We didn't put an NG in, so we're paying the price for that. But what we typically will do, or what some of the old school anesthetists, and I would assume that they've taught the fellows and their junior partners is you will suction the baby while awake in 3 different positions, head down, turn to the right, turn to the left to make sure you've sucked out that big atonic bag.
We didn't put an NG in, so we're paying the price for that. But what we typically will do, or what some of the old school anesthetists, and I would assume that they've taught the fellows and their junior partners is you will suction the baby while awake in 3 different positions, head down, turn to the right, turn to the left to make sure you've sucked out that big atonic bag.
We didn't put an NG in, so we're paying the price for that. But what we typically will do, or what some of the old school anesthetists, and I would assume that they've taught the fellows and their junior partners is you will suction the baby while awake in 3 different positions, head down, turn to the right, turn to the left to make sure you've sucked out that big atonic bag.
The rates of complication after pyeloromyotomy, they're either equivalent or better actually with open because I think to me lap pyloromyotomy is an experience and a feel operation. Because like we said, there's no magical way to know exactly how complete your myotomy is, because I definitely lose my nerve going towards the duodenum, and sometimes people will stop short.
That leaves more of the catheter to curve in the neck. And so that's where I, in my opinion, you run into problems with patients who, if they, when, if and when they turn their neck, or the more lax amount of catheter in the neck. I've seen catheter spit out of the, of the SVC. It's strange, but I've seen it a couple of times.
That leaves more of the catheter to curve in the neck. And so that's where I, in my opinion, you run into problems with patients who, if they, when, if and when they turn their neck, or the more lax amount of catheter in the neck. I've seen catheter spit out of the, of the SVC. It's strange, but I've seen it a couple of times.
clinicalThe Taiwanese published in the Journal of Pediatrics in 2006 that they send all their kids home with stool color cards↗
▶Ep 8 · 9:59
clinicalMMP7 was identified as a serum marker of epithelial injury in biliary atresia through large-scale proteomic analysis of 30 children with biliary atresia in 2017↗
▶Ep 8 · 10:40
clinicalMMP7 using a cutoff value of 52-53 nanograms per ml demonstrated a sensitivity of diagnosing biliary atresia of about 98% with a specificity of about 95% in 135 consecutive infants in China↗
▶Ep 8 · 13:10
opinionMMP7 has the potential to eliminate a lot of other testing and eliminate things like a liver biopsy if confidence grows in its impact↗
▶Ep 8 · 14:44
clinicalA combination of blood tests and laparoscopy can diagnose biliary atresia promptly and accurately↗
▶Ep 8 · 17:09
clinicalBile duct proliferation and portal edema may not appear on very early liver biopsies and may delay diagnosis by up to 30 days↗
▶Ep 8 · 26:20
clinicalCystic biliary atresia patients get to surgery earlier, potentially because of prenatal diagnosis and heightened level of suspicion↗
Choledochal Cyst Podcast
▶Ep 9 · 0:29
quotea choledocal cyst ray is a congenital cystic dilation of the biliary tree.↗
▶Ep 9 · 0:29
clinicalCholedochal cyst is a congenital cystic dilation of the biliary tree.↗
▶Ep 9 · 0:36
epidemiologicalCholedochal cysts are three to four times more likely in females than in males.↗
▶Ep 9 · 0:36
epidemiologicalIn Eastern Asia, choledochal cyst incidence is 1 in 13,000.↗
▶Ep 9 · 0:36
epidemiologicalIncidence of choledochal cysts in the Western world is about 1 in 100,000.↗
▶Ep 9 · 0:36
clinicalThere is no genetic predisposition to choledochal cysts, but some genes including PKD1 have been identified in limited studies for type 5 choledochal cysts.↗
▶Ep 9 · 0:36
quotethere isn't a genetic predisposition to choledocal cysts, there are some genes that have been identified in limited studies, possibly including PKD1 for type 5 choledocal cysts.↗
▶Ep 9 · 0:36
quoteIt's actually three to four times more likely in females than in males.↗
▶Ep 9 · 0:36
quoteIn the Western world, the incidence is about 1 in 100,000. But in Asia, specifically Eastern Asia, it's quite a bit more common, 1 in 13,000.↗
▶Ep 9 · 1:10
quoteit's thought that reflux of pancreatic enzymes from, obviously, the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 9 · 1:10
quoteit is likely embryologic, relating to the pancreatic obiliary duct junction, also known as, in this scenario, pancreatic obiliary malunion, which oftentimes creates what's called a long common channel of the pancreatic obiliary duct.↗
▶Ep 9 · 1:10
clinicalThe most common classification system for choledochal cysts was developed by a surgeon named Tadani in Japan and includes five types.↗
▶Ep 9 · 1:10
clinicalFor types 1 and 4 choledochal cysts, the etiology is likely embryologic, relating to pancreaticobiliary duct junction (pancreaticobiliary malunion), which creates a long common channel of the pancreaticobiliary duct.↗
▶Ep 9 · 1:10
clinicalReflux of pancreatic enzymes from the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes in types 1 and 4 choledochal cysts.↗
▶Ep 9 · 1:10
clinicalIn type 5 choledochal cysts, genetic mutation might predispose to more diffuse dilation of both the intra- and extrahepatic biliary trees.↗
▶Ep 9 · 2:05
clinicalType 1 choledochal cyst is a dilation of the extrahepatic common bile duct only, which can be fusiform or saccular.↗
▶Ep 9 · 2:05
clinicalType 4b choledochal cyst consists of multiple cysts in the extrahepatic biliary tree only.↗
▶Ep 9 · 2:05
clinicalType 4a choledochal cyst consists of multiple cysts in both the intra- and extrahepatic biliary tree.↗
▶Ep 9 · 2:05
clinicalType 3 choledochal cyst is a choledochocele affecting the portion of the common bile duct in the wall of the duodenum.↗
▶Ep 9 · 2:05
clinicalType 2 choledochal cyst is a small diverticulum off of the common bile duct.↗
▶Ep 9 · 2:05
clinicalType 5 choledochal cyst is intrahepatic only and diffusely throughout, called Caroli's disease, which can be diffuse or limited to one lobe or one hemi-liver.↗
▶Ep 9 · 2:05
quoteType 1 is a dilation of the common bile duct only, the extrahepatic common bile duct only, and that can either be fusiform or saccular.↗
▶Ep 9 · 2:05
quotetype 5 is intra-hepatic only and sort of diffusely throughout, called Corolli's disease.↗
▶Ep 9 · 2:05
quoteType 4a, which is a multitude of cysts, both in the intra- and extrahepatic biliary tree, and type 4b are multiple cysts, but in the extrahepatic biliary tree only.↗
▶Ep 9 · 2:05
quoteType 2, choledocal cyst, is just a small diverticulum off of the common bile duct.↗
▶Ep 9 · 2:05
quoteType 3 is what's called a choledocal seal, so it affects the portion of the common bile duct in the wall of the duodenum.↗
▶Ep 9 · 3:25
guidelinePrenatally diagnosed choledochal cysts require fetal consultation at a fetal surgery center for establishment of care and counseling, because cystic biliary atresia must be ruled out postnatally.↗
▶Ep 9 · 3:25
quoteif a cyst was diagnosed prenatally, and it was larger than four and a half centimeters at the 20 week anatomy scan, there was a higher rate of postnatal symptomatology.↗
▶Ep 9 · 3:25
quoteonce the child is born, there are variants of other apatobiliary disease, most specifically cystic biliary atresia, that has to be ruled out.↗
▶Ep 9 · 3:25
quotegiant choledocal cysts can be diagnosed prenatally on week 20 ultrasounds.↗
▶Ep 9 · 3:25
quotesometimes, and also in small children, giant cysts that children are born with can actually perforate and present with biliary ascites.↗
▶Ep 9 · 3:25
quotethis is known as Charcot's triad, but actually, this is incredibly uncommon as far as presentations are concerned.↗
▶Ep 9 · 3:25
quoteThe patients also can have a palpable right upper quadrant mass.↗
▶Ep 9 · 3:25
quoteIn children, oftentimes, you will get symptoms consistent with cholangitis, such as jaundice or fever.↗
▶Ep 9 · 3:25
quoteOftentimes, in younger children, such as infants, it's diagnosed incidentally on axial imaging or ultrasound imaging for other causes.↗
▶Ep 9 · 3:25
clinicalIn younger children such as infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound for other causes.↗
▶Ep 9 · 3:25
clinicalIn children, choledochal cysts often present with symptoms consistent with cholangitis, such as jaundice or fever.↗
▶Ep 9 · 3:25
clinicalPatients with choledochal cysts can have a palpable right upper quadrant mass.↗
▶Ep 9 · 3:25
clinicalThe triad of jaundice, fever, and palpable right upper quadrant mass (Charcot's triad) is incredibly uncommon as a presentation of choledochal cysts.↗
▶Ep 9 · 3:25
clinicalGiant choledochal cysts in small children can perforate and present with biliary ascites.↗
▶Ep 9 · 3:25
clinicalGiant choledochal cysts can be diagnosed prenatally on week 20 ultrasounds.↗
▶Ep 9 · 3:25
clinicalA recent citation demonstrated that if a choledochal cyst was diagnosed prenatally and was larger than 4.5 centimeters at the 20-week anatomy scan, there was a higher rate of postnatal symptomatology, suggesting these patients may benefit from earlier intervention.↗
▶Ep 9 · 5:12
clinicalA one-year-old with jaundice is a little old for biliary atresia, which is usually considered in an infant.↗
▶Ep 9 · 5:12
clinicalDifferential diagnosis for a one-year-old presenting with jaundice includes problems with the pancreatic or biliary tree, stone disease (choledocholithiasis, cholelithiasis), gallstone pancreatitis, and choledochal cyst.↗
▶Ep 9 · 5:46
clinicalLabs to check for suspected choledochal cyst include liver function tests (total, direct, and indirect bilirubin levels) and possibly a CBC to look for evidence of cholangitis or infection.↗
▶Ep 9 · 5:46
clinicalPhysical exam findings to look for in suspected choledochal cyst include jaundice or scleral icterus and, in younger children, a palpable abdominal mass.↗
▶Ep 9 · 5:46
clinicalThe major initial screening imaging test for choledochal cyst is an abdominal ultrasound.↗
▶Ep 9 · 5:46
quotethe major initial screening imaging test would be an abdominal ultrasound.↗
▶Ep 9 · 6:25
quotea liver biopsy does become critical if you're talking about a neonate or a newborn. Because again, as discussed earlier, you have to rule out the cystic biliary atresia variant. Cannot miss that.↗
▶Ep 9 · 6:25
clinicalLiver biopsy is not typically needed for older patients with reliable ultrasound imaging, but becomes critical in neonates or newborns to rule out cystic biliary atresia variant.↗
▶Ep 9 · 6:47
clinicalMRCP is useful for choledochal cysts with hilar or intrahepatic disease to understand the extent of cystic change and to identify variant biliary anatomy, which occurs in 15 to 20% of patients.↗
▶Ep 9 · 6:47
clinicalCT scan is commonly used for choledochal cyst workup because of the ease with which young children can be scanned.↗
▶Ep 9 · 6:47
clinicalERCP can be used for both diagnostic and therapeutic purposes in choledochal cysts, depending on prior scan findings and the type of cyst.↗
▶Ep 9 · 6:47
quoteprobably up to 15 to 20% of patients have some kind of variant biliary tract anatomy.↗
clinicalEven after surgical resection of choledochal cysts, some studies suggest there is still about a 4% lifetime risk of malignancy, requiring lifelong surveillance.↗
▶Ep 9 · 8:00
clinicalStudies estimate the lifetime risk of malignancy in choledochal cysts to be anywhere from 6% to 30%.↗
▶Ep 9 · 8:00
clinicalType 1 and type 4 choledochal cysts with pancreaticobiliary malunion carry approximately an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma and gallbladder cancer.↗
▶Ep 9 · 8:00
clinicalCholedochal cysts require surgery due to the risk of recurrent cholangitis from biliary stasis and superinfection.↗
▶Ep 9 · 8:00
clinicalThere are no non-surgical treatment options for choledochal cysts.↗
▶Ep 9 · 8:00
quoteeven after surgical resection of these cysts, some studies suggest that there is still about a 4% lifetime risk of malignancy, which means that these patients need to be surveilled through their lifetime.↗
▶Ep 9 · 8:00
quotethere is, as we can best estimate, about an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma, which, as we all know, is a very aggressive malignancy and hard-to-treat malignancy, as well as gallbladder cancer.↗
▶Ep 9 · 8:00
quotethere have been a whole bunch of studies estimating that this lifetime risk is anywhere from 6% to 30%.↗
▶Ep 9 · 9:16
opinionFor incidentally found choledochal cysts, surgery should be scheduled sooner rather than later, when it makes sense for the family schedule.↗
▶Ep 9 · 9:16
clinicalIf a patient with choledochal cyst presents with active infection, pancreatitis, or cholangitis, the best approach is to cool the patient off and treat the underlying process before scheduling surgery after sufficient recovery.↗
▶Ep 9 · 10:14
clinicalMRCP is recommended preoperatively if there is any question about the patient's anatomy or if the patient has a very proximal choledochal cyst or dilation into the hepatic ducts.↗
▶Ep 9 · 10:14
clinicalPreoperative workup for choledochal cyst surgery includes laboratory values to ensure no other disease process is impairing liver function, and imaging (ultrasound and CT scan are often sufficient).↗
▶Ep 9 · 11:13
clinicalFor type 1 and type 4 choledochal cysts, biliary drainage reconstruction often includes a Roux-en-Y hepaticojejunostomy, but a hepaticoduodenostomy is also an option.↗
▶Ep 9 · 11:13
clinicalThe surgical goal for choledochal cyst repair is complete excision of the cyst.↗
▶Ep 9 · 11:13
clinicalFor type 1 and type 4 choledochal cysts, the goal is to remove as much of the duct as possible, taking the duct all the way down behind or into the head of the pancreas to where it tapers, to avoid leaving remnant cyst.↗
▶Ep 9 · 11:13
clinicalType 2 choledochal cyst can be treated by simple removal of the diverticulum at its neck with repair of the common bile duct.↗
▶Ep 9 · 11:13
clinicalType 3 choledochal cyst (limited choledochocele) can be treated with ERCP and sphincterotomy.↗
▶Ep 9 · 11:13
clinicalIf type 3 choledochal cyst involves the wall of the duodenum, transduodenal resection options exist, and biopsy of the choledochocele mucosa is important because biliary epithelium exposed to intestinal secretions could become malignant.↗
▶Ep 9 · 11:13
clinicalType 5 choledochal cyst (Caroli's disease) management depends on disease extent: if limited to an anatomic part of the liver, resection may be appropriate; if diffuse throughout the liver without adequate functional remnant, transplantation may be necessary.↗
▶Ep 9 · 13:19
clinicalDr. Bondock performs the Roux-en-Y limb retrocolic and closes the small bowel mesentery.↗
▶Ep 9 · 13:19
clinicalDuring choledochal cyst dissection, hepatic arteries are medial and the portal vein is posterior to the cyst.↗
▶Ep 9 · 13:19
clinicalDr. Bondock performs an intraoperative cholangiogram through the gallbladder to understand where the tapering of the distal cyst occurs to avoid leaving remnant cyst.↗
▶Ep 9 · 13:19
clinicalFor Roux-en-Y hepaticojejunostomy reconstruction, Dr. Bondock goes about 15 to 20 centimeters distal from the ligament of Treitz, performs a two-layer jejunojejunostomy, and does a hepaticojejunostomy with interrupted 5-0 or 6-0 Maxon suture.↗
▶Ep 9 · 13:19
clinicalFor choledochal cyst surgery in children less than 2 years old, a transverse incision or right subcostal incision is preferred; for older children, an upper midline incision is a viable option.↗
▶Ep 9 · 16:47
clinicalType 3 choledochal cyst can be approached endoscopically with ERCP and sphincterotomy, but if the lesion is large and obstructing the common duct, a transduodenal approach is needed, sometimes with preoperative stents to separate it from the duodenum.↗
▶Ep 9 · 16:47
clinicalType 5 choledochal cyst (Caroli's disease) can be addressed surgically with liver resection if cystic disease is limited to one hemi-liver with adequate liver remnant and preserved biliary outflow, but if diffuse throughout the liver, liver transplantation may be necessary.↗
▶Ep 9 · 16:47
clinicalFor type 2 choledochal cyst, once the cyst is tapered down to the common bile duct, the neck is resected and the common bile duct is repaired with interrupted absorbable suture without leaving a T-tube.↗
▶Ep 9 · 18:45
clinicalShort-term to long-term surgical complications of choledochal cyst surgery include anastomotic stricture, small bowel obstruction from intra-abdominal surgery, reflux gastritis, and recurrent cholangitis.↗
▶Ep 9 · 18:45
clinicalDr. Bondock typically places an NG tube postoperatively because of the new jejunojejunostomy, but tries to remove it the day after surgery.↗
▶Ep 9 · 18:45
clinicalPostoperative considerations for choledochal cyst surgery include enteric drainage and awaiting return of bowel function.↗
▶Ep 9 · 18:45
clinicalDrains are placed postoperatively to assess for biliary leaks from the new hepatoenteric anastomosis and are typically removed once the patient is tolerating a regular diet.↗
▶Ep 9 · 18:45
clinicalInstitutionally, patients are placed on a choleretic like Actigall and cholangitis prophylaxis (daily Bactrim) for three to six months after choledochal cyst surgery.↗
▶Ep 9 · 18:45
clinicalLifelong follow-up is needed for choledochal cyst patients because of the possibility of developing future malignancy even after resection of the cyst.↗
quotea choledocal cyst ray is a congenital cystic dilation of the biliary tree.↗
▶Ep 1 · 0:29
clinicalCholedochal cyst is a congenital cystic dilation of the biliary tree.↗
▶Ep 1 · 0:29
quotea choledocal cyst ray is a congenital cystic dilation of the biliary tree.↗
▶Ep 1 · 0:29
clinicalCholedochal cyst is a congenital cystic dilation of the biliary tree.↗
▶Ep 1 · 0:36
epidemiologicalCholedochal cysts are three to four times more likely in females than in males.↗
▶Ep 1 · 0:36
epidemiologicalIncidence of choledochal cysts in the Western world is about 1 in 100,000.↗
▶Ep 1 · 0:36
epidemiologicalIn Eastern Asia, choledochal cyst incidence is 1 in 13,000.↗
▶Ep 1 · 0:36
epidemiologicalCholedochal cysts are three to four times more likely in females than in males.↗
▶Ep 1 · 0:36
clinicalThere is no genetic predisposition to choledochal cysts, but some genes including PKD1 have been identified in limited studies for type 5 choledochal cysts.↗
▶Ep 1 · 0:36
quoteIn the Western world, the incidence is about 1 in 100,000. But in Asia, specifically Eastern Asia, it's quite a bit more common, 1 in 13,000.↗
▶Ep 1 · 0:36
quoteIt's actually three to four times more likely in females than in males.↗
▶Ep 1 · 0:36
quotethere isn't a genetic predisposition to choledocal cysts, there are some genes that have been identified in limited studies, possibly including PKD1 for type 5 choledocal cysts.↗
▶Ep 1 · 0:36
clinicalThere is no genetic predisposition to choledochal cysts, but some genes including PKD1 have been identified in limited studies for type 5 choledochal cysts.↗
▶Ep 1 · 0:36
quoteIt's actually three to four times more likely in females than in males.↗
▶Ep 1 · 0:36
epidemiologicalIncidence of choledochal cysts in the Western world is about 1 in 100,000.↗
▶Ep 1 · 0:36
epidemiologicalIn Eastern Asia, choledochal cyst incidence is 1 in 13,000.↗
▶Ep 1 · 0:36
quoteIn the Western world, the incidence is about 1 in 100,000. But in Asia, specifically Eastern Asia, it's quite a bit more common, 1 in 13,000.↗
▶Ep 1 · 0:36
quotethere isn't a genetic predisposition to choledocal cysts, there are some genes that have been identified in limited studies, possibly including PKD1 for type 5 choledocal cysts.↗
▶Ep 1 · 1:10
quoteit is likely embryologic, relating to the pancreatic obiliary duct junction, also known as, in this scenario, pancreatic obiliary malunion, which oftentimes creates what's called a long common channel of the pancreatic obiliary duct.↗
▶Ep 1 · 1:10
quoteit's thought that reflux of pancreatic enzymes from, obviously, the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 1 · 1:10
clinicalIn type 5 choledochal cysts, genetic mutation might predispose to more diffuse dilation of both the intra- and extrahepatic biliary trees.↗
▶Ep 1 · 1:10
clinicalReflux of pancreatic enzymes from the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes in types 1 and 4 choledochal cysts.↗
▶Ep 1 · 1:10
clinicalFor types 1 and 4 choledochal cysts, the etiology is likely embryologic, relating to pancreaticobiliary duct junction (pancreaticobiliary malunion), which creates a long common channel of the pancreaticobiliary duct.↗
▶Ep 1 · 1:10
clinicalThe most common classification system for choledochal cysts was developed by a surgeon named Tadani in Japan and includes five types.↗
▶Ep 1 · 1:10
quoteit's thought that reflux of pancreatic enzymes from, obviously, the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 1 · 1:10
quoteit is likely embryologic, relating to the pancreatic obiliary duct junction, also known as, in this scenario, pancreatic obiliary malunion, which oftentimes creates what's called a long common channel of the pancreatic obiliary duct.↗
▶Ep 1 · 1:10
clinicalIn type 5 choledochal cysts, genetic mutation might predispose to more diffuse dilation of both the intra- and extrahepatic biliary trees.↗
▶Ep 1 · 1:10
clinicalReflux of pancreatic enzymes from the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes in types 1 and 4 choledochal cysts.↗
▶Ep 1 · 1:10
clinicalFor types 1 and 4 choledochal cysts, the etiology is likely embryologic, relating to pancreaticobiliary duct junction (pancreaticobiliary malunion), which creates a long common channel of the pancreaticobiliary duct.↗
▶Ep 1 · 1:10
clinicalThe most common classification system for choledochal cysts was developed by a surgeon named Tadani in Japan and includes five types.↗
▶Ep 1 · 2:05
clinicalType 3 choledochal cyst is a choledochocele affecting the portion of the common bile duct in the wall of the duodenum.↗
▶Ep 1 · 2:05
clinicalType 1 choledochal cyst is a dilation of the extrahepatic common bile duct only, which can be fusiform or saccular.↗
▶Ep 1 · 2:05
clinicalType 2 choledochal cyst is a small diverticulum off of the common bile duct.↗
▶Ep 1 · 2:05
clinicalType 4a choledochal cyst consists of multiple cysts in both the intra- and extrahepatic biliary tree.↗
▶Ep 1 · 2:05
clinicalType 4b choledochal cyst consists of multiple cysts in the extrahepatic biliary tree only.↗
▶Ep 1 · 2:05
clinicalType 5 choledochal cyst is intrahepatic only and diffusely throughout, called Caroli's disease, which can be diffuse or limited to one lobe or one hemi-liver.↗
▶Ep 1 · 2:05
clinicalType 4b choledochal cyst consists of multiple cysts in the extrahepatic biliary tree only.↗
▶Ep 1 · 2:05
clinicalType 4a choledochal cyst consists of multiple cysts in both the intra- and extrahepatic biliary tree.↗
▶Ep 1 · 2:05
clinicalType 3 choledochal cyst is a choledochocele affecting the portion of the common bile duct in the wall of the duodenum.↗
▶Ep 1 · 2:05
clinicalType 2 choledochal cyst is a small diverticulum off of the common bile duct.↗
▶Ep 1 · 2:05
clinicalType 1 choledochal cyst is a dilation of the extrahepatic common bile duct only, which can be fusiform or saccular.↗
▶Ep 1 · 2:05
quotetype 5 is intra-hepatic only and sort of diffusely throughout, called Corolli's disease.↗
▶Ep 1 · 2:05
quoteType 4a, which is a multitude of cysts, both in the intra- and extrahepatic biliary tree, and type 4b are multiple cysts, but in the extrahepatic biliary tree only.↗
▶Ep 1 · 2:05
quoteType 3 is what's called a choledocal seal, so it affects the portion of the common bile duct in the wall of the duodenum.↗
▶Ep 1 · 2:05
quoteType 2, choledocal cyst, is just a small diverticulum off of the common bile duct.↗
▶Ep 1 · 2:05
quoteType 1 is a dilation of the common bile duct only, the extrahepatic common bile duct only, and that can either be fusiform or saccular.↗
▶Ep 1 · 2:05
clinicalType 5 choledochal cyst is intrahepatic only and diffusely throughout, called Caroli's disease, which can be diffuse or limited to one lobe or one hemi-liver.↗
▶Ep 1 · 2:05
quoteType 1 is a dilation of the common bile duct only, the extrahepatic common bile duct only, and that can either be fusiform or saccular.↗
▶Ep 1 · 2:05
quoteType 2, choledocal cyst, is just a small diverticulum off of the common bile duct.↗
▶Ep 1 · 2:05
quoteType 3 is what's called a choledocal seal, so it affects the portion of the common bile duct in the wall of the duodenum.↗
▶Ep 1 · 2:05
quoteType 4a, which is a multitude of cysts, both in the intra- and extrahepatic biliary tree, and type 4b are multiple cysts, but in the extrahepatic biliary tree only.↗
▶Ep 1 · 2:05
quotetype 5 is intra-hepatic only and sort of diffusely throughout, called Corolli's disease.↗
▶Ep 1 · 3:25
quoteOftentimes, in younger children, such as infants, it's diagnosed incidentally on axial imaging or ultrasound imaging for other causes.↗
▶Ep 1 · 3:25
quoteIn children, oftentimes, you will get symptoms consistent with cholangitis, such as jaundice or fever.↗
▶Ep 1 · 3:25
quoteThe patients also can have a palpable right upper quadrant mass.↗
▶Ep 1 · 3:25
quotethis is known as Charcot's triad, but actually, this is incredibly uncommon as far as presentations are concerned.↗
▶Ep 1 · 3:25
quotesometimes, and also in small children, giant cysts that children are born with can actually perforate and present with biliary ascites.↗
▶Ep 1 · 3:25
quotegiant choledocal cysts can be diagnosed prenatally on week 20 ultrasounds.↗
▶Ep 1 · 3:25
clinicalIn younger children such as infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound for other causes.↗
▶Ep 1 · 3:25
clinicalA recent citation demonstrated that if a choledochal cyst was diagnosed prenatally and was larger than 4.5 centimeters at the 20-week anatomy scan, there was a higher rate of postnatal symptomatology, suggesting these patients may benefit from earlier intervention.↗
▶Ep 1 · 3:25
clinicalIn children, choledochal cysts often present with symptoms consistent with cholangitis, such as jaundice or fever.↗
▶Ep 1 · 3:25
clinicalPatients with choledochal cysts can have a palpable right upper quadrant mass.↗
▶Ep 1 · 3:25
clinicalThe triad of jaundice, fever, and palpable right upper quadrant mass (Charcot's triad) is incredibly uncommon as a presentation of choledochal cysts.↗
▶Ep 1 · 3:25
clinicalGiant choledochal cysts in small children can perforate and present with biliary ascites.↗
▶Ep 1 · 3:25
clinicalGiant choledochal cysts can be diagnosed prenatally on week 20 ultrasounds.↗
▶Ep 1 · 3:25
guidelinePrenatally diagnosed choledochal cysts require fetal consultation at a fetal surgery center for establishment of care and counseling, because cystic biliary atresia must be ruled out postnatally.↗
▶Ep 1 · 3:25
quoteOftentimes, in younger children, such as infants, it's diagnosed incidentally on axial imaging or ultrasound imaging for other causes.↗
▶Ep 1 · 3:25
clinicalA recent citation demonstrated that if a choledochal cyst was diagnosed prenatally and was larger than 4.5 centimeters at the 20-week anatomy scan, there was a higher rate of postnatal symptomatology, suggesting these patients may benefit from earlier intervention.↗
▶Ep 1 · 3:25
quoteonce the child is born, there are variants of other apatobiliary disease, most specifically cystic biliary atresia, that has to be ruled out.↗
▶Ep 1 · 3:25
quotesometimes, and also in small children, giant cysts that children are born with can actually perforate and present with biliary ascites.↗
▶Ep 1 · 3:25
quotethis is known as Charcot's triad, but actually, this is incredibly uncommon as far as presentations are concerned.↗
▶Ep 1 · 3:25
quoteIn children, oftentimes, you will get symptoms consistent with cholangitis, such as jaundice or fever.↗
▶Ep 1 · 3:25
quotegiant choledocal cysts can be diagnosed prenatally on week 20 ultrasounds.↗
▶Ep 1 · 3:25
quoteif a cyst was diagnosed prenatally, and it was larger than four and a half centimeters at the 20 week anatomy scan, there was a higher rate of postnatal symptomatology.↗
▶Ep 1 · 3:25
quoteonce the child is born, there are variants of other apatobiliary disease, most specifically cystic biliary atresia, that has to be ruled out.↗
▶Ep 1 · 3:25
clinicalIn younger children such as infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound for other causes.↗
▶Ep 1 · 3:25
clinicalIn children, choledochal cysts often present with symptoms consistent with cholangitis, such as jaundice or fever.↗
▶Ep 1 · 3:25
clinicalPatients with choledochal cysts can have a palpable right upper quadrant mass.↗
▶Ep 1 · 3:25
clinicalThe triad of jaundice, fever, and palpable right upper quadrant mass (Charcot's triad) is incredibly uncommon as a presentation of choledochal cysts.↗
▶Ep 1 · 3:25
clinicalGiant choledochal cysts in small children can perforate and present with biliary ascites.↗
▶Ep 1 · 3:25
clinicalGiant choledochal cysts can be diagnosed prenatally on week 20 ultrasounds.↗
▶Ep 1 · 3:25
quoteThe patients also can have a palpable right upper quadrant mass.↗
▶Ep 1 · 3:25
guidelinePrenatally diagnosed choledochal cysts require fetal consultation at a fetal surgery center for establishment of care and counseling, because cystic biliary atresia must be ruled out postnatally.↗
▶Ep 1 · 3:25
quoteif a cyst was diagnosed prenatally, and it was larger than four and a half centimeters at the 20 week anatomy scan, there was a higher rate of postnatal symptomatology.↗
▶Ep 1 · 5:12
clinicalA one-year-old with jaundice is a little old for biliary atresia, which is usually considered in an infant.↗
▶Ep 1 · 5:12
clinicalDifferential diagnosis for a one-year-old presenting with jaundice includes problems with the pancreatic or biliary tree, stone disease (choledocholithiasis, cholelithiasis), gallstone pancreatitis, and choledochal cyst.↗
▶Ep 1 · 5:12
clinicalDifferential diagnosis for a one-year-old presenting with jaundice includes problems with the pancreatic or biliary tree, stone disease (choledocholithiasis, cholelithiasis), gallstone pancreatitis, and choledochal cyst.↗
▶Ep 1 · 5:12
clinicalA one-year-old with jaundice is a little old for biliary atresia, which is usually considered in an infant.↗
▶Ep 1 · 5:46
clinicalThe major initial screening imaging test for choledochal cyst is an abdominal ultrasound.↗
▶Ep 1 · 5:46
clinicalLabs to check for suspected choledochal cyst include liver function tests (total, direct, and indirect bilirubin levels) and possibly a CBC to look for evidence of cholangitis or infection.↗
▶Ep 1 · 5:46
clinicalPhysical exam findings to look for in suspected choledochal cyst include jaundice or scleral icterus and, in younger children, a palpable abdominal mass.↗
▶Ep 1 · 5:46
quotethe major initial screening imaging test would be an abdominal ultrasound.↗
▶Ep 1 · 5:46
clinicalLabs to check for suspected choledochal cyst include liver function tests (total, direct, and indirect bilirubin levels) and possibly a CBC to look for evidence of cholangitis or infection.↗
▶Ep 1 · 5:46
clinicalPhysical exam findings to look for in suspected choledochal cyst include jaundice or scleral icterus and, in younger children, a palpable abdominal mass.↗
▶Ep 1 · 5:46
quotethe major initial screening imaging test would be an abdominal ultrasound.↗
▶Ep 1 · 5:46
clinicalThe major initial screening imaging test for choledochal cyst is an abdominal ultrasound.↗
▶Ep 1 · 6:25
quotea liver biopsy does become critical if you're talking about a neonate or a newborn. Because again, as discussed earlier, you have to rule out the cystic biliary atresia variant. Cannot miss that.↗
▶Ep 1 · 6:25
quotea liver biopsy does become critical if you're talking about a neonate or a newborn. Because again, as discussed earlier, you have to rule out the cystic biliary atresia variant. Cannot miss that.↗
▶Ep 1 · 6:25
clinicalLiver biopsy is not typically needed for older patients with reliable ultrasound imaging, but becomes critical in neonates or newborns to rule out cystic biliary atresia variant.↗
▶Ep 1 · 6:25
clinicalLiver biopsy is not typically needed for older patients with reliable ultrasound imaging, but becomes critical in neonates or newborns to rule out cystic biliary atresia variant.↗
▶Ep 1 · 6:47
clinicalMRCP is useful for choledochal cysts with hilar or intrahepatic disease to understand the extent of cystic change and to identify variant biliary anatomy, which occurs in 15 to 20% of patients.↗
▶Ep 1 · 6:47
clinicalCT scan is commonly used for choledochal cyst workup because of the ease with which young children can be scanned.↗
▶Ep 1 · 6:47
clinicalERCP can be used for both diagnostic and therapeutic purposes in choledochal cysts, depending on prior scan findings and the type of cyst.↗
▶Ep 1 · 6:47
clinicalMRCP is useful for choledochal cysts with hilar or intrahepatic disease to understand the extent of cystic change and to identify variant biliary anatomy, which occurs in 15 to 20% of patients.↗
▶Ep 1 · 6:47
clinicalCT scan is commonly used for choledochal cyst workup because of the ease with which young children can be scanned.↗
▶Ep 1 · 6:47
quoteprobably up to 15 to 20% of patients have some kind of variant biliary tract anatomy.↗
▶Ep 1 · 6:47
quoteprobably up to 15 to 20% of patients have some kind of variant biliary tract anatomy.↗
▶Ep 1 · 6:47
clinicalERCP can be used for both diagnostic and therapeutic purposes in choledochal cysts, depending on prior scan findings and the type of cyst.↗
▶Ep 1 · 8:00
quotethere have been a whole bunch of studies estimating that this lifetime risk is anywhere from 6% to 30%.↗
▶Ep 1 · 8:00
clinicalStudies estimate the lifetime risk of malignancy in choledochal cysts to be anywhere from 6% to 30%.↗
quotethere is, as we can best estimate, about an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma, which, as we all know, is a very aggressive malignancy and hard-to-treat malignancy, as well as gallbladder cancer.↗
▶Ep 1 · 8:00
quoteeven after surgical resection of these cysts, some studies suggest that there is still about a 4% lifetime risk of malignancy, which means that these patients need to be surveilled through their lifetime.↗
clinicalThere are no non-surgical treatment options for choledochal cysts.↗
▶Ep 1 · 8:00
clinicalCholedochal cysts require surgery due to the risk of recurrent cholangitis from biliary stasis and superinfection.↗
▶Ep 1 · 8:00
clinicalType 1 and type 4 choledochal cysts with pancreaticobiliary malunion carry approximately an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma and gallbladder cancer.↗
▶Ep 1 · 8:00
clinicalEven after surgical resection of choledochal cysts, some studies suggest there is still about a 4% lifetime risk of malignancy, requiring lifelong surveillance.↗
▶Ep 1 · 8:00
quoteeven after surgical resection of these cysts, some studies suggest that there is still about a 4% lifetime risk of malignancy, which means that these patients need to be surveilled through their lifetime.↗
▶Ep 1 · 8:00
quotethere is, as we can best estimate, about an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma, which, as we all know, is a very aggressive malignancy and hard-to-treat malignancy, as well as gallbladder cancer.↗
▶Ep 1 · 8:00
clinicalType 1 and type 4 choledochal cysts with pancreaticobiliary malunion carry approximately an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma and gallbladder cancer.↗
▶Ep 1 · 8:00
clinicalCholedochal cysts require surgery due to the risk of recurrent cholangitis from biliary stasis and superinfection.↗
▶Ep 1 · 8:00
clinicalThere are no non-surgical treatment options for choledochal cysts.↗
▶Ep 1 · 8:00
quotethere have been a whole bunch of studies estimating that this lifetime risk is anywhere from 6% to 30%.↗
▶Ep 1 · 8:00
clinicalEven after surgical resection of choledochal cysts, some studies suggest there is still about a 4% lifetime risk of malignancy, requiring lifelong surveillance.↗
▶Ep 1 · 8:00
clinicalStudies estimate the lifetime risk of malignancy in choledochal cysts to be anywhere from 6% to 30%.↗
▶Ep 1 · 9:16
opinionFor incidentally found choledochal cysts, surgery should be scheduled sooner rather than later, when it makes sense for the family schedule.↗
▶Ep 1 · 9:16
clinicalIf a patient with choledochal cyst presents with active infection, pancreatitis, or cholangitis, the best approach is to cool the patient off and treat the underlying process before scheduling surgery after sufficient recovery.↗
▶Ep 1 · 9:16
opinionFor incidentally found choledochal cysts, surgery should be scheduled sooner rather than later, when it makes sense for the family schedule.↗
▶Ep 1 · 9:16
clinicalIf a patient with choledochal cyst presents with active infection, pancreatitis, or cholangitis, the best approach is to cool the patient off and treat the underlying process before scheduling surgery after sufficient recovery.↗
▶Ep 1 · 10:14
clinicalMRCP is recommended preoperatively if there is any question about the patient's anatomy or if the patient has a very proximal choledochal cyst or dilation into the hepatic ducts.↗
▶Ep 1 · 10:14
clinicalPreoperative workup for choledochal cyst surgery includes laboratory values to ensure no other disease process is impairing liver function, and imaging (ultrasound and CT scan are often sufficient).↗
▶Ep 1 · 10:14
clinicalMRCP is recommended preoperatively if there is any question about the patient's anatomy or if the patient has a very proximal choledochal cyst or dilation into the hepatic ducts.↗
▶Ep 1 · 10:14
clinicalPreoperative workup for choledochal cyst surgery includes laboratory values to ensure no other disease process is impairing liver function, and imaging (ultrasound and CT scan are often sufficient).↗
▶Ep 1 · 11:13
clinicalType 3 choledochal cyst (limited choledochocele) can be treated with ERCP and sphincterotomy.↗
▶Ep 1 · 11:13
clinicalFor type 1 and type 4 choledochal cysts, the goal is to remove as much of the duct as possible, taking the duct all the way down behind or into the head of the pancreas to where it tapers, to avoid leaving remnant cyst.↗
▶Ep 1 · 11:13
clinicalType 2 choledochal cyst can be treated by simple removal of the diverticulum at its neck with repair of the common bile duct.↗
▶Ep 1 · 11:13
clinicalIf type 3 choledochal cyst involves the wall of the duodenum, transduodenal resection options exist, and biopsy of the choledochocele mucosa is important because biliary epithelium exposed to intestinal secretions could become malignant.↗
▶Ep 1 · 11:13
clinicalThe surgical goal for choledochal cyst repair is complete excision of the cyst.↗
▶Ep 1 · 11:13
clinicalFor type 1 and type 4 choledochal cysts, biliary drainage reconstruction often includes a Roux-en-Y hepaticojejunostomy, but a hepaticoduodenostomy is also an option.↗
▶Ep 1 · 11:13
clinicalType 5 choledochal cyst (Caroli's disease) management depends on disease extent: if limited to an anatomic part of the liver, resection may be appropriate; if diffuse throughout the liver without adequate functional remnant, transplantation may be necessary.↗
▶Ep 1 · 11:13
clinicalType 2 choledochal cyst can be treated by simple removal of the diverticulum at its neck with repair of the common bile duct.↗
▶Ep 1 · 11:13
clinicalType 3 choledochal cyst (limited choledochocele) can be treated with ERCP and sphincterotomy.↗
▶Ep 1 · 11:13
clinicalIf type 3 choledochal cyst involves the wall of the duodenum, transduodenal resection options exist, and biopsy of the choledochocele mucosa is important because biliary epithelium exposed to intestinal secretions could become malignant.↗
▶Ep 1 · 11:13
clinicalType 5 choledochal cyst (Caroli's disease) management depends on disease extent: if limited to an anatomic part of the liver, resection may be appropriate; if diffuse throughout the liver without adequate functional remnant, transplantation may be necessary.↗
▶Ep 1 · 11:13
clinicalFor type 1 and type 4 choledochal cysts, biliary drainage reconstruction often includes a Roux-en-Y hepaticojejunostomy, but a hepaticoduodenostomy is also an option.↗
▶Ep 1 · 11:13
clinicalFor type 1 and type 4 choledochal cysts, the goal is to remove as much of the duct as possible, taking the duct all the way down behind or into the head of the pancreas to where it tapers, to avoid leaving remnant cyst.↗
▶Ep 1 · 11:13
clinicalThe surgical goal for choledochal cyst repair is complete excision of the cyst.↗
▶Ep 1 · 13:19
clinicalDuring choledochal cyst dissection, hepatic arteries are medial and the portal vein is posterior to the cyst.↗
▶Ep 1 · 13:19
clinicalFor choledochal cyst surgery in children less than 2 years old, a transverse incision or right subcostal incision is preferred; for older children, an upper midline incision is a viable option.↗
▶Ep 1 · 13:19
clinicalFor Roux-en-Y hepaticojejunostomy reconstruction, Dr. Bondock goes about 15 to 20 centimeters distal from the ligament of Treitz, performs a two-layer jejunojejunostomy, and does a hepaticojejunostomy with interrupted 5-0 or 6-0 Maxon suture.↗
▶Ep 1 · 13:19
clinicalDr. Bondock performs an intraoperative cholangiogram through the gallbladder to understand where the tapering of the distal cyst occurs to avoid leaving remnant cyst.↗
▶Ep 1 · 13:19
clinicalDuring choledochal cyst dissection, hepatic arteries are medial and the portal vein is posterior to the cyst.↗
▶Ep 1 · 13:19
clinicalDr. Bondock performs an intraoperative cholangiogram through the gallbladder to understand where the tapering of the distal cyst occurs to avoid leaving remnant cyst.↗
▶Ep 1 · 13:19
clinicalDr. Bondock performs the Roux-en-Y limb retrocolic and closes the small bowel mesentery.↗
▶Ep 1 · 13:19
clinicalFor choledochal cyst surgery in children less than 2 years old, a transverse incision or right subcostal incision is preferred; for older children, an upper midline incision is a viable option.↗
▶Ep 1 · 13:19
clinicalFor Roux-en-Y hepaticojejunostomy reconstruction, Dr. Bondock goes about 15 to 20 centimeters distal from the ligament of Treitz, performs a two-layer jejunojejunostomy, and does a hepaticojejunostomy with interrupted 5-0 or 6-0 Maxon suture.↗
▶Ep 1 · 13:19
clinicalDr. Bondock performs the Roux-en-Y limb retrocolic and closes the small bowel mesentery.↗
▶Ep 1 · 16:47
clinicalFor type 2 choledochal cyst, once the cyst is tapered down to the common bile duct, the neck is resected and the common bile duct is repaired with interrupted absorbable suture without leaving a T-tube.↗
▶Ep 1 · 16:47
clinicalType 5 choledochal cyst (Caroli's disease) can be addressed surgically with liver resection if cystic disease is limited to one hemi-liver with adequate liver remnant and preserved biliary outflow, but if diffuse throughout the liver, liver transplantation may be necessary.↗
▶Ep 1 · 16:47
clinicalType 3 choledochal cyst can be approached endoscopically with ERCP and sphincterotomy, but if the lesion is large and obstructing the common duct, a transduodenal approach is needed, sometimes with preoperative stents to separate it from the duodenum.↗
▶Ep 1 · 16:47
clinicalType 3 choledochal cyst can be approached endoscopically with ERCP and sphincterotomy, but if the lesion is large and obstructing the common duct, a transduodenal approach is needed, sometimes with preoperative stents to separate it from the duodenum.↗
▶Ep 1 · 16:47
clinicalFor type 2 choledochal cyst, once the cyst is tapered down to the common bile duct, the neck is resected and the common bile duct is repaired with interrupted absorbable suture without leaving a T-tube.↗
▶Ep 1 · 16:47
clinicalType 5 choledochal cyst (Caroli's disease) can be addressed surgically with liver resection if cystic disease is limited to one hemi-liver with adequate liver remnant and preserved biliary outflow, but if diffuse throughout the liver, liver transplantation may be necessary.↗
▶Ep 1 · 18:45
clinicalShort-term to long-term surgical complications of choledochal cyst surgery include anastomotic stricture, small bowel obstruction from intra-abdominal surgery, reflux gastritis, and recurrent cholangitis.↗
▶Ep 1 · 18:45
clinicalPostoperative considerations for choledochal cyst surgery include enteric drainage and awaiting return of bowel function.↗
▶Ep 1 · 18:45
clinicalDr. Bondock typically places an NG tube postoperatively because of the new jejunojejunostomy, but tries to remove it the day after surgery.↗
▶Ep 1 · 18:45
clinicalDrains are placed postoperatively to assess for biliary leaks from the new hepatoenteric anastomosis and are typically removed once the patient is tolerating a regular diet.↗
▶Ep 1 · 18:45
clinicalInstitutionally, patients are placed on a choleretic like Actigall and cholangitis prophylaxis (daily Bactrim) for three to six months after choledochal cyst surgery.↗
▶Ep 1 · 18:45
clinicalLifelong follow-up is needed for choledochal cyst patients because of the possibility of developing future malignancy even after resection of the cyst.↗
▶Ep 1 · 18:45
clinicalPostoperative considerations for choledochal cyst surgery include enteric drainage and awaiting return of bowel function.↗
▶Ep 1 · 18:45
clinicalDr. Bondock typically places an NG tube postoperatively because of the new jejunojejunostomy, but tries to remove it the day after surgery.↗
▶Ep 1 · 18:45
clinicalDrains are placed postoperatively to assess for biliary leaks from the new hepatoenteric anastomosis and are typically removed once the patient is tolerating a regular diet.↗
▶Ep 1 · 18:45
clinicalInstitutionally, patients are placed on a choleretic like Actigall and cholangitis prophylaxis (daily Bactrim) for three to six months after choledochal cyst surgery.↗
▶Ep 1 · 18:45
clinicalShort-term to long-term surgical complications of choledochal cyst surgery include anastomotic stricture, small bowel obstruction from intra-abdominal surgery, reflux gastritis, and recurrent cholangitis.↗
▶Ep 1 · 18:45
clinicalLifelong follow-up is needed for choledochal cyst patients because of the possibility of developing future malignancy even after resection of the cyst.↗
Choledochal Cysts: In Brief with Dr. Alexander Bondoc
▶Ep 2 · 0:00
host_summaryCholedochal cysts are a congenital dilation of the biliary tree.↗
▶Ep 2 · 0:00
clinicalCholedochal cysts are a congenital dilation of the biliary tree.↗
▶Ep 2 · 1:14
epidemiologicalCholedochal cysts have a female predominance.↗
▶Ep 2 · 1:14
epidemiologicalIn the Western world the incidence of choledochal cysts is about one in 100,000.↗
▶Ep 2 · 1:14
epidemiologicalCholedochal cysts have a female predominance.↗
▶Ep 2 · 1:14
epidemiologicalIn the Western world the incidence of choledochal cysts is about one in 100,000.↗
▶Ep 2 · 1:14
quoteIn the Western world it's about the incidence is about one in 100,000 but in Asia specifically Eastern Asia it's actually a little quite more quite a bit more common one in 13,000.↗
▶Ep 2 · 1:14
quoteIn the Western world it's about the incidence is about one in 100,000 but in Asia specifically Eastern Asia it's actually a little quite more quite a bit more common one in 13,000.↗
▶Ep 2 · 1:35
epidemiologicalIn Asia, specifically Eastern Asia, choledochal cyst incidence is one in 13,000.↗
▶Ep 2 · 1:35
epidemiologicalIn Asia, specifically Eastern Asia, choledochal cyst incidence is one in 13,000.↗
▶Ep 2 · 2:10
clinicalFor Todani types 1 and 4, the etiology is likely embryologic relating to the pancreaticobiliary duct junction (pancreaticobiliary malunion).↗
▶Ep 2 · 2:10
clinicalFor Todani types 1 and 4, the etiology is likely embryologic relating to the pancreaticobiliary duct junction (pancreaticobiliary malunion).↗
▶Ep 2 · 2:40
opinionPancreaticobiliary malunion is just one theory for the etiology of choledochal cysts and doesn't explain the higher incidence in the Far East.↗
▶Ep 2 · 2:40
opinionPancreaticobiliary malunion is just one theory for the etiology of choledochal cysts and doesn't explain the higher incidence in the Far East.↗
▶Ep 2 · 2:40
quoteNow keep in mind that pancreatic obiliary malunion is just one theory for the etiology of colidocle cysts. It's not a slam dunk not even for Todani types one and four and it doesn't really explain why there's a higher incidence in the Far East.↗
▶Ep 2 · 2:40
quoteNow keep in mind that pancreatic obiliary malunion is just one theory for the etiology of colidocle cysts. It's not a slam dunk not even for Todani types one and four and it doesn't really explain why there's a higher incidence in the Far East.↗
▶Ep 2 · 3:05
quoteIn adults that common channel are basically the confluence of the biliary pancreatic ducts. It's supposed to be less than 0.9 centimeters but in the pediatric patient any common channel is abnormal and that is the cause for a lot of these issues.↗
▶Ep 2 · 3:05
clinicalIn adults, the common channel (confluence of biliary and pancreatic ducts) is supposed to be less than 0.9 centimeters, but in pediatric patients any common channel is abnormal.↗
▶Ep 2 · 3:05
quoteIn adults that common channel are basically the confluence of the biliary pancreatic ducts. It's supposed to be less than 0.9 centimeters but in the pediatric patient any common channel is abnormal and that is the cause for a lot of these issues.↗
▶Ep 2 · 3:05
clinicalIn adults, the common channel (confluence of biliary and pancreatic ducts) is supposed to be less than 0.9 centimeters, but in pediatric patients any common channel is abnormal.↗
▶Ep 2 · 3:30
clinicalReflux of pancreatic enzymes into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 2 · 3:30
clinicalReflux of pancreatic enzymes into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 2 · 4:00
clinicalType 5 choledochal cyst (Caroli's disease) has an associated genetic mutation in PKHD1.↗
▶Ep 2 · 4:00
clinicalType 5 choledochal cyst (Caroli's disease) has an associated genetic mutation in PKHD1.↗
▶Ep 2 · 4:40
clinicalType 1 choledochal cyst is a dilation of the extrahepatic common bile duct only, either fusiform or saccular.↗
▶Ep 2 · 4:40
clinicalType 1 choledochal cyst is a dilation of the extrahepatic common bile duct only, either fusiform or saccular.↗
▶Ep 2 · 5:00
clinicalType 2 choledochal cyst is a small diverticulum off the common bile duct.↗
▶Ep 2 · 5:00
clinicalType 2 choledochal cyst is a small diverticulum off the common bile duct.↗
▶Ep 2 · 5:10
clinicalType 3 choledochal cyst (choledochocele) is a dilation of the common bile duct in the wall of the duodenum.↗
▶Ep 2 · 5:10
clinicalType 3 choledochal cyst (choledochocele) is a dilation of the common bile duct in the wall of the duodenum.↗
▶Ep 2 · 5:25
clinicalType 4a choledochal cyst consists of multiple cysts in both the intra- and extrahepatic biliary tree.↗
▶Ep 2 · 5:25
clinicalType 4a choledochal cyst consists of multiple cysts in both the intra- and extrahepatic biliary tree.↗
▶Ep 2 · 5:40
clinicalType 4b choledochal cyst consists of multiple cysts in the extrahepatic biliary tree only.↗
▶Ep 2 · 5:40
clinicalType 4b choledochal cyst consists of multiple cysts in the extrahepatic biliary tree only.↗
▶Ep 2 · 5:50
clinicalType 5 choledochal cyst (Caroli's disease) has diffuse cystic dilation that can be throughout the liver or limited to one lobe.↗
▶Ep 2 · 5:50
clinicalType 5 choledochal cyst (Caroli's disease) has diffuse cystic dilation that can be throughout the liver or limited to one lobe.↗
▶Ep 2 · 6:10
clinicalIn younger children and infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound.↗
▶Ep 2 · 6:10
clinicalIn younger children and infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound.↗
▶Ep 2 · 6:25
clinicalIn children, choledochal cysts often present with symptoms consistent with cholangitis such as jaundice or fever, and patients can have a palpable right upper quadrant mass.↗
▶Ep 2 · 6:25
clinicalIn children, choledochal cysts often present with symptoms consistent with cholangitis such as jaundice or fever, and patients can have a palpable right upper quadrant mass.↗
▶Ep 2 · 6:55
clinicalGiant choledochal cysts that children are born with can perforate and present with biliary ascites.↗
▶Ep 2 · 6:55
clinicalGiant choledochal cysts that children are born with can perforate and present with biliary ascites.↗
▶Ep 2 · 7:10
guidelineLarge choledochal cysts can be identified on 20-week fetal ultrasound and should be referred to a fetal center for workup and close monitoring after birth.↗
▶Ep 2 · 7:10
guidelineLarge choledochal cysts can be identified on 20-week fetal ultrasound and should be referred to a fetal center for workup and close monitoring after birth.↗
▶Ep 2 · 7:30
clinicalA recent study showed that if a choledochal cyst was diagnosed prenatally and was larger than 4.5 centimeters at the 20-week anatomy scan, there was a higher rate of postnatal symptoms, suggesting these patients may benefit from earlier intervention.↗
▶Ep 2 · 7:30
host_summaryA recent study showed that if a choledochal cyst was diagnosed prenatally and was larger than 4.5 centimeters at the 20-week anatomy scan, there was a higher rate of postnatal symptoms, suggesting these patients may benefit from earlier intervention.↗
▶Ep 2 · 7:31
epidemiologicalUp to 15 to 20 percent of choledochal cyst patients have some kind of variant biliary tract anatomy.↗
▶Ep 2 · 7:31
epidemiologicalUp to 15 to 20 percent of choledochal cyst patients have some kind of variant biliary tract anatomy.↗
▶Ep 2 · 8:40
quoteLiver biopsy does become critical if you're talking about a neonate or a newborn because again as men as we discussed earlier you have to rule out the cystic biliary atresia variant. Cannot miss that.↗
▶Ep 2 · 8:40
quoteLiver biopsy does become critical if you're talking about a neonate or a newborn because again as men as we discussed earlier you have to rule out the cystic biliary atresia variant. Cannot miss that.↗
▶Ep 2 · 8:40
guidelineIn neonates or newborns with suspected choledochal cyst, liver biopsy is critical to rule out the cystic biliary atresia variant.↗
▶Ep 2 · 8:40
guidelineIn neonates or newborns with suspected choledochal cyst, liver biopsy is critical to rule out the cystic biliary atresia variant.↗
▶Ep 2 · 9:00
guidelineWhile ultrasound and labs are sufficient to diagnose a choledochal cyst, axial imaging such as CT scan is needed before taking patients to the operating room.↗
▶Ep 2 · 9:00
guidelineWhile ultrasound and labs are sufficient to diagnose a choledochal cyst, axial imaging such as CT scan is needed before taking patients to the operating room.↗
▶Ep 2 · 9:20
clinicalMRCP is useful for operative planning when there are questions about anatomic details, specifically for high disease (into the hilum or intrahepatic) to assess the extent of cystic change.↗
▶Ep 2 · 9:20
clinicalMRCP is useful for operative planning when there are questions about anatomic details, specifically for high disease (into the hilum or intrahepatic) to assess the extent of cystic change.↗
▶Ep 2 · 12:08
quoteI personally like to do Roux-en-Y hepaticojejunostomies. The way I construct those in my practice is I usually go about 15 to 20 centimeters distal from the ligament of trites or whatever you think will be comfortable and allow reach of the Roux-en-Y hepaticojejunostomy.↗
▶Ep 2 · 12:08
quoteI personally like to do Roux-en-Y hepaticojejunostomies. The way I construct those in my practice is I usually go about 15 to 20 centimeters distal from the ligament of trites or whatever you think will be comfortable and allow reach of the Roux-en-Y hepaticojejunostomy.↗
▶Ep 2 · 12:08
clinicalDr. Bondoc constructs Roux-en-Y hepaticojejunostomies by going 15 to 20 centimeters distal from the ligament of Treitz, performing a jejunojejunostomy in two layers if child size allows, then doing a hepaticojejunostomy with interrupted 5-0 or 6-0 Maxon suture.↗
▶Ep 2 · 12:08
clinicalDr. Bondoc constructs Roux-en-Y hepaticojejunostomies by going 15 to 20 centimeters distal from the ligament of Treitz, performing a jejunojejunostomy in two layers if child size allows, then doing a hepaticojejunostomy with interrupted 5-0 or 6-0 Maxon suture.↗
▶Ep 2 · 13:20
quoteI don't usually biopsy the liver unless there's something obvious, but I do close the mesentery.↗
▶Ep 2 · 13:20
opinionDr. Bondoc does not usually biopsy the liver unless there is something obvious, but does close the mesenteric defect.↗
▶Ep 2 · 13:20
quoteI don't usually biopsy the liver unless there's something obvious, but I do close the mesentery.↗
▶Ep 2 · 13:20
opinionDr. Bondoc does not usually biopsy the liver unless there is something obvious, but does close the mesenteric defect.↗
▶Ep 2 · 13:35
clinicalType 2 choledochal cysts require resection of the diverticulum and primary repair of the common bile duct.↗
▶Ep 2 · 13:35
clinicalType 2 choledochal cysts require resection of the diverticulum and primary repair of the common bile duct.↗
▶Ep 2 · 13:50
clinicalFor type 3 choledochal cysts, ERCP and sphincterotomy can be therapeutic in some cases.↗
▶Ep 2 · 13:50
clinicalFor type 3 choledochal cysts, ERCP and sphincterotomy can be therapeutic in some cases.↗
▶Ep 2 · 14:05
clinicalIf a type 3 choledochal cyst is large and obstructing the common duct, a transduodenal approach is often needed to resect the cyst and reconstruct the outflow, sometimes with preoperative stents placed via ERCP.↗
▶Ep 2 · 14:05
clinicalIf a type 3 choledochal cyst is large and obstructing the common duct, a transduodenal approach is often needed to resect the cyst and reconstruct the outflow, sometimes with preoperative stents placed via ERCP.↗
▶Ep 2 · 14:35
clinicalType 5 choledochal cysts may require liver transplant if cystic disease is diffuse throughout the liver.↗
▶Ep 2 · 14:35
clinicalType 5 choledochal cysts may require liver transplant if cystic disease is diffuse throughout the liver.↗
▶Ep 2 · 14:55
clinicalIf type 5 cystic burden is limited to one hemi-liver or allows for resection with adequate liver remnant and preserved biliary outflow, it can be addressed surgically with liver resection.↗
▶Ep 2 · 14:55
clinicalIf type 5 cystic burden is limited to one hemi-liver or allows for resection with adequate liver remnant and preserved biliary outflow, it can be addressed surgically with liver resection.↗
▶Ep 2 · 15:20
clinicalPostoperatively, choledochal cyst patients have an NG tube for about 24 hours to protect the jejunal anastomosis and have temporary biliary drains until eating a regular diet to catch any leaks from the hepaticojejunostomy.↗
▶Ep 2 · 15:20
clinicalPostoperatively, choledochal cyst patients have an NG tube for about 24 hours to protect the jejunal anastomosis and have temporary biliary drains until eating a regular diet to catch any leaks from the hepaticojejunostomy.↗
▶Ep 2 · 15:50
clinicalPostoperative complications for choledochal cyst surgery include recurrent cholangitis due to the connection between the biliary tree and enteric system, anastomotic stricture, small bowel obstruction, and reflux gastritis.↗
▶Ep 2 · 15:50
clinicalPostoperative complications for choledochal cyst surgery include recurrent cholangitis due to the connection between the biliary tree and enteric system, anastomotic stricture, small bowel obstruction, and reflux gastritis.↗
▶Ep 2 · 16:00
clinicalProphylactically, choledochal cyst patients are put on Bactrim postoperatively; Actigall can also be helpful but may be institution-specific.↗
▶Ep 2 · 16:00
clinicalProphylactically, choledochal cyst patients are put on Bactrim postoperatively; Actigall can also be helpful but may be institution-specific.↗
▶Ep 2 · 16:12
guidelineLifelong follow-up is critical for choledochal cyst patients because of the possibility of developing future malignancy even after resection of the cyst.↗
▶Ep 2 · 16:12
guidelineLifelong follow-up is critical for choledochal cyst patients because of the possibility of developing future malignancy even after resection of the cyst.↗
clinicalCholedochal cyst is a congenital cystic dilation of the biliary tree.↗
▶Ep 1 · 0:29
quotea choledocal cyst ray is a congenital cystic dilation of the biliary tree.↗
▶Ep 1 · 0:29
quotea choledocal cyst ray is a congenital cystic dilation of the biliary tree.↗
▶Ep 1 · 0:29
clinicalCholedochal cyst is a congenital cystic dilation of the biliary tree.↗
▶Ep 1 · 0:36
quoteIn the Western world, the incidence is about 1 in 100,000. But in Asia, specifically Eastern Asia, it's quite a bit more common, 1 in 13,000.↗
▶Ep 1 · 0:36
epidemiologicalIncidence of choledochal cysts in the Western world is about 1 in 100,000.↗
▶Ep 1 · 0:36
quotethere isn't a genetic predisposition to choledocal cysts, there are some genes that have been identified in limited studies, possibly including PKD1 for type 5 choledocal cysts.↗
▶Ep 1 · 0:36
quoteIt's actually three to four times more likely in females than in males.↗
▶Ep 1 · 0:36
quoteIt's actually three to four times more likely in females than in males.↗
▶Ep 1 · 0:36
epidemiologicalIncidence of choledochal cysts in the Western world is about 1 in 100,000.↗
▶Ep 1 · 0:36
epidemiologicalIn Eastern Asia, choledochal cyst incidence is 1 in 13,000.↗
▶Ep 1 · 0:36
epidemiologicalCholedochal cysts are three to four times more likely in females than in males.↗
▶Ep 1 · 0:36
clinicalThere is no genetic predisposition to choledochal cysts, but some genes including PKD1 have been identified in limited studies for type 5 choledochal cysts.↗
▶Ep 1 · 0:36
epidemiologicalIn Eastern Asia, choledochal cyst incidence is 1 in 13,000.↗
▶Ep 1 · 0:36
epidemiologicalCholedochal cysts are three to four times more likely in females than in males.↗
▶Ep 1 · 0:36
clinicalThere is no genetic predisposition to choledochal cysts, but some genes including PKD1 have been identified in limited studies for type 5 choledochal cysts.↗
▶Ep 1 · 0:36
quotethere isn't a genetic predisposition to choledocal cysts, there are some genes that have been identified in limited studies, possibly including PKD1 for type 5 choledocal cysts.↗
▶Ep 1 · 0:36
quoteIn the Western world, the incidence is about 1 in 100,000. But in Asia, specifically Eastern Asia, it's quite a bit more common, 1 in 13,000.↗
▶Ep 1 · 1:10
clinicalThe most common classification system for choledochal cysts was developed by a surgeon named Tadani in Japan and includes five types.↗
▶Ep 1 · 1:10
quoteit is likely embryologic, relating to the pancreatic obiliary duct junction, also known as, in this scenario, pancreatic obiliary malunion, which oftentimes creates what's called a long common channel of the pancreatic obiliary duct.↗
▶Ep 1 · 1:10
quoteit's thought that reflux of pancreatic enzymes from, obviously, the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 1 · 1:10
clinicalIn type 5 choledochal cysts, genetic mutation might predispose to more diffuse dilation of both the intra- and extrahepatic biliary trees.↗
▶Ep 1 · 1:10
clinicalThe most common classification system for choledochal cysts was developed by a surgeon named Tadani in Japan and includes five types.↗
▶Ep 1 · 1:10
clinicalFor types 1 and 4 choledochal cysts, the etiology is likely embryologic, relating to pancreaticobiliary duct junction (pancreaticobiliary malunion), which creates a long common channel of the pancreaticobiliary duct.↗
▶Ep 1 · 1:10
clinicalReflux of pancreatic enzymes from the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes in types 1 and 4 choledochal cysts.↗
▶Ep 1 · 1:10
clinicalIn type 5 choledochal cysts, genetic mutation might predispose to more diffuse dilation of both the intra- and extrahepatic biliary trees.↗
▶Ep 1 · 1:10
clinicalReflux of pancreatic enzymes from the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes in types 1 and 4 choledochal cysts.↗
▶Ep 1 · 1:10
quoteit is likely embryologic, relating to the pancreatic obiliary duct junction, also known as, in this scenario, pancreatic obiliary malunion, which oftentimes creates what's called a long common channel of the pancreatic obiliary duct.↗
▶Ep 1 · 1:10
quoteit's thought that reflux of pancreatic enzymes from, obviously, the head of the pancreas back into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 1 · 1:10
clinicalFor types 1 and 4 choledochal cysts, the etiology is likely embryologic, relating to pancreaticobiliary duct junction (pancreaticobiliary malunion), which creates a long common channel of the pancreaticobiliary duct.↗
▶Ep 1 · 2:05
quoteType 4a, which is a multitude of cysts, both in the intra- and extrahepatic biliary tree, and type 4b are multiple cysts, but in the extrahepatic biliary tree only.↗
▶Ep 1 · 2:05
quoteType 1 is a dilation of the common bile duct only, the extrahepatic common bile duct only, and that can either be fusiform or saccular.↗
▶Ep 1 · 2:05
quoteType 3 is what's called a choledocal seal, so it affects the portion of the common bile duct in the wall of the duodenum.↗
▶Ep 1 · 2:05
quotetype 5 is intra-hepatic only and sort of diffusely throughout, called Corolli's disease.↗
▶Ep 1 · 2:05
quoteType 4a, which is a multitude of cysts, both in the intra- and extrahepatic biliary tree, and type 4b are multiple cysts, but in the extrahepatic biliary tree only.↗
▶Ep 1 · 2:05
clinicalType 4a choledochal cyst consists of multiple cysts in both the intra- and extrahepatic biliary tree.↗
▶Ep 1 · 2:05
clinicalType 4b choledochal cyst consists of multiple cysts in the extrahepatic biliary tree only.↗
▶Ep 1 · 2:05
clinicalType 5 choledochal cyst is intrahepatic only and diffusely throughout, called Caroli's disease, which can be diffuse or limited to one lobe or one hemi-liver.↗
▶Ep 1 · 2:05
quoteType 3 is what's called a choledocal seal, so it affects the portion of the common bile duct in the wall of the duodenum.↗
▶Ep 1 · 2:05
quotetype 5 is intra-hepatic only and sort of diffusely throughout, called Corolli's disease.↗
▶Ep 1 · 2:05
quoteType 2, choledocal cyst, is just a small diverticulum off of the common bile duct.↗
▶Ep 1 · 2:05
clinicalType 3 choledochal cyst is a choledochocele affecting the portion of the common bile duct in the wall of the duodenum.↗
▶Ep 1 · 2:05
clinicalType 2 choledochal cyst is a small diverticulum off of the common bile duct.↗
▶Ep 1 · 2:05
clinicalType 1 choledochal cyst is a dilation of the extrahepatic common bile duct only, which can be fusiform or saccular.↗
▶Ep 1 · 2:05
clinicalType 5 choledochal cyst is intrahepatic only and diffusely throughout, called Caroli's disease, which can be diffuse or limited to one lobe or one hemi-liver.↗
▶Ep 1 · 2:05
clinicalType 4b choledochal cyst consists of multiple cysts in the extrahepatic biliary tree only.↗
▶Ep 1 · 2:05
clinicalType 4a choledochal cyst consists of multiple cysts in both the intra- and extrahepatic biliary tree.↗
▶Ep 1 · 2:05
clinicalType 3 choledochal cyst is a choledochocele affecting the portion of the common bile duct in the wall of the duodenum.↗
▶Ep 1 · 2:05
clinicalType 2 choledochal cyst is a small diverticulum off of the common bile duct.↗
▶Ep 1 · 2:05
clinicalType 1 choledochal cyst is a dilation of the extrahepatic common bile duct only, which can be fusiform or saccular.↗
▶Ep 1 · 2:05
quoteType 1 is a dilation of the common bile duct only, the extrahepatic common bile duct only, and that can either be fusiform or saccular.↗
▶Ep 1 · 2:05
quoteType 2, choledocal cyst, is just a small diverticulum off of the common bile duct.↗
▶Ep 1 · 3:25
quoteIn children, oftentimes, you will get symptoms consistent with cholangitis, such as jaundice or fever.↗
▶Ep 1 · 3:25
clinicalIn younger children such as infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound for other causes.↗
▶Ep 1 · 3:25
clinicalIn children, choledochal cysts often present with symptoms consistent with cholangitis, such as jaundice or fever.↗
▶Ep 1 · 3:25
clinicalPatients with choledochal cysts can have a palpable right upper quadrant mass.↗
▶Ep 1 · 3:25
clinicalThe triad of jaundice, fever, and palpable right upper quadrant mass (Charcot's triad) is incredibly uncommon as a presentation of choledochal cysts.↗
▶Ep 1 · 3:25
clinicalGiant choledochal cysts in small children can perforate and present with biliary ascites.↗
▶Ep 1 · 3:25
clinicalGiant choledochal cysts can be diagnosed prenatally on week 20 ultrasounds.↗
▶Ep 1 · 3:25
guidelinePrenatally diagnosed choledochal cysts require fetal consultation at a fetal surgery center for establishment of care and counseling, because cystic biliary atresia must be ruled out postnatally.↗
▶Ep 1 · 3:25
clinicalA recent citation demonstrated that if a choledochal cyst was diagnosed prenatally and was larger than 4.5 centimeters at the 20-week anatomy scan, there was a higher rate of postnatal symptomatology, suggesting these patients may benefit from earlier intervention.↗
▶Ep 1 · 3:25
quoteOftentimes, in younger children, such as infants, it's diagnosed incidentally on axial imaging or ultrasound imaging for other causes.↗
▶Ep 1 · 3:25
quoteThe patients also can have a palpable right upper quadrant mass.↗
▶Ep 1 · 3:25
quotethis is known as Charcot's triad, but actually, this is incredibly uncommon as far as presentations are concerned.↗
▶Ep 1 · 3:25
quotesometimes, and also in small children, giant cysts that children are born with can actually perforate and present with biliary ascites.↗
▶Ep 1 · 3:25
quotegiant choledocal cysts can be diagnosed prenatally on week 20 ultrasounds.↗
▶Ep 1 · 3:25
quoteonce the child is born, there are variants of other apatobiliary disease, most specifically cystic biliary atresia, that has to be ruled out.↗
▶Ep 1 · 3:25
quoteif a cyst was diagnosed prenatally, and it was larger than four and a half centimeters at the 20 week anatomy scan, there was a higher rate of postnatal symptomatology.↗
▶Ep 1 · 3:25
clinicalIn younger children such as infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound for other causes.↗
▶Ep 1 · 3:25
clinicalIn children, choledochal cysts often present with symptoms consistent with cholangitis, such as jaundice or fever.↗
▶Ep 1 · 3:25
clinicalPatients with choledochal cysts can have a palpable right upper quadrant mass.↗
▶Ep 1 · 3:25
clinicalThe triad of jaundice, fever, and palpable right upper quadrant mass (Charcot's triad) is incredibly uncommon as a presentation of choledochal cysts.↗
▶Ep 1 · 3:25
clinicalGiant choledochal cysts in small children can perforate and present with biliary ascites.↗
▶Ep 1 · 3:25
clinicalGiant choledochal cysts can be diagnosed prenatally on week 20 ultrasounds.↗
▶Ep 1 · 3:25
guidelinePrenatally diagnosed choledochal cysts require fetal consultation at a fetal surgery center for establishment of care and counseling, because cystic biliary atresia must be ruled out postnatally.↗
▶Ep 1 · 3:25
quoteOftentimes, in younger children, such as infants, it's diagnosed incidentally on axial imaging or ultrasound imaging for other causes.↗
▶Ep 1 · 3:25
quoteonce the child is born, there are variants of other apatobiliary disease, most specifically cystic biliary atresia, that has to be ruled out.↗
▶Ep 1 · 3:25
quoteif a cyst was diagnosed prenatally, and it was larger than four and a half centimeters at the 20 week anatomy scan, there was a higher rate of postnatal symptomatology.↗
▶Ep 1 · 3:25
quoteThe patients also can have a palpable right upper quadrant mass.↗
▶Ep 1 · 3:25
quotethis is known as Charcot's triad, but actually, this is incredibly uncommon as far as presentations are concerned.↗
▶Ep 1 · 3:25
quotesometimes, and also in small children, giant cysts that children are born with can actually perforate and present with biliary ascites.↗
▶Ep 1 · 3:25
clinicalA recent citation demonstrated that if a choledochal cyst was diagnosed prenatally and was larger than 4.5 centimeters at the 20-week anatomy scan, there was a higher rate of postnatal symptomatology, suggesting these patients may benefit from earlier intervention.↗
▶Ep 1 · 3:25
quoteIn children, oftentimes, you will get symptoms consistent with cholangitis, such as jaundice or fever.↗
▶Ep 1 · 3:25
quotegiant choledocal cysts can be diagnosed prenatally on week 20 ultrasounds.↗
▶Ep 1 · 5:12
clinicalDifferential diagnosis for a one-year-old presenting with jaundice includes problems with the pancreatic or biliary tree, stone disease (choledocholithiasis, cholelithiasis), gallstone pancreatitis, and choledochal cyst.↗
▶Ep 1 · 5:12
clinicalA one-year-old with jaundice is a little old for biliary atresia, which is usually considered in an infant.↗
▶Ep 1 · 5:12
clinicalA one-year-old with jaundice is a little old for biliary atresia, which is usually considered in an infant.↗
▶Ep 1 · 5:12
clinicalDifferential diagnosis for a one-year-old presenting with jaundice includes problems with the pancreatic or biliary tree, stone disease (choledocholithiasis, cholelithiasis), gallstone pancreatitis, and choledochal cyst.↗
▶Ep 1 · 5:46
clinicalLabs to check for suspected choledochal cyst include liver function tests (total, direct, and indirect bilirubin levels) and possibly a CBC to look for evidence of cholangitis or infection.↗
▶Ep 1 · 5:46
clinicalThe major initial screening imaging test for choledochal cyst is an abdominal ultrasound.↗
▶Ep 1 · 5:46
quotethe major initial screening imaging test would be an abdominal ultrasound.↗
▶Ep 1 · 5:46
clinicalPhysical exam findings to look for in suspected choledochal cyst include jaundice or scleral icterus and, in younger children, a palpable abdominal mass.↗
▶Ep 1 · 5:46
clinicalThe major initial screening imaging test for choledochal cyst is an abdominal ultrasound.↗
▶Ep 1 · 5:46
quotethe major initial screening imaging test would be an abdominal ultrasound.↗
▶Ep 1 · 5:46
clinicalLabs to check for suspected choledochal cyst include liver function tests (total, direct, and indirect bilirubin levels) and possibly a CBC to look for evidence of cholangitis or infection.↗
▶Ep 1 · 5:46
clinicalPhysical exam findings to look for in suspected choledochal cyst include jaundice or scleral icterus and, in younger children, a palpable abdominal mass.↗
▶Ep 1 · 6:25
clinicalLiver biopsy is not typically needed for older patients with reliable ultrasound imaging, but becomes critical in neonates or newborns to rule out cystic biliary atresia variant.↗
▶Ep 1 · 6:25
clinicalLiver biopsy is not typically needed for older patients with reliable ultrasound imaging, but becomes critical in neonates or newborns to rule out cystic biliary atresia variant.↗
▶Ep 1 · 6:25
quotea liver biopsy does become critical if you're talking about a neonate or a newborn. Because again, as discussed earlier, you have to rule out the cystic biliary atresia variant. Cannot miss that.↗
▶Ep 1 · 6:25
quotea liver biopsy does become critical if you're talking about a neonate or a newborn. Because again, as discussed earlier, you have to rule out the cystic biliary atresia variant. Cannot miss that.↗
▶Ep 1 · 6:47
quoteprobably up to 15 to 20% of patients have some kind of variant biliary tract anatomy.↗
▶Ep 1 · 6:47
clinicalMRCP is useful for choledochal cysts with hilar or intrahepatic disease to understand the extent of cystic change and to identify variant biliary anatomy, which occurs in 15 to 20% of patients.↗
▶Ep 1 · 6:47
clinicalERCP can be used for both diagnostic and therapeutic purposes in choledochal cysts, depending on prior scan findings and the type of cyst.↗
▶Ep 1 · 6:47
clinicalERCP can be used for both diagnostic and therapeutic purposes in choledochal cysts, depending on prior scan findings and the type of cyst.↗
▶Ep 1 · 6:47
clinicalMRCP is useful for choledochal cysts with hilar or intrahepatic disease to understand the extent of cystic change and to identify variant biliary anatomy, which occurs in 15 to 20% of patients.↗
▶Ep 1 · 6:47
quoteprobably up to 15 to 20% of patients have some kind of variant biliary tract anatomy.↗
▶Ep 1 · 6:47
clinicalCT scan is commonly used for choledochal cyst workup because of the ease with which young children can be scanned.↗
▶Ep 1 · 6:47
clinicalCT scan is commonly used for choledochal cyst workup because of the ease with which young children can be scanned.↗
▶Ep 1 · 8:00
clinicalStudies estimate the lifetime risk of malignancy in choledochal cysts to be anywhere from 6% to 30%.↗
▶Ep 1 · 8:00
quoteeven after surgical resection of these cysts, some studies suggest that there is still about a 4% lifetime risk of malignancy, which means that these patients need to be surveilled through their lifetime.↗
▶Ep 1 · 8:00
quotethere is, as we can best estimate, about an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma, which, as we all know, is a very aggressive malignancy and hard-to-treat malignancy, as well as gallbladder cancer.↗
clinicalThere are no non-surgical treatment options for choledochal cysts.↗
▶Ep 1 · 8:00
clinicalCholedochal cysts require surgery due to the risk of recurrent cholangitis from biliary stasis and superinfection.↗
▶Ep 1 · 8:00
clinicalType 1 and type 4 choledochal cysts with pancreaticobiliary malunion carry approximately an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma and gallbladder cancer.↗
▶Ep 1 · 8:00
clinicalEven after surgical resection of choledochal cysts, some studies suggest there is still about a 4% lifetime risk of malignancy, requiring lifelong surveillance.↗
▶Ep 1 · 8:00
quotethere is, as we can best estimate, about an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma, which, as we all know, is a very aggressive malignancy and hard-to-treat malignancy, as well as gallbladder cancer.↗
▶Ep 1 · 8:00
quotethere have been a whole bunch of studies estimating that this lifetime risk is anywhere from 6% to 30%.↗
▶Ep 1 · 8:00
quoteeven after surgical resection of these cysts, some studies suggest that there is still about a 4% lifetime risk of malignancy, which means that these patients need to be surveilled through their lifetime.↗
▶Ep 1 · 8:00
clinicalStudies estimate the lifetime risk of malignancy in choledochal cysts to be anywhere from 6% to 30%.↗
▶Ep 1 · 8:00
clinicalEven after surgical resection of choledochal cysts, some studies suggest there is still about a 4% lifetime risk of malignancy, requiring lifelong surveillance.↗
▶Ep 1 · 8:00
clinicalType 1 and type 4 choledochal cysts with pancreaticobiliary malunion carry approximately an 8% lifetime risk of hepatobiliary malignancy, most specifically cholangiocarcinoma and gallbladder cancer.↗
▶Ep 1 · 8:00
clinicalCholedochal cysts require surgery due to the risk of recurrent cholangitis from biliary stasis and superinfection.↗
▶Ep 1 · 8:00
clinicalThere are no non-surgical treatment options for choledochal cysts.↗
▶Ep 1 · 8:00
quotethere have been a whole bunch of studies estimating that this lifetime risk is anywhere from 6% to 30%.↗
opinionFor incidentally found choledochal cysts, surgery should be scheduled sooner rather than later, when it makes sense for the family schedule.↗
▶Ep 1 · 9:16
clinicalIf a patient with choledochal cyst presents with active infection, pancreatitis, or cholangitis, the best approach is to cool the patient off and treat the underlying process before scheduling surgery after sufficient recovery.↗
▶Ep 1 · 9:16
clinicalIf a patient with choledochal cyst presents with active infection, pancreatitis, or cholangitis, the best approach is to cool the patient off and treat the underlying process before scheduling surgery after sufficient recovery.↗
▶Ep 1 · 9:16
opinionFor incidentally found choledochal cysts, surgery should be scheduled sooner rather than later, when it makes sense for the family schedule.↗
▶Ep 1 · 10:14
clinicalPreoperative workup for choledochal cyst surgery includes laboratory values to ensure no other disease process is impairing liver function, and imaging (ultrasound and CT scan are often sufficient).↗
▶Ep 1 · 10:14
clinicalMRCP is recommended preoperatively if there is any question about the patient's anatomy or if the patient has a very proximal choledochal cyst or dilation into the hepatic ducts.↗
▶Ep 1 · 10:14
clinicalPreoperative workup for choledochal cyst surgery includes laboratory values to ensure no other disease process is impairing liver function, and imaging (ultrasound and CT scan are often sufficient).↗
▶Ep 1 · 10:14
clinicalMRCP is recommended preoperatively if there is any question about the patient's anatomy or if the patient has a very proximal choledochal cyst or dilation into the hepatic ducts.↗
▶Ep 1 · 11:13
clinicalThe surgical goal for choledochal cyst repair is complete excision of the cyst.↗
▶Ep 1 · 11:13
clinicalType 5 choledochal cyst (Caroli's disease) management depends on disease extent: if limited to an anatomic part of the liver, resection may be appropriate; if diffuse throughout the liver without adequate functional remnant, transplantation may be necessary.↗
▶Ep 1 · 11:13
clinicalIf type 3 choledochal cyst involves the wall of the duodenum, transduodenal resection options exist, and biopsy of the choledochocele mucosa is important because biliary epithelium exposed to intestinal secretions could become malignant.↗
▶Ep 1 · 11:13
clinicalType 3 choledochal cyst (limited choledochocele) can be treated with ERCP and sphincterotomy.↗
▶Ep 1 · 11:13
clinicalType 2 choledochal cyst can be treated by simple removal of the diverticulum at its neck with repair of the common bile duct.↗
▶Ep 1 · 11:13
clinicalFor type 1 and type 4 choledochal cysts, biliary drainage reconstruction often includes a Roux-en-Y hepaticojejunostomy, but a hepaticoduodenostomy is also an option.↗
▶Ep 1 · 11:13
clinicalFor type 1 and type 4 choledochal cysts, the goal is to remove as much of the duct as possible, taking the duct all the way down behind or into the head of the pancreas to where it tapers, to avoid leaving remnant cyst.↗
▶Ep 1 · 11:13
clinicalThe surgical goal for choledochal cyst repair is complete excision of the cyst.↗
▶Ep 1 · 11:13
clinicalType 5 choledochal cyst (Caroli's disease) management depends on disease extent: if limited to an anatomic part of the liver, resection may be appropriate; if diffuse throughout the liver without adequate functional remnant, transplantation may be necessary.↗
▶Ep 1 · 11:13
clinicalIf type 3 choledochal cyst involves the wall of the duodenum, transduodenal resection options exist, and biopsy of the choledochocele mucosa is important because biliary epithelium exposed to intestinal secretions could become malignant.↗
▶Ep 1 · 11:13
clinicalType 3 choledochal cyst (limited choledochocele) can be treated with ERCP and sphincterotomy.↗
▶Ep 1 · 11:13
clinicalType 2 choledochal cyst can be treated by simple removal of the diverticulum at its neck with repair of the common bile duct.↗
▶Ep 1 · 11:13
clinicalFor type 1 and type 4 choledochal cysts, biliary drainage reconstruction often includes a Roux-en-Y hepaticojejunostomy, but a hepaticoduodenostomy is also an option.↗
▶Ep 1 · 11:13
clinicalFor type 1 and type 4 choledochal cysts, the goal is to remove as much of the duct as possible, taking the duct all the way down behind or into the head of the pancreas to where it tapers, to avoid leaving remnant cyst.↗
▶Ep 1 · 13:19
clinicalDr. Bondock performs the Roux-en-Y limb retrocolic and closes the small bowel mesentery.↗
▶Ep 1 · 13:19
clinicalFor Roux-en-Y hepaticojejunostomy reconstruction, Dr. Bondock goes about 15 to 20 centimeters distal from the ligament of Treitz, performs a two-layer jejunojejunostomy, and does a hepaticojejunostomy with interrupted 5-0 or 6-0 Maxon suture.↗
▶Ep 1 · 13:19
clinicalFor choledochal cyst surgery in children less than 2 years old, a transverse incision or right subcostal incision is preferred; for older children, an upper midline incision is a viable option.↗
▶Ep 1 · 13:19
clinicalDuring choledochal cyst dissection, hepatic arteries are medial and the portal vein is posterior to the cyst.↗
▶Ep 1 · 13:19
clinicalDr. Bondock performs an intraoperative cholangiogram through the gallbladder to understand where the tapering of the distal cyst occurs to avoid leaving remnant cyst.↗
▶Ep 1 · 13:19
clinicalFor Roux-en-Y hepaticojejunostomy reconstruction, Dr. Bondock goes about 15 to 20 centimeters distal from the ligament of Treitz, performs a two-layer jejunojejunostomy, and does a hepaticojejunostomy with interrupted 5-0 or 6-0 Maxon suture.↗
▶Ep 1 · 13:19
clinicalDr. Bondock performs the Roux-en-Y limb retrocolic and closes the small bowel mesentery.↗
▶Ep 1 · 13:19
clinicalDuring choledochal cyst dissection, hepatic arteries are medial and the portal vein is posterior to the cyst.↗
▶Ep 1 · 13:19
clinicalDr. Bondock performs an intraoperative cholangiogram through the gallbladder to understand where the tapering of the distal cyst occurs to avoid leaving remnant cyst.↗
▶Ep 1 · 13:19
clinicalFor choledochal cyst surgery in children less than 2 years old, a transverse incision or right subcostal incision is preferred; for older children, an upper midline incision is a viable option.↗
▶Ep 1 · 16:47
clinicalFor type 2 choledochal cyst, once the cyst is tapered down to the common bile duct, the neck is resected and the common bile duct is repaired with interrupted absorbable suture without leaving a T-tube.↗
▶Ep 1 · 16:47
clinicalFor type 2 choledochal cyst, once the cyst is tapered down to the common bile duct, the neck is resected and the common bile duct is repaired with interrupted absorbable suture without leaving a T-tube.↗
▶Ep 1 · 16:47
clinicalType 3 choledochal cyst can be approached endoscopically with ERCP and sphincterotomy, but if the lesion is large and obstructing the common duct, a transduodenal approach is needed, sometimes with preoperative stents to separate it from the duodenum.↗
▶Ep 1 · 16:47
clinicalType 5 choledochal cyst (Caroli's disease) can be addressed surgically with liver resection if cystic disease is limited to one hemi-liver with adequate liver remnant and preserved biliary outflow, but if diffuse throughout the liver, liver transplantation may be necessary.↗
▶Ep 1 · 16:47
clinicalType 3 choledochal cyst can be approached endoscopically with ERCP and sphincterotomy, but if the lesion is large and obstructing the common duct, a transduodenal approach is needed, sometimes with preoperative stents to separate it from the duodenum.↗
▶Ep 1 · 16:47
clinicalType 5 choledochal cyst (Caroli's disease) can be addressed surgically with liver resection if cystic disease is limited to one hemi-liver with adequate liver remnant and preserved biliary outflow, but if diffuse throughout the liver, liver transplantation may be necessary.↗
▶Ep 1 · 18:45
clinicalShort-term to long-term surgical complications of choledochal cyst surgery include anastomotic stricture, small bowel obstruction from intra-abdominal surgery, reflux gastritis, and recurrent cholangitis.↗
▶Ep 1 · 18:45
clinicalPostoperative considerations for choledochal cyst surgery include enteric drainage and awaiting return of bowel function.↗
▶Ep 1 · 18:45
clinicalDr. Bondock typically places an NG tube postoperatively because of the new jejunojejunostomy, but tries to remove it the day after surgery.↗
▶Ep 1 · 18:45
clinicalDrains are placed postoperatively to assess for biliary leaks from the new hepatoenteric anastomosis and are typically removed once the patient is tolerating a regular diet.↗
▶Ep 1 · 18:45
clinicalInstitutionally, patients are placed on a choleretic like Actigall and cholangitis prophylaxis (daily Bactrim) for three to six months after choledochal cyst surgery.↗
▶Ep 1 · 18:45
clinicalLifelong follow-up is needed for choledochal cyst patients because of the possibility of developing future malignancy even after resection of the cyst.↗
▶Ep 1 · 18:45
clinicalPostoperative considerations for choledochal cyst surgery include enteric drainage and awaiting return of bowel function.↗
▶Ep 1 · 18:45
clinicalShort-term to long-term surgical complications of choledochal cyst surgery include anastomotic stricture, small bowel obstruction from intra-abdominal surgery, reflux gastritis, and recurrent cholangitis.↗
▶Ep 1 · 18:45
clinicalLifelong follow-up is needed for choledochal cyst patients because of the possibility of developing future malignancy even after resection of the cyst.↗
▶Ep 1 · 18:45
clinicalInstitutionally, patients are placed on a choleretic like Actigall and cholangitis prophylaxis (daily Bactrim) for three to six months after choledochal cyst surgery.↗
▶Ep 1 · 18:45
clinicalDrains are placed postoperatively to assess for biliary leaks from the new hepatoenteric anastomosis and are typically removed once the patient is tolerating a regular diet.↗
▶Ep 1 · 18:45
clinicalDr. Bondock typically places an NG tube postoperatively because of the new jejunojejunostomy, but tries to remove it the day after surgery.↗
Choledochal Cysts: In Brief with Dr. Alexander Bondoc
▶Ep 2 · 0:00
clinicalCholedochal cysts are a congenital dilation of the biliary tree.↗
▶Ep 2 · 0:00
host_summaryCholedochal cysts are a congenital dilation of the biliary tree.↗
▶Ep 2 · 1:14
epidemiologicalIn the Western world the incidence of choledochal cysts is about one in 100,000.↗
▶Ep 2 · 1:14
epidemiologicalCholedochal cysts have a female predominance.↗
▶Ep 2 · 1:14
quoteIn the Western world it's about the incidence is about one in 100,000 but in Asia specifically Eastern Asia it's actually a little quite more quite a bit more common one in 13,000.↗
▶Ep 2 · 1:14
epidemiologicalCholedochal cysts have a female predominance.↗
▶Ep 2 · 1:14
epidemiologicalIn the Western world the incidence of choledochal cysts is about one in 100,000.↗
▶Ep 2 · 1:14
quoteIn the Western world it's about the incidence is about one in 100,000 but in Asia specifically Eastern Asia it's actually a little quite more quite a bit more common one in 13,000.↗
▶Ep 2 · 1:35
epidemiologicalIn Asia, specifically Eastern Asia, choledochal cyst incidence is one in 13,000.↗
▶Ep 2 · 1:35
epidemiologicalIn Asia, specifically Eastern Asia, choledochal cyst incidence is one in 13,000.↗
▶Ep 2 · 2:10
clinicalFor Todani types 1 and 4, the etiology is likely embryologic relating to the pancreaticobiliary duct junction (pancreaticobiliary malunion).↗
▶Ep 2 · 2:10
clinicalFor Todani types 1 and 4, the etiology is likely embryologic relating to the pancreaticobiliary duct junction (pancreaticobiliary malunion).↗
▶Ep 2 · 2:40
opinionPancreaticobiliary malunion is just one theory for the etiology of choledochal cysts and doesn't explain the higher incidence in the Far East.↗
▶Ep 2 · 2:40
quoteNow keep in mind that pancreatic obiliary malunion is just one theory for the etiology of colidocle cysts. It's not a slam dunk not even for Todani types one and four and it doesn't really explain why there's a higher incidence in the Far East.↗
▶Ep 2 · 2:40
opinionPancreaticobiliary malunion is just one theory for the etiology of choledochal cysts and doesn't explain the higher incidence in the Far East.↗
▶Ep 2 · 2:40
quoteNow keep in mind that pancreatic obiliary malunion is just one theory for the etiology of colidocle cysts. It's not a slam dunk not even for Todani types one and four and it doesn't really explain why there's a higher incidence in the Far East.↗
▶Ep 2 · 3:05
quoteIn adults that common channel are basically the confluence of the biliary pancreatic ducts. It's supposed to be less than 0.9 centimeters but in the pediatric patient any common channel is abnormal and that is the cause for a lot of these issues.↗
▶Ep 2 · 3:05
clinicalIn adults, the common channel (confluence of biliary and pancreatic ducts) is supposed to be less than 0.9 centimeters, but in pediatric patients any common channel is abnormal.↗
▶Ep 2 · 3:05
clinicalIn adults, the common channel (confluence of biliary and pancreatic ducts) is supposed to be less than 0.9 centimeters, but in pediatric patients any common channel is abnormal.↗
▶Ep 2 · 3:05
quoteIn adults that common channel are basically the confluence of the biliary pancreatic ducts. It's supposed to be less than 0.9 centimeters but in the pediatric patient any common channel is abnormal and that is the cause for a lot of these issues.↗
▶Ep 2 · 3:30
clinicalReflux of pancreatic enzymes into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 2 · 3:30
clinicalReflux of pancreatic enzymes into the biliary tree causes inflammation, degeneration, and epithelial changes.↗
▶Ep 2 · 4:00
clinicalType 5 choledochal cyst (Caroli's disease) has an associated genetic mutation in PKHD1.↗
▶Ep 2 · 4:00
clinicalType 5 choledochal cyst (Caroli's disease) has an associated genetic mutation in PKHD1.↗
▶Ep 2 · 4:40
clinicalType 1 choledochal cyst is a dilation of the extrahepatic common bile duct only, either fusiform or saccular.↗
▶Ep 2 · 4:40
clinicalType 1 choledochal cyst is a dilation of the extrahepatic common bile duct only, either fusiform or saccular.↗
▶Ep 2 · 5:00
clinicalType 2 choledochal cyst is a small diverticulum off the common bile duct.↗
▶Ep 2 · 5:00
clinicalType 2 choledochal cyst is a small diverticulum off the common bile duct.↗
▶Ep 2 · 5:10
clinicalType 3 choledochal cyst (choledochocele) is a dilation of the common bile duct in the wall of the duodenum.↗
▶Ep 2 · 5:10
clinicalType 3 choledochal cyst (choledochocele) is a dilation of the common bile duct in the wall of the duodenum.↗
▶Ep 2 · 5:25
clinicalType 4a choledochal cyst consists of multiple cysts in both the intra- and extrahepatic biliary tree.↗
▶Ep 2 · 5:25
clinicalType 4a choledochal cyst consists of multiple cysts in both the intra- and extrahepatic biliary tree.↗
▶Ep 2 · 5:40
clinicalType 4b choledochal cyst consists of multiple cysts in the extrahepatic biliary tree only.↗
▶Ep 2 · 5:40
clinicalType 4b choledochal cyst consists of multiple cysts in the extrahepatic biliary tree only.↗
▶Ep 2 · 5:50
clinicalType 5 choledochal cyst (Caroli's disease) has diffuse cystic dilation that can be throughout the liver or limited to one lobe.↗
▶Ep 2 · 5:50
clinicalType 5 choledochal cyst (Caroli's disease) has diffuse cystic dilation that can be throughout the liver or limited to one lobe.↗
▶Ep 2 · 6:10
clinicalIn younger children and infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound.↗
▶Ep 2 · 6:10
clinicalIn younger children and infants, choledochal cysts are often diagnosed incidentally on axial imaging or ultrasound.↗
▶Ep 2 · 6:25
clinicalIn children, choledochal cysts often present with symptoms consistent with cholangitis such as jaundice or fever, and patients can have a palpable right upper quadrant mass.↗
▶Ep 2 · 6:25
clinicalIn children, choledochal cysts often present with symptoms consistent with cholangitis such as jaundice or fever, and patients can have a palpable right upper quadrant mass.↗
▶Ep 2 · 6:55
clinicalGiant choledochal cysts that children are born with can perforate and present with biliary ascites.↗
▶Ep 2 · 6:55
clinicalGiant choledochal cysts that children are born with can perforate and present with biliary ascites.↗
▶Ep 2 · 7:10
guidelineLarge choledochal cysts can be identified on 20-week fetal ultrasound and should be referred to a fetal center for workup and close monitoring after birth.↗
▶Ep 2 · 7:10
guidelineLarge choledochal cysts can be identified on 20-week fetal ultrasound and should be referred to a fetal center for workup and close monitoring after birth.↗
▶Ep 2 · 7:30
clinicalA recent study showed that if a choledochal cyst was diagnosed prenatally and was larger than 4.5 centimeters at the 20-week anatomy scan, there was a higher rate of postnatal symptoms, suggesting these patients may benefit from earlier intervention.↗
▶Ep 2 · 7:30
host_summaryA recent study showed that if a choledochal cyst was diagnosed prenatally and was larger than 4.5 centimeters at the 20-week anatomy scan, there was a higher rate of postnatal symptoms, suggesting these patients may benefit from earlier intervention.↗
▶Ep 2 · 7:31
epidemiologicalUp to 15 to 20 percent of choledochal cyst patients have some kind of variant biliary tract anatomy.↗
▶Ep 2 · 7:31
epidemiologicalUp to 15 to 20 percent of choledochal cyst patients have some kind of variant biliary tract anatomy.↗
▶Ep 2 · 8:40
quoteLiver biopsy does become critical if you're talking about a neonate or a newborn because again as men as we discussed earlier you have to rule out the cystic biliary atresia variant. Cannot miss that.↗
▶Ep 2 · 8:40
guidelineIn neonates or newborns with suspected choledochal cyst, liver biopsy is critical to rule out the cystic biliary atresia variant.↗
▶Ep 2 · 8:40
guidelineIn neonates or newborns with suspected choledochal cyst, liver biopsy is critical to rule out the cystic biliary atresia variant.↗
▶Ep 2 · 8:40
quoteLiver biopsy does become critical if you're talking about a neonate or a newborn because again as men as we discussed earlier you have to rule out the cystic biliary atresia variant. Cannot miss that.↗
▶Ep 2 · 9:00
guidelineWhile ultrasound and labs are sufficient to diagnose a choledochal cyst, axial imaging such as CT scan is needed before taking patients to the operating room.↗
▶Ep 2 · 9:00
guidelineWhile ultrasound and labs are sufficient to diagnose a choledochal cyst, axial imaging such as CT scan is needed before taking patients to the operating room.↗
▶Ep 2 · 9:20
clinicalMRCP is useful for operative planning when there are questions about anatomic details, specifically for high disease (into the hilum or intrahepatic) to assess the extent of cystic change.↗
▶Ep 2 · 9:20
clinicalMRCP is useful for operative planning when there are questions about anatomic details, specifically for high disease (into the hilum or intrahepatic) to assess the extent of cystic change.↗
▶Ep 2 · 12:08
clinicalDr. Bondoc constructs Roux-en-Y hepaticojejunostomies by going 15 to 20 centimeters distal from the ligament of Treitz, performing a jejunojejunostomy in two layers if child size allows, then doing a hepaticojejunostomy with interrupted 5-0 or 6-0 Maxon suture.↗
▶Ep 2 · 12:08
quoteI personally like to do Roux-en-Y hepaticojejunostomies. The way I construct those in my practice is I usually go about 15 to 20 centimeters distal from the ligament of trites or whatever you think will be comfortable and allow reach of the Roux-en-Y hepaticojejunostomy.↗
▶Ep 2 · 12:08
clinicalDr. Bondoc constructs Roux-en-Y hepaticojejunostomies by going 15 to 20 centimeters distal from the ligament of Treitz, performing a jejunojejunostomy in two layers if child size allows, then doing a hepaticojejunostomy with interrupted 5-0 or 6-0 Maxon suture.↗
▶Ep 2 · 12:08
quoteI personally like to do Roux-en-Y hepaticojejunostomies. The way I construct those in my practice is I usually go about 15 to 20 centimeters distal from the ligament of trites or whatever you think will be comfortable and allow reach of the Roux-en-Y hepaticojejunostomy.↗
▶Ep 2 · 13:20
quoteI don't usually biopsy the liver unless there's something obvious, but I do close the mesentery.↗
▶Ep 2 · 13:20
opinionDr. Bondoc does not usually biopsy the liver unless there is something obvious, but does close the mesenteric defect.↗
▶Ep 2 · 13:20
opinionDr. Bondoc does not usually biopsy the liver unless there is something obvious, but does close the mesenteric defect.↗
▶Ep 2 · 13:20
quoteI don't usually biopsy the liver unless there's something obvious, but I do close the mesentery.↗
▶Ep 2 · 13:35
clinicalType 2 choledochal cysts require resection of the diverticulum and primary repair of the common bile duct.↗
▶Ep 2 · 13:35
clinicalType 2 choledochal cysts require resection of the diverticulum and primary repair of the common bile duct.↗
▶Ep 2 · 13:50
clinicalFor type 3 choledochal cysts, ERCP and sphincterotomy can be therapeutic in some cases.↗
▶Ep 2 · 13:50
clinicalFor type 3 choledochal cysts, ERCP and sphincterotomy can be therapeutic in some cases.↗
▶Ep 2 · 14:05
clinicalIf a type 3 choledochal cyst is large and obstructing the common duct, a transduodenal approach is often needed to resect the cyst and reconstruct the outflow, sometimes with preoperative stents placed via ERCP.↗
▶Ep 2 · 14:05
clinicalIf a type 3 choledochal cyst is large and obstructing the common duct, a transduodenal approach is often needed to resect the cyst and reconstruct the outflow, sometimes with preoperative stents placed via ERCP.↗
▶Ep 2 · 14:35
clinicalType 5 choledochal cysts may require liver transplant if cystic disease is diffuse throughout the liver.↗
▶Ep 2 · 14:35
clinicalType 5 choledochal cysts may require liver transplant if cystic disease is diffuse throughout the liver.↗
▶Ep 2 · 14:55
clinicalIf type 5 cystic burden is limited to one hemi-liver or allows for resection with adequate liver remnant and preserved biliary outflow, it can be addressed surgically with liver resection.↗
▶Ep 2 · 14:55
clinicalIf type 5 cystic burden is limited to one hemi-liver or allows for resection with adequate liver remnant and preserved biliary outflow, it can be addressed surgically with liver resection.↗
▶Ep 2 · 15:20
clinicalPostoperatively, choledochal cyst patients have an NG tube for about 24 hours to protect the jejunal anastomosis and have temporary biliary drains until eating a regular diet to catch any leaks from the hepaticojejunostomy.↗
▶Ep 2 · 15:20
clinicalPostoperatively, choledochal cyst patients have an NG tube for about 24 hours to protect the jejunal anastomosis and have temporary biliary drains until eating a regular diet to catch any leaks from the hepaticojejunostomy.↗
▶Ep 2 · 15:50
clinicalPostoperative complications for choledochal cyst surgery include recurrent cholangitis due to the connection between the biliary tree and enteric system, anastomotic stricture, small bowel obstruction, and reflux gastritis.↗
▶Ep 2 · 15:50
clinicalPostoperative complications for choledochal cyst surgery include recurrent cholangitis due to the connection between the biliary tree and enteric system, anastomotic stricture, small bowel obstruction, and reflux gastritis.↗
▶Ep 2 · 16:00
clinicalProphylactically, choledochal cyst patients are put on Bactrim postoperatively; Actigall can also be helpful but may be institution-specific.↗
▶Ep 2 · 16:00
clinicalProphylactically, choledochal cyst patients are put on Bactrim postoperatively; Actigall can also be helpful but may be institution-specific.↗
▶Ep 2 · 16:12
guidelineLifelong follow-up is critical for choledochal cyst patients because of the possibility of developing future malignancy even after resection of the cyst.↗
▶Ep 2 · 16:12
guidelineLifelong follow-up is critical for choledochal cyst patients because of the possibility of developing future malignancy even after resection of the cyst.↗
Clinical & Research Update: Pediatric Liver Tumors - A Case-Based Discussion with Drs. Katherine Somers & Alex Bondoc
▶Ep 14 · 23:04
epidemiologicalThere is data in pediatrics about the approach of a tumor board as it pertains to the success and long-term outcomes of patients whose cases are presented at a tumor board style multidisciplinary conference.↗
▶Ep 14 · 23:04
epidemiologicalThere is data in pediatrics about the approach of a tumor board as it pertains to the success and long-term outcomes of patients whose cases are presented at a tumor board style multidisciplinary conference.↗
▶Ep 14 · 24:34
clinicalYou get the maximal effect of tumor shrinkage after the first block or cycle of chemotherapy in intermediate risk patients; you typically won't get as much shrinkage after subsequent blocks.↗
▶Ep 14 · 24:34
quotethere is also some data to suggest that you get the maximal bang for your buck after the first block or cycle of C5VD in, in intermediate risk patients or the first block after of Cyopel 4, you typically won't get as much shrinkage or contraction of the tumor after your subsequent blocks.↗
▶Ep 14 · 24:34
quotethere is also some data to suggest that you get the maximal bang for your buck after the first block or cycle of C5VD in, in intermediate risk patients or the first block after of Cyopel 4, you typically won't get as much shrinkage or contraction of the tumor after your subsequent blocks.↗
▶Ep 14 · 24:34
clinicalYou get the maximal effect of tumor shrinkage after the first block or cycle of chemotherapy in intermediate risk patients; you typically won't get as much shrinkage after subsequent blocks.↗
▶Ep 14 · 26:05
clinicalIndocyanine green (ICG) is highly sensitive but not specific for tumor detection; it can help find multifocal disease.↗
▶Ep 14 · 26:05
clinicalIndocyanine green (ICG) is highly sensitive but not specific for tumor detection; it can help find multifocal disease.↗
▶Ep 14 · 26:21
clinicalIn about 15% of lung resections for hepatoblastoma metastases, ICG fluorescence finds lesions not visible on high-resolution CT imaging.↗
▶Ep 14 · 26:21
clinicalIn about 15% of lung resections for hepatoblastoma metastases, ICG fluorescence finds lesions not visible on high-resolution CT imaging.↗
▶Ep 14 · 26:46
clinicalYou can see tumor through vessel walls with indocyanine green.↗
▶Ep 14 · 26:46
clinicalYou can see tumor through vessel walls with indocyanine green.↗
▶Ep 14 · 36:56
clinicalHematogenous metastases to the lungs are the primary metastatic site for hepatoblastoma.↗
▶Ep 14 · 36:56
clinicalHematogenous metastases to the lungs are the primary metastatic site for hepatoblastoma.↗
▶Ep 14 · 40:42
clinicalICG fluorescence correlates with the viability of lung metastases; non-fluorescent masses may represent dead tumor.↗
▶Ep 14 · 40:42
clinicalICG fluorescence correlates with the viability of lung metastases; non-fluorescent masses may represent dead tumor.↗
▶Ep 14 · 52:15
clinicalPRETEXT 4 multifocal disease mandates liver transplant as the surgical approach.↗
▶Ep 14 · 52:15
clinicalPRETEXT 4 multifocal disease mandates liver transplant as the surgical approach.↗
▶Ep 14 · 52:15
quoteif Alex showed me this MRI of pretext for multifocal disease, I'm gonna tell you right off the bat this patient's a trans is gonna have to have a transplant.↗
▶Ep 14 · 52:15
quoteif Alex showed me this MRI of pretext for multifocal disease, I'm gonna tell you right off the bat this patient's a trans is gonna have to have a transplant.↗
▶Ep 14 · 58:50
clinicalIn deceased donor liver transplant for hepatoblastoma, you cannot have extrahepatic disease because of the huge induction of immunosuppression required.↗
▶Ep 14 · 58:50
clinicalIn deceased donor liver transplant for hepatoblastoma, you cannot have extrahepatic disease because of the huge induction of immunosuppression required.↗
▶Ep 14 · 59:46
guidelineIn the United States, a child with hepatoblastoma automatically gets status 1B categorization on the deceased donor list, which is the second highest stratum for organ allocation.↗
▶Ep 14 · 59:46
guidelineIn the United States, a child with hepatoblastoma automatically gets status 1B categorization on the deceased donor list, which is the second highest stratum for organ allocation.↗
▶Ep 14 · 59:46
quoteIn the United States when you're on the deceased donor list, a child with hepatoblastoma automatically gets status 1B categorization, which is the second highest stratum for organ allocation.↗
▶Ep 14 · 59:46
quoteIn the United States when you're on the deceased donor list, a child with hepatoblastoma automatically gets status 1B categorization, which is the second highest stratum for organ allocation.↗
▶Ep 14 · 1:00:10
clinicalA patient with hepatoblastoma typically does not have underlying liver disease, unlike most liver transplant candidates.↗
▶Ep 14 · 1:00:10
clinicalA patient with hepatoblastoma typically does not have underlying liver disease, unlike most liver transplant candidates.↗
Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations
▶Ep 15 · 0:26
quoteHere at Cincinnati, we deal with the bulk of some of the complex uh vascular access, as well as all the, um, catheter-based access for dialysis.↗
▶Ep 15 · 0:26
clinicalAt Cincinnati Children's Hospital, the transplant surgery team manages complex vascular access and catheter-based dialysis access.↗
▶Ep 15 · 2:09
clinicalFrom a logistical standpoint, chest and neck central venous access is preferred over femoral access.↗
▶Ep 15 · 2:09
quoteFrom a purely logistical standpoint, um, chest and neck, central venous access is preferred.↗
▶Ep 15 · 2:39
clinicalContraindications for central venous access include thrombosis, collateralization, and central stenosis of the SVC, which may require exotic concurrent procedures or alternative access sites.↗
▶Ep 15 · 3:09
clinicalUnless patients have congenital anomalies (usually cardiovascular), routine pre-procedural ultrasound is not necessary for first-time line placement.↗
▶Ep 15 · 3:20
clinicalFor patients requiring multiple lines (line number 4, 5, or 6), Doppler venous ultrasound of the jugulars is recommended, and in small children the SVC and subclavians can sometimes be visualized.↗
▶Ep 15 · 3:37
clinicalPre-procedural imaging may be escalated to contrast-enhanced MR or CT venography, and sometimes intraoperative venography with fluoroscopy is performed.↗
▶Ep 15 · 3:59
clinicalFor small children, neonates, and infants, positioning over a vertically oriented shoulder roll (parallel with the spine) provides hyperextension of the neck and allows shoulder weight to drop posteriorly, giving access to bilateral subclavians and jugulars.↗
▶Ep 15 · 4:55
clinicalDr. Bonddo prefers using a micropuncture kit with a 21-gauge finder needle for small babies, which is smaller than the 18-gauge needle in standard tunnel line kits.↗
▶Ep 15 · 5:25
clinicalUsing ultrasound for internal jugular central line placement is the number one preferred method, with the lowest risk of pneumothorax and carotid artery injury.↗
▶Ep 15 · 5:25
quoteUsing an ultrasound for an IJ, um, central line, uh, attempt is the number one preferred way of doing things. It's certainly the safest, uh, the lowest risk of pneumothorax, the lowest risk of, um, injuring the artery of the carotid.↗
▶Ep 15 · 5:52
clinicalFor large-bore access like dialysis catheters, the patient should be stuck as low as possible on the neck, using the ultrasound probe (approximately 12mm diameter) levered against the clavicle as a landmark.↗
▶Ep 15 · 6:22
clinicalLow neck puncture leaves more catheter to curve in the neck; mid-neck puncture creates lax catheter that can lead to problems with neck turning and catheter displacement from the SVC.↗
▶Ep 15 · 6:22
quoteThat leaves more of the catheter to curve in the neck. And so that's where I, in my opinion, you run into problems with patients who, if they, when, if and when they turn their neck, or the more lax amount of catheter in the neck. I've seen catheter spit out of the, of the SVC. It's strange, but I've seen it a couple of times.↗
▶Ep 15 · 6:56
clinicalFor subclavian access, the insertion point is at the junction of the median and medial aspects of the clavicle, at least one finger breadth (approximately 1cm) inferiorly and laterally, to allow levering under the bone.↗
▶Ep 15 · 7:14
clinicalWhen approaching the clavicle during subclavian access, the needle should be kept flat with downward pressure on the skin rather than angling at 30 degrees.↗
▶Ep 15 · 7:34
clinicalFor subclavian access, the needle should be aimed directly at the sternal notch initially, then angled wider toward the angle of the mandible in a radial motion if unsuccessful.↗
▶Ep 15 · 8:04
clinicalThe right triangle technique for catheter tip positioning uses the trachea as the theoretical midline continued from the carina, with the right main stem bronchus as the hypotenuse; the catheter tip should be within this triangle to ensure atriocaval junction placement.↗
▶Ep 15 · 8:38
clinicalPost-procedural chest X-ray is not routinely ordered for single-stick, uncomplicated line placement using fluoroscopy, based on data from Children's Mercy Hospital Kansas City.↗
▶Ep 15 · 9:06
clinicalPost-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rare complications like chylothorax or thoracic duct injury.↗
▶Ep 15 · 9:41
clinicalFor line infection management, the first clinical decision is whether the patient is septic from the line; if septic and in the ICU, source control requires bedside line removal under light sedation.↗
▶Ep 15 · 9:41
quoteYour first clinical decision point is, is the patient septic from this line? If the patient is septic from the line, it's source control, right? The patient's in the ICU and sick. Go to the bedside, with under light sedation, pull the cuff, get the line out.↗
▶Ep 15 · 10:04
clinicalFor non-septic line-dependent patients with complex vascular access, the organism and antibiotic sensitivity are determined, serial blood cultures are obtained, and the line may be salvaged if sustained culture negativity is achieved.↗
▶Ep 15 · 12:19
clinicalFor patients with exhausted femoral, IJ, and subclavian access options, translumbar line placement through the back musculature into the intrahepatic IVC is an alternative approach performed with interventional radiology.↗
▶Ep 15 · 12:48
clinicalFor emergency vascular access via facial vein cutdown, a horizontal incision is made just lateral to the sternocleidomastoid at the angle of the mandible with the head turned to the patient's left, and the facial vein is typically the first large vein encountered.↗
▶Ep 15 · 13:04
clinicalFor facial vein cutdown, the catheter should be beveled hard to allow blind passage without wire guidance, theoretically allowing it to follow a path without bumping against the vessel wall.↗
Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations
▶Ep 63 · 0:26
clinicalAt Cincinnati Children's Hospital, the transplant surgery team manages complex vascular access and catheter-based dialysis access.↗
▶Ep 63 · 0:26
quoteHere at Cincinnati, we deal with the bulk of some of the complex uh vascular access, as well as all the, um, catheter-based access for dialysis.↗
▶Ep 63 · 2:09
quoteFrom a purely logistical standpoint, um, chest and neck, central venous access is preferred.↗
▶Ep 63 · 2:09
clinicalFrom a logistical standpoint, chest and neck central venous access is preferred over femoral access.↗
▶Ep 63 · 2:39
clinicalContraindications for central venous access include thrombosis, collateralization, and central stenosis of the SVC, which may require exotic concurrent procedures or alternative access sites.↗
▶Ep 63 · 3:09
clinicalUnless patients have congenital anomalies (usually cardiovascular), routine pre-procedural ultrasound is not necessary for first-time line placement.↗
▶Ep 63 · 3:20
clinicalFor patients requiring multiple lines (line number 4, 5, or 6), Doppler venous ultrasound of the jugulars is recommended, and in small children the SVC and subclavians can sometimes be visualized.↗
▶Ep 63 · 3:37
clinicalPre-procedural imaging may be escalated to contrast-enhanced MR or CT venography, and sometimes intraoperative venography with fluoroscopy is performed.↗
▶Ep 63 · 3:59
clinicalFor small children, neonates, and infants, positioning over a vertically oriented shoulder roll (parallel with the spine) provides hyperextension of the neck and allows shoulder weight to drop posteriorly, giving access to bilateral subclavians and jugulars.↗
▶Ep 63 · 4:55
clinicalDr. Bonddo prefers using a micropuncture kit with a 21-gauge finder needle for small babies, which is smaller than the 18-gauge needle in standard tunnel line kits.↗
▶Ep 63 · 5:25
clinicalUsing ultrasound for internal jugular central line placement is the number one preferred method, with the lowest risk of pneumothorax and carotid artery injury.↗
▶Ep 63 · 5:25
quoteUsing an ultrasound for an IJ, um, central line, uh, attempt is the number one preferred way of doing things. It's certainly the safest, uh, the lowest risk of pneumothorax, the lowest risk of, um, injuring the artery of the carotid.↗
▶Ep 63 · 5:52
clinicalFor large-bore access like dialysis catheters, the patient should be stuck as low as possible on the neck, using the ultrasound probe (approximately 12mm diameter) levered against the clavicle as a landmark.↗
▶Ep 63 · 6:22
quoteThat leaves more of the catheter to curve in the neck. And so that's where I, in my opinion, you run into problems with patients who, if they, when, if and when they turn their neck, or the more lax amount of catheter in the neck. I've seen catheter spit out of the, of the SVC. It's strange, but I've seen it a couple of times.↗
▶Ep 63 · 6:22
clinicalLow neck puncture leaves more catheter to curve in the neck; mid-neck puncture creates lax catheter that can lead to problems with neck turning and catheter displacement from the SVC.↗
▶Ep 63 · 6:56
clinicalFor subclavian access, the insertion point is at the junction of the median and medial aspects of the clavicle, at least one finger breadth (approximately 1cm) inferiorly and laterally, to allow levering under the bone.↗
▶Ep 63 · 7:14
clinicalWhen approaching the clavicle during subclavian access, the needle should be kept flat with downward pressure on the skin rather than angling at 30 degrees.↗
▶Ep 63 · 7:34
clinicalFor subclavian access, the needle should be aimed directly at the sternal notch initially, then angled wider toward the angle of the mandible in a radial motion if unsuccessful.↗
▶Ep 63 · 8:04
clinicalThe right triangle technique for catheter tip positioning uses the trachea as the theoretical midline continued from the carina, with the right main stem bronchus as the hypotenuse; the catheter tip should be within this triangle to ensure atriocaval junction placement.↗
▶Ep 63 · 8:38
clinicalPost-procedural chest X-ray is not routinely ordered for single-stick, uncomplicated line placement using fluoroscopy, based on data from Children's Mercy Hospital Kansas City.↗
▶Ep 63 · 9:06
clinicalPost-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rare complications like chylothorax or thoracic duct injury.↗
▶Ep 63 · 9:41
quoteYour first clinical decision point is, is the patient septic from this line? If the patient is septic from the line, it's source control, right? The patient's in the ICU and sick. Go to the bedside, with under light sedation, pull the cuff, get the line out.↗
▶Ep 63 · 9:41
clinicalFor line infection management, the first clinical decision is whether the patient is septic from the line; if septic and in the ICU, source control requires bedside line removal under light sedation.↗
▶Ep 63 · 10:04
clinicalFor non-septic line-dependent patients with complex vascular access, the organism and antibiotic sensitivity are determined, serial blood cultures are obtained, and the line may be salvaged if sustained culture negativity is achieved.↗
▶Ep 63 · 12:19
clinicalFor patients with exhausted femoral, IJ, and subclavian access options, translumbar line placement through the back musculature into the intrahepatic IVC is an alternative approach performed with interventional radiology.↗
▶Ep 63 · 12:48
clinicalFor emergency vascular access via facial vein cutdown, a horizontal incision is made just lateral to the sternocleidomastoid at the angle of the mandible with the head turned to the patient's left, and the facial vein is typically the first large vein encountered.↗
▶Ep 63 · 13:04
clinicalFor facial vein cutdown, the catheter should be beveled hard to allow blind passage without wire guidance, theoretically allowing it to follow a path without bumping against the vessel wall.↗
Clinical & Research Update: Pediatric Liver Tumors - A Case-Based Discussion with Drs. Katherine Somers & Alex Bondoc
▶Ep 17 · 23:04
epidemiologicalThere is data in pediatrics about the approach of a tumor board as it pertains to the success and long-term outcomes of patients whose cases are presented at a tumor board style multidisciplinary conference.↗
▶Ep 17 · 23:04
epidemiologicalThere is data in pediatrics about the approach of a tumor board as it pertains to the success and long-term outcomes of patients whose cases are presented at a tumor board style multidisciplinary conference.↗
▶Ep 17 · 24:34
clinicalYou get the maximal effect of tumor shrinkage after the first block or cycle of chemotherapy in intermediate risk patients; you typically won't get as much shrinkage after subsequent blocks.↗
▶Ep 17 · 24:34
quotethere is also some data to suggest that you get the maximal bang for your buck after the first block or cycle of C5VD in, in intermediate risk patients or the first block after of Cyopel 4, you typically won't get as much shrinkage or contraction of the tumor after your subsequent blocks.↗
▶Ep 17 · 24:34
quotethere is also some data to suggest that you get the maximal bang for your buck after the first block or cycle of C5VD in, in intermediate risk patients or the first block after of Cyopel 4, you typically won't get as much shrinkage or contraction of the tumor after your subsequent blocks.↗
▶Ep 17 · 24:34
clinicalYou get the maximal effect of tumor shrinkage after the first block or cycle of chemotherapy in intermediate risk patients; you typically won't get as much shrinkage after subsequent blocks.↗
▶Ep 17 · 26:05
clinicalIndocyanine green (ICG) is highly sensitive but not specific for tumor detection; it can help find multifocal disease.↗
▶Ep 17 · 26:05
clinicalIndocyanine green (ICG) is highly sensitive but not specific for tumor detection; it can help find multifocal disease.↗
▶Ep 17 · 26:21
clinicalIn about 15% of lung resections for hepatoblastoma metastases, ICG fluorescence finds lesions not visible on high-resolution CT imaging.↗
▶Ep 17 · 26:21
clinicalIn about 15% of lung resections for hepatoblastoma metastases, ICG fluorescence finds lesions not visible on high-resolution CT imaging.↗
▶Ep 17 · 26:46
clinicalYou can see tumor through vessel walls with indocyanine green.↗
▶Ep 17 · 26:46
clinicalYou can see tumor through vessel walls with indocyanine green.↗
▶Ep 17 · 36:56
clinicalHematogenous metastases to the lungs are the primary metastatic site for hepatoblastoma.↗
▶Ep 17 · 36:56
clinicalHematogenous metastases to the lungs are the primary metastatic site for hepatoblastoma.↗
▶Ep 17 · 40:42
clinicalICG fluorescence correlates with the viability of lung metastases; non-fluorescent masses may represent dead tumor.↗
▶Ep 17 · 40:42
clinicalICG fluorescence correlates with the viability of lung metastases; non-fluorescent masses may represent dead tumor.↗
▶Ep 17 · 52:15
quoteif Alex showed me this MRI of pretext for multifocal disease, I'm gonna tell you right off the bat this patient's a trans is gonna have to have a transplant.↗
▶Ep 17 · 52:15
clinicalPRETEXT 4 multifocal disease mandates liver transplant as the surgical approach.↗
▶Ep 17 · 52:15
clinicalPRETEXT 4 multifocal disease mandates liver transplant as the surgical approach.↗
▶Ep 17 · 52:15
quoteif Alex showed me this MRI of pretext for multifocal disease, I'm gonna tell you right off the bat this patient's a trans is gonna have to have a transplant.↗
▶Ep 17 · 58:50
clinicalIn deceased donor liver transplant for hepatoblastoma, you cannot have extrahepatic disease because of the huge induction of immunosuppression required.↗
▶Ep 17 · 58:50
clinicalIn deceased donor liver transplant for hepatoblastoma, you cannot have extrahepatic disease because of the huge induction of immunosuppression required.↗
▶Ep 17 · 59:46
quoteIn the United States when you're on the deceased donor list, a child with hepatoblastoma automatically gets status 1B categorization, which is the second highest stratum for organ allocation.↗
▶Ep 17 · 59:46
guidelineIn the United States, a child with hepatoblastoma automatically gets status 1B categorization on the deceased donor list, which is the second highest stratum for organ allocation.↗
▶Ep 17 · 59:46
quoteIn the United States when you're on the deceased donor list, a child with hepatoblastoma automatically gets status 1B categorization, which is the second highest stratum for organ allocation.↗
▶Ep 17 · 59:46
guidelineIn the United States, a child with hepatoblastoma automatically gets status 1B categorization on the deceased donor list, which is the second highest stratum for organ allocation.↗
▶Ep 17 · 1:00:10
clinicalA patient with hepatoblastoma typically does not have underlying liver disease, unlike most liver transplant candidates.↗
▶Ep 17 · 1:00:10
clinicalA patient with hepatoblastoma typically does not have underlying liver disease, unlike most liver transplant candidates.↗
quoteSo it's a relatively rare diagnosis, about 4 to 5 in 1000 live births, and the preponderance is heavily male.↗
▶Ep 3 · 3:05
epidemiologicalPyloric stenosis incidence is approximately 4 to 5 in 1000 live births with heavy male preponderance.↗
▶Ep 3 · 4:00
quoteAnd is it a cause and effect relationship? Perhaps not, but we're talking adversity. This is a patient population you have to be aware of. Perhaps they're not seeking care as soon or they've been placed in the waiting room. They're not being seen as fast. Hard to say.↗
▶Ep 3 · 4:55
quoteAs you're rolling the hypertrophied muscle over the retroperitoneum or even over the spine, so they tell you to warm up your hands, have mom or dad holding them tight so that they're not upset, and then maybe sometimes you can elicit it, especially if it's particularly large.↗
▶Ep 3 · 7:34
opinionAtropine is traditional medical management but has fallen out of favor because pediatric anesthetists are skilled and there is low concordance between congenital anomalies creating high anesthetic risk.↗
▶Ep 3 · 8:40
quoteThe first pyloomyotomy was done actually the year before by someone else, but Ramstead was the one who popularized it and the spreader bears his name. He used a coffee spoon and he actually intended to do a pyloroplasty, but ended up doing myotomy only because the baby got unstable or, you know, they couldn't do it appropriately, so we only did the myotomy.↗
▶Ep 3 · 8:40
clinicalThe first pyloromyotomy was performed the year before Ramstedt, who popularized it using a coffee spoon, intending pyloroplasty but performing only myotomy when the baby became unstable.↗
▶Ep 3 · 9:16
clinicalGastric suction in three positions (head down, right, left) while awake is performed before induction to prevent aspiration from the atonic stomach.↗
▶Ep 3 · 9:16
quoteWe didn't put an NG in, so we're paying the price for that. But what we typically will do, or what some of the old school anesthetists, and I would assume that they've taught the fellows and their junior partners is you will suction the baby while awake in 3 different positions, head down, turn to the right, turn to the left to make sure you've sucked out that big atonic bag.↗
▶Ep 3 · 9:38
quoteBecause again, you relax the baby. You have no NG. The baby vomits and aspirates. So it's very specific to paroxysmosis because of what's happened metabolically, physiologically with the stomach.↗
▶Ep 3 · 10:12
clinicalFor laparoscopic pyloromyotomy, 3-millimeter instruments are used through three incisions: umbilicus, right upper quadrant, and left upper quadrant.↗
▶Ep 3 · 10:57
quoteThis is why you should know how long the channel is, because if it's 1518 millimeters. The 3 millimeter Maryland grass for when you open it completely is 13 millimeters. If you only make a 13 millimeter myotomy on a 15 or an 18 millimeter channel. You're going to have an incomplete myotomy.↗
▶Ep 3 · 10:57
clinicalThe 3-millimeter Maryland grasper when fully opened is 13 millimeters, so a 13mm myotomy on a 15-18mm channel will be incomplete.↗
▶Ep 3 · 12:05
clinicalAir can be insufflated down a suction catheter to look for bubbles indicating mucosal perforation.↗
▶Ep 3 · 12:05
quoteThe other thing sometimes we can do is when there's blood or serous fluid, I'll have the Anesthetist put air down a suction catheter and theoretically looking for bubbles of air if you've violated the mucosa.↗
▶Ep 3 · 12:20
clinicalOmentum is placed on top of the myotomy site.↗
▶Ep 3 · 12:27
clinicalOpen pyloromyotomy can be performed through a periumbilical incision with tunneling up to the right upper quadrant, taking advantage of babies' stretchable skin.↗
▶Ep 3 · 13:06
clinicalIncisional hernias can occur because fascia is typically not closed on stab incisions in upper quadrants; omental hernias have been observed.↗
▶Ep 3 · 13:23
quoteThe rates of complication after pyeloromyotomy, they're either equivalent or better actually with open because I think to me lap pyloromyotomy is an experience and a feel operation. Because like we said, there's no magical way to know exactly how complete your myotomy is, because I definitely lose my nerve going towards the duodenum, and sometimes people will stop short.↗
▶Ep 3 · 13:23
opinionComplication rates after pyloromyotomy are equivalent or better with open approach because laparoscopic pyloromyotomy is an experience and feel operation.↗
▶Ep 3 · 13:54
clinicalPost-operative vomiting is very common and does not necessarily mean the operation did not work; the atonic stomach does not remodel immediately.↗
▶Ep 3 · 13:54
quoteI tell them that it is very common for babies to vomit afterwards, and it doesn't necessarily mean that the operation didn't work.↗
▶Ep 3 · 14:03
quoteMy theory is that the stomach is still atonic, right? It's not going to remodel itself immediately. Sometimes if you're challenging the baby, they still will vomit, and that's OK.↗
▶Ep 3 · 14:13
quoteNow, once you get into days and complete intolerance of feeds, then you have to worry about something like an incomplete myotomy.↗
▶Ep 3 · 14:13
clinicalComplete intolerance of feeds lasting into days post-operatively raises concern for incomplete myotomy.↗
epidemiologicalPyloric stenosis incidence is approximately 4 to 5 in 1000 live births with heavy male preponderance.↗
▶Ep 24 · 3:05
quoteSo it's a relatively rare diagnosis, about 4 to 5 in 1000 live births, and the preponderance is heavily male.↗
▶Ep 24 · 3:05
epidemiologicalPyloric stenosis incidence is approximately 4 to 5 in 1000 live births with heavy male preponderance.↗
▶Ep 24 · 3:05
quoteSo it's a relatively rare diagnosis, about 4 to 5 in 1000 live births, and the preponderance is heavily male.↗
▶Ep 24 · 4:00
quoteAnd is it a cause and effect relationship? Perhaps not, but we're talking adversity. This is a patient population you have to be aware of. Perhaps they're not seeking care as soon or they've been placed in the waiting room. They're not being seen as fast. Hard to say.↗
▶Ep 24 · 4:00
quoteAnd is it a cause and effect relationship? Perhaps not, but we're talking adversity. This is a patient population you have to be aware of. Perhaps they're not seeking care as soon or they've been placed in the waiting room. They're not being seen as fast. Hard to say.↗
▶Ep 24 · 4:55
quoteAs you're rolling the hypertrophied muscle over the retroperitoneum or even over the spine, so they tell you to warm up your hands, have mom or dad holding them tight so that they're not upset, and then maybe sometimes you can elicit it, especially if it's particularly large.↗
▶Ep 24 · 4:55
quoteAs you're rolling the hypertrophied muscle over the retroperitoneum or even over the spine, so they tell you to warm up your hands, have mom or dad holding them tight so that they're not upset, and then maybe sometimes you can elicit it, especially if it's particularly large.↗
▶Ep 24 · 7:34
opinionAtropine is traditional medical management but has fallen out of favor because pediatric anesthetists are skilled and there is low concordance between congenital anomalies creating high anesthetic risk.↗
▶Ep 24 · 7:34
opinionAtropine is traditional medical management but has fallen out of favor because pediatric anesthetists are skilled and there is low concordance between congenital anomalies creating high anesthetic risk.↗
▶Ep 24 · 8:40
clinicalThe first pyloromyotomy was performed the year before Ramstedt, who popularized it using a coffee spoon, intending pyloroplasty but performing only myotomy when the baby became unstable.↗
▶Ep 24 · 8:40
clinicalThe first pyloromyotomy was performed the year before Ramstedt, who popularized it using a coffee spoon, intending pyloroplasty but performing only myotomy when the baby became unstable.↗
▶Ep 24 · 8:40
quoteThe first pyloomyotomy was done actually the year before by someone else, but Ramstead was the one who popularized it and the spreader bears his name. He used a coffee spoon and he actually intended to do a pyloroplasty, but ended up doing myotomy only because the baby got unstable or, you know, they couldn't do it appropriately, so we only did the myotomy.↗
▶Ep 24 · 8:40
quoteThe first pyloomyotomy was done actually the year before by someone else, but Ramstead was the one who popularized it and the spreader bears his name. He used a coffee spoon and he actually intended to do a pyloroplasty, but ended up doing myotomy only because the baby got unstable or, you know, they couldn't do it appropriately, so we only did the myotomy.↗
▶Ep 24 · 9:16
quoteWe didn't put an NG in, so we're paying the price for that. But what we typically will do, or what some of the old school anesthetists, and I would assume that they've taught the fellows and their junior partners is you will suction the baby while awake in 3 different positions, head down, turn to the right, turn to the left to make sure you've sucked out that big atonic bag.↗
▶Ep 24 · 9:16
quoteWe didn't put an NG in, so we're paying the price for that. But what we typically will do, or what some of the old school anesthetists, and I would assume that they've taught the fellows and their junior partners is you will suction the baby while awake in 3 different positions, head down, turn to the right, turn to the left to make sure you've sucked out that big atonic bag.↗
▶Ep 24 · 9:16
clinicalGastric suction in three positions (head down, right, left) while awake is performed before induction to prevent aspiration from the atonic stomach.↗
▶Ep 24 · 9:16
clinicalGastric suction in three positions (head down, right, left) while awake is performed before induction to prevent aspiration from the atonic stomach.↗
▶Ep 24 · 9:38
quoteBecause again, you relax the baby. You have no NG. The baby vomits and aspirates. So it's very specific to paroxysmosis because of what's happened metabolically, physiologically with the stomach.↗
▶Ep 24 · 9:38
quoteBecause again, you relax the baby. You have no NG. The baby vomits and aspirates. So it's very specific to paroxysmosis because of what's happened metabolically, physiologically with the stomach.↗
▶Ep 24 · 10:12
clinicalFor laparoscopic pyloromyotomy, 3-millimeter instruments are used through three incisions: umbilicus, right upper quadrant, and left upper quadrant.↗
▶Ep 24 · 10:12
clinicalFor laparoscopic pyloromyotomy, 3-millimeter instruments are used through three incisions: umbilicus, right upper quadrant, and left upper quadrant.↗
▶Ep 24 · 10:57
clinicalThe 3-millimeter Maryland grasper when fully opened is 13 millimeters, so a 13mm myotomy on a 15-18mm channel will be incomplete.↗
▶Ep 24 · 10:57
clinicalThe 3-millimeter Maryland grasper when fully opened is 13 millimeters, so a 13mm myotomy on a 15-18mm channel will be incomplete.↗
▶Ep 24 · 10:57
quoteThis is why you should know how long the channel is, because if it's 1518 millimeters. The 3 millimeter Maryland grass for when you open it completely is 13 millimeters. If you only make a 13 millimeter myotomy on a 15 or an 18 millimeter channel. You're going to have an incomplete myotomy.↗
▶Ep 24 · 10:57
quoteThis is why you should know how long the channel is, because if it's 1518 millimeters. The 3 millimeter Maryland grass for when you open it completely is 13 millimeters. If you only make a 13 millimeter myotomy on a 15 or an 18 millimeter channel. You're going to have an incomplete myotomy.↗
▶Ep 24 · 12:05
quoteThe other thing sometimes we can do is when there's blood or serous fluid, I'll have the Anesthetist put air down a suction catheter and theoretically looking for bubbles of air if you've violated the mucosa.↗
▶Ep 24 · 12:05
clinicalAir can be insufflated down a suction catheter to look for bubbles indicating mucosal perforation.↗
▶Ep 24 · 12:05
quoteThe other thing sometimes we can do is when there's blood or serous fluid, I'll have the Anesthetist put air down a suction catheter and theoretically looking for bubbles of air if you've violated the mucosa.↗
▶Ep 24 · 12:05
clinicalAir can be insufflated down a suction catheter to look for bubbles indicating mucosal perforation.↗
▶Ep 24 · 12:20
clinicalOmentum is placed on top of the myotomy site.↗
▶Ep 24 · 12:20
clinicalOmentum is placed on top of the myotomy site.↗
▶Ep 24 · 12:27
clinicalOpen pyloromyotomy can be performed through a periumbilical incision with tunneling up to the right upper quadrant, taking advantage of babies' stretchable skin.↗
▶Ep 24 · 12:27
clinicalOpen pyloromyotomy can be performed through a periumbilical incision with tunneling up to the right upper quadrant, taking advantage of babies' stretchable skin.↗
▶Ep 24 · 13:06
clinicalIncisional hernias can occur because fascia is typically not closed on stab incisions in upper quadrants; omental hernias have been observed.↗
▶Ep 24 · 13:06
clinicalIncisional hernias can occur because fascia is typically not closed on stab incisions in upper quadrants; omental hernias have been observed.↗
▶Ep 24 · 13:23
opinionComplication rates after pyloromyotomy are equivalent or better with open approach because laparoscopic pyloromyotomy is an experience and feel operation.↗
▶Ep 24 · 13:23
quoteThe rates of complication after pyeloromyotomy, they're either equivalent or better actually with open because I think to me lap pyloromyotomy is an experience and a feel operation. Because like we said, there's no magical way to know exactly how complete your myotomy is, because I definitely lose my nerve going towards the duodenum, and sometimes people will stop short.↗
▶Ep 24 · 13:23
quoteThe rates of complication after pyeloromyotomy, they're either equivalent or better actually with open because I think to me lap pyloromyotomy is an experience and a feel operation. Because like we said, there's no magical way to know exactly how complete your myotomy is, because I definitely lose my nerve going towards the duodenum, and sometimes people will stop short.↗
▶Ep 24 · 13:23
opinionComplication rates after pyloromyotomy are equivalent or better with open approach because laparoscopic pyloromyotomy is an experience and feel operation.↗
▶Ep 24 · 13:54
clinicalPost-operative vomiting is very common and does not necessarily mean the operation did not work; the atonic stomach does not remodel immediately.↗
▶Ep 24 · 13:54
quoteI tell them that it is very common for babies to vomit afterwards, and it doesn't necessarily mean that the operation didn't work.↗
▶Ep 24 · 13:54
quoteI tell them that it is very common for babies to vomit afterwards, and it doesn't necessarily mean that the operation didn't work.↗
▶Ep 24 · 13:54
clinicalPost-operative vomiting is very common and does not necessarily mean the operation did not work; the atonic stomach does not remodel immediately.↗
▶Ep 24 · 14:03
quoteMy theory is that the stomach is still atonic, right? It's not going to remodel itself immediately. Sometimes if you're challenging the baby, they still will vomit, and that's OK.↗
▶Ep 24 · 14:03
quoteMy theory is that the stomach is still atonic, right? It's not going to remodel itself immediately. Sometimes if you're challenging the baby, they still will vomit, and that's OK.↗
▶Ep 24 · 14:13
quoteNow, once you get into days and complete intolerance of feeds, then you have to worry about something like an incomplete myotomy.↗
▶Ep 24 · 14:13
clinicalComplete intolerance of feeds lasting into days post-operatively raises concern for incomplete myotomy.↗
▶Ep 24 · 14:13
clinicalComplete intolerance of feeds lasting into days post-operatively raises concern for incomplete myotomy.↗
▶Ep 24 · 14:13
quoteNow, once you get into days and complete intolerance of feeds, then you have to worry about something like an incomplete myotomy.↗
