (30-40% risk over 5 years), antiphospholipid antibody syndrome, and unprovoked venous thromboembolism (20-30% recurrence rate)." — Joe (clinical) [Ep 6 · 2:41](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=161)
- "Relative hypoxia and loss of pulsatile flow in the venous system is very thrombogenic for endothelial cells." — Joe (clinical) [Ep 6 · 4:52](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=292)
- "Hypoxia and loss of pulsatile flow result in upregulation of tissue factor expression (the primary initiator of the clotting cascade), upregulation of adhesion molecules that activate inflammatory cells, and increased secretion of factor VIII and von Willebrand factor." — Joe (clinical) [Ep 6 · 5:01](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=301)
- "Protein-losing enteropathy (PLE) results in increased inflammatory system activation in Fontan patients." — Joe (clinical) [Ep 6 · 5:17](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=317)
- "Liver synthetic dysfunction can develop over time in Fontan patients and worsen hemostatic system activation." — Joe (clinical) [Ep 6 · 5:22](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=322)
- "Overall data supports that warfarin is better thromboprophylaxis than aspirin in Fontan patients." — Joe (clinical) [Ep 6 · 6:05](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=365)
- "Reanalysis of Monagle's data showed that warfarin with time-in-therapeutic-range of 60% or better edged out aspirin over time." — Joe (host_summary) [Ep 6 · 6:14](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=374)
- "Retrospective data from Cedric Manliot's group showed warfarin was clearly better than aspirin, though both were significantly better than no thromboprophylaxis." — Joe (host_summary) [Ep 6 · 6:39](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=399)
- "Excellent time-in-therapeutic-range above 80% with warfarin is achievable using a paternalistic approach with aggressive monitoring and phone follow-up." — Joe (clinical) [Ep 6 · 7:05](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=425)
- "In patients with excellent time-in-therapeutic-range (>80%), Grushin's group observed only one thrombotic event over 53 patient-years." — Joe (host_summary) [Ep 6 · 7:14](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=434)
- "Even with well-managed anticoagulation, the bleeding risk is around 2% per year." — Joe (epidemiological) [Ep 6 · 8:33](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=513)
- "Warfarin is very problematic from a pharmacokinetic standpoint and poorly managed warfarin may actually increase thrombotic risk." — Joe (clinical) [Ep 6 · 8:43](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=523)
- "Direct oral anticoagulants (DOACs) such as rivaroxaban and apixaban seem superior to warfarin in many ways but are completely unproven in Fontan patients." — Joe (clinical) [Ep 6 · 8:52](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=532)
- "Thrombotic risk in Fontan patients follows a bimodal incidence: initial post-surgical risk, then a honeymoon phase of variable duration, followed by inexorable increase in thrombotic risk." — Joe (host_summary) [Ep 6 · 9:16](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=556)
- "The honeymoon phase duration can vary and may be predictable using biomarkers." — Joe (opinion) [Ep 6 · 9:40](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=580)
- "Elevated D-dimer is a strong marker of increased thrombotic risk in adults with unprovoked venous thromboembolism." — Joe (host_summary) [Ep 6 · 10:08](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=608)
- "Elevated factor VIII is a strong marker of increased thrombotic risk and can be elevated due to genetic factors, endothelial cell activation, or as an acute phase reactant indicating inflammation." — Joe (clinical) [Ep 6 · 10:17](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=617)
- "Factor VIII activity increases significantly post-Fontan, and in one study the four patients with the highest factor VIII levels were the ones who developed thrombotic complications." — Joe (host_summary) [Ep 6 · 10:49](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=649)
- "In Fontan patients, natural anticoagulants (antithrombin, protein C) are often lower, consistent with liver synthetic dysfunction developing over time." — Joe (host_summary) [Ep 6 · 11:10](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=670)
- "Despite lower procoagulants from liver dysfunction, Fontan patients have elevated prothrombin fragment 1.2, indicating they are at thrombotic risk rather than bleeding risk." — Joe (host_summary) [Ep 6 · 11:46](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=706)
- "Fontan circulation, even in the context of liver dysfunction, shifts the hemostatic balance toward a thrombophilic state." — Joe (clinical) [Ep 6 · 12:13](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=733)
- "Monitoring D-dimer, factor VIII, liver function tests, and albumin every 6 months can predict when the honeymoon period of relatively low thrombotic risk is ending." — Joe (opinion) [Ep 6 · 13:00](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=780)
- "Aspirin VerifyNow is an extremely reliable and reproducible test that confirms patients are taking aspirin and having an antiplatelet response." — Joe (clinical) [Ep 6 · 14:40](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=880)
- "DOACs need to be studied in the Fontan population before determining how good or bad they are." — Joe (opinion) [Ep 6 · 15:26](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=926)
- "To use DOACs routinely in Fontan patients, reliable monitoring methods are needed because organ function can change rapidly in these patients." — Joe (clinical) [Ep 6 · 15:36](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=936)
- "DOACs are most likely better than poorly controlled warfarin, but high time-in-therapeutic-range is achievable with warfarin in most patients." — Joe (opinion) [Ep 6 · 16:21](https://qa.library.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=981)
- "6-40% of prenatally diagnosed lung lesions regress with time and may appear to completely disappear" — Steven Rothenberg (epidemiological) [Ep 20 · 5:43](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=343)
- "Fetal intervention for lung lesions is extremely rare; CHOP performs open fetal surgery less than once every couple of years" — Steven Rothenberg (epidemiological) [Ep 20 · 6:11](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=371)
- "Cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis for fetal lung lesions" — Steven Rothenberg (clinical) [Ep 20 · 7:54](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=474)
- "Hybrid lesions showing features of both CPAM and sequestration are not uncommon on pathology" — Steven Rothenberg (clinical) [Ep 20 · 9:09](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=549)
- "Intralobar sequestration shares a common pleura with the lobe, usually the lower lobe" — Steven Rothenberg (clinical) [Ep 20 · 9:48](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=588)
- "Extralobar sequestration has its own pleural lining and is 90% separate from the lobe" — Steven Rothenberg (clinical) [Ep 20 · 9:52](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=592)
- "Sequestrations are defined by having a systemic artery coming directly off the aorta" — Steven Rothenberg (clinical) [Ep 20 · 10:02](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=602)
- "Systemic vessels to sequestrations can come off the abdominal aorta and pass through the diaphragm" — Steven Rothenberg (clinical) [Ep 20 · 10:14](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=614)
- "CPAM type 3 lesions are more solid and have the worst prognosis" — Steven Rothenberg (clinical) [Ep 20 · 10:40](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=640)
- "Chest X-ray alone is not adequate to ensure there is no residual lung lesion after prenatal diagnosis" — Steven Rothenberg (clinical) [Ep 20 · 14:50](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=890)
- "20-40% of untreated congenital lung lesions will develop significant infection at some point" — Steven Rothenberg (epidemiological) [Ep 20 · 15:47](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=947)
- "The incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series" — Steven Rothenberg (epidemiological) [Ep 20 · 16:58](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1018)
- "Operating by 3 months of age avoids pneumonia or severe respiratory infection before surgery" — Steven Rothenberg (opinion) [Ep 20 · 18:04](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1084)
- "Surgery is technically easier in younger infants because vessels are smaller and anatomy is fresh" — Steven Rothenberg (opinion) [Ep 20 · 18:20](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1100)
- "Even asymptomatic patients often have enlarged lymph nodes and inflammation in fissures by one year of age" — Steven Rothenberg (clinical) [Ep 20 · 18:46](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1126)
- "Hospital stay, chest tube duration, recovery, and operative time are less in patients under 5 kg compared to those under 10 kg" — Steven Rothenberg (clinical) [Ep 20 · 19:32](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1172)
- "Most infants undergoing early lobectomy are discharged within 48 hours" — Steven Rothenberg (clinical) [Ep 20 · 19:46](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1186)
- "By one month post-op, chest X-ray shows no evidence of prior surgery due to compensatory lung growth" — Steven Rothenberg (clinical) [Ep 20 · 19:46](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1186)
- "Most asymptomatic infants will tolerate single lung ventilation without problem" — Steven Rothenberg (clinical) [Ep 20 · 23:38](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1418)
- "Babies initially desaturate after lung collapse but saturations improve once they stop shunting blood to the collapsed lung" — Steven Rothenberg (clinical) [Ep 20 · 26:02](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1562)
- "End-tidal CO2 in the mid-40s during thoracoscopy does not cause significant acidosis or deleterious effects" — Steven Rothenberg (clinical) [Ep 20 · 27:41](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1661)
- "Standing at the patient's front provides more room from the chest wall to the hilum than standing at the back" — Steven Rothenberg (opinion) [Ep 20 · 30:02](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1802)
- "The camera port should be anterior to the tip of the scapula in the mid-axillary line to allow working from front to back" — Steven Rothenberg (opinion) [Ep 20 · 30:39](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1839)
- "A 4mm scope provides a more wide-angle view comparable to a 5mm scope compared to a 3mm scope" — Steven Rothenberg (opinion) [Ep 20 · 33:01](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=1981)
- "Short scopes (20cm) allow the surgeon to get close to the patient without the assistant getting in the way" — Steven Rothenberg (opinion) [Ep 20 · 33:22](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2002)
- "3mm vessel sealing devices can seal vessels up to 5mm in diameter" — Steven Rothenberg (clinical) [Ep 20 · 35:01](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2101)
- "Making two separate seals 4-5mm apart on vessels and cutting between them maximizes safety" — Steven Rothenberg (opinion) [Ep 20 · 35:15](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2115)
- "Cutting partway through a sealed vessel until seeing the lumen allows detection of bleeding while maintaining control" — Steven Rothenberg (opinion) [Ep 20 · 36:11](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2171)
- "Clips on vessels can be knocked off and are less reliable than vessel sealing" — Steven Rothenberg (opinion) [Ep 20 · 36:50](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2210)
- "Using energy devices that seal and cut simultaneously is a mistake that sets up the surgeon for trouble" — Steven Rothenberg (opinion) [Ep 20 · 37:44](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2264)
- "Every sealing device can fail at some point, so techniques should allow for recovery" — Steven Rothenberg (opinion) [Ep 20 · 38:30](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2310)
- "The inferior pulmonary ligament should be taken down first to check energy source function and identify systemic vessels" — Steven Rothenberg (opinion) [Ep 20 · 42:01](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2521)
- "Systemic vessels to sequestrations can be missed on CT scan and should be actively looked for during surgery" — Steven Rothenberg (clinical) [Ep 20 · 42:24](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2544)
- "Incomplete fissures can be completed by working through tissue layer by layer, similar to finger fracturing in liver surgery" — Steven Rothenberg (opinion) [Ep 20 · 43:13](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2593)
- "The bronchus sits directly underneath the pulmonary artery and can be felt to aid dissection" — Steven Rothenberg (clinical) [Ep 20 · 45:20](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2720)
- "The pulmonary vein is directly behind the bronchus in the same plane as the fissure dissection" — Steven Rothenberg (clinical) [Ep 20 · 48:31](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2911)
- "A 5mm stapler is inadequate for bronchus or vessels in children over 10 kg" — Steven Rothenberg (clinical) [Ep 20 · 49:11](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=2951)
- "The pulmonary vein trunk must never be taken near the pericardium because retraction into the pericardium after device failure causes fatal hemorrhage" — Steven Rothenberg (clinical) [Ep 20 · 50:33](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3033)
- "Middle lobe vessels come off just above the right lower lobe pulmonary artery and can be damaged if dissection migrates too cephalad" — Steven Rothenberg (clinical) [Ep 20 · 51:10](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3070)
- "Large cysts should be decompressed with the sealing device at the beginning of the procedure to improve visualization and lung manipulation" — Steven Rothenberg (opinion) [Ep 20 · 57:38](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3458)
- "Systemic vessels to sequestrations can number up to 6 and range from small to 15mm in diameter" — Steven Rothenberg (clinical) [Ep 20 · 58:40](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3520)
- "Using both sealing technology and clips on the same vessel risks delayed bleeding as the vessel changes nature and clips lose secure footing" — Steven Rothenberg (clinical) [Ep 20 · 59:55](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3595)
- "Systemic vessels to sequestrations have higher pressure from the aorta compared to low-pressure pulmonary vessels" — Steven Rothenberg (clinical) [Ep 20 · 60:43](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3643)
- "Extralobar sequestrations become infected and can cause problems even if malignant potential is uncertain" — Steven Rothenberg (clinical) [Ep 20 · 61:07](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3667)
- "Embolization of sequestrations requires general anesthesia and significant arterial intervention with no advantage over thoracoscopic resection" — Steven Rothenberg (opinion) [Ep 20 · 61:23](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3683)
- "Extralobar sequestration resection does not require a chest tube and patients go home the next day" — Steven Rothenberg (clinical) [Ep 20 · 61:35](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3695)
- "Segmentectomy is feasible when disease is confined to the superior segment of lower lobe or lingula with favorable anatomy" — Steven Rothenberg (opinion) [Ep 20 · 63:48](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3828)
- "Average length of stay for lobectomy in patients coming in the morning is about 2.5 days" — Steven Rothenberg (clinical) [Ep 20 · 65:33](https://qa.library.globalcastmd.com/watch/neonatal-lung-lesions-with-dr-steven-rothenberg-948?t=3933)
- "The most common prenatal ultrasound finding in cloaca is a pelvic mass, often representing a dilated vagina (hydrocolpos)." — Marc Levitt (clinical) [Ep 32 · 2:38](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=158)
- "Fetal intervention for cloaca is unlikely to be necessary; babies should typically go to term." — Marc Levitt (clinical) [Ep 32 · 3:56](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=236)
- "Fetal hydrocolpos drainage has been performed at least once (case report from Japan) for massive hydronephrosis with impending renal loss, similar to bladder drainage for urethral valves." — Marc Levitt (clinical) [Ep 32 · 5:14](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=314)
- "In cloaca, there is one perineal hole below the clitoris and no anus; this is not ambiguous genitalia, there is no adrenal problem, and the baby is a normal female with two normal ovaries." — Marc Levitt (clinical) [Ep 32 · 6:37](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=397)
- "A urogenital sinus (single hole with normal anus present) may be associated with virilization and requires evaluation for adrenal hyperplasia and electrolyte abnormalities." — Marc Levitt (clinical) [Ep 32 · 6:57](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=417)
- "To examine a newborn for cloaca, grab the labia and lift them up and out with very good lighting to see if there is a single hole or distinct urethral, vaginal, and rectal orifices." — Marc Levitt (clinical) [Ep 32 · 8:36](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=516)
- "Many patients considered cloacas actually have vestibular fistulas; with better examination you can see three holes (urethra, vagina, and rectal opening in vestibule)." — Marc Levitt (clinical) [Ep 32 · 9:03](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=543)
- "Initial workup for cloaca includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, cardiac auscultation, and plain X-ray of spine to assess sacrum." — Marc Levitt (clinical) [Ep 32 · 9:59](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=599)
- "Intermittent catheterization of the common channel may decompress hydrocolpos, but is not reliable because the catheter may enter the urethra, right or left vagina, or rectum; success should be confirmed by ultrasound." — Marc Levitt (clinical) [Ep 32 · 11:14](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=674)
- "If hydrocolpos is bilateral, open into both vaginas at the dome, remove some of the common wall (septum), and one tube will drain both sides." — Marc Levitt (clinical) [Ep 32 · 13:14](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=794)
- "For vaginostomy, use an 8 or 10 French pigtail catheter (not a straight catheter) because as hydrocolpos recedes, straight catheters fall out but curled catheters do not." — Marc Levitt (clinical) [Ep 32 · 14:15](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=855)
- "Vesicostomy is rarely needed in cloaca; the problem is usually hydrocolpos compressing the trigone and distal ureters, not bladder drainage. Draining the hydrocolpos relieves the ureteral obstruction." — Marc Levitt (clinical) [Ep 32 · 15:05](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=905)
- "Vesicostomy is indicated only when the bladder does not drain after successful hydrocolpos decompression, which occurs in very rare circumstances with very long narrow common channels or absent urethra." — Marc Levitt (clinical) [Ep 32 · 16:28](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=988)
- "Vesicostomy is also indicated in the rare circumstance of massive bilateral ureteral reflux, where decompressing the system protects the ureters until later repair." — Marc Levitt (clinical) [Ep 32 · 17:54](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1074)
- "Hydronephrosis in cloaca is caused by hydrocolpos pressing forward on the trigone and compressing the distal ureters where they enter the bladder." — Marc Levitt (clinical) [Ep 32 · 20:11](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1211)
- "Hydrocolpos develops because urine preferentially fills the vagina through the vaginal fistula rather than exiting the common channel, likely due to mechanical factors (steep urethral angle)." — Marc Levitt (clinical) [Ep 32 · 18:21](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1101)
- "Hydrocolpos fluid is typically a turbid combination of mucus and urine; maternal estrogen effect can increase mucus production and rarely cause blood in the hydrocolpos." — Marc Levitt (clinical) [Ep 32 · 18:48](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1128)
- "Cystoscopy in the newborn period is not advantageous; the required scope is tiny, visualization is poor, the perineum is swollen, and it is better to minimize OR time in newborns." — Marc Levitt (opinion) [Ep 32 · 20:29](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1229)
- "Laparoscopic approach to colostomy and hydrocolpos drainage (described by Michigan group) provides excellent visualization and is a valuable technique." — Marc Levitt (clinical) [Ep 32 · 20:49](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1249)
- "For massive hydrocolpos extending above the umbilicus, use a lower midline incision to access the dome, and consider a tubeless vaginostomy sutured to the abdominal wall like a G-tube." — Marc Levitt (clinical) [Ep 32 · 21:17](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1277)
- "Urogenital sinus (single perineal opening with normal anus) requires workup for adrenal problems causing virilization, though it can occur without virilization." — Marc Levitt (clinical) [Ep 32 · 22:28](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1348)
- "Most urogenital sinuses can be managed with perineal urogenital mobilization without touching the rectum; high UG sinus cases may require a transrectal (Astra) approach." — Marc Levitt (clinical) [Ep 32 · 23:17](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1397)
- "Definitive cloaca repair timing: perform endoscopy and cloacography at 2–3 months of age, then repair anytime thereafter within one year, ideally before 6 months if managing from birth." — Marc Levitt (clinical) [Ep 32 · 23:57](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1437)
- "The two critical endoscopic measurements are common channel length (from perineum to urethral takeoff) and urethral length (from urethral takeoff to bladder neck); urethral length determines the surgical approach." — Marc Levitt (clinical) [Ep 32 · 25:25](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1525)
- "Traditional classification uses 3 cm common channel length (≤3 cm straightforward, >3 cm complicated), but urethral length is equally important and not mentioned in published papers." — Marc Levitt (clinical) [Ep 32 · 25:27](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1527)
- "Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum high in the abdomen; contrast study (cloacogram) is needed to assess this." — Marc Levitt (clinical) [Ep 32 · 26:21](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1581)
- "3D cloacogram reconstruction is superior to 2D fluoroscopy; experienced surgeons answer anatomy questions more correctly with 3D imaging, and printed 3D models may be even better." — Marc Levitt (clinical) [Ep 32 · 28:34](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1714)
- "Cloaca patients benefit from collaborative multidisciplinary approach; the days of a single surgeon handling these cases alone are over." — Marc Levitt (opinion) [Ep 32 · 30:29](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1829)
- "Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate of prior techniques." — Marc Levitt (clinical) [Ep 32 · 32:15](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=1935)
- "Urogenital mobilization is appropriate when common channel is ≤3 cm AND urethral length above the takeoff is at least 1.5–2 cm; this leaves adequate urethral length after splitting the common channel." — Marc Levitt (clinical) [Ep 32 · 33:39](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2019)
- "With inadequate urethral length, do not perform total urogenital mobilization; instead leave the common channel to become the urethra and separate the vagina from it—a technically demanding operation." — Marc Levitt (clinical) [Ep 32 · 34:26](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2066)
- "After separating vagina from common channel, repair the common channel and cover with anorectal fat pad and possibly SIS to ensure well-healed urethra and avoid urethral-vaginal fistula." — Marc Levitt (clinical) [Ep 32 · 34:50](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2090)
- "If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery of the urogenital complex; if this fails, separating the vagina from a circumferentially dissected common channel risks devascularizing and losing the urethra." — Marc Levitt (clinical) [Ep 32 · 35:09](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2109)
- "Urogenital mobilization with inadequate urethral length leaves the patient with urinary leakage that cannot be controlled without tightening or closing the bladder neck." — Marc Levitt (clinical) [Ep 32 · 35:52](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2152)
- "Separating the vagina from the common channel and leaving the common channel as the entire urethra gives the patient about a 4 cm urethra, allowing intermittent catheterization and continence." — Marc Levitt (clinical) [Ep 32 · 36:05](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2165)
- "Type 1 cloaca (common channel ~1 cm with adequate urethral length): mobilize the vagina and leave the urethra slightly hypospadiac; patient will void if no neurogenic bladder component." — Marc Levitt (clinical) [Ep 32 · 36:40](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2200)
- "Patients with tethered cord or neurogenic bladder need a visible urethral orifice that is easily catheterized; slightly hypospadiac urethra is acceptable only if certain the patient will void and not need intermittent catheterization." — Marc Levitt (clinical) [Ep 32 · 37:11](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2231)
- "When native vagina does not reach after full mobilization, options include vaginal switch (disconnect one side preserving ovarian blood supply, switch dome down, remove septum) or vaginal replacement." — Marc Levitt (clinical) [Ep 32 · 38:00](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2280)
- "For vaginal replacement, left colon is the preferred option; sigmoid may be used depending on the vascular arcade." — Marc Levitt (opinion) [Ep 32 · 38:46](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2326)
- "Tissue engineering of vaginas using patient stem cells is on the horizon (work at Wake Forest and Mexico); this would revolutionize cloaca care by eliminating the need for vaginal replacement." — Marc Levitt (clinical) [Ep 32 · 39:10](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2350)
- "Complex cloacas requiring specialized expertise include those with common channel >3 cm or urethral length (takeoff to bladder neck) <1.5 cm." — Marc Levitt (clinical) [Ep 32 · 39:48](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2388)
- "The most common problem in redo cloacas is the surgeon never realized it was a cloaca and only fixed the rectum, leaving the urogenital sinus untouched." — Marc Levitt (clinical) [Ep 32 · 40:27](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2427)
- "The second most common redo problem is inadequate mobilization of structures, leaving the patient with a stenosed or lost vagina." — Marc Levitt (clinical) [Ep 32 · 40:58](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-299?t=2458)
- "The paper by first author Hester Sche and last author Russell Jennings examined 98 patients who had severe tracheomalacia with posterior membranous intrusion." — Ian Glenn (host_summary) [Ep 1 · 0:16](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=16)
- "All patients received bronchoscopy showing the trachea tended to collapse inward from the posterior aspect." — Ian Glenn (host_summary) [Ep 1 · 0:35](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=35)
- "The authors distinguished between anterior compression (from the aortic arch) and posterior compression (collapse)." — Ian Glenn (host_summary) [Ep 1 · 0:44](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=44)
- "Posterior tracheopexy involves taking pledgeted sutures and sewing the posterior wall of the trachea to the anterior longitudinal ligament of the spine." — Ian Glenn (host_summary) [Ep 1 · 0:54](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=54)
- "88% of the 98 patients had esophageal atresia with or without TEF." — Ian Glenn (host_summary) [Ep 1 · 1:05](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=65)
- "Patients were followed anywhere from 1 week to 36 months." — Ian Glenn (host_summary) [Ep 1 · 1:05](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=65)
- "Clinical symptoms including cough, barking cough, noisy breathing, and infections improved across the board." — Ian Glenn (host_summary) [Ep 1 · 1:15](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=75)
- "Patients improved on bronchoscopic evaluation." — Ian Glenn (host_summary) [Ep 1 · 1:25](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=85)
- "Exercise tolerance did not improve statistically but showed a trend towards improvement." — Ian Glenn (host_summary) [Ep 1 · 1:30](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=90)
- "Tracheomalacia is not a homogeneous disease." — Ian Glenn (host_summary) [Ep 1 · 1:35](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=95)
- "The paper emphasized the importance of systematic bronchoscopic evaluation." — Ian Glenn (host_summary) [Ep 1 · 1:41](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=101)
- "Some patients benefit from posterior tracheopexy, some from aortopexy or anterior approach, and some need both." — Ian Glenn (host_summary) [Ep 1 · 1:45](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=105)
- "Approximately 20% of patients in the study required both posterior tracheopexy and aortopexy." — Ian Glenn (host_summary) [Ep 1 · 1:54](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=114)
- "There is a need for standardization in the approach to tracheomalacia." — Ian Glenn (opinion) [Ep 1 · 1:58](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-320?t=118)
- "The paper examined 98 patients who had severe tracheomalacia with posterior membranous intrusion." — Ian Glenn (host_summary) [Ep 2 · 0:28](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=28)
- "All patients received bronchoscopy showing the trachea tended to collapse inward from the posterior aspect." — Ian Glenn (host_summary) [Ep 2 · 0:35](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=35)
- "The study distinguished between anterior compression (from the aortic arch) and posterior compression (collapse)." — Ian Glenn (host_summary) [Ep 2 · 0:44](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=44)
- "Posterior tracheopexy involves taking pledgeted sutures and sewing the posterior wall of the trachea to the anterior longitudinal ligament of the spine." — Ian Glenn (host_summary) [Ep 2 · 0:54](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=54)
- "88% of the 98 patients had esophageal atresia with or without TEF." — Ian Glenn (host_summary) [Ep 2 · 1:05](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=65)
- "Patients were followed anywhere from 1 week to 36 months." — Ian Glenn (host_summary) [Ep 2 · 1:05](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=65)
- "Clinical symptoms improved pretty much across the board, including cough, barking cough, noisy breathing, and infections." — Ian Glenn (host_summary) [Ep 2 · 1:15](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=75)
- "Patients improved on bronchoscopic evaluation." — Ian Glenn (host_summary) [Ep 2 · 1:25](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=85)
- "Exercise tolerance did not improve statistically but showed a trend towards improvement." — Ian Glenn (host_summary) [Ep 2 · 1:30](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=90)
- "Tracheomalacia is not one homogeneous disease." — Ian Glenn (host_summary) [Ep 2 · 1:35](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=95)
- "The paper emphasized the importance of systematic bronchoscopic evaluation." — Ian Glenn (host_summary) [Ep 2 · 1:41](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=101)
- "Some patients benefit from posterior tracheopexy, some from aortopexy or anterior approach, and some need both." — Ian Glenn (host_summary) [Ep 2 · 1:45](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=105)
- "Almost 20% of patients in the study required both posterior tracheopexy and aortopexy." — Ian Glenn (host_summary) [Ep 2 · 1:54](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=114)
- "There is a need for standardization in the treatment of tracheomalacia." — Ian Glenn (opinion) [Ep 2 · 1:58](https://qa.library.globalcastmd.com/watch/posterior-tracheopexy-for-severe-tracheomalacia-375?t=118)
- "The Fontan is a surgically created condition of severe chronic right heart failure with sequelae including venous hypertension, hepatic congestion, lymphatic congestion, restrictive lung disease, altered pulmonary vasculature, and single ventricle dysfunction." — Twaddle (clinical) [Ep 5 · 1:41](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=101)
- "Fontan takedown indications include low cardiac output and elevated CVP, frequently resulting in a progressive downward spiral." — Twaddle (clinical) [Ep 5 · 2:50](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=170)
- "Early revision is reasonable for Fontan failure if the anatomic problem is clearly established and the patient is not too debilitated." — Twaddle (clinical) [Ep 5 · 3:00](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=180)
- "Temporary mechanical support may be considered if the problem is primarily arrhythmias or predictably temporary ventricular dysfunction." — Twaddle (clinical) [Ep 5 · 3:13](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=193)
- "Late Fontan takedown might help hepatic congestion problems, but there are not many large series and outcomes are generally poor." — Twaddle (clinical) [Ep 5 · 3:38](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=218)
- "Bambino Gesù in Rome reported 18 Fontan takedowns over 25 years (1990-2015), with 2 in immediate postoperative period and 16 within 2 months of completion Fontan." — Twaddle (epidemiological) [Ep 5 · 4:03](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=243)
- "In the Bambino Gesù series, there were 17 early survivors, 3 underwent subsequent successful Fontan palliation, 4 underwent transplantation with 2 late survivors, and 10 remained with bidirectional Glenn physiology with reasonable saturations at median 7-year follow-up." — Twaddle (epidemiological) [Ep 5 · 4:33](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=273)
- "A European multi-institutional registry study (1971-2012) reported 38 Fontan takedowns with average time from Fontan to takedown of 0.6 years, early mortality of approximately 25%, five late deaths, and 44% reaching final endpoint by study conclusion." — Twaddle (epidemiological) [Ep 5 · 5:10](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=310)
- "Fontan conversion is primarily used for patients after atrial-pulmonary Fontan with atrial arrhythmias." — Twaddle (clinical) [Ep 5 · 6:30](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=390)
- "Fontan conversion always involves large atrial reduction combined with a maze operation or lesion set to prevent propagation of macro-reentrant circuits, which are the mechanism for most arrhythmias encountered." — Twaddle (clinical) [Ep 5 · 6:55](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=415)
- "The maze lesion set is accomplished by incision and use of a cryo catheter using frozen argon to achieve cryo lesions." — Twaddle (clinical) [Ep 5 · 7:21](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=441)
- "The lesion set for maze procedure must be altered to accommodate specific anatomy when patients lack typical tricuspid and mitral valves or have atypical coronary sinus position as in heterotaxy syndrome." — Twaddle (clinical) [Ep 5 · 8:32](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=512)
- "Data from Chicago shows that the more complete the arrhythmia procedure (biattrial maze vs. right atrial maze vs. isthmal ablation), the lower the risk of arrhythmia recurrence." — Twaddle (epidemiological) [Ep 5 · 9:15](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=555)
- "A more complete lesion set is indicated if performing the operation for arrhythmias." — Twaddle (opinion) [Ep 5 · 9:43](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=583)
- "The Chicago group reported low Fontan conversion mortality of 1.4%, while multi-center trials show early mortality around 10%." — Twaddle (epidemiological) [Ep 5 · 9:53](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=593)
- "Conditional survival after Fontan conversion appears similar between European experience and Chicago, suggesting mortality differences are primarily due to patient selection and execution of the operation." — Twaddle (epidemiological) [Ep 5 · 10:19](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=619)
- "A Japanese study examined prophylactic Fontan conversion in 7 arrhythmia-free atrial-pulmonary Fontan patients versus 25 with tachyarrhythmias, finding the prophylactic group had no late deaths and complete freedom from arrhythmias and protein-losing enteropathy." — Twaddle (epidemiological) [Ep 5 · 10:39](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=639)
- "It is uncertain whether the Japanese study justifies prophylactic Fontan conversion because it is unclear how those patients would have done if left alone." — Twaddle (opinion) [Ep 5 · 11:32](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=692)
- "The number of patients with atrial-pulmonary Fontan is decreasing, making Fontan conversion potentially a short-lived concern." — Twaddle (epidemiological) [Ep 5 · 11:47](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=707)
- "Candidates for Fontan conversion require preserved ventricular function and preserved end-organ function, as this is primarily an arrhythmia procedure." — Twaddle (clinical) [Ep 5 · 12:04](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=724)
- "Contraindications to Fontan conversion include protein-losing enteropathy, older age (related to elevation of end-diastolic pressure), ascites, and right or indeterminate ventricular morphology." — Twaddle (clinical) [Ep 5 · 12:15](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=735)
- "Biattrial arrhythmia operation has been identified as a risk factor for mortality in Fontan conversion." — Twaddle (epidemiological) [Ep 5 · 12:38](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=758)
- "In Australia and New Zealand, the number of atrial-pulmonary Fontans peaked in early 1990s and is now decreasing, with only extracardiac conduit Fontans performed since 2007." — Twaddle (epidemiological) [Ep 5 · 13:04](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=784)
- "The classic atrial-pulmonary Fontan conversion operation is anticipated to decrease in the next few years." — Twaddle (opinion) [Ep 5 · 13:32](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=812)
- "All Fontan patients being considered for transplant will have concerning pulmonary artery anatomy." — Twaddle (clinical) [Ep 5 · 14:13](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=853)
- "Pulmonary arteries in Fontan patients have been at low pressure throughout life and can be very delicate and thin-walled, with many aortopulmonary collaterals creating surgical challenges." — Twaddle (clinical) [Ep 5 · 14:48](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=888)
- "After Fontan heart excision and Glenn takedown, defects from the Glenn and extracardiac conduit commonly require repair, along with management of stented areas that are frequently not adequately dilated." — Twaddle (clinical) [Ep 5 · 15:11](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=911)
- "Some have recommended replacing central pulmonary arteries with a Gore-Tex graft in Fontan transplant patients." — Twaddle (host_summary) [Ep 5 · 15:26](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=926)
- "Hilar pulmonary arteries in Fontan patients are very thin, frequently manipulated at previous surgery, may be deserosalized or have adventitia removed, are prone to injury, and posterior injuries can be very challenging to repair." — Twaddle (clinical) [Ep 5 · 15:37](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=937)
- "The preferred strategy for pulmonary artery reconstruction in Fontan transplant is to perform this part of the operation with circulatory arrest, manipulating only central pulmonary arteries rather than hilar vessels." — Twaddle (opinion) [Ep 5 · 16:00](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=960)
- "Lymphatic circulation drains into central venous circulation, so venous hypertension results in lymphatic hypertension, which leads to protein-losing enteropathy and plastic bronchitis." — Twaddle (clinical) [Ep 5 · 16:59](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1019)
- "Most lymphatic drainage from the lower half of the body and left half of the trunk drains to the junction of the left internal jugular vein and innominate vein." — Twaddle (clinical) [Ep 5 · 17:17](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1037)
- "Doctor Hiroska published two case reports of innominate vein detachment from superior vena cava and anastomosis to low-pressure atrium, with improvement in protein-losing enteropathy." — Twaddle (epidemiological) [Ep 5 · 17:36](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1056)
- "Christian Kreutzer from Argentina has suggested creating a second detachment of proximal innominate vein from left internal jugular and left subclavian vein, then reconstructing innominate vein using Gore-Tex tube graft to avoid right-to-left shunting and cyanosis." — Twaddle (clinical) [Ep 5 · 18:04](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1084)
- "Fontan takedown is a life-saving operation for some patients with early failure." — Twaddle (opinion) [Ep 5 · 18:42](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1122)
- "Fontan conversion is an option for individuals with atrial-pulmonary Fontan, arrhythmias, and preserved function." — Twaddle (opinion) [Ep 5 · 18:52](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1132)
- "The future role of Fontan conversion is unclear as the number of individuals with atrial-pulmonary connections decreases over time." — Twaddle (opinion) [Ep 5 · 18:58](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1138)
- "Lymphatic decompression may provide palliation, but experience is very early." — Twaddle (opinion) [Ep 5 · 19:06](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1146)
- "The best hope for long-term survival probably rests with mechanical support and transplantation, requiring better understanding of support, sensitization, and immunosuppression." — Twaddle (opinion) [Ep 5 · 19:11](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1151)
- "In the case scenario of an 8-year-old with heterotaxy, post-op day 2 from fenestrated Fontan with low output, elevated CVP, oliguria, ascites, worsening acidosis, good ventricular function, mild AV valve regurgitation, sinus rhythm, and no pathway obstruction, the patient likely has elevation of end-diastolic pressure or increased pulmonary vascular resistance as cause of failure." — Twaddle (clinical) [Ep 5 · 20:48](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1248)
- "ECMO (either VA or VV) is unlikely to fix elevated end-diastolic pressure or increased pulmonary vascular resistance and may make them worse." — Twaddle (clinical) [Ep 5 · 21:16](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1276)
- "VV ECMO would not have much role in the face of low cardiac output." — Twaddle (clinical) [Ep 5 · 21:25](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1285)
- "While dialysis might be required at some point in acute Fontan failure, it is unlikely to reverse the process." — Twaddle (clinical) [Ep 5 · 21:30](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1290)
- "Poor ventricular function is a contraindication to Fontan conversion, while severe mitral regurgitation and left pulmonary artery stenosis are problems that can potentially be rectified." — Twaddle (clinical) [Ep 5 · 22:28](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1348)
- "Either people are not doing late Fontan takedown in adults, or if they are doing it, the results were not worthy of publication." — Twaddle (opinion) [Ep 5 · 24:14](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1454)
- "The degree of cyanosis after late Fontan takedown would be dramatic, even with an additional source of pulmonary blood flow or shunt." — Twaddle (opinion) [Ep 5 · 24:23](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1463)
- "Older patients who have been acyanotic will not do well with significant cyanosis, even if cardiac output is improved, despite such cyanosis being well tolerated in small children." — Twaddle (clinical) [Ep 5 · 24:36](https://qa.library.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1476)
- "In early Boston Fontan data, macro-reentrant atrial tachycardia was ubiquitous out to 20 years" — Rick Choi (host_summary) [Ep 9 · 1:45](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=105)
- "After first atrial tachycardia and cardioversion in Fontan patients, risk of future tachycardia is upwards of 80 or 90%" — Rick Choi (host_summary) [Ep 9 · 2:13](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=133)
- "While incidence of tachycardia is heavily related to Fontan type, risk of recurrent tachycardia is the same for all Fontan types" — Rick Choi (host_summary) [Ep 9 · 2:29](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=149)
- "Anti-arrhythmic medications do not achieve complete suppression of atrial tachycardia in Fontan patients" — Rick Choi (host_summary) [Ep 9 · 2:40](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=160)
- "In multiple studies, essentially 100% of Fontan patients on anti-arrhythmics alone have recurrence of tachycardia over 5 to 6 years" — Rick Choi (host_summary) [Ep 9 · 2:52](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=172)
- "Lateral tunnel Fontans have had significantly less incidence of atrial arrhythmias compared to atrial-pulmonary Fontans" — Rick Choi (host_summary) [Ep 9 · 4:37](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=277)
- "Data on whether extracardiac conduit has significantly lower arrhythmia incidence than intracardiac conduit is discrepant, with some studies showing significant improvement and others showing less difference" — Rick Choi (host_summary) [Ep 9 · 4:45](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=285)
- "In Boston study of ~90 Fontan ablation patients, over half required trans-baffle procedure, with moderate or severe complication rate of about 10%" — Rick Choi (host_summary) [Ep 9 · 6:11](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=371)
- "In trans-baffle ablation cases, catastrophic complications included death and major shunts with cyanosis, whereas non-trans-baffle complications were primarily kidney injury" — Rick Choi (host_summary) [Ep 9 · 6:30](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=390)
- "In study of 52 Fontan ablation patients, 80 different arrhythmia mechanisms were identified, meaning majority of patients had more than one mechanism" — Rick Choi (host_summary) [Ep 9 · 7:52](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=472)
- "In Fontan ablations, macro-reentrant tachycardia was most common type but represented less than half of ablations, with focal atrial tachycardia and AVNRT being important mechanisms" — Rick Choi (host_summary) [Ep 9 · 8:05](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=485)
- "Atrial fibrillation as an isolated phenomenon in Fontan patients is relatively rare" — Rick Choi (clinical) [Ep 9 · 8:30](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=510)
- "Ed Walsh felt that atrial tachycardia was a risk factor for sudden death in Fontan patients" — Rick Choi (host_summary) [Ep 9 · 10:18](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=618)
- "In several studies, Fontans with arrhythmias do worse than Fontans without arrhythmias in terms of freedom from death or transplant" — Rick Choi (host_summary) [Ep 9 · 10:38](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=638)
- "Arrhythmia is a significant predictor of outcome in Fontan risk stratification models" — Rick Choi (host_summary) [Ep 9 · 10:52](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=652)
- "It is unknown whether ablating arrhythmia substrates in Fontan patients will change their overall risk of death or transplant" — Rick Choi (opinion) [Ep 9 · 11:00](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=660)
- "In Mayo study of 260 Fontan patients with arrhythmia, almost all patients had recurrence of atrial tachycardia regardless of management strategy" — Rick Choi (host_summary) [Ep 9 · 11:47](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=707)
- "High recurrence rate in Mayo study was heavily driven by high prevalence of patients on anti-arrhythmic medications alone" — Rick Choi (host_summary) [Ep 9 · 11:56](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=716)
- "Catheter ablation in Fontan patients achieved freedom from recurrence in the range of 40 to 50%, not the 95-97% typical of other ablation types" — Rick Choi (host_summary) [Ep 9 · 12:05](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=725)
- "In study using clinical arrhythmia severity scores, Fontan patients who underwent ablation had significant improvement in scores following ablation" — Rick Choi (host_summary) [Ep 9 · 12:31](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=751)
- "Even in Fontan patients who had recurrence of tachycardia after ablation, there was still some improvement in overall arrhythmia burden, though not as robust as in patients without recurrence" — Rick Choi (host_summary) [Ep 9 · 12:52](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=772)
- "Fontan conversion with arrhythmia surgery achieves freedom from arrhythmia around 50 to 60%, probably not all that different than catheter ablation alone" — Rick Choi (clinical) [Ep 9 · 13:23](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=803)
- "Fontan patients with SVT are likely to have recurrence of SVT" — Rick Choi (clinical) [Ep 9 · 14:16](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=856)
- "Anti-arrhythmic medications are reasonable but unlikely to keep Fontan patients completely tachycardia-free" — Rick Choi (clinical) [Ep 9 · 14:23](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=863)
- "New onset atrial tachycardia or increased tachycardia burden is often an early indicator of other issues in Fontan patients" — Rick Choi (clinical) [Ep 9 · 14:30](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=870)
- "Catheter ablation plays a major role in management of SVT in Fontan patients and is reasonable as either first or second line management" — Rick Choi (opinion) [Ep 9 · 14:37](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=877)
- "In older Fontan patients undergoing ablation, sometimes 2/3 of the atrial tissue is essentially scar with no electrical activity" — Rick Choi (clinical) [Ep 9 · 16:50](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1010)
- "Extracardiac Fontan patients will have reduced early arrhythmia incidence due to less surgical scarring, but may face same late risk from atrial stretch and fibrosis unless there is true hemodynamic benefit at 20-30 years" — Rick Choi (opinion) [Ep 9 · 17:02](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1022)
- "Mayo Clinic Fontan arrhythmia data was largely from atrial-pulmonary Fontan patients" — Grushin (clinical) [Ep 9 · 17:22](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1042)
- "Rick's typical approach is to give Fontan patients one arrhythmia episode and monitor them going forward, either off or on medications, then consider ablation after recurrent atrial arrhythmia" — Rick Choi (opinion) [Ep 9 · 13:35](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=815)
- "If Fontan patient's goal is to be completely off Coumadin after atrial arrhythmia, the only way to probably do that safely is to go ahead with catheter ablation" — Rick Choi (opinion) [Ep 9 · 18:43](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1123)
- "Early ablation procedures in Fontan patients are easier, probably involving one or two circuits, whereas waiting 5-6 years results in more complex cases with 5 or 6 circuits" — Rick Choi (clinical) [Ep 9 · 19:01](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1141)
- "In surgical ablation data from Chicago, isthmus ablation-only strategy had much worse outcomes than more aggressive strategies, but aggressive strategies bring sinus node dysfunction into the equation" — Rick Choi (host_summary) [Ep 9 · 16:06](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=966)
- "Rick's center has not seen many young patients with atrial arrhythmias, having done lateral tunnels or extracardiac Fontans primarily for a long time" — Rick Choi (clinical) [Ep 9 · 19:46](https://qa.library.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1186)
- "In the Bernstein 2006 pediatric heart transplant study group multi-center analysis, risk factors for poor Fontan transplant outcomes included mechanical ventilation at listing, younger age (0-4 years), status 1 listing, and shorter time interval from Fontan (less than 6 months)." — Andrew Lotz (host_summary) [Ep 10 · 2:55](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=175)
- "If Fontan patients are selected appropriately, they do just as well as dilated cardiomyopathy patients post-heart transplant." — Andrew Lotz (host_summary) [Ep 10 · 4:57](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=297)
- "Protein-losing enteropathy causes accumulating risk factors including edema, low albumin, poor nutrition, electrolyte disturbances, low IgG with increased infections, malnutrition, and prothrombotic state." — Andrew Lotz (clinical) [Ep 10 · 5:55](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=355)
- "A patient with PLE for 5 years becomes very prothrombotic, which is important for VAD outcomes, and becomes malnourished, making them a poor transplant or VAD candidate." — Andrew Lotz (clinical) [Ep 10 · 6:33](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=393)
- "The 1998 Mertens study showed approximately 50% survival at 5 years after PLE diagnosis." — Andrew Lotz (host_summary) [Ep 10 · 7:06](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=426)
- "A 2014 paper showed 85% survival five years after PLE diagnosis." — Andrew Lotz (host_summary) [Ep 10 · 7:26](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=446)
- "Schumacher from Michigan showed 50% freedom from death or transplant at 5 years in patients diagnosed with plastic bronchitis." — Andrew Lotz (host_summary) [Ep 10 · 8:01](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=481)
- "Plastic bronchitis patients who go through to transplant do very well post-transplant." — Andrew Lotz (clinical) [Ep 10 · 8:17](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=497)
- "Current pediatric transplant survival across all centers is 92% at 1 year and 86% at 5 years." — Andrew Lotz (host_summary) [Ep 10 · 9:19](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=559)
- "Fontan transplant survival, aggregating available data, is approximately 80% at 1 year and 75% at 5 years." — Andrew Lotz (host_summary) [Ep 10 · 9:28](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=568)
- "Multi-center Fontan post-transplant studies show higher waitlist time and mortality compared to dilated cardiomyopathy." — Andrew Lotz (host_summary) [Ep 10 · 9:53](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=593)
- "Standard listing criteria underestimate the degree of illness in Fontan patients." — Andrew Lotz (host_summary) [Ep 10 · 10:07](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=607)
- "Fontan transplant patients have increased risk for early graft failure post-transplant." — Andrew Lotz (host_summary) [Ep 10 · 10:11](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=611)
- "Death from sepsis is more common in Fontan transplant patients." — Andrew Lotz (host_summary) [Ep 10 · 10:17](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=617)
- "Bleeding is more common in Fontan transplant patients since they are multiple-time redo surgeries." — Andrew Lotz (host_summary) [Ep 10 · 10:20](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=620)
- "PLE resolves in Fontan transplant survivors." — Andrew Lotz (host_summary) [Ep 10 · 10:28](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=628)
- "Under recent pediatric allocation system changes, congenital patients on one inotrope can be status 1A only if they are in the hospital; Fontan patients with PLE or plastic bronchitis who are not on inotropes will be status 2." — Andrew Lotz (guideline) [Ep 10 · 10:56](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=656)
- "Approximately one year ago, patients could be sent home on low-dose dopamine or milrinone and remain status 1A; this is no longer the case under current allocation rules." — Andrew Lotz (guideline) [Ep 10 · 11:20](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=680)
- "For urgent VAD placement at Cincinnati Children's, continuous-flow short-term devices (CentriMag in particular, some institutions use Rotaflow) are used to support patients for weeks to months to transplantation." — Andrew Lotz (clinical) [Ep 10 · 13:04](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=784)
- "The Berlin Heart is still available for small children, but most Fontans are bigger, so HVAD is increasingly used." — Andrew Lotz (clinical) [Ep 10 · 13:42](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=822)
- "HVAD can be safely placed in 25 kg single-ventricle patients, and many institutions (including Cincinnati) may push down to 15 kg." — Andrew Lotz (clinical) [Ep 10 · 13:52](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=832)
- "Continuous-flow devices for single-ventricle physiology seem to be working very well compared to Berlin Heart data." — Andrew Lotz (opinion) [Ep 10 · 13:58](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=838)
- "For patients over approximately 35 kg, SynCardia total artificial heart is an option, removing all ventricular mass and supporting the patient." — Andrew Lotz (clinical) [Ep 10 · 14:15](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=855)
- "In the Excor (Berlin Heart) registry, there were only 5 stage 3 (Fontan) patients, with 3 survivors; days on support were 1, 3, and 229 days, representing a very limited dataset." — Andrew Lotz (host_summary) [Ep 10 · 14:51](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=891)
- "The Intermacs adult registry shows only 17 single-ventricle patients, and the device type used is not clear in the registry." — Andrew Lotz (host_summary) [Ep 10 · 15:16](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=916)
- "If a patient does not need respiratory support, supporting an organ that doesn't need support should probably be avoided, which is why ECMO is not the preferred option when lungs are functioning well." — Andrew Lotz (opinion) [Ep 10 · 16:03](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=963)
- "Only 2 SynCardia devices have been placed in single-ventricle patients in the US." — Andrew Lotz (epidemiological) [Ep 10 · 17:44](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1064)
- "For SynCardia placement in single-ventricle patients, a capacitant chamber must be built because two AV valves are needed or the anatomy must be addressed in some fashion." — Andrew Lotz (clinical) [Ep 10 · 17:52](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1072)
- "A smaller 50 cc SynCardia device is now available, making it an option for smaller Fontan patients." — Andrew Lotz (clinical) [Ep 10 · 18:07](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1087)
- "Among all adults listed as status 2 (where PLE adult Fontan patients would be), only 30-40% get transplanted within one year." — Andrew Lotz (host_summary) [Ep 10 · 18:25](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1105)
- "Among congenital heart disease patients on medical therapy (not all Fontans), one-third would be transplanted at 1 year." — Andrew Lotz (host_summary) [Ep 10 · 18:37](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1117)
- "The advanced cardiomyopathy learning network is now operational and working to share experiences with Fontan and VAD to understand which patients benefit from VAD and what the best support strategy is." — Andrew Lotz (clinical) [Ep 10 · 19:10](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1150)
- "The upcoming adult allocation system changes will be more favorable for Fontan patients, but the recent pediatric allocation changes were not favorable for Fontan PLE or plastic bronchitis patients." — Andrew Lotz (guideline) [Ep 10 · 19:34](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1174)
- "In pediatric VAD practice, 'destination therapy' has been reframed as 'chronic therapy,' with the concept that patients can transition in and out of transplant candidacy status." — Andrew Lotz (clinical) [Ep 10 · 20:48](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1248)
- "If a patient is not labeled as destination therapy, the goal remains getting them to transplant candidacy, which may result in longer life and probably better quality of life, although that is yet to be determined." — Andrew Lotz (opinion) [Ep 10 · 21:06](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1266)
- "There are only about 20 Fontans in all of Intermacs and Pedimacs (the two VAD registries) available to study." — Andrew Lotz (epidemiological) [Ep 10 · 21:40](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1300)
- "A handful of Fontan patients have been successfully supported with atrial cannulation." — Andrew Lotz (clinical) [Ep 10 · 22:22](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1342)
- "In restrictive cardiomyopathy, Berlin Heart data shows that atrial cannulation does not perform as well as ventricular cannulation." — Andrew Lotz (host_summary) [Ep 10 · 22:31](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1351)
- "Atrial cannulation allows flow into the VAD where a restrictive or small-cavity ventricle sometimes clamps around the cannula and does not allow flow; this phenomenon has been observed." — Andrew Lotz (clinical) [Ep 10 · 22:54](https://qa.library.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1374)
- "Peripheral venous pressure measured in the antecubital vein during exercise is highly correlated with central venous pressure in Fontan patients, based on data from Hideki Senzaki's group." (host_summary) [Ep 11 · 3:11](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=191)
- "Mean capillary filling pressure measured using arm cuff occlusion technique correlates highly with values obtained in the catheterization laboratory." (host_summary) [Ep 11 · 3:26](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=206)
- "Mean capillary filling pressure is a measure of intravascular volume status and venous wall tension and compliance, which is very often abnormal in Fontan circulation patients with reduced compliance." (clinical) [Ep 11 · 3:41](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=221)
- "Fontan patients who respond with rapid venous pressure increases during exercise tend to have diminished exercise capacity, while those with minimal pressure changes tend to exercise longer." (clinical) [Ep 11 · 4:30](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=270)
- "Fontan patients drop their renal near-infrared spectroscopy values very precipitously and early during exercise compared to normal controls, and these values do not return to normal even after 5-6 minutes of recovery." (clinical) [Ep 11 · 5:02](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=302)
- "Cerebral near-infrared spectroscopy shows an early drop in Fontan patients during exercise but returns to normal by the second minute of exercise, in contrast to renal NIRS." (clinical) [Ep 11 · 5:24](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=324)
- "Data suggests that when venous pressures transduced to hepatic veins exceed 25 mmHg for any length of time, subclinical evidence of hepatocellular damage occurs due to perfusion problems." (host_summary) [Ep 11 · 5:57](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=357)
- "Dynamic assessment of the Fontan patient is essential, and this technique gives good insight to pick up occult abnormal physiology in well-functioning Fontans that would not be appreciated until much later when the patient becomes ill." (opinion) [Ep 11 · 7:31](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=451)
- "Exercise participation, whether formal or informal, begets improved exercise capacity, and exercise should be seen as a good thing for Fontan patients who may have been inappropriately restricted." (host_summary) [Ep 11 · 8:16](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=496)
- "With exercise comes central venous hypertension in Fontan patients, which begets liver disease amongst other things." (clinical) [Ep 11 · 8:38](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=518)
- "With any form of exercise, if you take the extremes, the detrimental effects may well outweigh the beneficial effects." (opinion) [Ep 11 · 9:04](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=544)
- "Submaximal exercise protocols already incorporate most of the venous pressure rise seen during maximal testing." (clinical) [Ep 11 · 10:06](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=606)
- "Patients on transplant lists get better with exercise largely because of skeletal muscle function and oxygen extraction improvements, but the hemodynamics may or may not change." (clinical) [Ep 11 · 10:36](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=636)
- "Vessels in Fontan patients change in their histopathology to accommodate higher pressures, with perivenular changes in the liver being quite striking, and vascular adaptive responses seen in the SVC and IVC." (clinical) [Ep 11 · 11:04](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=664)
- "There is virtually no data in any condition suggesting that if you change vascular biology acutely, you change exercise function." (clinical) [Ep 11 · 11:38](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=698)
- "In biventricular patients, supine exercise is limited compared to upright exercise." (clinical) [Ep 11 · 13:15](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=795)
- "In Fontan patients, exercise limitation during supine exercise looks the same as in biventricular patients, with no particular advantage to swimming or other flat exercises in terms of ultimate performance." (clinical) [Ep 11 · 13:38](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=818)
- "Gravity affects flow patterns in Fontan patients, with very different patterns of hepatic venous flow depending on whether lying flat or standing up, as shown by Ty Shah at Great Ormond Street." (host_summary) [Ep 11 · 13:55](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=835)
- "This testing increasingly picks up occult problems including obstructions in the Fontan circuit that may not be known about with just echo and clinical assessment." (clinical) [Ep 11 · 14:10](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=850)
- "In any circulation, blood flow per unit time is dependent upon the drop in pressure across the vascular bed and the vascular resistance (Ohm's law)." — Brian Goldstein (clinical) [Ep 12 · 1:26](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=86)
- "Biventricular circulation is characterized by low right ventricular pressure, low pulmonary arterial pressure, and low pulmonary vascular resistance." — Brian Goldstein (clinical) [Ep 12 · 2:07](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=127)
- "During exercise in biventricular circulation, cardiac output can increase to approximately 5 times baseline cardiac output." — Brian Goldstein (clinical) [Ep 12 · 2:31](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=151)
- "The pulmonary vascular resistance falls characteristically during exercise in biventricular circulation, allowing for substantial augmentation of pulmonary blood flow." — Brian Goldstein (clinical) [Ep 12 · 2:41](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=161)
- "In the Fontan circuit, the pulmonary vascular resistance is typically both fixed and elevated." — Brian Goldstein (clinical) [Ep 12 · 3:01](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=181)
- "In Fontan circulation, baseline cardiac output is typically near normal but a bit reduced, 70 to 80%." — Brian Goldstein (clinical) [Ep 12 · 3:28](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=208)
- "Central venous pressure in Fontan patients is chronically elevated because there is no ventricle to do the work of the subpulmonary blood flow." — Brian Goldstein (clinical) [Ep 12 · 3:39](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=219)
- "With exercise in Fontan patients, cardiac output increases quite a bit more limited than in the two ventricle population, characterized by increased central venous pressure and increased pulmonary vascular resistance." — Brian Goldstein (clinical) [Ep 12 · 3:49](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=229)
- "At rest with zero exercise, cardiac output in typical or good Fontan patients is 70 to 80% of a normal biventricular patient, and identifying differences between these two populations may be subtle." — Brian Goldstein (clinical) [Ep 12 · 4:30](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=270)
- "With augmentation of cardiac output or with stress or exercise, the difference between the Fontan patient and the biventricular patient becomes substantially increased." — Brian Goldstein (clinical) [Ep 12 · 4:49](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=289)
- "The limitations of cardiac output in the Fontan circulation can be distilled down to pulmonary vascular resistance, diastolic function of the ventricle, and systolic function of the ventricle." — Brian Goldstein (clinical) [Ep 12 · 5:16](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=316)
- "Systolic function is typically preserved in Fontan patients, at least preserved until very late in the clinical presentation with difficulties." — Brian Goldstein (clinical) [Ep 12 · 5:28](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=328)
- "Most or all variables in Fontan circulation may be pretty typical or near normal at rest, thus to understand limitations, one must evaluate these variables in a dynamic or stressed state." — Brian Goldstein (clinical) [Ep 12 · 5:50](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=350)
- "In a series of Fontan patients who underwent supine exercise with invasive hemodynamics, pulmonary vascular resistance was elevated at rest and with exercise, the pulmonary vascular resistance was quite static and did not decrease as expected with maximal exercise." — Brian Goldstein (clinical) [Ep 12 · 6:56](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=416)
- "In patients with biventricular circulation, pulmonary vascular resistance begins lower and falls with exercise." — Brian Goldstein (clinical) [Ep 12 · 7:21](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=441)
- "The Pediatric Heart Network Fuel trial is a randomized trial of 400 Fontan patients, with 200 receiving udenafil (a PDE5 inhibitor) and 200 receiving placebo, evaluating exercise capacity after 6 months of therapy." — Brian Goldstein (clinical) [Ep 12 · 8:05](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=485)
- "With echocardiographic assessment of diastolic function, nearly 3/4 of Fontan patients demonstrate abnormalities of early relaxation or elevated atrial filling pressure, suggesting problems with diastolic function are quite prevalent." — Brian Goldstein (host_summary) [Ep 12 · 9:03](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=543)
- "In a study comparing Fontan patients with normal diastolic function versus those with diastolic dysfunction by echocardiography, patients with diastolic dysfunction had reduced peak VO2 and peak work with both supine and upright exercise." — Brian Goldstein (clinical) [Ep 12 · 9:27](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=567)
- "Echocardiographic measures of diastolic function have not been validated in a Fontan population." — Brian Goldstein (clinical) [Ep 12 · 10:16](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=616)
- "Invasive assessment of end-diastolic pressure in symptomatic Fontan patients is frequently unrevealing in the resting state because patients are often preload starved from being NPO, lying supine, and not undergoing stress." — Brian Goldstein (clinical) [Ep 12 · 10:27](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=627)
- "In a protocol of rapid volume expansion (ventricular stress testing) in 46 Fontan patients, ventricular filling pressure (end-diastolic pressure) was significantly increased after exposure to volume, while transpulmonary gradient, pulmonary vascular resistance, and cardiac index were not significantly affected." — Brian Goldstein (clinical) [Ep 12 · 11:05](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=665)
- "About 35% of Fontan patients demonstrated occult diastolic dysfunction, defined as a post volume challenge end-diastolic pressure of greater than or equal to 15 millimeters of mercury." — Brian Goldstein (clinical) [Ep 12 · 12:09](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=729)
- "In univariate analysis, higher baseline end-diastolic pressure, longer duration of Fontan circulation, and lower baseline cardiac index were associated with higher fluid challenge end-diastolic pressure." — Brian Goldstein (clinical) [Ep 12 · 12:22](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=742)
- "Longer duration of Fontan circulation was associated with a greater change in filling pressure during volume challenge." — Brian Goldstein (clinical) [Ep 12 · 12:53](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=773)
- "In multivariable analysis, baseline end-diastolic pressure was the only finding associated with the final end-diastolic pressure after volume challenge." — Brian Goldstein (clinical) [Ep 12 · 12:58](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=778)
- "The volume challenge protocol has been shared with a number of other large congenital heart centers and has now been performed in over 100 patients." — Brian Goldstein (clinical) [Ep 12 · 13:06](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=786)
- "Fontan patients can have the presence of mechanical dyssynchrony without electrical dyssynchrony, which contributes to overall ventricular dysfunction, both systolic and diastolic." — Brian Goldstein (clinical) [Ep 12 · 14:24](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=864)
- "Acute improvements in ventricular mechanics from pacing could translate to long-term clinical benefits, though this is an unproven assertion." — Brian Goldstein (opinion) [Ep 12 · 15:02](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=902)
- "In the catheterization laboratory, a multimodality setup with conductance catheter feeds, electrical anatomic mapping, fluoro, ECG, and voltage mapping can identify ideal pacing sites and demonstrate ventricular mechanic changes at each site." — Brian Goldstein (clinical) [Ep 12 · 15:37](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=937)
- "Dynamic assessment of the Fontan circulation might provide substantial insight beyond what can be obtained in the resting state." — Brian Goldstein (opinion) [Ep 12 · 16:09](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=969)
- "Pathologies in pulmonary vascular resistance and diastolic function are likely to play critical roles in the limitations of Fontan patients." — Brian Goldstein (opinion) [Ep 12 · 16:38](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=998)
- "In the Fuel trial with 400 patients, efforts have not been made to identify those patients who specifically have problems with pulmonary vascular resistance before inclusion in the trial." — Brian Goldstein (clinical) [Ep 12 · 18:07](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=1087)
- "Patients with relatively low pulmonary vascular resistance but substantial ventricular noncompliance may not respond to PDE5 inhibitor therapy if the drug does not have lusotropic effects to overcome ventricular fibrosis and noncompliance." — Brian Goldstein (opinion) [Ep 12 · 18:24](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=1104)
- "BNP was measured after exercise in the invasive exercise cohort, and almost universally it was a meaningless measure, with every patient's number between 15 and 40." — Brian Goldstein (clinical) [Ep 12 · 21:09](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=1269)
- "The easy biomarker has proved difficult to identify in Fontan patients because their end-diastolic pressure is probably quite low and not straining their atrium." — Brian Goldstein (opinion) [Ep 12 · 21:27](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=1287)
- "Hideki Senzaki's group has looked at profibrotic markers in the blood in the Fontan circulation, with some patients having very high levels of circulating effectors of fibrosis." — Reddington (clinical) [Ep 12 · 21:56](https://qa.library.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=1316)
- "In all reproductive age females presenting with lower abdominal pain, a pregnancy test should be checked regardless of sexual activity history." — Jennifer Dietrich (guideline) [Ep 16 · 1:48](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=108)
- "Ultrasound provides adequate penetration for ovarian evaluation in both low and high BMI females when the patient has a full bladder." — Jennifer Dietrich (clinical) [Ep 16 · 2:57](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=177)
- "Significant asymmetry between ovaries on ultrasound, particularly enlargement on the symptomatic side, raises concern for adnexal torsion." — Jennifer Dietrich (clinical) [Ep 16 · 3:31](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=211)
- "Peripheralization of follicles to the ovarian periphery suggests vascular congestion from torsion, as the edematous center pushes follicles outward." — Jennifer Dietrich (clinical) [Ep 16 · 7:15](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=435)
- "Complete absence of blood flow on ultrasound is the most concerning and reliable finding for torsion; presence of blood flow is less reliable and does not rule out torsion." — Jennifer Dietrich (clinical) [Ep 16 · 4:29](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=269)
- "Blood flow may be present in torsion because only the tube is torsed (ovary still perfused) or because the torsion is intermittent or loose rather than complete." — Jennifer Dietrich (clinical) [Ep 16 · 4:47](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=287)
- "Intermittent torsion can occur, and if the diagnosis is uncertain, observation with repeat ultrasound may help if the patient declares herself with worsening pain." — Jennifer Dietrich (clinical) [Ep 16 · 6:14](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=374)
- "Lesions 5-6 cm or larger increase the risk of torsion in the setting of symptoms by making the adnexa heavy enough to twist." — Jennifer Dietrich (clinical) [Ep 16 · 8:50](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=530)
- "In prepubertal girls, normal ovaries can torse, and torsion is the most common reason for gynecologic surgery in this age group." — Jennifer Dietrich (epidemiological) [Ep 16 · 9:31](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=571)
- "There is no absolute size cutoff for torsion risk; in a prepubertal child with a normally 1-1.5 cm ovary, even a 2-3 cm cyst can cause torsion." — Jennifer Dietrich (clinical) [Ep 16 · 10:19](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=619)
- "Complex ultrasound features (partly cystic, partly solid), hypervascular flow on Doppler within a lesion, and elevated tumor markers raise concern for malignancy." — Jennifer Dietrich (clinical) [Ep 16 · 11:25](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=685)
- "The tumor marker panel for pediatric ovarian lesions includes alpha-fetoprotein, quantitative beta-HCG, lactate dehydrogenase, and CA-125." — Jennifer Dietrich (guideline) [Ep 16 · 15:06](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=906)
- "CT is useful to distinguish an adnexal lesion from an abscess or appendiceal pathology; MRI is useful to distinguish torsion from müllerian anomalies with hematosalpinx." — Jennifer Dietrich (clinical) [Ep 16 · 12:17](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=737)
- "Studies from Boston Children's show higher ovarian salvage rates when surgery occurs within 24-72 hours of pain onset compared to one week." — Jennifer Dietrich (host_summary) [Ep 16 · 17:26](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1046)
- "It is impossible to predict preoperatively whether a torsion is loose (more time available) or tight (rapid ischemia), so suspected torsion should be addressed as soon as the diagnosis is made." — Jennifer Dietrich (clinical) [Ep 16 · 17:52](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1072)
- "If clinical suspicion for torsion is high, it is a clinical diagnosis and surgery should proceed regardless of ultrasound findings; if uncertain, observation with potential repeat imaging is acceptable but the patient should not be sent home." — Jennifer Dietrich (guideline) [Ep 16 · 18:47](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1127)
- "A classic torsion presentation includes acute onset pain after vigorous physical activity (gymnastics, bouncing on a boat), persistent pain unresponsive to over-the-counter measures, nausea and vomiting, and an enlarged ovary on the symptomatic side." — Jennifer Dietrich (clinical) [Ep 16 · 19:52](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1192)
- "Hemorrhagic ovarian cysts are more likely in menstruating females; menstrual history (regularity, timing of last cycle) helps determine risk for hemorrhagic or corpus luteum cysts." — Jennifer Dietrich (clinical) [Ep 16 · 21:22](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1282)
- "In hemorrhagic cysts, Doppler shows no flow within the cyst itself but flow peripheral to the cyst, which can help differentiate from torsion." — Jennifer Dietrich (clinical) [Ep 16 · 22:09](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1329)
- "Surgical management of torsion includes detorsion and removal of any causative lesion (ovarian or peritubal cyst) to eliminate the weight that caused torsion." — Jennifer Dietrich (clinical) [Ep 16 · 22:51](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1371)
- "Oophorectomy and salpingo-oophorectomy should be avoided; the goal is ovarian salvage even when the ovary appears purple, black, and blue, as many recover over time." — Jennifer Dietrich (guideline) [Ep 16 · 23:16](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1396)
- "For ovarian cysts, cystectomy (complete excision of cyst wall) is preferred over drainage alone; peritubal cysts will recur if not completely excised." — Jennifer Dietrich (clinical) [Ep 16 · 23:49](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1429)
- "For peritubal cysts, open the mesosalpinx beneath the splayed fallopian tube, expose the cyst wall, and shell it out." — Jennifer Dietrich (clinical) [Ep 16 · 24:29](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1469)
- "For hemorrhagic ovarian cysts, if the cyst wall is not completely removed, the cyst may continue to bleed." — Jennifer Dietrich (clinical) [Ep 16 · 25:21](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1521)
- "Even necrotic-appearing ovaries should be salvaged unless the tissue is literally falling apart during detorsion; follow-up studies show return of ovarian function and follicles within months." — Jennifer Dietrich (clinical) [Ep 16 · 26:20](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1580)
- "Whether to remove a necrotic fallopian tube depends on whether it is involved in the torsion and completely devitalized; this is a judgment call at the time of surgery." — Jennifer Dietrich (clinical) [Ep 16 · 27:35](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1655)
- "Ovarian bivalving involves making an incision into the ovarian cortex after detorsion to release compartment syndrome-like pressure and improve blood supply to the periphery." — Jennifer Dietrich (clinical) [Ep 16 · 27:56](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1676)
- "Bivalving is indicated when the ovary remains edematous after detorsion, when there is no lesion to remove but the ovary is bulky and at risk for re-torsion, or when debulking is needed after cystectomy." — Jennifer Dietrich (clinical) [Ep 16 · 28:48](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1728)
- "Energy devices such as harmonic scalpel or monopolar hook can be used for ovarian bivalving and debulking." — Jennifer Dietrich (clinical) [Ep 16 · 29:49](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1789)
- "Oophoropexy is considered in cases of recurrent torsion, when a patient has only one ovary, or when the ovary remains at high risk for re-torsion after addressing the primary pathology." — Jennifer Dietrich (clinical) [Ep 16 · 30:53](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1853)
- "Oophoropexy may change future fertility potential by altering ovarian position, but preserving the ovary is better than losing it, and IVF remains an option." — Jennifer Dietrich (opinion) [Ep 16 · 31:18](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1878)
- "Absorbable suture can be used for oophoropexy to hold the adnexa still for 4-6 weeks while inflammation resolves, minimizing near-term re-torsion risk; permanent suture is used for long-term fixation." — Jennifer Dietrich (clinical) [Ep 16 · 31:54](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1914)
- "Clipping the utero-ovarian ligament does not reliably prevent torsion because the adnexa can still twist on either the utero-ovarian ligament or the infundibulopelvic ligament." — Jennifer Dietrich (clinical) [Ep 16 · 32:37](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1957)
- "Oophoropexy techniques include shortening the utero-ovarian ligament (by suturing or clipping it in an accordioned fashion), pexing to the pelvic sidewall (away from ureters), or pexing to the posterior uterus." — Jennifer Dietrich (clinical) [Ep 16 · 33:10](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=1990)
- "For tubo-ovarian abscess, antibiotics should be started and the abscess should not be disturbed surgically unless the patient is unstable, to avoid seeding other pelvic structures." — Jennifer Dietrich (guideline) [Ep 16 · 35:14](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=2114)
- "Ectopic pregnancy can present similarly to torsion with acute pain and an adnexal mass; surgery is indicated for ruptured or unstable ectopic regardless of pregnancy status." — Jennifer Dietrich (clinical) [Ep 16 · 35:57](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=2157)
- "Transvaginal ultrasound is more sensitive than transabdominal for detecting early pregnancy, but many children's hospitals do not perform or have access to transvaginal probes." — Jennifer Dietrich (clinical) [Ep 16 · 37:15](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=2235)
- "For tubal ectopic pregnancy, perform salpingostomy (longitudinal incision), remove the ectopic pregnancy, ensure hemostasis, and do not suture the tube closed; pelvic structures heal well without suturing and suturing may cause stricture." — Jennifer Dietrich (clinical) [Ep 16 · 38:07](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=2287)
- "Endometriosis in adolescents presents with early lesions that are clear or red rather than the classic blue-black lesions seen in adults with advanced disease." — Jennifer Dietrich (clinical) [Ep 16 · 39:57](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=2397)
- "To visualize clear endometriosis lesions, fill the pelvis with crystalloid fluid and dive the camera under to see bleb-like lesions pulling away from the peritoneum, particularly in the cul-de-sac." — Jennifer Dietrich (clinical) [Ep 16 · 40:55](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=2455)
- "Endometriosis lesions can be excised with cold scissors (especially near ureter or bowel) or ablated depending on location." — Jennifer Dietrich (clinical) [Ep 16 · 41:52](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=2512)
- "After laparoscopic management of torsion, patients can be discharged the same day if they meet milestones, with activity restriction for 4-6 weeks to allow incision healing and avoid hernia formation." — Jennifer Dietrich (guideline) [Ep 16 · 42:22](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=2542)
- "Oral contraceptives can prevent recurrence if the torsion was caused by a functional cyst, but they do not prevent recurrence from dermoid cysts or peritubal cysts." — Jennifer Dietrich (clinical) [Ep 16 · 43:31](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=2611)
- "Surveillance ultrasound is performed at 3 months postoperatively (to allow inflammation to resolve), then at 3-6 months if the ovary is still recovering, then annually." — Jennifer Dietrich (guideline) [Ep 16 · 43:58](https://qa.library.globalcastmd.com/watch/ovarian-torsion-with-dr-jennifer-dietrich-949?t=2638)
- "Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally not occurring at rest but with exertion." — Robert Kelly (clinical) [Ep 21 · 1:33](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=93)
- "Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker." — Robert Kelly (clinical) [Ep 21 · 2:55](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=175)
- "In a normal chest, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner)." — Robert Kelly (clinical) [Ep 21 · 4:04](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=244)
- "In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath the xyphoid pulls back towards the spine." — Robert Kelly (clinical) [Ep 21 · 4:29](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=269)
- "In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis." — Robert Kelly (epidemiological) [Ep 21 · 6:05](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=365)
- "When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first." — Robert Kelly (clinical) [Ep 21 · 6:36](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=396)
- "In the multi-center study of pectus excavatum at 11 centers, roughly 2/3 of patients had symptoms of easy fatigability, shortness of breath, or chest pain." — Robert Kelly (epidemiological) [Ep 21 · 8:39](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=519)
- "The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine; an index greater than 3.25 indicates severe pectus excavatum." — Robert Kelly (clinical) [Ep 21 · 9:44](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=584)
- "The Kansas City group recognized that in a patient with a barrel chest, the Haller index underestimates the depth of the depression because the AP diameter is increased, and they advocate an alternative index comparing the AP distance at the depression to the normal lateral chest." — Robert Kelly (clinical) [Ep 21 · 10:09](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=609)
- "Mitral valve prolapse is present in about 14% of pectus excavatum patients, compared to about 1% in young patients generally." — Robert Kelly (epidemiological) [Ep 21 · 12:53](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=773)
- "On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted)." — Robert Kelly (epidemiological) [Ep 21 · 13:37](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=817)
- "Patients with pectus excavatum came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored through surgery." — Robert Kelly (clinical) [Ep 21 · 14:15](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=855)
- "Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is seen in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected." — Robert Kelly (clinical) [Ep 21 · 14:37](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=877)
- "Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems." — Robert Kelly (clinical) [Ep 21 · 15:05](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=905)
- "Surgical indications for pectus excavatum include at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests <80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, and major psychosocial issues related to body image." — Robert Kelly (guideline) [Ep 21 · 15:11](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=911)
- "The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty (ages 11-13 for girls, a year or two older for boys)." — Robert Kelly (clinical) [Ep 21 · 16:47](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1007)
- "Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed." — Robert Kelly (clinical) [Ep 21 · 17:02](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1022)
- "Some Asian groups, particularly in Korea (Dr. Park), operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results." — Robert Kelly (clinical) [Ep 21 · 17:29](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1049)
- "The hard part of pain management is not to relieve the pain, but to relieve the pain without obliterating consciousness, which requires feedback from the patient." — Robert Kelly (clinical) [Ep 21 · 18:32](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1112)
- "About half of pectus excavatum patients don't have their usual appetite after surgery, while about half eat very well." — Robert Kelly (clinical) [Ep 21 · 20:03](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1203)
- "For the first month after pectus excavatum surgery, patients should only walk and do activities of daily life; beginning at 1 month they can liberalize physical activities; by 3-6 months they can do pretty much any activity except those where they know they'll get a blow to the chest." — Robert Kelly (guideline) [Ep 21 · 20:46](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1246)
- "The Allergies test developed in Canada includes all components of the stainless steel bar, and patients have reacted against a number of minor components including nickel, chromium, and cobalt." — Robert Kelly (clinical) [Ep 21 · 21:40](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1300)
- "Titanium bars must be bent at the factory and have to be ordered in advance; they are currently much more expensive than stainless steel bars." — Robert Kelly (clinical) [Ep 21 · 22:17](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1337)
- "The likelihood of transfusion in Nuss procedure is exceedingly low." — Robert Kelly (clinical) [Ep 21 · 22:45](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1365)
- "Measuring the bar length from mid-axillary line to mid-axillary line and subtracting an inch is one method that works very well." — Robert Kelly (clinical) [Ep 21 · 23:29](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1409)
- "It should be standard practice in patients with any difficulty in visualization to use some technique of sternal elevation during Nuss procedure." — Robert Kelly (guideline) [Ep 21 · 24:43](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1483)
- "The most important part of the Nuss procedure, whatever techniques are used, is that the surgeon sees the tip of the introducer at all times—not just knowing it's in there somewhere, but actually seeing it—to minimize the likelihood of injuring the heart." — Robert Kelly (clinical) [Ep 21 · 26:02](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1562)
- "The bar must be positioned medial to the pectus ridge so there is a rib providing counterforce; if placed very laterally, only the intercostal muscles prevent movement and they will strip or rip under the load." — Robert Kelly (clinical) [Ep 21 · 28:54](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1734)
- "In patients who are growing, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so they are generally placed on only one side." — Robert Kelly (clinical) [Ep 21 · 30:07](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1807)
- "If a patient is over approximately 6 feet 2 inches tall, the chances of needing two bars are almost 100%." — Robert Kelly (clinical) [Ep 21 · 30:39](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1839)
- "In multiple series, short-term complications of the Nuss procedure are few and intervention has been infrequent." — Robert Kelly (epidemiological) [Ep 21 · 33:03](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1983)
- "In a series of past 2000 Nuss procedures, about 2.7% of patients required some sort of revision for bar displacement." — Robert Kelly (epidemiological) [Ep 21 · 33:14](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=1994)
- "The incidence of bar displacement has been cut to about half (approximately 1.35%) by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures." — Robert Kelly (clinical) [Ep 21 · 33:28](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2008)
- "Most bar displacement now occurs due to some kind of marked force or trauma rather than spontaneous displacement." — Robert Kelly (clinical) [Ep 21 · 33:43](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2023)
- "Bar allergy occurred in a little less than 1% (0.9%) of patients; screening for metal allergy has been performed since 2004 and has dramatically decreased the incidence." — Robert Kelly (epidemiological) [Ep 21 · 34:13](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2053)
- "About 6.4% of pectus excavatum patients had clinical or patch test evidence of metal allergy." — Robert Kelly (epidemiological) [Ep 21 · 34:27](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2067)
- "Wound infection occurred in 2.3% of patients, with more than 2/3 being superficial or cellulitis." — Robert Kelly (epidemiological) [Ep 21 · 34:40](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2080)
- "Recurrence after Nuss procedure occurred in about 1.2% of patients." — Robert Kelly (epidemiological) [Ep 21 · 35:07](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2107)
- "Why recurrence happens after pectus excavatum surgery is still poorly understood; it can occur even when the bar is left in for 3 years." — Robert Kelly (opinion) [Ep 21 · 35:16](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2116)
- "The bar should remain in place for at least 2 years before removal, with preference for closer to 3 years than 2 years." — Robert Kelly (guideline) [Ep 21 · 36:39](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2199)
- "In a study from Saint Etienne, France published in Journal of Pediatric Surgery, vacuum bell treatment was effective in pretty much eliminating pectus excavatum in 23 of 73 patients." — Robert Kelly (epidemiological) [Ep 21 · 37:19](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2239)
- "In patients who are young (under approximately 10 years old), the vacuum bell can be very effective in lifting the chest up." — Robert Kelly (clinical) [Ep 21 · 37:58](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2278)
- "In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore movement of the chest wall, and patients will have some restrictive process from scarring." — Robert Kelly (clinical) [Ep 21 · 39:06](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2346)
- "Brace therapy for pectus carinatum is successful somewhere between 2/3 and 3/4 of the time." — Robert Kelly (epidemiological) [Ep 21 · 40:04](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2404)
- "Because any operation carries more morbidity than almost any brace, it's hard to say one shouldn't start with brace treatment for most patients with pectus carinatum." — Robert Kelly (opinion) [Ep 21 · 40:27](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2427)
- "Marcello Ferro's dynamic compression system brace solved two patient objections: it is comfortable (pressure can be adjusted) and it's concealable under even an opaque close-fitting t-shirt." — Robert Kelly (clinical) [Ep 21 · 41:23](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2483)
- "The Ferro brace works approximately 3/4 of the time in Dr. Kelly's experience." — Robert Kelly (epidemiological) [Ep 21 · 42:00](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2520)
- "Most patients with pectus carinatum do not have symptoms, but there is a small subset who complain of pain and exercise limitation who should be considered for operation." — Robert Kelly (clinical) [Ep 21 · 42:43](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2563)
- "The reverse Nuss operation (Abramson procedure) works well in pectus carinatum patients with a flexible chest." — Robert Kelly (clinical) [Ep 21 · 43:13](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2593)
- "There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch." — Robert Kelly (opinion) [Ep 21 · 43:43](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2623)
- "There is a family tendency in pectus deformities in approximately 40% of patients, but the majority still don't have a family history." — Robert Kelly (epidemiological) [Ep 21 · 44:52](https://qa.library.globalcastmd.com/watch/chest-wall-deformities-with-dr-robert-kelly-950?t=2692)
- "Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period." — Marc Levitt (clinical) [Ep 19 · 2:57](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=177)
- "Male babies with perineal fistula may pass meconium and have the malformation go unnoticed, typically presenting in the first year of life with severe constipation." — Marc Levitt (clinical) [Ep 19 · 3:06](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=186)
- "In perineal fistula, the hole is too small and anterior to the center of the sphincters, causing the rectum and sigmoid to dilate as stool passes through a tiny fistulous orifice." — Marc Levitt (clinical) [Ep 19 · 3:26](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=206)
- "The standard practice of checking temperature on the forehead or ear rather than rectally means the anus may not be examined, potentially missing malformations." — Marc Levitt (clinical) [Ep 19 · 4:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=265)
- "Relocating a perineal fistula into the sphincters does not completely fix constipation, though it improves anatomy by making the hole adequately sized and lined by mucosa." — Marc Levitt (clinical) [Ep 19 · 4:54](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=294)
- "Patients with uncorrected perineal fistula may have some continence with formed stool but will soil with loose stool or athletic activity because sphincter contraction cannot completely close the anteriorly located hole." — Marc Levitt (clinical) [Ep 19 · 5:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=325)
- "A newborn anus should accept a size 12 Hagar dilator and a one-year-old should accept size 15." — Marc Levitt (clinical) [Ep 19 · 6:16](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=376)
- "A bucket handle skin tag is consistent with perineal fistula; a probe can be passed underneath it even when the fistula itself is not visible." — Marc Levitt (clinical) [Ep 19 · 6:42](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=402)
- "Diagnosing perineal fistula in females is probably the most confounding thing in pediatric colorectal surgery, with many patients either missed or overdiagnosed." — Marc Levitt (opinion) [Ep 19 · 7:33](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=453)
- "Criteria for perineal fistula in females: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter." — Marc Levitt (clinical) [Ep 19 · 8:02](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=482)
- "If the hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, the patient does not need surgery; the perineal body will lengthen with growth." — Marc Levitt (clinical) [Ep 19 · 8:47](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=527)
- "Examination under anesthesia with stimulation can confirm whether a questionable hole is properly centered within the sphincter." — Marc Levitt (clinical) [Ep 19 · 9:51](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=591)
- "An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 sphincter stimulators." — Marc Levitt (clinical) [Ep 19 · 11:06](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=666)
- "In rectourethral fistula, there is no anal opening and no hope for a hole; some babies pee meconium, making the diagnosis obvious." — Marc Levitt (clinical) [Ep 19 · 12:18](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=738)
- "Rectourethral fistulas should not be approached primarily because the rectum location (bladder neck, prostatic, or bulbar level) is unknown; attempting posterior sagittal incision may find urinary tract structures instead of rectum." — Marc Levitt (clinical) [Ep 19 · 12:45](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=765)
- "Rectourethral fistula patients should be managed with colostomy and distal colostogram, except in exceedingly rare cases where cross-table lateral at 20 hours shows very low rectum allowing safe primary posterior sagittal approach." — Marc Levitt (clinical) [Ep 19 · 13:20](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=800)
- "Cloaca can be missed in the newborn period; a recent case presented at 6 months with constipation when someone finally noticed no anus." — Marc Levitt (clinical) [Ep 19 · 14:07](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=847)
- "Ambiguous genitalia (clitoromegaly from endocrine stimulation) with urogenital sinus has a completely normal anus, distinguishing it from cloaca which has no anus." — Marc Levitt (clinical) [Ep 19 · 15:54](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=954)
- "Cloaca patients have no endocrine problem and two completely normal ovaries, unlike urogenital sinus with virilization." — Marc Levitt (clinical) [Ep 19 · 16:24](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=984)
- "The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula." — Marc Levitt (clinical) [Ep 19 · 17:18](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1038)
- "Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections." — Marc Levitt (clinical) [Ep 19 · 17:39](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1059)
- "Transverse colostomies can prolapse and, with large rectourethral fistula, the left colon absorbs urine causing acidosis; they also make distal colostogram difficult." — Marc Levitt (clinical) [Ep 19 · 18:30](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1110)
- "Preferred technique is very proximal sigmoid colostomy leaving entire sigmoid for pull-through, with tiny flat mucous fistula separated from proximal stoma." — Marc Levitt (clinical) [Ep 19 · 19:14](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1154)
- "Prolapse is related to colon mobility: mid-transverse colostomy both sides can prolapse, hepatic flexure only distal prolapses, proximal sigmoid only distal can prolapse because left colon is fixed to retroperitoneum." — Marc Levitt (clinical) [Ep 19 · 19:58](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1198)
- "Ileostomies prolapse frequently because they are free-floating unless tacked to anterior abdominal wall." — Marc Levitt (clinical) [Ep 19 · 20:37](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1237)
- "The anoplasty site should be marked before making the incision by drawing a circle around the pinkish ellipse where it stimulates on the skin surface, preventing confusion when anatomy is disrupted." — Marc Levitt (clinical) [Ep 19 · 21:30](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1290)
- "Without pre-marking, surgeons can choose the wrong place when seeing muscles jumping with stimulator after opening posterior sagittal incision, requiring re-operation despite good muscle potential." — Marc Levitt (clinical) [Ep 19 · 22:04](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1324)
- "The distal colostogram is an absolutely vital study; many mistakes result from poorly done studies and misinterpretation." — Marc Levitt (clinical) [Ep 19 · 23:29](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1409)
- "The colostogram must answer: where is the rectum, how low is it, is it reachable posterior sagittally or better laparoscopically, and what is its relationship to the urinary tract." — Marc Levitt (clinical) [Ep 19 · 23:55](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1435)
- "Common colostogram error is insufficient contrast and pressure, giving false impression of high rectum and no fistula." — Marc Levitt (clinical) [Ep 19 · 24:11](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1451)
- "If the distal rectum shows a straight line corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure; more pressure will show bulging rectum and fistula." — Marc Levitt (clinical) [Ep 19 · 24:26](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1466)
- "Fistula classification using urethra as reverse C or elbow: fistula at or below elbow is bulbar, above elbow is prostatic, at bladder neck is bladder neck fistula." — Marc Levitt (clinical) [Ep 19 · 25:23](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1523)
- "Bulbous rectum may be reachable posterior sagittally and hard laparoscopically due to girth; tapered rectum is better approached laparoscopically." — Marc Levitt (clinical) [Ep 19 · 25:55](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1555)
- "Opening posterior sagittally without knowing rectum location will find a whitish shiny structure that may be bladder neck, not rectum." — Marc Levitt (clinical) [Ep 19 · 27:00](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1620)
- "Adjunct techniques to locate rectum include balloon catheter in mucous fistula inflated with fluid or gastroscope to look for light, though the speaker has not used these." — Marc Levitt (clinical) [Ep 19 · 28:42](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1722)
- "Never go to the operating room without knowing exactly what anatomy to expect from a proper distal colostogram; the key question is where is the rectum and is it the most posterior structure." — Marc Levitt (clinical) [Ep 19 · 29:28](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1768)
- "Bulbar or low prostatic rectum with bulge is more easily approached posterior sagittally; high prostatic tapered rectum is best served by laparoscopy; bladder neck fistulas are certainly best by laparoscopy." — Marc Levitt (clinical) [Ep 19 · 30:09](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1809)
- "Laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level requires unnecessary extra work and risks leaving remnant of original fistula (roof) if surgeon is timid." — Marc Levitt (clinical) [Ep 19 · 30:43](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1843)
- "Posterior sagittal approach for high rectum is very difficult to mobilize and risks urinary tract injury." — Marc Levitt (clinical) [Ep 19 · 31:16](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1876)
- "Laparoscopy replaces laparotomy as elegant dissection from above but should not give away advantages of PSARP; a mini-PSARP during laparoscopy allows safe pelvic entry and rectal tacking to prevent prolapse." — Marc Levitt (clinical) [Ep 19 · 31:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1908)
- "Preferred terminology is laparoscopic-assisted PSARP rather than laparoscopy versus PSARP." — Marc Levitt (opinion) [Ep 19 · 32:44](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1964)
- "Prolapse prevention: proper levator closure, tacking rectum to posterior edge of muscle complex for 3-4 stitches, not dissecting rectum more than necessary, avoiding excessive trimming." — Marc Levitt (clinical) [Ep 19 · 33:04](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=1984)
- "Prolapse occurs in about 3% of cases, particularly in those without great muscles." — Marc Levitt (epidemiological) [Ep 19 · 33:35](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2015)
- "Rectal prolapse causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential because they cannot close the opening with prolapsed tissue through it." — Marc Levitt (clinical) [Ep 19 · 33:54](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2034)
- "Prolapse more than 3 millimeters should be treated; ideal time is when colostomy is still present." — Marc Levitt (clinical) [Ep 19 · 34:18](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2058)
- "For circumferential prolapse, performing half the circumference in two different ambulatory settings is preferred by families over hospitalization and avoids need for dilation since half is untouched." — Marc Levitt (clinical) [Ep 19 · 34:48](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2088)
- "Perineal body dehiscence prevention requires complete anterior rectal wall separation from posterior vaginal wall to reach areolar plane, avoiding tension on anoplasty." — Marc Levitt (clinical) [Ep 19 · 35:41](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2141)
- "Perineal body dehiscence is the most common cause of reoperation in female ARM repairs." — Marc Levitt (clinical) [Ep 19 · 36:03](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2163)
- "Traditional postoperative management is NPO for 7 days on 10% dextrose (hyperalimentation only if longer than 7 days); recently trialing clear liquids only for a week to avoid hard stool while allowing some oral intake." — Marc Levitt (clinical) [Ep 19 · 36:35](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2195)
- "Daily perineal examination during the first week is critical; if dehiscence is detected on day 5-8, taking the patient back to OR to re-suture can salvage the repair, but by 3-4 weeks later nothing can be done." — Marc Levitt (clinical) [Ep 19 · 37:32](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2252)
- "Laparoscopy causes trouble if dissecting a rectum that is too low, getting too close to urinary tract or being too timid and leaving remnant of original fistula (distal rectum)." — Marc Levitt (clinical) [Ep 19 · 38:36](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2316)
- "For high rectums, particularly bladder neck fistulas, dissection to make the rectum reach with good blood supply is challenging; the IMA must be preserved because prior colostomy may have disrupted left colic collaterals." — Marc Levitt (clinical) [Ep 19 · 39:20](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2360)
- "The rectum has excellent intramural blood supply from the IMA; taking tiny distal vessels along the rectal wall preserves this, but taking IMA or branches too close to aorta will cause rectal necrosis." — Marc Levitt (clinical) [Ep 19 · 39:47](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2387)
- "The biggest PSARP problem is exploring without knowing rectum location and finding bladder neck, urethra, seminal vesicles, vas deferens, or ectopic ureter instead of distal rectum." — Marc Levitt (clinical) [Ep 19 · 40:18](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2418)
- "Famous cases exist of bladder neck being pulled through and made into beautiful anoplasties, with the patient postoperatively draining liquid (urine) from the anoplasty." — Marc Levitt (clinical) [Ep 19 · 41:02](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2462)
- "To determine continence potential, assess three factors: original malformation type, sacral quality and calculated sacral ratio, and spine quality (ARM continence index)." — Marc Levitt (clinical) [Ep 19 · 42:14](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2534)
- "Three A's in continence index (malformation type, sacrum, spine) predicts continence; three C's predicts incontinence; intermediate grades are being quantified through data collection." — Marc Levitt (clinical) [Ep 19 · 42:57](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2577)
- "Bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control; bladder neck fistula with sacral ratio 0.4 and tethered cord or myelomeningocele has no chance of good bowel control." — Marc Levitt (clinical) [Ep 19 · 43:19](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2599)
- "For 4-year-old with soiling and continence potential, first step is mechanical cleaning with bowel management enemas to gain confidence, then when older try switching to laxatives for voluntary bowel movements." — Marc Levitt (clinical) [Ep 19 · 43:52](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2632)
- "If patient cannot be weaned from enemas, consider antegrade option like Malone procedure." — Marc Levitt (clinical) [Ep 19 · 44:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2665)
- "Indications for redo pull-through: any continence potential with imperfect anatomy including improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum)." — Marc Levitt (clinical) [Ep 19 · 44:39](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2679)
- "Redoing anoplasty to center rectum in sphincter can change a patient to have continence potential; success is very good when the right patient is selected." — Marc Levitt (clinical) [Ep 19 · 45:08](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2708)
- "One of the biggest problems with anorectal malformations is that surgical errors do not become apparent for years, unlike most surgical complications which are evident immediately." — Marc Levitt (opinion) [Ep 19 · 46:25](https://qa.library.globalcastmd.com/watch/complications-of-anorectal-malformations-with-dr-marc-levitt-951?t=2785)
- "The most common prenatal ultrasound finding in cloaca is a pelvic mass, often initially thought to be the bladder but actually representing a dilated vagina (hydrocolpos)." — Marc Levitt (clinical) [Ep 17 · 2:38](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=158)
- "Fetal intervention for cloaca is unlikely but may be necessary for massive hydronephrosis with impending renal loss; one case report from Japan described hydrocolpos drainage similar to bladder drainage for urethral valves." — Marc Levitt (clinical) [Ep 17 · 3:59](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=239)
- "In newborn examination, cloaca presents as one hole below the clitoris with no anus; this is distinct from urogenital sinus which has one hole but a normal anus." — Marc Levitt (clinical) [Ep 17 · 6:35](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=395)
- "Cloaca is not ambiguous genitalia and has no adrenal problem; the baby is a normal female with two normal ovaries and will be hormonally normal." — Marc Levitt (clinical) [Ep 17 · 7:25](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=445)
- "Many patients considered cloacas are actually vestibular fistulas; with better examination pulling the labia up and out, you can see three distinct holes (urethra, vagina, and vestibular fistula)." — Marc Levitt (clinical) [Ep 17 · 9:03](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=543)
- "Initial workup includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, plain X-ray of spine for hemivertebrae and sacral quality, and echocardiogram at most centers." — Marc Levitt (guideline) [Ep 17 · 9:59](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=599)
- "Vesicostomy is rarely needed in cloaca because the problem is not the bladder but the hydrocolpos compressing the trigone and distal ureters; draining the hydrocolpos relieves the obstruction." — Marc Levitt (clinical) [Ep 17 · 15:02](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=902)
- "Vesicostomy or suprapubic tube is indicated only when the common channel is very narrow or absent, preventing bladder drainage even after hydrocolpos decompression." — Marc Levitt (clinical) [Ep 17 · 16:28](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=988)
- "Massive bilateral ureteral reflux is an exception where vesicostomy may be needed to decompress the system until later in life." — Marc Levitt (clinical) [Ep 17 · 17:54](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1074)
- "Hydrocolpos forms because the bladder preferentially fills the vagina through a fistula rather than exiting the common channel; the vagina also contains mucus, and maternal estrogen can increase mucus production." — Marc Levitt (clinical) [Ep 17 · 18:24](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1104)
- "The urethra in cloaca often requires a steep turn (scope on floor pointing to ceiling) to reach the bladder, explaining why urine does not drain easily and instead fills the vagina." — Marc Levitt (clinical) [Ep 17 · 19:31](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1171)
- "Cystoscopy is not performed in the newborn period; it is delayed until 2-3 months when a larger scope can be used, visualization is better, and the baby is healthier." — Marc Levitt (clinical) [Ep 17 · 20:29](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1229)
- "For vaginostomy tube placement, use an 8 or 10 French pigtail catheter from interventional radiology; a curled catheter prevents tube fallout as the hydrocolpos recedes, unlike straight catheters which fall out." — Marc Levitt (clinical) [Ep 17 · 14:15](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=855)
- "For bilateral hydrocolpos, open into both vaginas at the dome, remove some of the common wall (septum), and one tube will drain both sides." — Marc Levitt (clinical) [Ep 17 · 13:27](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=807)
- "The two critical endoscopic measurements are common channel length (traditional measure, with 3 cm or less being straightforward) and urethral length from urethral takeoff to bladder neck (newly emphasized measure that determines surgical approach)." — Marc Levitt (clinical) [Ep 17 · 25:25](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1525)
- "Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum in the abdomen; a contrast study (cloacogram) is needed to determine this." — Marc Levitt (clinical) [Ep 17 · 26:21](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1581)
- "The cloacogram technique involves leaving catheters in the bladder, distal colostomy, and perineal orifice during endoscopy, then having interventional radiology inject these structures and create a 3D reconstruction." — Marc Levitt (clinical) [Ep 17 · 27:24](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1644)
- "Studies comparing 2D cloacogram, 3D reconstruction, 3D printed models, and virtual reality showed that more complex modalities led to more correct anatomic descriptions; 3D is definitely better than 2D." — Marc Levitt (clinical) [Ep 17 · 28:34](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1714)
- "Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes the urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate from prior techniques." — Marc Levitt (clinical) [Ep 17 · 32:15](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1935)
- "Urogenital mobilization is appropriate when common channel is 3 cm or less AND there is at least 1.5-2 cm of urethra above the urethral takeoff; this leaves adequate urethral length after splitting the common channel." — Marc Levitt (clinical) [Ep 17 · 33:39](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2019)
- "When urethral length is inadequate (less than 1.5 cm from takeoff to bladder neck), the common channel must be left alone to become the urethra, and the vagina must be separated from the common channel—a technically demanding operation." — Marc Levitt (clinical) [Ep 17 · 34:34](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2074)
- "If urogenital mobilization is attempted with inadequate urethral length and the complex does not reach, the only option is abdominal delivery of the urogenital complex, which often does not work and can lead to urethral devascularization and loss." — Marc Levitt (clinical) [Ep 17 · 35:17](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2117)
- "Leaving a patient with inadequate urethral length after urogenital mobilization results in leakage with no way to gain control without tightening or closing the bladder neck." — Marc Levitt (clinical) [Ep 17 · 35:52](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2152)
- "Separating the vagina from the common channel and leaving the common channel as the entire urethra gives the patient about a 4 cm urethra, allowing intermittent catheterization and continence." — Marc Levitt (clinical) [Ep 17 · 36:05](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2165)
- "For type 1 cloaca (common channel of 1 cm with adequate urethral length), mobilizing the vagina alone and leaving a slightly hypospadiac urethra is acceptable if the patient will void and not require intermittent catheterization." — Marc Levitt (clinical) [Ep 17 · 36:40](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2200)
- "When native vagina does not reach after full mobilization, options include vaginal switch (disconnecting one side while preserving ovarian blood supply) or vaginal replacement with colon (preferred), small bowel, or rectum." — Marc Levitt (clinical) [Ep 17 · 38:00](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2280)
- "Tissue engineering of vaginas using patient stem cells is on the horizon, with work done at Wake Forest and in Mexico; this could revolutionize cloaca care by eliminating the need for vaginal replacement." — Marc Levitt (opinion) [Ep 17 · 39:17](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2357)
- "The most common problem in redo cloaca surgery is that the surgeon never realized they were dealing with a cloaca and only fixed the rectum, leaving the urogenital sinus untouched." — Marc Levitt (clinical) [Ep 17 · 40:27](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2427)
- "The second most common redo problem is inadequate mobilization of structures, leaving the patient with a stenosed or lost vagina." — Marc Levitt (clinical) [Ep 17 · 40:58](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2458)
- "Cloacal repair timing is typically 2-3 months for diagnostic endoscopy and cloacogram, with definitive repair anytime thereafter within the first year; Dr. Levitt aims for before 6 months if managing from birth, before 1 year if referred." — Marc Levitt (clinical) [Ep 17 · 24:07](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1447)
- "Urogenital sinus (one hole with normal anus) requires workup for adrenal problems and virilization; if virilized, likely has adrenal hyperplasia requiring electrolyte monitoring." — Marc Levitt (clinical) [Ep 17 · 22:27](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=1347)
- "Many cloaca patients have neurogenic bladder component whether or not they have tethered cord; a visible urethral orifice that is easily catheterized is needed if intermittent catheterization will be required." — Marc Levitt (clinical) [Ep 17 · 37:11](https://qa.library.globalcastmd.com/watch/cloaca-management-with-dr-marc-levitt-dr-aaron-garrison-957?t=2231)
- "CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies managed by community obstetricians." — Charlie Stolar (epidemiological) [Ep 18 · 2:45](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=165)
- "CDH diagnosis is usually made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart." — Charlie Stolar (clinical) [Ep 18 · 3:37](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=217)
- "CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side." — Charlie Stolar (clinical) [Ep 18 · 4:14](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=254)
- "At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation." — Charlie Stolar (clinical) [Ep 18 · 4:23](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=263)
- "CDH is a medical physiologic emergency, not a surgical emergency." — Charlie Stolar (clinical) [Ep 18 · 5:00](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=300)
- "The diagnosis of CDH alone is not an indication for cesarean section." — Charlie Stolar (guideline) [Ep 18 · 5:24](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=324)
- "Antenatal interventions for CDH are no better than investigational and experimental at best." — Charlie Stolar (opinion) [Ep 18 · 6:35](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=395)
- "Babies with CDH should be born at a full-service children's facility with ECMO capability." — Charlie Stolar (guideline) [Ep 18 · 7:23](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=443)
- "Maybe 10-15% of babies diagnosed with CDH will benefit from ECMO." — Charlie Stolar (epidemiological) [Ep 18 · 7:34](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=454)
- "In single-center experiences, presence of liver in the chest is of no prognostic value for CDH." — Charlie Stolar (clinical) [Ep 18 · 8:31](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=511)
- "Lung-to-head ratio (LHR) is of limited prognostic value except when very low (less than 0.8)." — Charlie Stolar (clinical) [Ep 18 · 8:42](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=522)
- "Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis in CDH." — Charlie Stolar (clinical) [Ep 18 · 9:07](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=547)
- "If shown 100 children with CDH, 80-85% will survive to become teenagers." — Charlie Stolar (epidemiological) [Ep 18 · 10:13](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=613)
- "Steroids have tremendous value for preterm labor under 35 weeks but their role in near-term CDH babies (37-39 weeks) is arguable." — Charlie Stolar (clinical) [Ep 18 · 10:37](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=637)
- "Exit-to-ECMO for CDH is essentially moving the goalposts and deck chairs around on the Titanic for non-viable babies." — Charlie Stolar (opinion) [Ep 18 · 12:06](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=726)
- "We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth." — Charlie Stolar (clinical) [Ep 18 · 13:00](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=780)
- "All therapy for CDH should be guided by preductal oximetry, not postductal, because all babies have some degree of pulmonary hypertension with shunting." — Charlie Stolar (guideline) [Ep 18 · 19:06](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1146)
- "If preductal saturation is 90% (PaO2 of 65 torr), the brain is doing fine because this is fetal hemoglobin." — Charlie Stolar (clinical) [Ep 18 · 19:32](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1172)
- "Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today because they trash lungs in a heartbeat." — Charlie Stolar (opinion) [Ep 18 · 21:38](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1298)
- "CDH babies should not be paralyzed and should have minimal sedation to maintain spontaneous breathing." — Charlie Stolar (guideline) [Ep 18 · 21:56](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1316)
- "Most CDH babies don't tolerate conventional ventilator settings (rate 40, peak pressure 25-28, PEEP 5) and require unconventional high-rate (100 breaths/min) low-pressure ventilation." — Charlie Stolar (clinical) [Ep 18 · 22:15](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1335)
- "High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO." — Charlie Stolar (clinical) [Ep 18 · 24:38](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1478)
- "Nitric oxide is a waste of money for CDH babies; meta-analyses show it's terrific for premature babies with immature lung disease but of no value in CDH." — Charlie Stolar (clinical) [Ep 18 · 25:45](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1545)
- "The best drug for CDH is oxygen." — Charlie Stolar (opinion) [Ep 18 · 26:07](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1567)
- "ECMO should not be used in babies under 36 weeks gestational age initially, though this has been pushed down to 35 weeks, maybe 34 weeks, with intracranial hemorrhage rates taking off below 32 weeks." — Charlie Stolar (guideline) [Ep 18 · 26:22](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1582)
- "The smallest ECMO arterial perfusion cannula available is about 8 French, and resistance is related to both length and diameter, making adequate flow difficult in very small babies." — Charlie Stolar (clinical) [Ep 18 · 27:40](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1660)
- "For ECMO candidacy, the real risk for intracranial hemorrhage is the germinal matrix, which is usually OK by 35-36 weeks gestation, so it's gestational age that matters, not size." — Charlie Stolar (clinical) [Ep 18 · 28:15](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1695)
- "The broad principle for ECMO candidacy is whether you can get out of ECMO with reasonable confidence if you get in—don't start something you can't finish." — Charlie Stolar (guideline) [Ep 18 · 29:10](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1750)
- "VV ECMO is terrific if the heart works, but in CDH the heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum." — Charlie Stolar (clinical) [Ep 18 · 30:27](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1827)
- "VA bypass is essentially dialing in a PaO2, while VV ECMO is much more annoying with mixing, cannula position issues, and CDH babies are generally too unstable for VV." — Charlie Stolar (opinion) [Ep 18 · 31:53](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1913)
- "Echo guidance during ECMO cannulation is really helpful to prevent driving the arterial cannula out the subclavian artery or the venous cannula into the innominate vein." — Charlie Stolar (clinical) [Ep 18 · 32:17](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1937)
- "If the arterial cannula goes out the subclavian artery, you'll have a very well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen." — Charlie Stolar (clinical) [Ep 18 · 33:01](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=1981)
- "The first few hours on ECMO can be unstable; hyperkalemia cardiac arrest can occur if blood isn't washed, but you just perfuse through it and give calcium." — Charlie Stolar (clinical) [Ep 18 · 34:19](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2059)
- "ECMO flow should be slowly increased over 45 minutes to 1.5 hours to about 100-125 cc/kg/min (about 80% of cardiac output) to reduce intracranial hemorrhage incidence." — Charlie Stolar (guideline) [Ep 18 · 34:55](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2095)
- "The hyperoxia test—turning FIO2 up to 1.0 on the ventilator while on ECMO—gives courage to begin weaning if the PaO2 rises, showing the baby can use their lungs." — Charlie Stolar (clinical) [Ep 18 · 36:34](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2194)
- "For babies stuck on ECMO at 2 weeks, ensure they are maximally dried out (bone dry, eyes sucked into back of head, turned into a prune) before considering on-ECMO repair." — Charlie Stolar (guideline) [Ep 18 · 38:18](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2298)
- "The problem in CDH is not that bowel is in the chest; the problem is growth arrest of the lungs that happened at 14-15 weeks gestation. Getting bowel out of the chest is not miraculous." — Charlie Stolar (clinical) [Ep 18 · 39:14](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2354)
- "Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) make clot on ECMO. A platelet thrombus lasts 48-72 hours, giving a window to operate and get off ECMO before bleeding starts." — Charlie Stolar (clinical) [Ep 18 · 40:37](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2437)
- "Preferred approach is to wean ECMO down to 20 cc/kg/min, do the operation, accept 1 day of post-op edema, then have 2-3 days to get off ECMO before bleeding starts." — Charlie Stolar (guideline) [Ep 18 · 41:14](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2474)
- "If you take a baby off ECMO then operate, every patient gets stiff after surgery, pulmonary hypertension relapses, and you're talking about a second ECMO run." — Charlie Stolar (clinical) [Ep 18 · 41:51](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2511)
- "When operating on ECMO, load with Amicar preoperatively, do it as an abdominal operation, use a patch with low threshold to avoid tension, place a Jackson-Pratt drain under the patch, and place a chest tube." — Charlie Stolar (guideline) [Ep 18 · 42:39](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2559)
- "Futility on ECMO starts to rear its head after about 2-3 weeks." — Charlie Stolar (opinion) [Ep 18 · 44:14](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2654)
- "The typical stable CDH baby not requiring ECMO takes 3-4 days to wean to minimal ventilator settings (FIO2 0.4, conventional settings) before repair." — Charlie Stolar (clinical) [Ep 18 · 45:42](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2742)
- "Use the infant ventilator instead of an anesthesia machine intraoperatively because infant anesthesia machines have high dead space and are not very compliant." — Charlie Stolar (guideline) [Ep 18 · 46:07](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2767)
- "For repair timing, three variables matter: pre/post-ductal gradient on pulse ox, right ventricle dilation on echo, and RV pressure versus LV pressure (RV should be no more than systemic)." — Charlie Stolar (guideline) [Ep 18 · 46:47](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2807)
- "The thoracoscopic approach for CDH is gorgeous with a sparkling view, but the recurrence rate is really high—about 25% in under a year in Dr. Stolar's series of 35 stable kids." — Charlie Stolar (clinical) [Ep 18 · 48:32](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=2912)
- "The APSA outcomes committee meta-analysis came to a very similar conclusion about high thoracoscopic CDH recurrence rates." — Charlie Stolar (clinical) [Ep 18 · 50:02](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=3002)
- "For open CDH repair, need a real subcostal incision (not a small two-finger incision), rotate the liver out of chest and abdomen, eviscerate bowel, and mobilize the posterior leaflet like unrolling a window shade down to rib." — Charlie Stolar (guideline) [Ep 18 · 55:02](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=3302)
- "The medial part of CDH repair is hardest because sometimes the esophagus or aorta is hanging out with nothing to sew to." — Charlie Stolar (clinical) [Ep 18 · 56:06](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=3366)
- "When there's no diaphragm to sew to medially, make an upside-down U-shaped incision on the pericardium and rotate that down to where the diaphragm would be to begin the repair." — Charlie Stolar (guideline) [Ep 18 · 56:28](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=3388)
- "Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike Vicryl which saws tissue." — Charlie Stolar (opinion) [Ep 18 · 57:16](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=3436)
- "Favor non-biologic material like 1mm Gore-Tex for patches, and anchor the patch to the ribs laterally by getting a needle around the rib." — Charlie Stolar (guideline) [Ep 18 · 57:59](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=3479)
- "Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out taking a deep breath; over time it gets incorporated into fibrous tissue." — Charlie Stolar (guideline) [Ep 18 · 58:43](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=3523)
- "For thoracoscopic CDH repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and put solid organs (spleen or left liver lobe) in last to plug the hole and keep bowel down." — Charlie Stolar (guideline) [Ep 18 · 60:23](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=3623)
- "There is no indication for a chest tube in CDH except for active air leak or anticipated/active bleeding. The ipsilateral lung is small and won't fill the pleural space—that's how God made this lung." — Charlie Stolar (guideline) [Ep 18 · 66:47](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4007)
- "A pneumothorax in CDH is a pneumothorax ex vacuo, not air under pressure. Putting in a chest tube on water seal suction will just distort the mediastinum and precipitate a pulmonary hypertensive crisis." — Charlie Stolar (clinical) [Ep 18 · 67:13](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4033)
- "The typical stable CDH baby will be crummy for about a day postoperatively, then get better and be extubated in 4-5 days and go home." — Charlie Stolar (clinical) [Ep 18 · 68:54](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4134)
- "CDH is a field defect affecting the whole foregut from pharynx to ligament of Treitz. Everything—esophagus, stomach, gastric emptying—has abnormal motility." — Charlie Stolar (clinical) [Ep 18 · 69:39](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4179)
- "If you do a GI series on CDH kids, the esophagus will be very dilated, ectatic, and abnormal-looking. Manometry and impedance manometry are abnormal." — Charlie Stolar (clinical) [Ep 18 · 69:51](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4191)
- "It's not really reflux in CDH—calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture." — Charlie Stolar (opinion) [Ep 18 · 70:09](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4209)
- "CDH kids generally do well with continuous feedings slowly condensed to bolus. It's unusual to need surgical intervention for foregut dysmotility." — Charlie Stolar (clinical) [Ep 18 · 70:28](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4228)
- "When surgery is needed for CDH foregut dysmotility, approach it as palliation: some sort of fundoplication (not Nissen—it's fully competent on an abnormal-motility esophagus), combined with gastrostomy and a real drainage procedure like Jaboulay-Finney, not Heineke-Mikulicz." — Charlie Stolar (guideline) [Ep 18 · 70:36](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4236)
- "Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis and now recommends lifelong proton pump inhibitors and regular scoping for all CDH patients." — Charlie Stolar (clinical) [Ep 18 · 73:18](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4398)
- "Dr. Stolar's 1989-1990 paper showed most CDH kids turn out OK unless the mother had an 8th grade education and the child is a boy." — Charlie Stolar (clinical) [Ep 18 · 73:46](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4426)
- "There is an incidence of attention deficit disorders and autism in CDH survivors, prompting early intervention for neuropsychiatric issues." — Charlie Stolar (clinical) [Ep 18 · 73:58](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4438)
- "Because CDH is a field defect, there's asymmetric chest growth leading to pectus-like distorted chest wall growth requiring Nuss-type operations in some patients." — Charlie Stolar (clinical) [Ep 18 · 74:09](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4449)
- "Some CDH girls as teenagers have no breast development on the side of the hernia, requiring Nuss operation and breast implant." — Charlie Stolar (clinical) [Ep 18 · 74:20](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4460)
- "CDH patients can develop non-idiopathic scoliosis (mostly in boys, not the typical idiopathic scoliosis in girls), requiring early bracing to minimize thoracolumbar scoliosis." — Charlie Stolar (clinical) [Ep 18 · 74:34](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4474)
- "If you can see through the diaphragm tissue (it's nothing but pleura and peritoneum), resect it back to muscle for a fresh edge to sew together, or the plication will fail." — Charlie Stolar (guideline) [Ep 18 · 64:16](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=3856)
- "For right-sided CDH, the most important consideration is to ask echocardiographers where the hepatic veins drain, because they often enter directly into the right atrium, not the suprahepatic cava." — Charlie Stolar (guideline) [Ep 18 · 77:51](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4671)
- "Hepatopulmonary fusion actually exists in right-sided CDH. The liver and lung are fused and cannot be separated surgically. Most of these patients don't survive and often have severe congenital heart disease and IVC discontinuation." — Charlie Stolar (clinical) [Ep 18 · 78:36](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4716)
- "For right-sided CDH, prep the baby for both thoracic and abdominal incisions because you often need to be on both sides. Start in the abdomen, but if the liver is in the way, make a counter-incision in the chest." — Charlie Stolar (guideline) [Ep 18 · 79:48](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4788)
- "Even with an open thoracotomy, you can put a scope in to see around a corner without ugly retractors." — Charlie Stolar (guideline) [Ep 18 · 80:12](https://qa.library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-952?t=4812)
- "Esophagogastric dissociation was historically thought of as a last resort operation when Nissen fundoplication won't work." — Todd Ponsky (host_summary) [Ep 23 · 0:14](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=14)
- "Esophagogastric dissociation is now being suggested as an upfront primary operation for a small subset of patients with severe neurologic impairment." — Todd Ponsky (host_summary) [Ep 23 · 0:24](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=24)
- "The study compared patients with severe GERD and neurologic disability, half undergoing esophagogastric dissociation and half undergoing laparoscopic Nissen." — Ian Glenn (host_summary) [Ep 23 · 0:48](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=48)
- "Primary outcome was operative failure, defined as either recurrence of preoperative reflux symptoms or requirement of additional anti-reflux surgery." — Ian Glenn (host_summary) [Ep 23 · 1:01](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=61)
- "There was a 4% failure rate in the esophagogastric dissociation group and a 21% failure rate in the Nissen group." — Ian Glenn (host_summary) [Ep 23 · 1:13](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=73)
- "The difference in failure rates between esophagogastric dissociation (4%) and Nissen (21%) was not statistically significant." — Ian Glenn (host_summary) [Ep 23 · 1:21](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=81)
- "17% of patients in the esophagogastric dissociation group continued to require anti-reflux medications after surgery, compared to 54% in the Nissen group." — Ian Glenn (host_summary) [Ep 23 · 1:23](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=83)
- "The difference in continued requirement for anti-reflux medications (17% vs 54%) was statistically significant." — Ian Glenn (host_summary) [Ep 23 · 1:29](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=89)
- "Caregiver-evaluated quality of life and symptom scores were the same between the two groups with no statistically significant difference." — Ian Glenn (host_summary) [Ep 23 · 1:39](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=99)
- "The lack of statistical significance in failure rates could potentially be a type 2 error where there was actually a difference but the sample size was too small to detect it." — Ian Glenn (host_summary) [Ep 23 · 2:03](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=123)
- "A multi-center study will probably be needed to really understand the difference between these procedures." — Todd Ponsky (opinion) [Ep 23 · 2:12](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=132)
- "The study did not look at complication rates such as leaks and strictures, which are the main concern for why most surgeons don't perform esophagogastric dissociation." — Todd Ponsky (clinical) [Ep 23 · 2:16](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=136)
- "Esophagogastric dissociation is a much bigger surgery than Nissen fundoplication." — Ian Glenn (clinical) [Ep 23 · 2:24](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=144)
- "The study examined perioperative factors including time in the OR, length of hospital stay, need for ICU stay, and time to full feeds, with statistically significant differences following expected trends." — Ian Glenn (host_summary) [Ep 23 · 2:26](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=146)
- "The study did not report on leaks, strictures, or long-term requirement for additional surgeries other than anti-reflux operations." — Ian Glenn (host_summary) [Ep 23 · 2:39](https://qa.library.globalcastmd.com/watch/esophagogastric-dissociation-for-gerd-in-severe-neurodisability-962?t=159)
- "The frequency and incidence of abdominal wall defects appears to be increasing" (host_summary) [Ep 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 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 22 · 51:09](https://qa.library.globalcastmd.com/watch/abdominal-wall-defects-with-dr-jacob-langer-959?t=3069)
- "After 2-3 recurrences of pilonidal cyst, definitive surgery is indicated rather than repeat I&D." (opinion) [Ep 24 · 0:30](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=30)
- "The Bascom technique involves excising 1-millimeter pits at skin level under local anesthesia, allowing secondary healing, with 70% not recurring by their data (though no control group exists)." (clinical) [Ep 24 · 0:54](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=54)
- "For large draining sinuses or recurrence after pit excision, formal OR excision of the entire affected area with off-midline layered closure and drain placement is performed." (clinical) [Ep 24 · 1:28](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=88)
- "Physical exam findings including deep gluteal fold and heavy hair burden are high-risk factors for pilonidal disease recurrence." (clinical) [Ep 24 · 2:25](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=145)
- "For severely infected pilonidal disease, open excision with wet-to-dry dressing changes or wound VAC is an option." (clinical) [Ep 24 · 2:50](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=170)
- "The Karydakis flap is superior to excision only and comparable to the modified Limberg flap for pilonidal disease." (host_summary) [Ep 24 · 3:10](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=190)
- "The modified elliptical rotation flap has short-term results comparable to Limberg and Karydakis flaps, though less data exists." (host_summary) [Ep 24 · 3:10](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=190)
- "Post-operative management with prone positioning until wound healing is critical for preventing recurrence; pilonidal disease is fundamentally a wound healing problem." (opinion) [Ep 24 · 3:43](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=223)
- "Plastic surgery consultation for flap reconstruction with strict prone post-operative positioning is used for multiply recurrent pilonidal disease." (clinical) [Ep 24 · 3:54](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=234)
- "One patient reported laser hair removal as the most painful procedure they had experienced, completing only half a session and refusing further treatment." (clinical) [Ep 24 · 4:28](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=268)
- "Laser hair removal for pilonidal disease is expensive and insurance reimbursement has not been successful." (clinical) [Ep 24 · 4:46](https://qa.library.globalcastmd.com/watch/pilonidal-cyst-case-presentation-update-course-2015-982?t=286)
- "5 to 15% of patients who have catheters removed require some sort of additional intervention to remove the catheter." — Ian Glenn (epidemiological) [Ep 25 · 0:32](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=32)
- "The actual number of catheters or catheter fragments that get left behind is 0.2 to 2%." — Ian Glenn (epidemiological) [Ep 25 · 0:57](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=57)
- "Risk factors for catheter retention include chemotherapy infusion through the line." — Ian Glenn (clinical) [Ep 25 · 1:12](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=72)
- "Risk factors for catheter retention include catheters that are indwelling for longer than about a year and a half." — Ian Glenn (clinical) [Ep 25 · 1:12](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=72)
- "There is an association between polyurethane catheter material and catheter retention when compared with silicone catheters." — Ian Glenn (clinical) [Ep 25 · 1:25](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=85)
- "Power ports are polyurethane catheters." (clinical) [Ep 25 · 1:31](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=91)
- "The recommendation would be to go with silastic catheters for long-term chemotherapy cases." — Ian Glenn (guideline) [Ep 25 · 1:46](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=106)
- "Surgical venotomy to retrieve a retained catheter carries a risk of bleeding." — Ian Glenn (clinical) [Ep 25 · 2:10](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=130)
- "In interventional radiology case series attempting endovascular catheter removal, there was a risk of the line completely breaking and embolizing distally." — Ian Glenn (clinical) [Ep 25 · 2:16](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=136)
- "In interventional radiology case series attempting endovascular catheter removal, there was a risk of thrombosis occurring during the procedure." — Ian Glenn (clinical) [Ep 25 · 2:16](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=136)
- "Multiple studies of patients with retained catheter fragments, with follow-up periods from months to the order of 5 years, found no complications." — Ian Glenn (epidemiological) [Ep 25 · 2:31](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=151)
- "No thrombosis was associated with retained catheter fragments in studies with follow-up from months to 5 years." — Ian Glenn (epidemiological) [Ep 25 · 2:42](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=162)
- "No infections were associated with retained catheter fragments in studies with follow-up from months to 5 years." — Ian Glenn (epidemiological) [Ep 25 · 2:42](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=162)
- "Silastic lines generally have a larger size diameter for a given lumen compared to polyurethane lines." (host_summary) [Ep 25 · 3:08](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=188)
- "There has never been a report of a problem by leaving a retained catheter tip in, although long-term data are lacking." (host_summary) [Ep 25 · 3:26](https://qa.library.globalcastmd.com/watch/management-of-retained-central-venous-catheters-1330?t=206)

## Changelog
- Sep 9: Summaries and takeaways published for 4 audiences
- Sep 7: Audit reverted — short clips unhidden
- Sep 7: 2 items hidden — never mention Single Ventricle / HLHS; unhide from the owner view
- Aug 31: 23 doctors auto-found from episode dossiers
- Aug 30: 23 doctors auto-found from episode dossiers
- Aug 30: 23 doctors auto-found from episode dossiers
- Aug 29: 23 doctors auto-found from episode dossiers
- Aug 29: 23 doctors auto-found from episode dossiers
- Aug 29: Collection generated from campaign corpus: 37 items, 34 dossiers, summaries for 4 audience(s)
- Aug 29: Collection reviewed and published
- Aug 29: Collection generated from campaign corpus: 35 items, 34 dossiers, summaries for 1 audience(s)
- Aug 29: Collection generated from campaign corpus: 35 items, 34 dossiers, summaries for 3 audience(s)

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