Jack Langer

1500 statements · 14 topics

Colorectal / ARM & Hirschsprung · guest expert Congenital Lung Lesions (CPAM) · guest expert Fetal Surgery · guest expert

Featured statements

There are two types of intestinal atresia in gastroschisis: early-onset atresia where bowel gets very dilated but not thick-walled, and late atresia where the abdominal wall defect becomes very small causing ischemia and potentially vanishing gastroschisis

clinical · Abdominal Wall Defects

Early papers showed benefit to cesarean section for gastroschisis, but those cesarean sections were usually done early at 36 or 37 weeks, raising the question of whether timing rather than cesarean section itself gave the benefit

clinical · Abdominal Wall Defects

Early papers showed a benefit to cesarean section in gastroschisis, but cesarean sections were usually done early at 36 or 37 weeks, raising the question of whether timing rather than cesarean section itself gave the benefit

clinical · CICU / Post-op CHD Care

For pentalogy of Cantrell patients, escharotic therapy is used due to cardiac problems; cardiac surgeons can patch the diaphragm from above through sternotomy, then abdominal wall is repaired later after cardiac optimization

clinical · Etiologies (Gastroschisis/NEC/Atresia/Volvulus)

There are two types of intestinal atresia in gastroschisis: early-onset atresia with dilated but not thick-walled bowel, and late atresia from a constricting defect causing ischemia and potentially vanishing gastroschisis

clinical · Etiologies (Gastroschisis/NEC/Atresia/Volvulus)

Inversion appendectomy during Ladd procedure makes sense if the appendix is encountered, as several omphalocele patients have developed perforated appendicitis with delayed diagnosis due to abnormal appendix location

clinical · Gastroschisis

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Jack's statements about Abdominal Wall Defects 320 statements

Open the Abdominal Wall Defects collection →

Abdominal Wall Defects with Dr. Jacob Langer

Quotation Diversification is not only important in your financial portfolio, it's also important in the rest of your life. Open

Statement Most gastroschisis patients don't have any other associated anomalies, and it's rare to have abnormal chromosomes with gastroschisis Open

Quotation Will the diagnosis change the location of delivery? Will the diagnosis change the timing of delivery? Will the diagnosis change the mode of delivery? In other words, do you need a cesarean section? And is there a role for some kind of fetal intervention? Open

Statement Early papers showed benefit to cesarean section for gastroschisis, but those cesarean sections were usually done early at 36 or 37 weeks, raising the question of whether timing rather than cesarean section itself gave the benefit Open

Statement Many studies have failed to show an advantage to cesarean section for gastroschisis, and most people nowadays would not do routine cesarean section Open

Statement There has not been any large randomized trial looking specifically at the issue of early delivery for gastroschisis Open

Statement Toronto's approach is to deliver gastroschisis patients at around 37 weeks unless they've already gone into spontaneous labor Open

Statement The mean gestational age of onset of labor is earlier in gastroschisis pregnancies, possibly because of inflammatory mediators produced by the inflamed bowel Open

Statement Labor induction at 37 weeks is successful most of the time in gastroschisis pregnancies, unlike regular pregnancies Open

Statement Most evidence, including from the CapsNet database, suggests that delivery in a perinatal center is beneficial for gastroschisis Open

Statement During transport, gastroschisis babies should be nursed on their side, usually right side down, to prevent kinking of the mesentery and ischemia of the bowel Open

Statement Adrian Bianchi first described bedside closure for gastroschisis Open

Statement Using forceps at the bedside to push bowel back in can damage the bowel in a squiggling baby Open

Statement Current technique uses pre-formed silos with fentanyl or morphine sedation without intubation in awake babies, slowly pushing bowel in while monitoring intraabdominal pressure to keep it below 20 Open

Statement If reduction is successful with good pressure and perfusion, the silo can be removed immediately and the umbilical cord stump used to cover the hole with a Duoderm dressing left for about 5 days Open

Statement Anthony Sandler championed the sutureless plastic closure approach after training in Toronto Open

Statement Some gastroschisis patients become tachypneic with bluish legs after reduction and require intubation by neonatologists an hour or two later Open

Statement Leaving a silo on for 24-48 hours causes the abdominal wall defect to stretch and get bigger, taking longer to close with plastic closure Open

Statement The incidence of intestinal atresia in gastroschisis is between 5 and 10% Open

Statement There are two types of intestinal atresia in gastroschisis: early-onset atresia with dilated but not thick-walled bowel, and late atresia from a constricting defect causing ischemia and potentially vanishing gastroschisis Open

Statement The prognosis for short bowel syndrome has improved dramatically over the last 10-15 years due to intestinal failure centers, better TPN that doesn't damage the liver, and improved sepsis control Open

Statement Three management options for atresia in gastroschisis: repair at time of closure, bring out stomas, or reduce everything and repair atresia in a couple months Open

Statement There is no good evidence for optimal management of atresia in gastroschisis because it's rare, so approach should be individualized Open

Quotation Usually when you say individualize, it means nobody knows what the right answer is. Open

Statement If bowel looks good without much peel, repair the atresia and reduce at the same sitting; if concerning, drop it back in without repair Open

Statement Stomas are only brought out when there's necrotic bowel requiring resection and the bowel is not healthy enough to anastomose Open

Statement The umbilicus is the preferred site for neonatal stomas; prolapse occurs regardless of location Open

Quotation I find they prolapse no matter what you do. Open

Statement Three weeks is average time to bowel function in gastroschisis, so investigations typically aren't started until 4 weeks Open

Statement Metoclopramide (Reglan) can be given intravenously as a prokinetic agent in gastroschisis patients with hypomotility Open

Statement A UK study showed cisapride shortened time to bowel function, but cisapride is no longer available Open

Statement Toronto is conducting a randomized prospective trial to determine if intravenous metoclopramide can shorten the period of hypomotility in gastroschisis Open

Statement At 4 weeks without bowel function, start with contrast enema to look for mechanical obstruction, can also do upper GI Open

Statement If still no resolution at 6 weeks, laparotomy is usually performed; sometimes mechanical obstruction is found, sometimes just adhesions Open

Statement Going in too early on gastroschisis patients with prolonged ileus is a mistake Open

Statement Undescended testis (usually right) in gastroschisis is directed down into the pelvis during reduction; in about half the cases it finds its way to the scrotum Open

Quotation One of the most amazing things in the human body. Open

Statement Omphalocele has a much higher incidence of associated anomalies and chromosomal abnormalities compared to gastroschisis Open

Statement Karyotype analysis and testing for Beckwith-Wiedemann syndrome are routinely done for omphalocele patients Open

Statement Small omphaloceles without liver are counterintuitively more likely to be associated with abnormal chromosomes than large omphaloceles Open

Statement There is no rationale for routine cesarean section, delivery at a perinatal center, or preterm delivery for small omphaloceles Open

Statement Small omphaloceles are simple to repair surgically Open

Statement For giant omphaloceles (with significant liver), most recommend cesarean section, though this is not evidence-based Open

Statement Giant omphaloceles should be delivered at a perinatal center due to need for pediatric surgeon and experienced neonatologists Open

Statement Pulmonary hypoplasia is associated with giant omphaloceles but is very difficult to diagnose prenatally; some patients require early intubation and respiratory support Open

Statement Stuart Lacy established intraabdominal pressure guideline of 20 mmHg based on rabbit studies in the 1980s, then validated in prospective study in children showing improved outcomes Open

Statement Lacy also described increase in central venous pressure of more than 4 as a concerning threshold Open

Statement Intraabdominal pressure can be measured through nasogastric tube or Foley catheter (intravesical pressure); the trend is more important than absolute number Open

Statement Primary closure is attempted for full-term omphalocele patients without significant cardiac disease, respiratory issues, or pulmonary hypoplasia Open

Statement The Montreal group described using the omphalocele sac as a silo, sequentially ligating it over days to allow abdominal wall stretching before definitive closure Open

Statement Sequential sac ligation requires a thick enough sac and umbilical cord coming off the top rather than the side Open

Statement Duoderm compression appears to achieve reduction more quickly than sac ligation and doesn't require a sac amenable to ligation Open

Statement Indications for escharotic therapy include prematurity, bad cardiac disease, pulmonary hypoplasia, multiple anomalies, abnormal chromosomes, or omphalocele too giant to reduce Open

Statement Mushroom-shaped omphaloceles (small abdominal wall defect with large amount of viscera out) are impossible to reduce primarily Open

Statement Sigy Ein used silver sulfadiazine (Silvadene) for escharotic therapy in omphaloceles for many years; Toronto published long-term follow-up Open

Statement Timing of delayed omphalocele repair depends on patient specifics; some can be repaired at 6-8 months if defect reduces spontaneously, others require waiting 3-4 years for cardiac or pulmonary optimization Open

Statement Mushroom-shaped omphaloceles never reduce spontaneously and stay large Open

Statement For mushroom-shaped omphaloceles, the abdominal wall defect can be enlarged as a first step by incising the lower edge fascia, closing skin, and allowing more spontaneous reduction before definitive repair Open

Statement Formal adult-style component separation in small children carries risk of devascularization and worsening the situation Open

Statement In omphaloceles extending to the costal margin, the upper defect cannot be closed, so inferior defect is closed and a patch placed superiorly Open

Statement Surgisis patch fails about 50% of the time in omphalocele closure; can be replaced with non-absorbable prolene mesh Open

Statement Stratus is being used more recently for patches but long-term follow-up is not yet available to compare with Surgisis Open

Statement Omphaloceles can be part of pentalogy of Cantrell, often with missing pericardium or Morgagni hernia; these tend to be more superiorly placed Open

Statement For pentalogy of Cantrell patients, escharotic therapy is used due to cardiac problems; cardiac surgeons can patch the diaphragm from above through sternotomy, then abdominal wall is repaired later after cardiac optimization Open

Statement Reflux is very common in omphalocele patients, especially those with bad hearts or pulmonary hypoplasia who don't eat normally Open

Statement Interventional radiologists can place G-tubes under fluoroscopy in giant omphalocele patients by finding a window lateral to the defect, then convert to GJ tube after maturation Open

Statement Fundoplication in a child with a large omphalocele defect is extremely difficult because the liver is midline and accessing the hiatus is nearly impossible, especially with cardiac disease and congested liver Open

Statement GJ tube is a better short-term solution for reflux in omphalocele; fundoplication can be performed when fixing the abdominal wall defect after medical optimization Open

Statement In large omphaloceles with midline liver, the liver can put pressure on the duodenum or pylorus causing mechanical gastric outlet obstruction that worsens reflux Open

Statement Non-rotation in omphalocele is not a problem because it's not associated with risk of midgut volvulus, unlike malrotation Open

Statement Inversion appendectomy during Ladd procedure makes sense if the appendix is encountered, as several omphalocele patients have developed perforated appendicitis with delayed diagnosis due to abnormal appendix location Open

Statement If a child has renal abnormality requiring potential Mitrofanoff, the appendix should be preserved Open

Statement Hepatic veins in omphalocele are very superficial and can be injured during fascial dissection if not careful Open

Statement Kinking of hepatic veins during reduction has not been a problem when using intraabdominal pressure monitoring and not being too aggressive with pressures above 20 Open

Statement In immediate omphalocele reduction, fascial edges can usually be approximated at the bottom but often not at the top, requiring patch placement Open

Statement For partial reductions with liver still protruding superiorly, Gore-Tex or silastic can be sewn on, skin closed over it, then removed in 1-2 weeks after stretching allows fascial closure Open

Abdominal Wall Defects with Dr. Jacob Langer

Quotation Diversification is not only important in your financial portfolio, it's also important in the rest of your life. Open

Statement With gastroschisis, the main issue is that the bowel gets damaged through fetal life Open

Statement Most gastroschisis patients don't have any other associated anomalies, and it's pretty rare to have abnormal chromosomes Open

Statement Early papers showed a benefit to cesarean section in gastroschisis, but cesarean sections were usually done early at 36 or 37 weeks, raising the question of whether timing rather than cesarean section itself gave the benefit Open

Statement Many studies have failed to show an advantage to cesarean section, and most people nowadays would not do routine cesarean section for gastroschisis Open

Statement There has not been any large randomized trial looking specifically at the issue of early delivery in gastroschisis Open

Statement Toronto's approach is to deliver gastroschisis patients at around 37 weeks unless they've already gone into spontaneous labor Open

Statement The mean gestational age of onset of labor is a lot earlier in gastroschisis pregnancies, possibly because of inflammatory mediators produced by the inflamed bowel Open

Statement In gastroschisis pregnancies, labor can usually be successfully induced at 37 weeks, unlike regular pregnancies Open

Statement Most evidence, including from the CapsNet database, suggests that delivery in a perinatal center is beneficial for gastroschisis Open

Statement During transport of gastroschisis patients, it's important for the baby to be nursed on his or her side, usually right side down, to prevent kinking of the mesentery and ischemia of the bowel Open

Statement For gastroschisis, bedside closure is the first choice if the bowel is not too thickened and there's not too much peel Open

Statement Adrian Bianchi first described bedside closure for gastroschisis Open

Statement Using forceps at the bedside to push bowel back in can damage the bowel in a squiggling baby Open

Statement The current approach uses pre-formed silos, slowly pushing on them with fentanyl or morphine sedation in an awake baby, aiming to keep intraabdominal pressure below 20 Open

Statement Umbilical hernias from plastic closure generally close by age 2 or 3 years, just like any umbilical hernia Open

Statement Some gastroschisis patients become tachypneic with bluish legs after reduction and require intubation by neonatologists an hour or two later Open

Statement The disadvantage of leaving a silo on for 24-48 hours is that the abdominal wall defect gets stretched out and bigger, taking longer to close with plastic closure Open

Statement The incidence of intestinal atresia in gastroschisis is between 5 and 10% Open

Statement There are two types of intestinal atresia in gastroschisis: early-onset atresia where bowel gets very dilated but not thick-walled, and late atresia where the abdominal wall defect becomes very small causing ischemia and potentially vanishing gastroschisis Open

Statement The prognosis for short bowel syndrome has improved dramatically over the last 10-15 years because of intestinal failure centers, better TPN that doesn't damage the liver as much, and control of sepsis Open

Statement For atresia in gastroschisis, there are three management choices: repair at time of closure, bring out stomas, or drop everything back in and repair the atresia later Open

Statement There's no good evidence for optimal management of atresia in gastroschisis because it's such a rare occurrence Open

Quotation Usually when you say individualize, it means nobody knows what the right answer is. Open

Statement If bowel looks good without much peel, primary repair of atresia at initial closure is appropriate; if there's concern, drop it back in and repair later Open

Statement Stomas are brought out only when there's necrotic bowel requiring resection and the bowel is not healthy enough to anastomose Open

Statement The umbilicus is the preferred site for neonatal stomas because it results in a scar that would have been there anyway and is convenient for appliance placement Open

Statement Neonatal stomas prolapse no matter where they are placed Open

Statement Three weeks is average time to bowel function in gastroschisis, so investigations typically aren't started until 4 weeks Open

Statement A UK study showed cisapride helped gastroschisis patients achieve bowel function more quickly, but cisapride is no longer available Open

Statement Metoclopramide (Reglan) can be given intravenously for gastroschisis hypomotility, unlike oral prokinetics where absorption is uncertain Open

Statement A UK study showed cisapride helped gastroschisis patients achieve bowel function more quickly, but cisapride is no longer available Open

Statement Metoclopramide (Reglan) can be given intravenously for gastroschisis hypomotility, unlike oral prokinetics where absorption is uncertain Open

Statement A randomized prospective trial is currently underway to determine if intravenous metoclopramide can shorten the period of hypomotility in gastroschisis Open

Statement At 4 weeks without bowel function, contrast enema is performed to look for mechanical obstruction, sometimes followed by upper GI if enema is inconclusive Open

Statement If still no bowel function at 6 weeks, laparotomy is typically performed, often finding adhesions which are taken down Open

Statement Going in too early on gastroschisis patients with prolonged ileus is a mistake Open

Statement In gastroschisis, it's usually the right testis that is extruded, and in about half the cases it finds its way down into the scrotum after being reduced Open

Statement Omphalocele has a much higher incidence of associated anomalies and chromosomal abnormalities compared to gastroschisis Open

Statement Karyotype analysis and testing for Beckwith-Wiedemann syndrome are routinely performed for omphalocele patients Open

Statement Small omphaloceles without liver are more likely to be associated with abnormal chromosomes than large omphaloceles Open

Statement For small omphaloceles, there's no rationale for routine cesarean section, delivery at a perinatal center, or preterm delivery Open

Statement Small omphaloceles are simple to repair surgically Open

Statement For giant omphaloceles (defined as any omphalocele with a lot of liver out), most surgeons recommend cesarean section, though this is not evidence-based Open

Statement Giant omphaloceles should be delivered at a perinatal center because they need a pediatric surgeon and experienced neonatologists Open

Statement Pulmonary hypoplasia is associated with giant omphaloceles and is very difficult to diagnose prenatally Open

Statement Some giant omphalocele patients have severe pulmonary hypoplasia requiring early intubation and respiratory support Open

Statement The goal in omphalocele management is to reduce viscera without injury from direct trauma or increased intraabdominal pressure Open

Statement Intraabdominal pressure monitoring is very helpful in omphalocele management Open

Statement Stuart Lacy established the guideline of keeping intraabdominal pressure below 20 mmHg based on rabbit studies in the 1980s, which showed improved outcomes in a prospective study in children Open

Statement Lacy also described an increase in central venous pressure of more than 4 as a concerning threshold Open

Statement Intraabdominal pressure can be measured through the nasogastric tube or via Foley catheter measuring intravesical pressure Open

Statement The trend of pressure is more important than the absolute number during reduction Open

Statement Primary closure is attempted for full-term omphalocele patients without significant cardiac disease, respiratory issues, or pulmonary hypoplasia Open

Statement The Montreal group described using the omphalocele sac as a silo by sequentially ligating it over several days to allow abdominal wall stretching Open

Statement Sequential sac ligation requires a thick enough sac and umbilical cord insertion at the top rather than the side Open

Statement Using Duoderm to gradually reduce omphaloceles appears to achieve reduction more quickly than sac ligation Open

Statement Indications for escharotic therapy include prematurity, severe cardiac disease, pulmonary hypoplasia, multiple anomalies, chromosomal abnormalities, or giant omphaloceles where reduction is not feasible Open

Statement Mushroom-shaped omphaloceles have a small abdominal wall defect but large external contents, making reduction impossible Open

Statement Sigy Ein had long experience using silver sulfadiazine (Silvadene) for escharotic therapy in omphaloceles Open

Statement With escharotic therapy, the omphalocele is painted with the agent, forms an eschar, eventually epithelializes, and is later repaired like a large ventral hernia Open

Statement Timing of definitive omphalocele repair after escharotic therapy depends on the individual child, ranging from 6-8 months to 3-4 years depending on defect size and medical comorbidities Open

Statement Mushroom-shaped omphaloceles never reduce spontaneously and stay large Open

Statement For mushroom-shaped omphaloceles, the abdominal wall defect can be enlarged surgically as a first step to allow more spontaneous reduction before definitive repair Open

Statement Formal adult-style component separation in small children carries risk of devascularization and can leave patients in worse condition if complications occur Open

Statement In omphalocele closure, the defect often extends to the costal margin, making the upper portion impossible to close primarily, requiring patch placement Open

Statement Surgisis patch fails in approximately 50% of omphalocele repairs, requiring reoperation with non-absorbable mesh like Prolene Open

Statement Omphaloceles can be part of pentalogy of Cantrell, commonly associated with diaphragmatic hernia of Morgagni Open

Statement Pentalogy of Cantrell omphaloceles tend to be more superiorly placed Open

Statement Most pentalogy of Cantrell patients have cardiac problems requiring escharotic therapy for the omphalocele Open

Statement In pentalogy of Cantrell, the diaphragmatic patch can be placed from above through sternotomy during cardiac surgery, with abdominal wall repair performed later Open

Statement Reflux is very common in omphalocele patients, and many don't eat normally, especially with cardiac disease or pulmonary hypoplasia Open

Statement Interventional radiologists can place G-tubes under fluoroscopy in giant omphalocele patients by finding a window lateral to the defect Open

Statement After G-tube maturation, a GJ tube can be placed to allow feeding despite severe reflux Open

Statement Fundoplication in a child with unrepaired giant omphalocele is extremely difficult because the liver is midline and access to the hiatus is nearly impossible, especially with cardiac disease and congested liver Open

Statement GJ tube is a better short-term solution than fundoplication for reflux in unrepaired omphalocele, with fundoplication performed at the time of definitive abdominal wall repair Open

Statement In giant omphaloceles with midline liver, the liver can put pressure on the duodenum or pylorus causing mechanical gastric outlet obstruction that worsens reflux Open

Statement Non-rotation in omphalocele is not associated with risk of midgut volvulus, so Ladd's procedure is not necessary Open

Statement Inversion appendectomy during omphalocele repair makes sense if the surgeon performs appendectomies during Ladd's procedures Open

Statement Children with repaired omphaloceles can develop perforated appendicitis with delayed diagnosis due to abnormal appendix location Open

Statement If a child with omphalocele has renal abnormalities requiring potential Mitrofanoff procedure, the appendix should be preserved Open

Statement During omphalocele reduction with liver, hepatic veins are very superficial and can be injured during fascial dissection if not careful Open

Statement Kinking of hepatic veins during omphalocele reduction is prevented by using intraabdominal pressure monitoring and not being too aggressive with reduction when pressures exceed 20 Open

Statement In immediate omphalocele reduction, fascial edges can usually be approximated at the bottom but often not at the top, requiring patch placement Open

Statement For partial omphalocele reduction with liver still protruding at the top, a temporary Gore-Tex or silastic patch can be sewn on with skin closed over it, then removed in 1-2 weeks for definitive fascial closure Open

Jack's statements about Anorectal Malformation 5 statements

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Cloaca - Prental Imaging & Diagnosis - Counseling

Statement At 20 weeks gestation when most ultrasounds are done, cloacal findings may be very subtle with nothing that tips the community obstetrician off that there's anything wrong Open

Quotation I think you, you have to have a, a high index of suspicion to start looking for these subtle findings and, and I just think most people out there in the, in the real world aren't even thinking about this possibility. Open

Prenatal Imaging and Counseling: Cloaca and Complex ARMs 2015

Statement At Sick Kids (Toronto), an increasing number of cloaca cases have prenatal diagnosis, but the majority still do not. Open

Quotation On routine ultrasound, these findings, especially early on in the, you know, 20 week range when most ultrasounds are done, they may be very subtle, and there may be nothing that, that tips the community obstetrician off that there's anything wrong. Open

Statement Findings of cloaca on routine 20-week ultrasound may be very subtle; community obstetricians may not suspect the diagnosis unless they have a high index of suspicion. Open

Jack's statements about Chest Pain 18 statements

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Tricks - Thoracoscopic-Assisted Partial Rib Resection - Jack Langer

Statement A 16-year-old male presented with a two-month history of left-sided chest pain. Open

Statement Chest X-ray showed an ill-defined 3×5×5 centimeter calcified lesion in the left lower lung zone. Open

Statement CT scan showed the lesion was pedunculated and exophytic, arising from the internal aspect of the left 6th rib. Open

Statement Resection was advised due to ongoing symptoms of pain and diagnostic uncertainty. Open

Statement Patient was positioned with left side elevated 30 degrees using a beanbag. Open

Statement A single 5 millimeter port was placed posteriorly in the fifth intercostal space. Open

Statement A 22 gauge needle was passed through the chest wall to map out the smallest incision possible and better define the margins. Open

Statement A 5 centimeter incision was made with electric cautery. Open

Statement The intercostal muscles and neurovascular bundles were separated from above and below the 6th rib. Open

Statement The rib was cut anterior and posterior to the stock of the lesion, and the rib segment and lesion were extracted. Open

Statement The operation duration was 67 minutes. Open

Statement The specimen consisted of a 3.5 centimeter rib segment and a 5×3×5 centimeter lesion. Open

Statement The operation was complicated by a small postoperative pneumothorax which was managed with oxygen therapy. Open

Statement The patient was discharged on the 3rd postoperative day. Open

Statement Final pathology showed an atypical osteochondroma with normal underlying rib and negative margins. Open

Quotation We have successfully demonstrated how thorascopic assistance during chest wall excision is a useful technique for benign and malignant lesions to optimize cosmesis and margins. Open

Statement At 8 months follow-up, the patient was pain-free and back to normal activities. Open

Quotation We weren't sure what the diagnosis was. We, I mean, that's what we thought it probably was, but I just wasn't completely happy that that's what it was. It was so big and, and, and it was symptomatic in this case. So, uh, that's why we took the piece of rib. Open

Jack's statements about CICU / Post-op CHD Care 84 statements

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