Aaron Garrison

Aaron's statements about Aerodigestive / ENT 51 statements

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QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison

Statement Pediatric surgery trainees were initially told that tracheomalacia is something that kids will grow out of and will get better. Open

Quotation I think some of us who are peat surgery trained were told initially that tracheomalacia is something that kids will grow out of and will get better and as data has shown recently that there's no long term consequences for soiling into the lungs and having chronic lung lung aspiration and over time that really is detrimental. Open

Statement Recent data has shown that there are long term consequences for soiling into the lungs and having chronic lung aspiration, which over time is detrimental. Open

Statement Preoperative dynamic reconstruction studies give a lot of information for determining which procedure is best for each patient. Open

Statement Dynamic expiratory films show what you need to see with the airway that inspiratory films alone do not reveal. Open

Quotation You really see what you need to see with the dynamic studies. Open

Statement Surgeons always look for the thymus and make sure that there is enough tissue to remove to be able to bring the trachea up anteriorly. Open

Quotation Our classification system is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging. Open

Statement The classification system for tracheomalacia is in evolution, and trying to describe what is mild or severe or moderate is a little bit challenging. Open

Quotation The benefits of minimally invasive to me, the biggest one is that visualization and exposure. Open

Statement The biggest benefit of minimally invasive approach is visualization and exposure. Open

Statement Disadvantages of minimally invasive approach include that it takes longer to learn and is more uncomfortable to learn. Open

Statement Anesthesia colleagues are sometimes hesitant to allow thoracoscopic cases to go on a little bit longer. Open

Statement For anterior mediastinal work, babies are positioned with the arm up and a bump underneath so that there is access to the axilla and anteriorly. Open

Statement The goal of aortopexy is to suspend the aorta. Open

Statement The first step in aortopexy is taking out the thymus, finding the innominate junction, and then identifying the arch of the aorta. Open

Quotation If you go up too high, then you're doing a pericardioexy and it isn't quite as successful or durable. Open

Statement If you go up too high during aortopexy, then you are doing a pericardiopexy and it is not quite as successful or durable. Open

Statement The goal of posterior tracheopexy is taking the anterior spinal ligament and fixing it to the posterior membranous trachea. Open

Statement The area of floppy membrane is distal to the dilated pouch usually. Open

Statement Surgeons can make an indent on the posterior wall of the trachea, and pulmonologists can see it pop up on their bronchoscopy to help guide suture placement. Open

Statement It usually takes about 2 or 3 sutures for posterior tracheopexy, leaving enough space for the esophagus to come through. Open

Statement Using the knot pusher and tension suture is helpful during tracheopexy. Open

Quotation And this is the part that I think is honestly the, the hardest. Getting that suture to roll through the anterior spinal ligament is actually pretty, pretty challenging. Open

Statement Getting the suture to roll through the anterior spinal ligament is the hardest part and is pretty challenging. Open

Statement There are times when the esophagus is put to the left of the trachea, and times when it is put to the right of the trachea. Open

Statement Dr. Garrison always worries a little bit about dysphagia when repositioning the esophagus, but it is not something he has seen a ton of. Open

Quotation I always worry a little bit about dysphagia, but honestly, it's not something that I've, I've seen a ton of. Open

QUAD #4: Surgical Management of Button Battery & Caustic Ingestion with Dr. Aaron Garrison

Quotation There are 3 locations in the esophagus where things tend to get stuck, so the upper esophageal sphincter behind the aortic arch, and then at the lower esophageal sphincter. Open

Statement There are 3 locations in the esophagus where button batteries tend to get stuck: the upper esophageal sphincter, behind the aortic arch, and at the lower esophageal sphincter. Open

Statement High-risk criteria include younger patients with smaller esophagus. Open

Statement Longer duration that the battery has been in the esophagus is associated with worse outcomes. Open

Quotation And I think the one take home point, if you can remember anything, is that if you have a patient who has had a battery removed and they present later with a bleed, that's an emergency that needs to be taken seriously and have a plan for. Open

Statement If a patient has had a battery removed and presents later with a bleed, that is an emergency that needs to be taken seriously and requires a plan. Open

Statement Two of the fatalities in the Colorado series presented with the button batteries already in the stomach. Open

Quotation And almost 25% of the patients in this series died, and what I thought was particularly sad is that 2 of the fatalities presented with the buttons already in the stomach. Open

Statement Almost 25% of patients in the Colorado series died. Open

Statement Any small communication between the esophagus and the aorta can be potentially life-threatening. Open

Statement Aortoesophageal fistulas do not always happen in the hospital, so having a high index of suspicion and a plan for what to do once the battery is removed is helpful. Open

Quotation So it is not something that always happens in the hospital, so I think having a high index of suspicion and a plan for what to do once the battery is removed is helpful. Open

Statement For sick patients with esophageal foreign bodies and active bleeding or clinical instability, it is recommended to have GI surgery and CT surgery available for the procedure. Open

Statement If imaging shows injury close to the aorta, continue NPO and antibiotics and repeat MRI in 5 to 7 days to assess the trajectory of inflammation. Open

Statement For high-risk patients (less than 5 years old, larger battery size), endoscopic evaluation of the esophagus is recommended because the duration of battery presence higher up than the stomach is unknown. Open

Statement The need for ECMO or cardiopulmonary bypass depends on the location of the fistula and whether you can intubate past the injury enough to ventilate during the case. Open

Statement If the fistula is near the carina, complex airway reconstruction will be needed and adequate ventilation during the case will not be possible. Open

Statement In one case with a large tracheoesophageal fistula, the patient was placed on ECMO because they were unable to adequately ventilate. Open

Statement In the Cincinnati Children's case, an interposition graft was performed by removing a segment of trachea and using that trachea as the front wall of the esophagus. Open

Quotation Sometimes I think it's easy to get caught up in what the child drank and to forget that the kind of airway may take priority. Open

Statement The airway may take priority in caustic ingestion cases, and patients can present in extremis or with an allergic-reaction-like presentation. Open

Statement For esophageal perforation, the approach is to maintain the same exposure, debride to viable tissue, achieve layered closure with coverage, and if possible use a muscle flap for coverage. Open

Statement If the perforation is too big, drain it to allow for delayed repair. Open

Aaron's statements about Colorectal / ARM & Hirschsprung 81 statements

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Hirschsprung's Disease

Statement Hirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction. Open

Quotation Hirschsprung disease is a congenital developmental anomaly of intestinal ganglion cell migration that results in a functional bowel obstruction. Open

Quotation And I'm Aaron Garrison. We're both pediatric surgeons at Cincinnati Children's. Open

Statement About 10% of children with Hirschsprung disease will have a positive family history. Open

Statement There are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease. Open

Statement Hirschsprung disease has an incidence of about 1 in 5,000 children. Open

Statement About 10% of children with Hirschsprung disease will have a positive family history. Open

Statement There are predisposing genetic conditions such as the RET gene that can be associated with Hirschsprung disease. Open

Statement Up to 10% of children with Hirschsprung's disease will have trisomy 21. Open

Statement Only 1 to 2% of patients with trisomy 21 have Hirschsprung disease. Open

Statement Hirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes. Open

Statement Up to 10% of children with Hirschsprung's disease will have trisomy 21. Open

Statement Only 1 to 2% of patients with trisomy 21 have Hirschsprung disease. Open

Statement Hirschsprung disease is associated with Waardenburg syndrome, congenital central hypoventilation (Ondine's curse), and some other syndromes. Open

Quotation So Hirschsprung disease is actually relatively common in a busy children's hospital. It's got an incidence of about 1 in 5,000 children. Open

Statement Hirschsprung disease has an incidence of about 1 in 5,000 children. Open

Statement Older children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases. Open

Statement Enterocolitis is the life-threatening part of Hirschsprung's disease. Open

Statement NICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended. Open

Quotation So the first thing I usually do is talk to the family and give them education about the disease, because most of them have never heard of it and they're not sure what to expect. Open

Statement Older children with Hirschsprung disease often have dilated colon and are not amenable to just doing a primary pull-through in many cases. Open

Statement NICU babies diagnosed with Hirschsprung's disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended. Open

Statement Enterocolitis is the life-threatening part of Hirschsprung's disease. Open

Statement The contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always. Open

Statement The goal of surgery is to get past the aganglionic segment into the normally innervated bowel that does not have hypertrophic nerves, and to pull that segment of bowel down through and perform anastomosis above the dentate line. Open

Statement The contrast enema can be used as a roadmap for surgery, and most times it is accurate to where the level is, but not always. Open

Statement Children who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch. Open

Statement The Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures. Open

Statement In the Duhamel procedure, you intentionally leave a portion of the aganglionic rectum behind and bring the normally ganglionated bowel posterior to that rectum, then make an anastomosis using a stapler to create a common panel. Open

Statement In the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision. Open

Statement The Duhamel procedure involves less dissection in the pelvis, so there may be less injury to pelvic structures. Open

Statement All three surgical techniques (Swenson, Suave, and Duhamel) are equally effective. Open

Statement Children who have the Duhamel procedure may have higher risks of constipation and stool withholding because they can have trouble evacuating the pouch. Open

Statement In the Duhamel procedure, the anastomosis can leave a spur if it is not large enough, sometimes requiring revision. Open

Statement All three surgical techniques (Swenson, Suave, and Duhamel) are equally effective. Open

Statement Early complications after Hirschsprung surgery include diaper rash and excoriation that can need to be treated like a burn. Open

Statement Anastomotic leaks are rare but usually show up in the first week after surgery with fever, abdominal distension, and possibly free air, often requiring another operation or proximal diversion. Open

Statement About 80% of kids with Hirschsprung's disease are constipated and will need some kind of management. Open

Statement Most patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten. Open

Statement About 80% of kids with Hirschsprung's disease are constipated and will need some kind of management. Open

Statement Most patients with rectosigmoid Hirschsprung disease should be continent by the time they enter kindergarten. Open

The Colorectal Quiz Episode 4: Classic Hirschsprung disease - Surgical Technique

Statement Surgeons should wait for frozen section confirmation before taking mesentery during Hirschsprung pull-through. Open

Statement Mesenteric dissection should stay close to the bowel wall, not deep in the mesentery, as this plane tends to be less bloody. Open

Statement For standard rectosigmoid Hirschsprung cases, the patient can remain supine with legs wrapped and fastened to the ether screen, avoiding the need to flip prone. Open

Statement Tacking sutures on the serosa to the pelvic sidewall at 3 and 9 o'clock positions help anchor the anastomosis in place, though this does not constitute a true two-layer anastomosis. Open

Hirschsprung Disease in Brief

Statement In Hirschsprung disease, the ganglion cells don't make it all the way down distally, and the colon ends up not being able to contract. Open

Quotation The ganglion cells don't make it all the way down distally. The colon ends up not being able to contract. Open

Statement Hirschsprung disease has an incidence of about 1 in 5,000 children. Open

Quotation The transition zone is from contracted rectum and all of a sudden it opens up into dilated rectum. That's the transition zone. Open

Statement The transition zone is from contracted rectum (where nerve cells are absent) to dilated rectum (where normal nerve cells are present). Open

Statement In Hirschsprung's disease, the rectum is usually less dilated than the proximal colon, making the rectosigmoid ratio less than 1. Open

Statement In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema. Open

Statement Inability to evacuate contrast is a finding suggestive of Hirschsprung disease. Open

Statement The recto-anal inhibitory reflex may be absent in other conditions besides Hirschsprung disease, and some children have a false positive test. Open

Statement In anorectal manometry for Hirschsprung disease, there is a lack of the recto-anal inhibitory reflex (RAIR). Open

Statement Suction rectal biopsy is painless and commonly done at the bedside in neonates. Open

Statement Children with Hirschsprung disease will need this condition managed for life, but the expectation is that they will live a normal life with close management and care. Open

Statement NPO babies diagnosed with Hirschsprung disease are typically managed with irrigations, antibiotics if they show evidence of enterocolitis, and NPO or NG tubes if they're distended. Open

Statement Older children with Hirschsprung disease are not amenable to just doing a primary pull through in many cases because the colon has become dilated. Open

Statement Older children with Hirschsprung disease will start on an enema program, and some may need diversion more proximally to give the colon time to decompress. Open

Statement Early postoperative complications include diaper rash and excoriation that can often need to be treated like a burn. Open

Statement Hirschsprung's associated enterocolitis is the main early complication everyone needs to be aware of. Open

Statement Anastomotic leak is a rare but possible early complication after Hirschsprung surgery. Open

Statement Assuming the operation has been done well and there are no transition zone or strictures, most patients with Hirschsprung disease are expected to do very well and be in kindergarten socially confident. Open

Statement About 80% of kids with Hirschsprung's disease are constipated and will need some kind of management. Open

The Colorectal Quiz Episode 4

Quotation It's so important to do a full thickness biopsy, and I like to cut a square, like a cube. And if we're looking at the sides of that cube, you want to make sure that the seromuscular side is the same as the mucosal side. Open

Statement Full-thickness biopsy must include seromuscular side same size as mucosal side (cube-shaped) Open

Statement Tacking sutures from serosa to pelvic sidewall at three and six o'clock positions anchor anastomosis in place Open

Aaron's statements about Enterocolitis 25 statements

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